ABSTRACT
This study moved the debate about the possibility of a two-tier service between fund-holders and other patients beyond the former reliance on anecdotal evidence. Fund-holding patients on the elective waiting list at four public providers did tend to have shorter waiting times for the operations covered by the fund-holding scheme than non fund-holders. Various hypotheses were investigated that could have explained this phenomenon, ranging from an idea that GP fund-holders systematically received overgenerous budgets, the case mix differences of the populations, and contrasts in the way each purchaser type performed their role. The reason was a component of the last of these factors. Whilst GPs had more desire than health authority managers did to shorten waits beyond national standards, motivation and incentives alone were not enough. They needed to be backed up with a ‘tool’ to do the job and this was supplied by the exit option, their capacity to refer to alternative hospitals, or at least being perceived as able to do so by providers.
