titches.The NHS and Community Care Act 1990 was a fundamental reshaping of the economic environment in which the health service operates. The proposals contained within the white paper Working for Patients and the subsequent Act held the prospect of a radically reformed, market-based NHS.(Appleby, et.al. 1993: pp 113-114.) It soon became apparent that the NHS continued to suffer from difficulties despite the changes, but it was (and remains) hard to determine which were a result of the transitional state it found itself in, which due to under funding of the NHS as a whole, which due to mis-management, and which due to fundamental flaws in the 'Changes' themselves.It soon became apparent that the NHS had become a two-tier service, whereby patients of Fund Holding GPs obtained treatment earlier than patients of Non-Fund holding GPs: A report in August 1994 told of a Fund Holding Practice which had moved all of its elective surgical work away from the local NHS hospital to a private hospital (probably staffed by the same senior medical staff) because the waiting lists there were considerably shorter. A two-tiered service, of course, would mean that the NHS was no longer providing care equally to all. Even more unacceptably it would mean that getting better care than the next man depended not on how rich you might be but arbitrarily on where you happened to live and whether your GP was fund holding or not.If all GPs had held Funds, this situation could not have arisen. Because most GPs didn't have the freedom (or energy) to move their patients around to where there was spare capacity, those that did have the freedom and energy were able to cherry-pick. However, many GPs vehemently opposed Fund holding, blaming it for the two-tier system, but also mindful of the fact that managing the Fund required increased work for little or no personal reward, and that as budgets became squeezed the work would only increase. Even those that were Fund hol...
