Despite rhetoric about developing a patient-focused and primary careled NHS, little has changed under New Labour from the typical patient's point of view, according to a report from the King's Fund.

The report, edited by King's Fund director of primary care Steve Gillam, says: 'Doctors still call the shots; opportunities for involvement in any significant decision-making are scarce; public board meetings are little more than faits accomplis; accountability to local people is negligible;

and poor service remains extraordinarily difficult to challenge. '

While the report points out that New Labour is committed to social inclusion and a reduction in health inequalities, it argues that 'its peculiar combination of populism and central control is not the ideal starting point for fostering greater user and public involvement in the process of change'.

It suggests that the NHS plan's vision of a health service designed around the patient does little to shift the balance of power away from the professionals who control the service. It also says the mechanisms for public involvement following the abolition of community health councils, such as the development of the new patient advocacy and liaison service, had not been thought through.

Mr Gillam suggests that Labour has done a great deal to make primary care accessible through initiatives such as NHS Direct, but it had not redressed the 'fundamental imbalance' between primary care and the acute sector.

'Over 90 per cent of all NHS care happens in the GP surgery or in people's own homes. Yet they still do not receive a fair share of NHS resources, and we have yet to see a major shift of power from hospitals to primary care groups under Labour. Even in the NHS plan, most new resources were earmarked for hospitals rather than GP surgeries or for services that visit people at home. '

The government's strategy for NHS dentistry comes in for particular criticism, with a confident prediction that 'the prime minister will be unable to keep his promise to provide for everyone who wants access to NHS dentistry by the end of 2001'.

The report points out that the new strategy neither increases NHS dental capacity nor offers sufficient incentives to encourage dentists to do NHS work. 'The government sets NHS fees, in discussion with the dental profession, and could if it wished increase their fees tomorrow. '

Paradoxically, it adds, forcing dentists to be more performancemanaged could drive more of them into the private sector. And it says that dentists now operate in a market which allows people to buy private care if they can afford it and believe it will be of high quality. The report continues:

'This vision haunts those who foresee GP secession from the NHS should their payment mechanisms be similarly destabilised. '

Clive Parr, chief executive of the National Association for Primary Care, said the 'performance management' culture of the NHS meant that resources continued to be directed to acute hospitals.

'There are procedures that can be done for half the cost and with a great deal more patient convenience in primary care, but for whatever reason health authorities continue to siphon the money into secondary care. '