Five years later, the Kings Fund says this has been frustrated by the institutions to which they posed a threat.Baron (Marmaduke) Hussey, chairman of the commission, said: “The main problem is that those with the greatest needs are getting the worst care. The result is higher costs and less flexibility to cope with emergencies.The lack of nursing homes for the elderly and poor community provision for the mentally ill means that beds are blocked by patients who should not be in them. In addition, the pressures of competition and the market have required trusts to sell their services to outlying health authorities to boost income, making it harder for local people to get a hospital bed.A key recommendation of the Tomlinson review was that specialties, which were fragmented across many sites, should be merged to concentrate skills and resources and raise standards. It says little progress has been made since its first report in 1992. That laid the ground for the Government-backed Tomlinson review which recommended a radical programme to close hospitals, concentrate specialties and divert funds to the GP service and community care.The new Kings Fund report, Transforming Health in London, says that while more than one in six acute hospital beds has been lost since 1989-90, because of the trend to day surgery and shorter in-patient stays, hospital sites have not closed. Sweeping changes are needed to improve health care and restore public confidence, the Kings Fund independent health policy think-tank, says.
The report is the second to be produced by the fund’s London Commission in five years. it is a clear admission that Frank Dobson cannot deliver the improved health service which only a few weeks ago he was billing as a racing certainty”..

A grim diagnosis of the state of London’s health service is offered by a report, published yesterday, which says health care in the capital has been damaged by the destructive effects of the NHS market and institutional rivalries between the major teaching hospitals. “I don’t think any fundholder is going to be happy about increasing their waiting lists. There is a possibility of chaos and discord.”Other bodies welcomed the move. The NHS Confederation said the principle of fair and equitable treatment for all patients was “clearly the right one” but the British Medical Association warned that equity for all “must not mean equity at a lower level”.John Maples, the Tory health spokesman, said the move amounted to “a levelling down of services to patients who need access to hospital care … If you live on the border of a health authority, a person two streets away could have a totally different waiting list,” he said.He said the move could also add to the financial pressure on hospitals as a doubled waiting list would halve the income from a fundholder. But in some cases, GP fundholders who have overspent their budgets have instructed trusts to delay hospital treatment to the maximum allowed under the Patient’s Charter – 12 or 18 months.

In this minority of cases, fundholding patients can expect a better service.Dr Rhidian Morris, chairman of the National Association of Fundholding Practices, said that, far from achieving equity in the NHS, the measure would simply push inequity up from the level of the local practice to the level of the trust or health authority “We will still have a multi- level waiting list. Almost 60 per cent of patients are now covered by GP fundholders who have been able to negotiate “fast track” deals with NHS trusts anxious for their business. It is also good news for doctors and other NHS staff, many of whom have found the unfair two-tier system repugnant to administer”.Faster hospital treatment has been touted as one of the main advantages to patients of joining a GP practice that holds its own budget for hospital care. A health department spokesman confirmed that yesterday’s announcement would mean waiting lists for patients of most fundholders would rise.Mr Dobson said: “Today is the beginning of the end of the two-tier NHS This is good news for patients. In addition, health authorities will be required to set maximum waiting times common to all their residents.
Official figures show that in 60 per cent of health authorities in England, patients of fundholding GPs get faster hospital treatment than those of non-fundholding GPs.