Managers' representatives have attacked NHS chief executive Duncan Nichol's demand for action on waiting lists. He wants no patients waiting more than two years for treatment by March 1992, and has said managers' performance-related pay would be judged on waiting times. But the Institute of Health Services Management said he was responding to 'politically motivated concerns'.

Casualty units in London are struggling to accommodate patients. The normally quiet summer months have seen no let-up in the pressure on beds, according to the EBS.

'Things are now difficult the whole year round. The referral rate we're currently seeing is the highest there has ever been, ' said EBS manager Graham Hayter.

Nearly three out of four people believe trusts will charge patients for some services, and almost half believe they will operate outside the NHS, according to an opinion poll for North West Thames regional health authority. More than two-thirds thought the government's aim was to 'reduce spending rather than improve care'.

Trade unions are seeking talks with managers of future trusts over recognition and deals.A spokesman for COHSE said it was negotiating more flexible working patterns with trusts in return for higher pay.

'Trusts will be a disaster for the health service, but we believe they represent an opportunity for members in terms of higher pay.'

Senior staff at West Midlands regional health authority are said to be 'shocked and stunned' at the ousting of two top managers in a boardroom shake-up. Planning director Ann Coulson and performance review director David Hands were told there was no place for them in the RHA's new management team when it met for the first time last week , and both were told to clear their desks.