The changes to the tariff for specialist services revealed in this week's HSJ risk inflaming public opinion just as Lord Darzi's review is supposed to be restoring confidence in how reconfigurations are managed.

In the chapter of his interim report headed 'A locally accountable NHS', the junior minister promised that service changes will only take place where there is a clear clinical case to support it, there has been early engagement with the public and there is clear evidence of improved outcomes.

Yet this is not what is happening. A month after his report was published, the Department of Health is, in effect, using adjustments to the tariff top-up to strip district general hospitals of specialist services.

This smacks of service reconfigurations by the back door.

While the public will not understand the arcane accounting practice driving change, the outcomes will be understood all too clearly if hospitals feel unable to subsidise this work and shut services.

The clinical case for change may well be robust - as one strategic health authority stresses, the aim is to improve services - and it may be possible to demonstrate that the financial turbulence forced on district hospitals is worth it. But it is difficult to understand why the government is failing to honour its commitment to openness on service reconfigurations weeks after it was made.

After enduring months of adverse publicity, with everyone from Cabinet ministers to Keith Richards campaigning against service closures, the ministerial team seemed to be getting a grip on the political necessity of sensitivity to local feelings.

But its first tentative steps to properly involving the public - and extending popular understanding of the issues involved - now risk being undermined by pulling so hard on this financial lever.

Transparency and openness are essential to securing support for service reform.

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