THE clearest evidence to date of a two-tier National Health Service has emerged in Salisbury, where only private patients and those from GP fund-holders are now getting routine operations.

Everyone else can wait. The Salisbury Healthcare NHS Trust hospital has cancelled non-emergency surgery for patients of non-fundholding practices for at least six months as it struggles to balance its books.

One elderly patient was initially told she could have surgery for a painful wrist "within a fortnight," but was subsequently rung at home and informed that it would be at least next April before she could be treated. Mary Newstead, 70, said: "The lady said the only way I could get it sooner was to pay myself or change to a fund-holding GP." Fundholders manage their own budgets and purchase treatments direct from hospitals.

One senior hospital consultant, who asked not to be named, said that when the patient of a non-fundholder is called up on hospital computer records, their details are now flagged by the statement "[treat] if only serious clinical need."

Details of Salisbury's two-tier health service came to light on the eve of the annual conference of the National Association of Fundholding Practices, and are likely to embarrass Stephen Dorrell, Secretary of State for Health, who addresses delegates in Harrogate on Wednesday.

Mr Dorrell last week said it was "not his ambition" to make every GP a fundholder but that every patient should benefit from the gains of fundholding. Critics will want to know how he intends to protect patients of non-fundholders from discrimination like that in Salisbury.

The crisis in Salisbury has been triggered by the cash-flow problems of the Wiltshire and Bath Health Commission, which buys care for non-budget holding GP practices. The commission has run out of money only half-way through the financial year, and is facing a shortfall of between pounds 2m and pounds 7.5m. It told the trust last month that it cannot pay for non-emergency treatments for its population. John Nicholas, a senior executive, blames a 17 per cent increase in emergency admissions in the past six months for the financial problems.

Christopher Mould, the trust chief executive, admitted there was a "slowing down" of treatment for patients of non-fundholders. "This is distressing but we have to work within the constraints. We have over-worked and treated more patients than we said we would, but I cannot spend taxpayers' money I don't have." The hospital had also instituted bed closures, a job-freeze and reduced its locum staff by half.

However, hospital consultants and local doctors are incensed by the trust's decision to discriminate against patients with similar clinical needs on financial grounds, something the Government insisted would not happen when it introduced fundholding.

They have also criticised hospital management for continuing to take in patients for whom payment is guaranteed from Dorset, Hampshire and other parts of Wiltshire, while Salisbury residents face long delays before being treated.

Dr Hugh Bond, of The Three Swans Health Centre, a non-fundholding practice said: "It is in effect a four-tier system, with the patients of non-fundholders in Salisbury at the bottom of the heap.

"I'm powerless to do anything for my patients. I have to face people every day who have received letters telling them their operation has been postponed until April 1996 at the earliest." He said one patient with a potentially life-threatening condition was treated only after he intervened directly with the consultant.

Dr Dougal Jeffries, from Salisbury's Bemerton Health Centre, who referred Mrs Newstead for treatment, said the consultant who saw her confirmed that there were in effect now two waiting lists at the hospital, one for the patients of non-fundholders and a "fast-track" list for fundholder patients. "I feel angry and frustrated on behalf of my patients. I made a principled decision not to become a fundholder and as a result it seems my patients are suffering."

Mr Doug McKenna, a gynaecologist at the Salisbury Healthcare NHS Trust, said the situation highlighted the anomalies of the fundholding system. He had patients suffering from conditions which seriously affected their quality of life, but who faced waits of a year or more for treatment. Patients of fundholders were operated on within six to eight months, he said. "I have stopped putting people on waiting lists. It is so uncertain."

A spokesman for the Department of Health said the situation was a "local matter" which would be resolved by purchaser and provider.

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