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London's NHS is in "urgent need of change" but there is a risk there will be no one in charge to push that change through, according to a report.

said there could be a "responsibility vacuum" in organising services when the strategic health authority is abolished in April 2013.

The independent think tank's report also warned there were huge health inequalities across the capital.

The government said a commissioning board would shape services.

The report said London's NHS could face severe financial difficulties over the next few years, with 18 hospitals forecast to have a net deficit of £170m by 2014.

It also said GP performance was often poor with people's satisfaction with GP services lower than elsewhere in the country.

The charity added many London trusts would struggle to meet the government's deadline to become foundation trusts by 2014, as currently only 16 out of 42 trusts have foundation status.

Chris Ham, chief executive, said: "London's NHS is in urgent need of change, but the risk is no-one will be behind the wheel to push through the changes needed to improve patient care.

"New pan-London health organisations are emerging but none has a clear mandate to take the lead.

"Strategic leadership is important across the NHS, but in London it is particularly important as the challenges are more acute and urgent."

The Royal College of Nursing (RCN) said the report raised "worrying questions" about the future of healthcare in London which required "urgent action".

Chief executive Dr Peter Carter said: "Without a strategic overview there is a real risk that we could see gaps or duplication of services start to appear."

Dr Carter said this was a problem for health trusts across the country.

Responding to the King's Fund report, chief executive for NHS London, Dame Ruth Carnall, said the review raised "valid questions" about who would lead health trusts in the future.

"The case for change to the NHS in London remains strong," she said. "Patient care is good in some places but not everywhere."

A Department of Health spokeswoman said the NHS Commissioning Board would work closely with clinical commissioning groups in London to provide ongoing strategic oversight and support.

The spokeswoman said no-one would be forced to take on commissioning before they were ready.

She added the department was helping hospital managements to become financially sustainable.