NHS plans that could lead to hospital and A&E closures have been kept secret from the public and barely involved frontline staff, a leading think tank has warned.
NHS England has told local health leaders not to reveal the plans to the public or the media until they are finalised and have been approved by their own officials first, according to published documents and a new analysis from the King's Fund.
The national body even told local managers to refuse applications from the media or the public wanting to see the proposals under the Freedom of Information Act.
Local managers accused NHS England of being intent on "managing" the "narrative" about the plans.
Health managers in 44 areas of England have been ordered to draw up the strategies, setting out how they will reduce costs, change services and improve care in the wake of a record £2.45 billion deficit.
The sustainability and transformation plans (STPs), some of which have been published or leaked, could see some hospitals, A&E units or maternity units close, and other services merged.
The proposal for Cheshire and Mersey includes the downgrade of at least one A&E department while in south-west London the number of acute hospitals could be cut from five to four.
In north-west London, there are plans to reduce the number of sites offering a full range of services while Birmingham and Solihull's STP proposes a single "lead provider" for maternity care.
NHS England and some health experts say the changes will improve patient care and are necessary to fulfil Health Secretary Jeremy Hunt's plan for full seven-day services.
Campaigners argue they are just a way of cutting services.
Some councils have objected so strongly to the lack of public involvement they have ignored NHS England's demand to keep the documents private until a later stage and have published them on their websites.
The new report from the King's Fund - based on a review of plans and interviews with local managers - said NHS England had set very tight timescales, which is partly to blame for why patients and doctors have been shut out.
Expensive management consultants have also been brought in but clinical teams or GPs have often only been "weakly engaged in the process".
The report said: "It is clear from our research that STPs have been developed at significant speed and without the meaningful involvement of frontline staff or the patients they serve."
It added:" Patients and the public have been largely absent from the STP process so far."
One local manager said of the lack of public involvement: "I've been in meetings where I've felt a little bit like, you know, 'where are the real people in this?'" while another described the secrecy demanded by NHS England as "ludicrous".
The report said: "As well as the timeline creating a barrier to meaningful public engagement, national NHS bodies had also asked STP leaders to keep details of draft STPs out of the public domain.
"This included instructions to actively reject Freedom of Information Act requests (FOIs) to see draft plans. Two main reasons were given for this. The first was that national NHS leaders wanted to be able to 'manage' the STP narrative at a national level - particularly where plans might involve politically-sensitive changes to hospital services.
"The second was that national leaders did not want draft proposals to be made public until they had agreed on their content."
On management consultants, the report said some leaders "felt that STPs had 'created an industry' for management consultants - and questions were raised about why money is being invested in advice from private companies instead of in frontline services."
However, the King's Fund said STPs still offered the "best hope" of improving health and care services.
Chris Ham, chief executive of the King's Fund, said: "The introduction of STPs has been beset by problems and has been frustrating for many of those involved, but it is vital that we stick with them.
'For all the difficulties over the last few months, their focus on organisations in each area working together is the right approach for improving care and meeting the needs of an ageing population.
"It is also clear that our health and care system is under unprecedented pressure and if STPs do not work then there is no plan B."
He said It was a "heroic assumption" to say out-of-hospital services and GPs could take on more of the work currently done by hospitals, given how under pressure they were.
He added there was "mixed evidence at best" that moving services closer to home improves care.
NHS medical director Professor Sir Bruce Keogh defended the plans, adding: "Advances in medicine also mean it is now possible to treat people at home who would previously have needed a trip to hospital.
"It also means those with the most serious illness need to be treated in centres where specialist help is available around the clock.
"So, this is not a moment to sit on our hands. There are straightforward and frankly overdue things we can do to improve care.
"We are talking about steady incremental improvement, not a big bang. If we don't, the problems will only get worse."