Image caption The reforms are passing into law after a political battle

Rising costs of GP care and poorer response to health emergencies are some of the risks of the ongoing NHS shake-up, a leaked document warns.

A draft risk register found a high chance of dangers such as a loss of financial control from the health bill, which gained Royal Assent on Tuesday.

The government has not published the final risk assessment, despite a ruling from the Information Commissioner.

The Department of Health says it does not comment on leaks.

A spokesperson said: "We do not comment on leaks. We have always been open about risk and have published all relevant information in the Impact Assessments alongside the Bill.

"As the latest performance figures show we are dealing with those risks, performance is improving - waiting times are down and mixed sex wards are at an all time low - and we are on course to make the efficiency savings that the NHS needs to safeguard it for the future."

The draft risk register, produced on 28 September 2010, identified 43 areas of potential risk. Each were rated on a scale of one (rare/low impact) to five (almost certain/very high impact). Among the areas rated four out of five for both impact and likelihood were:

Costs being driven up by GP consortia using private sector organisations and staff

Poorer preparation and response to health emergencies

Loss of financial control.

The draft of the risk register was leaked to the health writer Roy Lilley and published in The Guardian.

It is not known what changes have been made since, as the government has resisted a ruling from the Information Commissioner that it should release the final version in response to a freedom of information request from Labour.

Roy Lilley said he believed that very few of the risks had been mitigated during the passage of the bill.

He told the BBC: "Ninety percent of the risks that were identified in this September document have manifested or are manifesting now."

'Embattled plans'

The Shadow health secretary Andy Burnham said the document showed ministers were warned about risks from the NHS reforms.

He said: "Now we know why David Cameron refused to publish the risk register before the bill was through Parliament - it's because civil servants were telling him his reorganisation was likely to cause major damage to the NHS.

"David Cameron will never be forgiven for knowingly taking these risks with the country's best-loved institution."

Katherine Murphy, Chief Executive of the Patients Association, said the document was "deeply worrying".

"Parliament - and just as importantly, patients - should have had the opportunity to see this document to make informed opinions about the changes to the NHS.

"But instead, the embattled plans were forced through Parliament while outside doctors, patients, nurses, academics and NHS managers all railed against it."

The government has to make it clear how it plans to avoid the vision becoming the reality, she added.