With Labour pledged to abolish fund-holding, Mrs Bottomley's move is aimed at embedding it so that abolition is harder than Labour believes.
By April 1996, GPs with 5,000 rather than 7,000 patients will be allowed to join the existing fund- holding scheme, which will be extended to cover almost all waiting-list surgery and outpatient attendances.
A new 'easy entry' form of 'community' fund-holding, to allow practices with 3,000 to 5,000 patients to take budgets for staff, diagnostic tests and community services, will be introduced.
Up to 20 big practices will be allowed to become 'total' fund- holders, taking the budget for all services, including accident and emergencies. Five such pilot schemes began this year.
The announcement is another nail in the coffin of the traditional health authority. Fund- holding practices already cover 35 per cent of the population. The new measures mean 90 per cent could be covered if GPs co- operate.
Mrs Bottomley told the conference that her aim was 'not a two- tier service' but 'a top-tier service, for every patient'.
The announcement came after a debate which saw the NHS reforms praised but also attacked by Professor Roger Williams, the pioneering liver transplant specialist at King's College Hospital, London, and a member of the Conservative Medical Society.
The reforms had generated 'difficult issues' for consultants who believed in an equitable NHS, he said. 'They see an increasing bureaucracy. They see unbridled power given to chief executives and managers - not always in the patient's interest.'
He warned ministers not to introduce performance-related pay for doctors, saying consultants 'totally opposed' the idea.
David Skidmore, a cancer surgeon from Dartford and a fellow member of the Conservative Medical Society, said its executive was warning health ministers that performance-related pay would be 'a disaster'.
Rewarding doctors in more glamorous and more popular specialities would make it more difficult to attract good consultants to less popular parts of the country and less popular specialities, he said.
Mrs Bottomley reiterated her plans to cut bureaucracy but also outlined moves to stamp out prescription fraud and introduce a new power of 'supervised discharge' to cover seriously mentally ill people when they leave hospital.
Millions of pounds, perhaps tens of millions, in prescription charges were going missing through patients claiming exemptions to which they were not entitled, she said.
She declined to give details of the measures, but GPs are likely to be asked to sign certificates of exemption on age grounds, while those claiming to be on income support and family credit may have to show proof to pharmacists.
Mrs Bottomley also promised legislation on 'supervised discharge', making it easier to recall severely mentally ill people to hospital if they break agreements on regular visits to their GP for medication or attendance at day centres, for example.
The move was 'fair, it is sensible and it is going to happen', Mrs Bottomley said. A minority of such people 'need much tighter supervision' in the community, she said.
While they had rights, the public also had 'the right to be protected from the dangers of patients slipping through the net'.
The new pledge on waiting times for operations will require the removal of the 4,500 patients who have been on the waiting list for more than 18 months, while from next April a maximum waiting period for an initial outpatient appointment will be set.Reuse content