The Development of the London Hospital System,
1823 - 2015
Chapter 15 From Districts to Trusts
|Health service boundaries|
|Primary Health Care|
|1982-9 Conservative government & Working for Patients|
|1997 - The Labour government|
|1997 – Turnberg|
|Hospital Development in the 5 Turnberg sectors|
|University decisions on London medical schools|
- Labour's 2nd wave of changing structures
New patterns of hospital medicine in London
|Reconfiguring clinical services|
2010 - The Coalition, the White Paper
A health care system, any health care system, is in a state of permanent reform. I understand that annoys and upsets everybody who works in it. But it is almost inevitable.
Kenneth Clarke in The Wisdom of the Crowd, 2013 25
The period from the 1982 restructuring, through the Andrew Lansley reforms of 2012/3, saw a slow, progressive but massive change in the NHS. Secretaries of State grappled with the problem of how to combine the central responsibility to Parliament for a health service, with the need for devolution of decision making. Financially there were intermittent crises. Socially, greater patient/customer responsiveness was required. Clinically the service was moving from acute episodic diseases to the treatment of multiple chronic illnesses. The development of magnetic resonance and other forms of imaging, new pharmaceuticals increasingly based on genetic developments, rapid improvement in cardiac surgery, in minimal access surgery and in day care changed the hospital service. In general practice, family doctors gave up their 24-hour responsibility and considered the way in which they might cooperate across practices. Care in the community and integration of health and social services were thought to provide a solution.
In 1982 the hierarchy of the NHS was clear and strict, a planning system underpinned financial allocations and, in London as throughout England, organisation was the same, if not in the other countries of the UK. By 2016 financial flows had changed, with the introduction of commissioning, and care was delivered by a wide variety of trusts, some foundation ones with greater freedom, but also by private organisations holding contracts. Indeed whole hospitals might have been designed, built and partly managed by the private sector, perhaps under the private finance initiative (PFI). People received care paid for by the NHS; who provided it became less important both to Labour and the Conservatives. Yet at the same time, quality and outcomes of care had achieved an importance never previously seen.
From 2006 London had, for the first time, a single strategic authority, NHS London. When abolished in 2013, London had its own NHS England region, one of four. Instability had been consciously introduced. New styles of management were called for and, as the market swerved between collaboration and competition, new forms of regulation were needed partly driven by scandals.
Politically, the earlier years were dominated by the Conservatives, then for over a decade by Labour, then a coalition of Conservatives and Liberal Democrats and finally a Conservative administration once more. Nationally the economy expanded in the early eighties, but in 1989 there was a recession after Britain’s forced departure from the Exchange Rate Mechanism. By the mid-nineties, the economy was once more healthy, and from 2000-2008 there was an unprecedented increase in money for the NHS until in 2007 a worldwide financial recession brought growth to an end, and in spite strenuous efforts, the majority of trusts were in deficit.
London's population was changing substantially in numbers, distribution, and characteristics.1 From a peak of 8.6 million residents in 1939, it fell for half a century to a low point of 6.73 million in 1988, its size 80 years earlier. After 1981 inner London grew more rapidly than outer London and faster than the UK as a whole. By 2031 the population was expected to reach 8.8 million. In most of England the population was ageing, but in London it was getting bigger and younger, with an increasing birth rate and a net inflow of young adults. Docklands and the Light Railway, and building in Stratford for the 2012 Olympics spurred regeneration in the east. There was an influx of people from Eastern Europe as the European Community expanded. Soon the indigenous population of London would become a minority.
Inner London (millions
Outer London (millions)
All London (millions)
NHS structural change
Continuous structural changes took place nationally. Key dates were
1982 Restructuring increasing district power and simplifying the planning system
1989 Working for Patients; Conservative NHS Reform, splitting commissioning and provision
1997 Labour’s The New NHS, Modern, Dependable, followed by a further wave of structural change in 2000
2013 Lansley/Coalition structural changes abolishing Special Health Authorities and producing disastrous confusion, gradually mitigated without further legislation.
Against the changing national background, London's services were regularly reviewed. There was a new accent on quality, regional specialties, and primary care, presaged by the reports of the London Health Planning Consortium. A series of London reports, (1992 - Tomlinson 3, 1997 - Turnberg 4 and 2007 - Darzi 19) aimed for a hospital service that was smaller, stronger and with a more substantial research base and better infrastructure. Medical schools united, and health service mergers generally mirrored them. In multiple reorganisations District Health Authorities disappeared. Regional Health Authorities went as did their successor Strategic Health Authorities. Consortia of commissioners, the London regional branch of NHS England, and new Academic Health Science Centres replaces them as drivers of change. Of the five UK Academic Health Science Centres identified three were in London.
The initial perception was that there were too many beds and too many small specialist units, with only a small throughput of cases probably associated with poor results. There was certainly a dearth of services in the long term sector, for the mentally ill and the elderly. To the imperative of keeping within budgets was added a new pressure for quality of care, fuelled by scandals of poor care.
Underpinning the changes for much of the decade was the belief that competition was to be welcomed, not feared, and that incentives might deliver better performance. Change was driven by the financial climate, politically inspired organisational restructuring and the belief that patient choice was important.
Primary health care
Historically London's hospitals had ignored general practice. London seemed unique in its failure to resolve the problems. The mobile young, a multitude of ethnic and immigrant groups, an intelligentsia and users of drugs and alcohol all congregated in London. Academic general practice developed late in London, there were fewer innovative GPs and modern premises were less often to be found. High land values, unsavoury locations and planning problems made it almost impossible to find a good site in the right place. Recruiting young doctors was a perennial problem. Inner city GPs were, on average, older, often single-handed and many had trained overseas. Young doctors seldom wished to enter such practices. ‘Better’ doctors went to greener pastures.
It became received wisdom, without much supporting evidence, that substantial parts of care delivered in hospital could be moved into the community. In a report (Primary Health Care in Inner London, 1981 11) commissioned by the London Health Planning Consortium, Donald Acheson, later Chief Medical Officer, had provided an analysis of the problems. After the Acheson Report, it was no longer possible to discuss health services in London without taking note of the condition of primary care and making at least a symbolic gesture towards the solutions of its problems. Brian Jarman wrote later than none of the report's London-specific recommendations had been effectively implemented. Following Acheson, attempts to improve matters included a London Initiative Zone established after the Tomlinson Report to improve GPs' premises, recruit a new cadre of GPs, introduce innovative approaches to old problems and develop cost-effective care outside hospital. A review five years later showed improvement in premises but in some areas the standards remained unacceptably low. London still had fewer young GPs, more single-handed practices, and larger lists. There were more practice nurses, but although primary care in the capital was improving, it was doing so no more rapidly than elsewhere. The initiative was terminated. The Turnberg Report (1997) again recommended support for GPs and the need to improve recruitment and retention. It could be argued that the pattern of general practice that worked excellently elsewhere was unsuitable for inner cities and an alternative contract for GPs was introduced. "Personal Medical Services" made salaried service practicable and seemed particularly appropriate for London. After 2000, new national initiatives aimed to improve access to the NHS, for example, walk-in centres - which were not particularly successful. Urgent care centres were established alongside hospital A and E units to filter off those not requiring the most intensive facilities. The importance of primary health care was stressed again by Darzi 19 (2007), who wished to see the development of 150 large polyclinics from which all GPs and the associated staff would work. In many areas, there were already plans to provide better and larger premises, and these initiatives were promptly renamed polyclinics.
In general practice, family doctors gave up their 24-hour responsibility, throwing extra strains on the hospital service, and considered the way in which they might cooperate across practices, establishing clinical networks or federations.
Health Service Boundaries in London
Boundaries have always been significant in London hospital planning. If hospitals were to be part of a system, they either had to be looked at in groups or else in terms of the specialist services that they provided. Over the years there have been discussions about whether London's hospitals should be considered on a concentric or a radial pattern. The doughnut (with all the jam in the middle) placed emphasis on the teaching and specialisation in the centre, leaving the periphery alone. The alternative, the starfish (which had radial communications and relationships), tried to relate central expertise to the surrounding shire counties. In the late 1970s, the London Health Planning Consortium had planned on a London-wide basis, although the implementation had been left to the four Thames Regional Health Authorities and most took little action. Rationalisation increased in tempo after the 1982 restructuring of the NHS, spurred by financial pressures. After the demise of the London Health Planning Consortium, the chairmen of the twelve teaching districts examined what was happening and found it impossible to predict the future.
The spatial framework of planning in London often changed, confusing and delaying action. Sometimes the boundaries of the 4 Thames regions were used (1948 - 1994). Then there were Department regional offices (1996-2002). A five sector scheme proposed by the Turnberg report (1997) was used, reflected in five London SHAs (2002-2006) - North West London, North Central London, North East London, South East London, and South West London. The five were reduced to two and then a London-wide Strategic Health Authority (NHS London, July 2006) was introduced, to be abolished by the Lansley reforms in 2013 in favour of a London regional branch of the new NHS England. This appeared to follow the Turnberg five sector approach.
National organisational changes and their London effects
1982-9 Conservative government & Working for Patients
The General Management Function 5
NHS management changed after a major review in 1983 by Sir Roy Griffiths, an outcome of the industrial action of 1982 and the weakness of the 1974 restructuring. In a memorable sentence he said, ‘if Florence Nightingale was carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge.' Griffiths' recommendations included a small, strong general management board in Whitehall, that all day-to-day decisions should be taken in the main hospitals and clinicians should be involved more closely in management decisions and should have a management budget and administrative support. A general manager should be identified (regardless of discipline) at each level and authorities should have greater freedom to organise the management structure suited to their needs. Griffiths believed that the lack of a clearly defined general management function was responsible for many problems and that the development of management budgets was vital. Consensus had to go. The government accepted the report.
1989 Working for Patients 6
The next major organizational change took place under Mrs Thatcher and Kenneth Clarke. In 1986 twelve London hospital consultants wrote to the Times talking of the reduced allocations and falling bed numbers.
"The inner London population is no longer receiving an adequate medical service. The future of the hospital medical service in London looks grim."
There were demands for a review of the hospital and health service. What the professions got, the Conservative's NHS Reforms, was not that for which they had been hoping. Many of its concepts were later accepted by Labour. The basic NHS structure had not altered greatly either during reorganisation of 1974 or restructuring in 1982. The Conservative government repudiated consensus and partnership with the professions in policy making, and the broadly bipartisan approach to the NHS had ended. Among its beliefs were the importance of a sound economy without which public services could not be funded; the view that there was little the public sector could do that the private sector could not do better; and that managerial inefficiency was rife throughout the public sector. This approach was only part of a wider ideological battle about society, industry and public services. The main ideas often attributed to Enthoven’s Reflections on the management of the NHS, 7 were current in radical-right circles. Working for Patients accepted many basic principles of the NHS, central funding from taxation and largely free at the point of usage. The idea that a major injection of funds was all that was needed was rejected. Instead, reforming incentives and the introduction of a ‘market’ would improve productivity. The purchasing function would be separated from the provision of services. Health authorities would concentrate on the assessment of needs and contract for services; hospitals and trusts would provide them. A good performance would be rewarded for money would follow the patients. The high costs of central London, compared with the lower ones of hospitals on the periphery, might be a problem for central hospitals.
Hospitals and community services could apply for self-governing status. NHS hospitals were progressively transformed into publicly owned substantially self-governing trusts. Managerially élite hospitals had substantial freedom. The idea of trusts had been developed with acute hospitals in mind, but applications were received from mental illness and community services. They too saw advantages in the freedom of action.
The Trusts generated their revenue from contracts with districts, commissioning agencies and GP fundholders. They needed good financial information, but the data required to compare relative costs were poor; the necessary systems were not in place. Many hospitals had no price list. Block contracts, notional costs, and wild price variations were commonplace. It took much work to sort things out. Over the first few years, there was some change in the pattern of patient flows which had a potential to destabilise budgets, perhaps 5-10%. There had been anxiety that district purchasers would make more radical changes, building up services in local hospitals many of which were new with young staff and spare capacity, so avoiding high-cost hospitals in the centre. The countervailing advantage in the centre was that a high proportion of the medical and surgical consultants had sub-specialty expertise making them the natural place for junior medical training.
Doctors were now employed by the trust and not the RHA, so they began to think in a more local way. At Guy's, a hospital that had major financial problems but wished to expand its services, clinical directorates were established under medical control on the ‘Johns Hopkins’ model. Decisions could be taken more rapidly, new patterns of staffing could be introduced, and services could be improved without bureaucratic delays. Because their unit budgets were determined by contracts with purchasers, it was easier to persuade consultants to change their patterns of work.
The need for hospital trusts to generate income led to visible changes. Lilac coloured carpeting and easy chairs, smiling receptionists, a florist’s stall bursting with blooms, a bistro coffee bar and newsagents would appear. Trusts spent money on glossy pamphlets on their services, and logos. Acute hospital trusts established private patient units to compete with private hospitals and sometimes developed outreach services; community trusts looked at hospital-type day care. The borders could blur. The boundary between the NHS and private medicine was indistinct and the phrase ‘internal market’ seemed increasingly inappropriate.
There were two major planning exercises in early 1992, one by the King’s Fund led by Virginia Beardshaw and one later that year initiated by the government (Tomlinson 3).
1991 - The King’s Fund Commission 16
The King’s Fund appointed a Commission in 1991 to develop a vision of services that would make sense in the next ten years. RAWP was having a detrimental effect on London, the RHAs were not taking a London-wide view, and there were fears that the newly introduced internal market would disadvantage London’s hospitals. It spent £500,000 commissioning 12 research reports and the final document analysed the interlocking set of problems posed by health services, medical education and research in London. It said that Londoners received a poor deal and warned that health care in the inner-city might become inappropriate unless there was the political will to back a strategy of fundamental reform. The report accepted the case for a reduction in acute services with a complementary build-up of primary health care, but did not consider the paucity of back-up beds in nursing and residential homes that barely existed in the metropolis. It reported that at least 5,000 beds must be closed if the capital were to be guaranteed a good standard of health into the next century. ‘Costs in London are not just expensive, they are extremely expensive . . . change is inevitable . . . Inner London hospitals are top-heavy with doctors and the rate of patients going through is slower.' While the report indicated the direction of change needed, it did not suggest the choices that had to be made or which sites might be closed. Attacks were mounted on its findings because of a belief that it was working towards a pre-determined conclusion and that some of its members had little sympathy for London or for specialists. Virginia Bottomley, Secretary of State from April 1992 to July 1995, would have liked support for decisions she needed to take. She did not get it.
1991-2 Tomlinson 3
The Conservatives, committed to market solutions but faced with clear problems requiring decisions, embarked on strategic planning. At the 1991 Conservative Party conference William Waldegrave, then Secretary of State for Health, announced a review by Sir Bernard Tomlinson, Chairman of the Northern RHA. A safe pair of hands, he would ensure that the King's Fund did not 'run away with the ball.' Big building projects were imminent at UCH and St Mary's and there was no logical basis for making decisions. The Times said that Mr Waldegrave was ‘wringing his hands’ over what should be done and needed to be convinced that major decisions were intellectually based. UCH/Middlesex, strongly supported by the scientific community because of the quality of its work, wanted a new building and this might mean the closure of other hospitals. Already expansion had been approved at Guy’s, the Chelsea and Westminster was established and St Mary’s was being developed. The effects of RAWP on central hospitals, in the event over-estimated, and of the internal market, were key to the commissioning of the inquiry. However, William Waldegrave had delayed the need to take action before an election. Those working on the two reviews cooperated, and data was exchanged.
Tomlinson reported in October 1992.3 He emphasized the need to improve primary and community care to national standards and provide services for people with special needs such as the homeless. Tomlinson argued for this, and the government provided £170 million over six years in a ‘London Initiatives Zone’ covering about 4 million people, where needs were great, and an innovative approach was required. Most people under-estimated the complexities of building new and better facilities for GPs and primary health care teams. Neither was it easy to turn a theoretically attractive plan for the teaching hospitals and medical schools into schemes on the ground. The money helped new projects and encouraged the study of long-standing problems of inner London practice but the p Tomlinson reported in October 1992.3 He emphasized the need to improve primary and community care to national standards and provide services for people with special needs such as the homeless. Tomlinson argued for this and the government provided £170 million over six years in a ‘London Initiatives Zone’ covering about 4 million people, where needs were great and an innovative approach was required. Most people underestimated the complexities of building new and better facilities for GPs and primary health care teams. Neither was it easy to turn a theoretically attractive plan for the teaching hospitals and medical schools into schemes on the ground. The money helped new projects and encouraged the study of long-standing problems of inner London practice but the pace of change was slow and the effect on acute hospital services minimal.
The Tomlinson Report foresaw a surplus of 4-5,000 beds because of the withdrawal of inpatient flows from outside central London and the increasing efficiency with which beds were used. The report suggested reducing the number of medical students in London by 150. Whole hospitals should be taken out of use and the resources redeployed to develop primary care and community services. Tomlinson revived earlier proposals for rationalisation. UCH/Middlesex that had become a single, powerful and scientifically important organisation. The Middlesex site of the combined University College/Middlesex hospitals should close and its services relocated to the University College Hospital site. The London Hospital for Tropical Diseases, and the Royal National Throat, Nose and Ear, at Gray's Inn Road, would shut, and move to the redeveloped University College Hospital There would be a single management unit for St Bartholomew’s and The Royal London; the loss of one hospital from among the south London hospitals of Guys’, King’s, St Thomas’ and Lewisham, and Guy's and St Thomas's should merge on one site. The report proposed linking 8 of the 9 London medical schools into four and associating them with four multi-faculty colleges of the University.
The Homerton in Hackney should take most Hackney patients currently treated at Bart's. The Middlesex site of the combined University College/Middlesex hospitals should close and its services relocated on the University College Hospital site. The London Hospital for Tropical Diseases, and the Royal National Throat, Nose, and Ear, at Gray's Inn Road, would shut, and move to the redeveloped University College Hospital. Guy's, by London Bridge station, and St Thomas's, a mile away opposite the Palace of Westminster should merge on one site under a joint trust board. St Mark's Hospital, in Islington, which specialised in the treatment of bowel diseases, would become part of the Northwick Park district hospital complex in Harrow, Middlesex.
Charing Cross, in Hammersmith, which had the greatest excess costs, must close. The Royal Brompton hospitals, dealing with heart and lung complaints, and the Royal Marsden cancer hospital should be brought together on the vacated Charing Cross site. If not, the site should be sold. St Mary's, Paddington needed to reduce the number of its beds, and Queen Charlotte's maternity hospital should shut, and its services moved to the Hammersmith. The capital's postgraduate research institutions should consider ways to concentrate the single specialty research institutes on fewer sites.
Sir Bernard estimated that cuts in acute services and rationalisation could yield £54m a year. There were four broad responses: the optimistic that primary and community care could be brought up to the standards elsewhere; the realistic accepting the recipe but gloomy about the money and the difficulties; the despairing who doubted whether anything would be accomplished; and the reaction at St Bartholomew’s that was to indulge in old-style emotional campaigning against the proposals. St Bartholomew’s had come to believe its own rhetoric, and dismissed any proposal not to its liking, however well founded. Its campaign was given a voice by the Evening Standard in probably the most ferocious media war ever waged against health service managers and NHS policy, unparalleled in its unstinting aggression and partiality.
After the unexpected Conservative victory in April 1992, the new Secretary of State Virginia Bottomley began to take decisions although eminent men tried to bully her. "I had all these great-uncles who died in the first war, we were taught that when the whistle blows you get out of the trench and you walk towards the guns. That is what I was brought up to do, to get out of the trench and walk towards the guns."3 She redefined the NHS as the provision the provision of care on the basis of clinical need, regardless of the ability to pay, not by who provided the service. In February 1993 the Department of Health's response Making London Better, 3 accepted the general thrust of the recommendations, and the need to develop primary health care. It provided a comprehensive blueprint for further development, some of the changes ultimately proceeding. (*)
UNIVERSITY COLLEGE/MIDDLESEX: The hospitals should merge on one site and absorb two of the smaller specialist hospitals, the Royal National Throat, Nose and Ear, and the Hospital for Tropical Diseases. (*)
ST BARTHOLOMEW'S: appraise three options - closure, merger with the Royal London and the London Chest; or retention as a smaller specialist hospital (*)
ST THOMAS'S and GUY'S: Merger consolidating services on one site
CHARING CROSS: A&E workload to transfer to the new Westminster and Chelsea hospital. (*)
ROYAL BROMPTON and ROYAL MARSDEN: consider merger. Perhaps their institutes, could form part of a new Chelsea Health Sciences Centre
QUEEN ELIZABETH: merge with the nearby Homerton (*)
ST MARK'S: move to Northwick Park (*)
To drive the implementation of the Tomlinson proposals, a London Implementation Group (LIG) was formed, chaired by Tim Chessells, Chairman of North East Thames RHA, who had direct access to Ministers. Six specialty reviews were established to examine clinical requirements; the clinicians in the specialty under consideration came from outside London and could be brutal when faced with the pretensions they sometimes encountered. The reviews (1993) proposed that the best centres should be developed, the smaller ones should be closed or merged, and new ones established where they were needed as at St George’s where there was a long-standing need for renal replacement therapy. Many of the recommendations were implemented; too much was expected too fast. Some were revised as a result of more general considerations, e.g. in the south-east neurosurgery was not maintained at Guy's but at the Maudsley. Several initiatives now came together making change possible. A research review of the London postgraduate hospitals pointed to the need for a wide range of skills including biophysics and molecular biology, and association with general hospitals and university facilities. Medical school deans had to play a difficult hand; most were privately supportive of the need for change and prepared to work for it, but in public they had to take their colleagues with them as far as possible. Trust chairmen had been appointed knowing there was a job to be done. They and their chief executives were heavyweights who did not fool around, and transitional funds were available to sugar the pills of change and mergers. Ministers were far more involved than they had been in the work of the LHPC. The Higher Education Funding Council (HEFCE), as a member of the London Implementation Group, was involved in medical school mergers and amalgamations, as well as through its direct links with the institutions. The London Implementation Group closed down in April 1995, and the then two Thames RHAs north and south of the river became responsible for co-ordinating change, though they too were facing demise.
Guy's was in a difficult position. It had been lauded as a "Flagship" NHS Trust, but in 1991 a black hole appeared in its finances damaging its record. Tomlinson had suggested a merger on one site with St Thomas's, but which site? A vicious feud broke out, the Chairman and Chief Executive of Guy's were replaced, and their successors argued successfully for managerial integration but a two-site solution. Guy's increasingly became the major academic location with regional specialty work, and St Thomas's the acute hospital with accident and emergency. In parallel, the United Medical and Dental schools battled with academic integration. ‘During the past twenty years,’ wrote Lord Flowers in The Times, ‘with a few honourable exceptions every attempt to reform London medicine has been defeated by vigorous rear-guard action on behalf of any hospital or medical school adversely affected. The result has been that the standing of teaching and research in London’s famed medical schools has been steadily slipping. The time has come for the government to stand firm.’ In Making London Better 3, Virginia Bottomley took decisions that her predecessors had been canny enough to defer and for which her successors would be forever in her debt; she was prepared to bell the cat, as the BMJ had put it. She narrowly escaped defeat in Parliament and a rebellion of some senior London Tory MPs. Her reward was the Department of National Heritage. Robert Maxwell, Secretary of the King’s Fund, said that the creation of big medical centres across London, the main tertiary centres of service, research and education for the future, had been talked about for 50 years. Now it looked set to happen and would be Mrs Bottomley’s best legacy.
Industry had been removing middle management, ‘downsizing’ and producing ‘flatter’ organisations but few foresaw that regions might be abolished. A review in 1993 of the relationship of the 14 RHAs with the centre recommended that regions should be amalgamated into eight in April 1994. London was divided in 1996 into two regions, north and south of the river. Finally regions were abolished in favour of eight regional offices of the Department of Health.
1997 - The Labour government
The new NHS - Modern, Dependable 9
Labour took power in 1997 and Frank Dobson, the new Secretary of State, set out Labour's initial vision in The New NHS - Modern, Dependable. The harder edges of the internal market were softened. Fund-holding went, co-operation replacing more extreme forms of competition. The interdependence of health and social care, and joint programmes, were stressed. In June 1998 Frank Dobson, decided that London would form a single NHS region and a single London Regional Office of the NHS Executive was established in January 1999. The arguments against such a pattern, vetoed by Bevan in 1946 and also rejected at the time of the 1974 NHS reorganisation, were now weaker. A London region had been proposed by Tomlinson. Change had therefore been expected and affected the boundaries of the surrounding areas. Hospital trusts became accountable to regional offices for their statutory duties, and to health authorities and later primary care trusts for the services they delivered. The separation of planning from provision and decentralization of hospital management was maintained. If Tomlinson had been the Conservatives’ review of London, Turnberg was Labour’s.
1997 – Turnberg 4 The NHS and University Medical Schools
Until the mid-1990s it was believed that London's hospitals provided too many acute beds and it was right to reduce their number. As London came under ever increasing financial pressure following the Resource Allocation Working Party Report (1976), and clinical developments speeded earlier discharge, hospitals were closed against substantial opposition and the number of beds continued to fall. 'Every workhouse I tried to close,' said Kenneth Clarke, 'was regarded as a centre of clinical excellence by all the staff who worked there and all its patrons. The most extraordinary dumps were defended by banner-waving demonstrators.'25 Ultimately the belief that there were too many beds became untenable. After the election Labour had faced problems with commitments such as no hospital closures - Frank Dobson had made scurrilous remarks about Virginia Bottomley's decisions on St Bartholomew's - an end to a postcode lottery and the salvation of St Bartholomew's. Labour saw that health services needed to be coordinated with changes in medical education and, perhaps to get himself off the hook, Frank Dobson commissioned a strategic review of inner London, increasing uncertainty just as some clarity had been obtained. Led by Professor Sir Lesley Turnberg, it reported within months.4 It focussed on wider strategy, recommending large scale planning for major change, greater involvement of the public in the development of proposals and a future focus on primary and community care. It made specific recommendations in relation to several hospital sites. It was clear that there was great pressure on London services, workload was rising and the number of GPs was falling. Hospital bed numbers had fallen substantially; between 1990/1 and 1995/6 1130 acute inpatient beds had disappeared from inner London, and when geriatric, maternity and psychiatric beds were included the loss across London as a whole had been 9,271. Turnberg concluded that there was now no evidence that there were more acute beds available to Londoners than the English average, taking into account the use of London beds by non-Londoners. The subsequent NHS Plan (2000)10 accepted that a substantial increase in capacity was needed if waiting lists were ever to be reduced. Improvements in primary care had not been able to substitute for reductions in secondary care. The campaigning by St Bartholomew's gave an impression that its fate was the key decision Turnberg took, but the Royal London Hospital was planning a massive rebuild and other important issues included mental illness, primary care and community services, and the medical school mergers that had health service consequences. Queen Mary's Roehampton was also scheduled for closure.
Turnberg felt that a five sector scheme would assist planning and health authorities should work together at sectoral level. This scenario has had a permanent effect on health planning in London. The sectors were not unlike the inner parts of the old Regional Health Authorities (for the shire counties had been separated) and reflected a five sector scheme Tomlinson also had liked. Radial organisation had been referred to in the sixties as a "starfish" pattern. The more egalitarian term of Pizza slices was now used and within the slices PCTs, Trusts and the educational authorities had a commonality of interest that led them to work with each other, rather than with other slices.
A new imperative was now emerging - rationalising/reconfiguring the hospital system. The need to provide specialised expertise 24/7, medical staffing problems and the restriction of the hours worked under EC legislation had changed the criteria for defining the size a safe hospital. The progressive increase of sub-specialties meant that rotas of consultants in all the subspecialties could be accommodated in a large hospital but not in smaller District General Hospitals (DGHs). Now that far more specialties were involved in care, there had to be full cover of each to provide a 24-hour service. It was rational to plan for fewer major hospitals, strategically placed. These might be supported by more local facilities. National Service Frameworks developed for clinical specialties outlined clinical networks of hospitals varying in their sophistication. Reports of the BMA, Royal College of Physicians (RCP) and Royal College of Surgeons of England echoed the earlier thinking of the Bonham-Carter Report (1969), suggesting that a single general hospital now should serve populations of not less 500,000.14 Under pressure to improve the volume and quality of services without higher costs, some trusts, for example the Central Middlesex, introduced process re-engineering. If the stages in the delivery of care were examined, was there a better way of designing the system? Given better drugs and anaesthetics allowing more speedy recovery, state-of-the-art diagnostics and imaging, minimum intervention techniques and better information systems, could any stages be omitted, or be arranged more economically to save the time and money of both patients and staff? When financial pressures grew, and problems of quality emerged, trusts increasingly considered that merger would help to solve problems. Progressively these took place.
A related problem was the provision of effective emergency care when most consultants were super-specialists. The RCP said half of the hospitals it surveyed had adopted an emergency admission ward, perhaps of 20 beds, with a system of assigning patients to specialist units. The RCP suggested that Acute Medicine was a separate specialty, required by each hospital taking acute admissions.
Hospital development in the five Turnberg sectors
New hospitals planned in the 1970s had opened in the 1980s, for example, the Newham Hospital (1983) and the Homerton in Hackney (1986). Development was often supported by the Private Finance Initiative (PFI), and major changes took place in each of the five 'Turnberg' sectors adopted as the boundaries for managerial bodies. The problems with PFI were the inflexibility once the building had been opened and the financial costs that stretched way into the future and sometimes closed off other opportunities.
From 2002 until 2006 London had five Strategic Health Authorities and from then until 2012 a single one, NHS London, with an overview of the entire metropolis.
North East London
In the North East decisions were most needed about The Royal London and St Bartholomew's, Queen Mary College and the medical schools of the two hospitals. These two hospitals and their staff had long-standing divergences and a deep distrust of each other. As part of the Conservatives' NHS reforms (1990), the idea of self-governing hospital trusts within the NHS was introduced, and Bart’s was planning to set up such a Trust when its independent future was called into question by the Tomlinson Report which did not see Bart’s as a viable hospital and recommended its closure. The Government’s response in 1993 supporting Tomlinson gave three options for Bart’s: closure, retention as a small specialist hospital, or merger with the Royal London Hospital and the London Chest Hospital. This sparked an intense public debate and a campaign to save the hospital on its Smithfield site. In April 1994 a Trust was formed, incorporating the three hospitals. Turnberg had supported the case for the redevelopment of a 900 bed secondary and tertiary care hospital in Whitechapel while maintaining some tertiary services at Smithfield, mainly cardiac and cancer services. A billion pound PFI development began, the financial cost of which overhung the trust and prevented it achieving foundation trust status. Later mergers were encouraged, culminating in 2012 in the creation of a huge trust, Barts Health, uniting St Bartholomew's, The Royal London, Newham and Whipps Cross hospitals. Its management insisted that major savings could be made, but they proved illusory. By 2015 there was an annual deficit of £93 million, a CQC report revealed poor nursing standards particularly at Whipps, and the trust was put into special measures. An agreement was made with UCLH to exchange cardiac services for cancer, leaving Barts to concentrate on the former.
New building was undertaken at Whipps Cross and Newham General (an Ambulatory Care and Diagnostics Unit and an adult mental illness unit). A new Queen’s Hospital in Romford brought together the services previously run at Oldchurch and Harold Wood hospitals; built under the Private Finance Initiative, it opened in 2006, complementing the rebuilt St George's Hospital Ilford where lower risk and midwife-led maternity care was provided. It was the second of two huge hospitals in north-east London.
North Central London
The Department of Health had supported merger discussion between the medical schools of UCH and the Middlesex Hospital, two organisations with a similar ethos, and the previous boundary between North East Thames and North West Thames was moved so that the districts containing these hospitals united in 1982 as Bloomsbury. The Eastman Dental Hospital had special health authority status but in 1996 joined UCLH. The Elizabeth Garrett Anderson Hospital (1888) became part of UCLH in 1994. The Hospital for Tropical Diseases, the home for the London School of Tropical Medicine, moved first to St Pancras Hospital and then to the main part UCLH. The National Hospital for Neurology and Neurosurgery joined in 1996, the Institute of Neurology affiliating to UCL. The Royal London Homeopathic Hospital joined the group in April 2002.
Turnberg supported the proposal for capital development and ground was broken in 1999 for a £422 million private finance initiative that opened in 2005 uniting most of the University College London Hospitals on a single site. The old Middlesex Hospital site was sold off profitably for redevelopment as flats, gaining the Trust £175 million. With its new development commissioned, and its financial situation sound, the Trust rebuilt its obstetric hospital (the EGA wing) and cancer unit and looked to bring other hospitals, including postgraduate teaching hospitals, onto its site, e.g. the transfer of the Royal National Throat Nose and Ear Hospital from The Royal Free to UCLH.
Substantial development was taking place elsewhere. The first phase of a new Barnet General Hospital opened in 1997. A major development took place at the Whittington. At Chase Farm Hospital, a new surgical wing and Treatment Centre was built, and the North Middlesex was redeveloped with a new Emergency Care Centre, Diagnostic and Treatment Centre, and an Acute and Critical Care Centre.
A world-class medical science centre for London was developed by a partnership of Britain’s biggest funders of clinical research, the Medical Research Council (MRC) National Institute for Medical Research, the Wellcome Trust, Cancer Research UK and University College, London (UCL). A £350 million scheme went forward on a 3½ acre site near the British Library and St Pancras station. The Francis Crick Institute was the largest laboratory of its kind in the world, accommodating 1,500 leading researchers in different fields In 2011 Kings College and Imperial signalled their intention to associate with it.
North West London
Centrally the sector contained the Hammersmith, Queen Charlotte’s, Chelsea Hospital for Women, Charing Cross and, nearby St Mary’s, the Chelsea and Westminster and two specialist hospitals, the Royal Marsden and the Royal Brompton. It came to be dominated by Imperial College. In 1984 the medical schools of Charing Cross and Westminster hospitals united, and in the next year, the districts in which they were situated were merged into one authority, Riverside District Health Authority, with plans to rebuild and reduce the number of hospitals to two. Brent and Paddington District Health Authorities 'huddled together for strength and warmth,’ in the words of the district manager. In 1988 Parkside Health Authority was created, uniting St Mary’s and the Central Middlesex, leaving St Charles’ as a non-acute community hospital. Hospital planning involved the part-rebuilding of St Mary’s and rebuilding the Central Middlesex, the first phase being a pioneering ambulatory care centre. The new Chelsea and Westminster Hospital, which enabled the closure of five separate hospitals, opened in 1993. The Hammersmith/Queen Charlotte's new maternity facility opened in 2003.
The Turnberg report called for more rational distribution of specialist services in North West London. The outcome was the Paddington Health Campus project, a variant of the proposals in the Pickering Report of the 1960s to be funded by PFI. It would bring together Royal Brompton & Harefield NHS Trust, St. Mary's NHS Trust, Imperial College's National Heart and Lung Institute and North West London’s specialist children's services to one site in Paddington. The Business Case was approved by the Department of Health in 2001, but the cost steadily escalated until it was clear that it was not viable. It was cancelled in 2005.
In the early 1990s the Medical Research Council (MRC), under financial pressure, decided to pull out of its Northwick Park Clinical Research Centre and concentrate at the Hammersmith Hospital. Northwick Park had been bought by Charing Cross Hospital in 1944 to allow it to relocate from the centre. Ultimately it had became a colocation of research and a district general hospital that had a "normal" case-mix. Perhaps the idea of this association was flawed; science grafted into an unreceptive environment at a district general hospital where there were suspicions that patents would be "experimented upon.” Perhaps the decision was partly the result of forceful personalities and power politics.
This withdrawal freed modern accommodation and research space. A small specialist hospital concerned with coloproctology, St Marks, needed to move from its poor accommodation in City Road. St Marks had the foresight to realise that it had more to lose than gain from a merger with Barts and grasped the alternative, Northwick Park, with enthusiasm. Relocation in 1995 provided immediate access to intensive care, theatres and state-of-the-art imaging and service departments. St Marks had its own front door, clinical directorate and all the advantages of association with a busy district general hospital. Organisationally there was amalgamation within the North West London Hospitals NHS Trust incorporating Northwick Park & St Mark's and hospitals in Harrow, & the Central Middlesex.
The Royal Brompton & Harefield NHS Trust was established in April 1998 based on two sites, one in central London and one in Middlesex. The Trust provided services for all age groups from infancy to old age and associated with its multi-faculty university partner Imperial College School of Medicine within which was the National Heart and Lung Institute. Turnberg supported the approach to collaboration in the rationalization of services that was being undertaken by the hospital trusts and Imperial College. In 2007 under the aegis of Imperial College, it was proposed to bond the Hammersmith Hospital and St Mary's to create an Academic Health Sciences Centre, merging units such as renal medicine, and making it easier to bring cutting edge research earlier into clinical practice. This was accredited in March 2009.
In a collaborative exercise, the eight CCGs took forward an earlier Darzi era exercise, 'Shaping a healthier future' (2012) that aimed to provide better care in the community. Its proposals to downgrade some A & E Departments including Hammersmith and Charing Cross aroused opposition.
South West London
In south west London the position of St George’s was secure, and the plans to relocate the Atkinson Morley Hospital to the St George's site, and further developments there, were supported by Turnberg. The neuroscience and cardiac centre, the Atkinson Morley Wing, opened in October 2003
South East London
In southeast London, Turnberg said that the merger of the Guys’ and St Thomas’ had allowed the development of proposals for rationalizing services across the two sites. There was protracted discussion and much in-fighting about the future, whether one or the other site should close, where the accident and emergency department should be situated, and where specialised services should be concentrated. If these two hospitals agreed on anything, it was that King's College Hospital was subordinate. Ultimately the A & E Department went to St. Thomas’ because ambulance access was far better. There had also been discussion about the distribution of specialised services between St Thomas', Guy's and King's College Hospital. A new wing at King's College Hospital opened in 2003, and a new Children's Unit was planned.
Turnberg examined redevelopment of acute services in Bexley and Greenwich, and supported the redevelopment of Queen Elizabeth Hospital to replace services at Greenwich, built under PFI at the cost of £93M. This involved the redevelopment of the former military hospital including the design, construction and financing of new buildings, the refurbishment of existing ones and the maintenance and operation of the entire hospital. Both it and Bromley soon had large deficits because of the irreducible costs of their whole hospital PFI schemes.
University decisions and the London medical schools
Since the time of the Royal Commission on Medical Education (1968) academic mergers had been proposed. The earlier Todd pairs differed substantially from the pattern later implemented.
St Bartholomew's Medical College
The London Hospital Medical College
Queen Mary College
University College Medical School
Royal Free Hospital School of Medicine
St Mary's Hospital Medical School
Middlesex Hospital Medical School
Westminster Medical School
Charing Cross Hospital Medical School
Guy's Hospital Medical School
King's College Hospital Medical School
St Thomas's Hospital Medical School
St George's Hospital Medical School
St Bartholomew’s Medical College and The London Hospital Medical College;
University College Hospital Medical School with the Royal Free Hospital School of Medicine;
St Mary’s Hospital Medical School with the Middlesex Hospital Medical School;
Guy’s Hospital Medical School with King’s College Hospital Medical School;
Westminster Medical School with Charing Cross Hospital Medical School;
St Thomas’s Hospital Medical School with St George’s Hospital Medical School.
Westminster Medical School
Charing Cross Hospital Medical School
St Mary's Hospital Medical School
Queen Mary College
St Bartholomew’s Medical College
The London Hospital Medical School;
Guy's Hospital Medical School
King's College Hospital Medical School
St Thomas's Hospital Medical School
University College London Hospitals
University College Medical School
Royal Free Hospital School of Medicine
Middlesex Hospital Medical School
wished for a medical faculty, but was in a financially weak situation, as were the two medical schools involved, St Bartholomew's and The Royal London. There were substantial objections to amalgamation from both the medical schools, and the merger in 1995 as Bart's and The London School of Medicine and Dentistry, the medical faculty of Queen Mary University of London, was not a happy one. Bart's and the Royal London had everything one could desire regarding a local population, but the association with QMC, comparatively weak as a research institution, did them no favours and the QMC and the two medical schools associated with UCL Partners.
University College London
University College/Middlesex schools merged in 1987. The Institute of Child Health became part of UCL in 1996 & the Royal Free and University College Medical School was formed in 1998. University College London Hospitals while having only small local catchments had substantial financial assets and an ideal academic location next to UCL, perhaps the strongest research base in London. As UCL Partners, it was selected as a National Biomedical Research Centre, in 2008 comprising UCL with Great Ormond Street, Moorfields Eye Hospital, The Royal Free, and University College London Hospitals. New "partners" steadily joined. As “London's leading health research powerhouse" it focussed on ten areas of research which posed a major health challenge, e.g. children's health, cancer and women's health. Though the medical schools merged, the Royal Free Hospital remained under separate NHS management.
Imperial and UCL discussed a merger but decided it was in the interests of neither side. However, the discussions divided the London medical schools into two camps, Imperial College and UCL neither of which were supportive of the concept of London University, and the other three. In 2005 UCL gained independent degree-awarding powers from the Privy Council. Students registering after 2007 had a UCL degree. Such moves, covering all subjects and not solely medicine, tended to undermine London University.
Imperial College gained a medical school by merger with St Mary’s Medical School in 1988. Its Faculty of Medicine was formed in 1997 by the merger of St Mary's Medical School with Charing Cross and Westminster Medical School, the Royal Postgraduate Medical School and the National Heart and Lung Institute. In 1988 the Royal Postgraduate Medical School had merged with the Institute of Obstetrics & Gynaecology and also became part of the Imperial College School of Medicine. The National Heart and Lung Institute situated next to the Royal Brompton Hospital became part of Imperial College in 1995 and part of Imperial College School of Medicine in 1997. Secure in its prestige and size, Imperial took a firm line with the medical schools that were now an intrinsic part of it, and with the hospitals to which they related. In 2007 St Mary's Hospital Trust, The Hammersmith Hospitals Trust and Imperial College united to become the Imperial College Health Care Trust, and this was selected as one of five National Biomedical Research Centres. In 2003 it was given the power to award its own degrees but did not immediately use it.
Imperial thought that globally there was only room for 5-6 major biomedical research and teaching centres, perhaps two in the USA, one in the Far East and two in Europe. Imperial considered itself the natural premier league centre in the UK. The Medical Faculty ethos was that of Imperial College, scientific based and of the highest standard. There was a thorough reorganization to develop an integrated Faculty, one organisation using the same letterheads The attempt to bring the NHS and the academic side together as a single body did not work. The huge problems of old buildings and financial deficits proved an excessive burden on top management.
The United Medical and Dental Schools (UMDS) of Guy's and St Thomas' was formed in 1982 and King's College London School of Medicine at Guy's, King's and St Thomas' Hospital (earlier the GKT School) in April 1998. KCL, associated with such powerful hospitals, gave UMDS room for manoeuvre. Internally there were power struggles on both the service and the academic sides to determine the future pattern of service. From 2007 students registered with King's were awarded a King's degree, rather than one from the University of London. In March 2009 King's Partners became accredited an Academic Health Sciences Centre and made rapid progress to become a major player.
St George's, far from the centre of London and with no substantial university link, was not in the same league. It maintained an independent position within the University of London but later established links with Kingston University
There were now four university centres, each related to a multi-faculty college, plus St George’s. The postgraduate institutes were finally brought within the fold, as proposed by Sir George Pickering in 1962.18 Within this structure, once the colleges became directly funded by the Higher Education Funding Council for England (the successor in 1993 to the University Funding Council) the University of London had to accept the realities of local ambitions, including the individual right to grant degrees. The colleges had gained financial and managerial autonomy, UCL, Queen Mary, Kings and Imperial being separately identified from 1993/4 and St George's two years later. The University maintained a coordinating group of the medical faculties to discuss strategy for mutual benefit but each college took a different approach to the integration of medical schools within their fief.
2000 Labour's second wave, changing structures and policies.
The replacement of Frank Dobson in 1999 as Secretary of State for Health by Alan Milburn heralded further change. Milburn wished it to be fast and over a broad front. Labour's second major health policy document, the NHS Plan, was issued in July 200010 with four main themes, increasing capacity, setting standards and targets, supervision of the way the NHS delivered services, and 'partnership'. There was no specific London agenda. Substantial progress was achieved in terms of waiting times and waiting lists. Milburn’s policies involved a greater role for the private sector, for example in the private finance initiative and independent treatment centres, radical changes in funding with the introduction of tariffs and Payment by Results, and Foundation Hospital Trusts with greater freedoms.
Trusts and Foundation trusts (FTs)
In July 2002 it was proposed that acute hospital trusts that had performed well could apply to be "NHS foundation trusts". These would have greater freedom in terms of management, closer links to their community and greater local financial control. Authorisation as a FT was hard to obtain as the trust had to meet high standards of financial security and governance excellence. Nevertheless three London hospitals appeared in the first wave in 2004, Moorfields, the Royal Marsden and the Homerton. Later UCH, King's College Hospital, the Royal Brompton and Harefield, and Guy's/St Thomas' also became FTs. The Royal Free became one in 2011 and Kingston in 2012. Compared with the rest of England fewer London hospitals became FTs. In many cases there were financial problems, often relating to a debt overhang from developments under the private finance initiative as in the case of the Royal London Hospital and hospitals in South London. The trusts of the West Middlesex and Barnet/Chase Farm sought association with existing FTs.
NHS Foundation Trusts differed from existing NHS Trusts in key ways for they had the freedom to decide at a local level how to meet their obligations; they were not under the supervision of the special health authority; they had an individual constitution that made them accountable to local people, who could become members; and governors who could hold the board to account and, indeed, appoint and sack the Chair
They were authorised and regulated by Monitor which kept a careful eye on financial risks, and could provide new services and develop their facilities from their own resources as they wished. For example, the Homerton successfully bid to provide community nursing services to its area. If an FT sold land, it could keep the proceeds for re-development. University College Hospital, also an FT, sold the site of the old Middlesex Hospital for over £175 million, which greatly assisted its redevelopment. Their revenue came largely from contracts with the local ‘purchaser’ for which they competed with other trusts.
New patterns of hospital medicine in London.
The NHS Plan's structural reorganisation took place on 1 April 2002, "devolution day." At that point, there were 28 Strategic Health Authorities.,with five for London. New factors began to drive changes in hospital medicine in London, far more than elsewhere. Increasingly services were planned across and between hospitals and trusts, not merely within them. Services might be provided more effectively in larger units, perhaps by hospital mergers reflecting changes in the pattern of London medical schools, and there was a drive to reconfigure services by clinical outcomes as in heart disease, trauma and stroke
Organisational change continued in London. In 2004 Ministers said 'the unique nature and scale of health service issues facing the capital might point to a single organisation to oversee service development.' Following the Government report Commissioning a Patient-led NHS (Department of Health, 2005), a single SHA was established in London, though the PCTs that were largely coterminous with boroughs were left unchanged.
NHS London (SHA) and the Darzi Reports
NHS London covered an area coterminous with the local government office region and was established in July 2006. It was closed as a result of the Health and Social Care Act 2012 on 31 March 2013. It brought together 5 SHAS, North West London, North Central London, North East London, South East London, and South West London. It was, therefore, the nearest that London had ever had to a "Central Hospital Board for London," providing strategic leadership for all of the health services in the capital and with responsibility for the performance of 31 primary care trusts. It had less responsibility for 16 self-governing foundation trusts. NHS London was chaired in turn by George Greener, and after his resignation in September 2008 by Sir Richard Sykes, previously chief executive of GlaxoSmith-Kline. Sykes resigned as Chair in May 2010. NHS London had responsibility for those trusts that were not Foundation trusts, for example, south London hospitals and Barts and the London, which involved substantial firefighting, but also the formation of a more strategic view of London health services.
At the time of its establishment, financial growth had never been greater, but this ended with the economic downturn. Trusts in south east London had long-standing financial problems, recording annual deficits every year since 2004/2005 from the unaffordable and irreducible costs of its whole hospital PFI schemes, 16% of their income. Cost-improvement schemes could not restore financial health without risking the quality and capacity of services. In 2005 a major review taking 5 years was established (A Picture of Health), covering Queen Elizabeth, Woolwich and Bromley Hospitals, Queen Mary Sidcup and Lewisham. The SHA would have liked to have examined all services in south east London simultaneously, but this proved too difficult. The final proposal was a large reduction in medical and acute bed capacity at the Queen Mary’s Sidcup site with the closure of 284 acute beds and the cessation of emergency admissions. To facilitate service changes a single merged trust was established to cover three hospitals in 2009 with a total combined debt of £149m. The merger was a financial failure, and the Care Quality Commission found the trust was not complying with some standards of safety and quality.
Perhaps the SHA's most important action was, while Sir David Nicholson was chief executive, to commission a clinician, Professor Sir Ara Darzi, to review London's health care system. Darzi, intelligent, hardworking and alert to trends had extensive support both in back office terms and from senior clinicians. Legitimacy was established through the clinical leadership with an extensive consultation programme, and by selecting a few priorities to be tackled properly rather than trying to do everything. The three priorities were stroke, trauma, and the polyclinic programme. The course and outcome of this programme were subsequently reviewed by its key officers.22 Darzi’s first report The Case for Change (March 2007) argued that the current system was wrong because it could not handle health inequalities, patients' expectations, the need to centralise specialised care, the relationship with academic medicine or give value for money. A Framework for Action was published in July 2007, days after Darzi’s ennoblement and his appointment by Gordon Brown as a junior health minister in the Lords.
Darzi was one of the "goats" in Brown's "government of all talents”, and he came to believe that his appointment as a Labour Minister turned people against his report, though it was the product of many hands including McKinsey’s.25 It recommended 5 principles, an individual focus on patients' needs, services local where possible and centralised where necessary, focus on health inequalities, prevention rather than cure and truly integrated care. Technical groups had looked at population trends, e.g. the population expansion in the "Thames Gateway", and the likely health problems in London over the coming years. Clinical working groups considered appropriate policies for care and the care pathways best suited to differing groups of patients. Hospitals might be classified as local hospitals, elective centres with high throughput, major acute hospitals handling complex work, specialist hospitals, and academic health science centres.
Brilliant in conception, but according to the Guardian a recipe for turbulence, it was a blueprint for a radically different NHS. Darzi envisaged that London primary care would be provided by 150 polyclinics, handling much work previously undertaken in hospitals. Some large practices already provided extensive facilities but the inclusion of imaging, consultant outpatient sessions, and minor surgery would require much investment. The number of major acute hospitals would be cut by more than a half, some being restricted largely to cold surgery. There might be some 12 specialist hospitals and 8-16 major acute hospitals. Patients in emergencies would be admitted to the hospital best suited to their needs; near or far. Services for the mentally ill and long-term conditions needed improvement, and the report was fleshed out with reports of working parties, for example on maternity services.
For maternity, a tiered system was proposed according to the clinical and social need of home delivery, midwife-run maternity units some on a hospital campus, and full-scale obstetrician round the clock hospital units. Darzi seemed to believe that the health service would be rebuilt starting from scratch. The costings provided by McKinsey's attracted significant criticism. Major savings depended on the ability to transfer services into the community, but some polyclinic schemes seemed lavish and were likely to cost and not to save money. Darzi accepted that the plan had a long timescale and was confident that he could take others with him, but this was only partly true. He wished his concepts to influence national thinking particularly on quality, but he offended some by offering instant solutions to problems with which people had wrestled for years. The SHA went to public consultation, and a bare majority accepted most of the proposals. A joint committee of primary care trusts (PCTs) accepted the proposals in June 2008.
Reconfiguring clinical services.
Trauma and Stroke reconfiguration
NHS London hosted Healthcare for London, a transient organisation paid for by the 31 PCTs to encourage planning of the most complex services London wide. Already heart attacks had been centred on four key hospitals. From 2006 NHS London consulted and implemented reconfiguration of major trauma and acute stroke units. It sponsored the work that established a ‘case for change’; usually led by a clinician from the field and a steering group
reviewing the evidence. This was not always hard or absolute but in general suggested that the more a centre did, the better they were at it. Economic arguments were not paramount. The decision about how many centres there would lie largely with NHS London and the expert group and might be contentious. Similarly, the expert group decided on the criteria by which applicant trusts would be judged for centre status. Trusts submitted their bids, NHS London evaluated them and once decided, the commissioning process was used to cement arrangements. Against much opposition but usually with strong clinical support specialist care was centralised. Many opponents of the proposals were converted. In February 2009 eight hyperacute stroke units (HASUs) and four trauma units were established. As a result of stroke reconfiguration virtually all patients who would benefit from thrombolysis got it (18%), three times more than in the country as a whole, saving some 400 lives a year. The HASUs were The Royal London Hospital, St George’s Hospital, King’s College Hospital, Northwick Park Hospital, Charing Cross Hospital, University College Hospital, The Princess Royal University Hospital and Queen’s Hospital Romford supported by 24 stroke units where patients would continue their recovery.
Post Darzi Reconfiguration in London
To aid reconfiguration, in 2009 the Primary Care Trusts created five subgroups, three north and two south of the Thames later followed by more formal merger of the PCTs. Reconfiguration proposals were developed in North East London and North West London (the Barnet, Enfield and Haringey Clinical Strategy) but stalled. So did the strategy for the south west, Healthcare for South West London. The delay imposed by Andrew Lansley provided opponents of local change with ammunition. The polyclinic programme, itself essentially based on proposals already in hand, was ended but the primary care trusts and their successor clinical commissioning groups pressed on with rational developments under the banner of integrated care to improve services for the frail elderly, with its increasing incidence of long-term problems. Evaluation showed little evidence that the polyclinic programme had improved service development, access, quality of care and patient experience, and it had not generated significant cost savings. Clinical pressure continued to ensure service transformation in cardiovascular, cancer, mental health, maternity and neonatal intensive care and paediatric services. A major reconfiguration in North West London, Shaping a Healthier Future, was approved, enabling the closure of A and E at Charing Cross, Central Middlesex Hospital, and Ealing, was approved in October 2013.
Biomedical Research Centres (BRCs) and Academic Health Science Centres (AHSCs)
Since the time of William Osler and the Flexner report a century previously
there had been recognition that service,
teaching and research were mutually supportive. Driven from a research
standpoint by Dame Sally Davies, the UK government
recognised the economic, financial and
clinical advantages of supporting medical developments, research leading to
better treatment. The example of major biomedical research
centres in the USA, which had spearheaded
clinical development, led to the establishment of the National Institute for
Health Research (NIHR) and consideration of which
centres should be supported to encourage
"translational research". A panel of
international experts chose centres in
open competition as world class in research. In December 2006 Patricia Hewitt,
the Secretary of State, announced five multispecialty trusts that would be
supported, three in London (Kings, UCLH and Imperial) plus Oxford and Cambridge,
and a further six in particular clinical fields. NHS research
moneys went preferentially to these
power houses of translational research.
Subsequently, sponsored elsewhere in the Department and strongly supported by the PM Tony Blair, Alan Johnson, announced in March 2009 that five academic health science centres would be created in England after a separate peer review of the final applicants by an international panel of experts. The keynote would be collaboration between a trust or trusts with a university. The successful centres were Cambridge University Health Partners, Imperial College, King’s Health Partners, Manchester AHSC, and University College London Partners. From the outset the AHSCs behaved differently. Imperial behaved imperially, centring power on the university with a single chief executive for the NHS and university sides. Equality between the partner trusts and the university was the ethos at UCL Partners, which subsequently applied to become an Academic Health Science Network following the Department of Health's paper on Innovation Health and Wealth (December 2011). These large centres began to play a major role in structuring local and specialist health services. While having no managerial authority over the NHS, their influence was considerable. Hospitals in a relationship with universities not selected began to consider their own future. Designation as a AHSN brought additional money to the organisation. Imperial followed suit but had substantial financial problems from poor building stock, that were not effectively addressed.
2010: The Coalition and the Health and Social Care Act (2012)
Labour was defeated in the 2010 election and the new Secretary of State, Andrew Lansley, arrived with further proposals for reorganisation that he had published while in opposition. Lansley was distrustful of central planning. He immediately moved to embargo proposed reconfigurations, imposing new criteria such as local support from the public and general practitioners. Because the London SHA had been in advance of other authorities, it was particularly affected by this decision and important strategic plans were placed at risk. The Chair, Sir Richard Sykes, previously chief executive of GlaxoSmith-Kline, resigned believing that the delay was driven politically and not by logic. Many of the reconfiguration proposals such as those in North East London had emerged from a long process of clinical involvement and public consultation. Others, as at Chase Farm, were necessary and had been delayed for years by political and public dissent. While some could be criticised, such as the belief that polyclinics would move up to half acute care into the community, saving money, to delay restructuring at a time of financial crisis was questionable. Many of the trusts where restructuring was planned had financial problems and were also at risk of providing poor care. NHS London considered how mergers might assist.
The White Paper, Equity & Excellence, Liberating the NHS was followed by compromises within the coalition, fierce political battles and following the Health and Social Welfare Act (2012), major organisational change.20 In 2013 the London SHA and Primary Care Trusts were abolished, to be replaced by a London regional branch of NHS England with three area groups, two north and one south of the Thames. Pan-London planning and hospital reconfiguration became more difficult. Commissioning functions were transferred to clinical commissioning consortia, and lines of accountability were confused. Within a year nobody could be found willing to defend the changes that were generally held to be mistaken. When appointed as Chief Executive of NHS England in 2014, Simon Stevens was left to try to sort out the mess without resorting to further legislation, against a worsening economic background.
Because of the economic outlook, McKinsey was commissioned in 2008 by the Department of Health to examine NHS finances. Its report in March 2009 suggested the need for swingeing economies. The NHS Chief Executive said that efficiency improvements of £15-20 billion would be required in the three years between 2011 and 2014. In 2011, tariff payments were cut, and some activity was restrained, most acute trusts in London projecting an in-year deficit of 6-9%. Monitor found that most trusts not yet of foundation status were financially at risk. Some such as the Royal London were burdened by major PFI commitments (10% of the entire hospital PFI programme) that debarred it from meeting tests of financial stability. Others had historical debts. NHS London confirmed that Newham, Whipps Cross, North West London Hospitals, West Middlesex, Barnet and Chase Farm, St George’s Healthcare, South London Healthcare, and Barking, Havering and Redbridge Hospitals would all remain in deficit in the medium term. In April 2011 Imperial College Health Care Trust, budget £910 million, had a deficit of £40 million, and the Chief Executive and Finance Officer resigned. The SHA rightly believed that if acute trusts were left with their levels of deficits, London would end up with failing trusts with significant debt, which would result in performance failure, not only financially, but in patient care. The Francis Report (2012) following the problems at Mid-Staffs had made clear that good care depended on safe nurse staff levels. Pressure to recruit added to financial problems, and conversely several trusts with poor staffing and bad CQC reports went into 'special measures.' In 2011 NHS London examined the financial viability and clinical sustainability of the 18 acute NHS Trusts in London yet to achieve Foundation Trust status. (Safe and Financially Effective - SaFE). Even assuming major improvements in productivity, only a third would be in a viable long-term financial position by 2014/15. In 2013 NHS London was abolished and responsibility for strategy passed to the new Clinical Commissioning Groups (CCGs) which formed a London wide Clinical Commissioning Council, to the London regional office of NHS England, to Monitor for foundation trusts, and the Trust Development Authority (TDA) for other trusts (two organisations amalgamated in 2016.)
Merger, at least for the Southeast London Healthcare Trust, was not a panacea. 24 In 2012 the Secretary of State placed the trust into administration. Faced with a rising deficit an administrator was appointed by the Secretary of State in 2012 who later approved his recommendations. Among them was the closure of the A and E department at Lewisham, but this went to Court, and it was ruled that it was outside the remit of the SOS for this to be done. In October 2013 the Trust was dissolved, and in its place a new trust (Lewisham and Greenwich) managed QE Woolwich and Lewisham hospitals; King's College Hospital FT took Princess Royal Bromley; and Oxleas FT Queen Mary's Sidcup. The DoH paid the excess costs of the PFI buildings and wrote off debts so that the new organisations were not saddled with historic deficits. Time had been lost and local staff traumatised.
Seeking solutions led to other risky decisions. The merger of Barts, the Royal London, Whipps Cross and Newham was agreed by the Secretary of State (2012). Within a year the merged trust was in "financial turnaround”, and in 2015 the Chair, Chief Executive, and Chief Nurse resigned. The hospital went into "Special Measures" because of its continuing deficit (£93 million) and poor CQC reports.
In North West London McKinsey's were asked to examine the configuration of services, an exercise that was expanded and led to consultation by the new CCGs on 'Shaping a healthier future' in 2012 that proposed a reduction in A & E units coupled with attempts to improve services in the community.
Several London trusts were placed into Special measures for either quality or financial reasons, or both. Trusts affected were Barking, Havering and Redbridge University Hospitals, Barts Health NHS Trust, Colchester University Hospital NHS Foundation Trust ,Medway NHS Foundation Trust and St George’s Hospital NHS Foundation Trust
Improving health and health care in London
In December 2011 the King's Fund also took stock of the financial and policy landscape, the successes and unfinished business of Darzi and Healthcare for London, and the loss of momentum through the decision to abolish the SHAs in London as elsewhere.21 Its assessment was updated in 2013 listing significant reconfiguration developments. A common theme was the aspiration to develop more integrated care, particularly in primary and community settings, 21 though this had never shown to save money.
The financial situation, though dismal, was at least clear. It was policy that was uncertain. The Fund thought that London, with a greater concentration of problems and financial difficulties than elsewhere, faced a strategic vacuum with no clear lead to coordinate services and drive through necessary changes. Much had been accomplished in heart disease, stroke and trauma by having a central focus. Only 16 of 42 London trusts were currently foundation trusts, with around half of the remainder unlikely to be financially viable in the medium term. The Fund saw a reduction in the number of hospitals and the resultant political conflicts as inevitable.
NHS England London Region published ‘London - A Call to Action’ in 2013, which like the Darzi reports aimed to stimulate debate about the challenges faced by the NHS in London and the case for "transformation.". A useful guide, the challenges were presented better than the possible solutions.26
The Academic Health Science Centres were now playing a role in reconfiguration. For example, it was agreed that specialist cardiac services should move from UCLH to Barts, creating the largest centre in the country, while specialist urological cancer surgery would transfer to University College London Hospitals. UCL Partners described the move as a “once-in-a-lifetime opportunity” to create world class cancer and cardiac care for 6 million people in London and beyond, on a scale similar to the reconfiguration of stroke care across London. UCLH said there were only two things it could do at world-class standard, neuroscience, and cancer. "It's not possible anymore for everyone to do everything.” The concentration of expertise allowed Barts to compete with international cardiac centres, such as the Cleveland Clinic, while UCLH competed with the equivalents for cancer, for example, the Memorial Sloan-Kettering cancer centre in the US.
The Conservative Government, 2015.
The return of a Conservative government with a modest majority did not lead to immediate change. Indeed the previous Secretary of State for Health, Jeremy Hunt, retained his position. The immediate problem was mitigating the problems that had been created by the Lansley reforms, without further legislation, and at a time of almost an unparalleled economic crisis.
A plethora of authorities and bodies had made administration, let alone management and planning difficult. The complexity of the changes in 2013, and the processes now to be gone through seemed massive, according to Ruth Carnall, retiring chief executive of NHS London.22a NHS England moved slowly to remedy matters. Monitor, which dealt with Foundation Trusts, and the Trust Development Authority concerned with the rest, were merged in 2016.
In 2014, against the background of falling resources and fragmented
commissioning responsibilities, The NHS
five year forward view was published,
emphasising prevention, integration of services and putting people in
control of their health, and described new care models. Most involved closer
relationships between providers, NHS Trusts,
and Local Authorities, stressing collaboration rather than competition. The two
principles now appeared to be working together,
rather than competition, and a move towards integration of health and social
services to aid the care of the elderly and those with disabilities and
and Transformation Plans (STPs) were developed, concerned with health,
care, and financial stability.
Forty-four 'footprints' were defined;
coterminosity was not
generally attempted, and they varied vastly in size. The five covering London
reflected the Turnberg sectors; the areas and local leadership
were often determined centrally. There
had been limited public involvement in
the process , but there had also been limited involvement of GPs and Local
Authorities in some areas. STPs had no legal framework or formal
All depended on cooperation and whether
this would suffice was doubtful
. All depended on cooperation and whether this would suffice was doubtful
The emerging plans and the financial costing were ‘high level,' often with little indication of specific changes in the services although the financial crises might drive the incorporation major changes. The assumptions made in some areas might not stand scrutiny, and many were dependent on taking beds out of the system, or on capital spending. The requests from London trusts were substantial.
Inner London Trusts and Foundation Trusts as of 2016
Structurally, the financial climate had encouraged organisational mergers. Larger Trust groupings appeared in four of the five Turnberg sectors
Dates of joining the trust and of foundation trust status.
North East London
Barts Health NHS Trust (Trust created 2012)
The Royal London Hospital, St Bartholomew’s Hospital, Newham University Hospital (2012), Whipps Cross University Hospital (2012)
Homerton University Hospital Foundation Trust (2004 FT Status)
North Central London
Royal Free Hospital London NHS Foundation Trust (2012 FT Status)
Royal Free Hospital, Barnet Hospital (2014), Chase Farm Hospital (2014)
University College London Hospital NHS Foundation Trust (1994/2004 FT Status)
University College Hospital & Middlesex Hospital (1982), National Hospital for Neurology and Neurosurgery (1996), Royal National Throat, Nose and Ear Hospital (2012), Eastman Dental Hospital (1996), Royal London Hospital for Integrated Medicine (2002)
Great Ormond Street Hospital for Children NHS Foundation Trust (2012 FT Status)
The Whittington Hospital NHS Trust
North Middlesex University Hospital NHS Trust
The Hillingdon Hospitals NHS Foundation Trust (2011)
Hillingdon Hospital, Mount Vernon Hospital
Royal National Orthopaedic Hospital Trust, (Stanmore & Bolsover Street)
Moorfields Eye Hospital Foundation Trust (2004 FT Status)
Moorfields has many satellite units embedded in other hospitals in London and the Home Counties
North West London
Imperial College NHS Healthcare Trust
Charing Cross Hospital (2007), Hammersmith Hospital (2007), Queen Charlotte’s Maternity Hospital (2007), St Mary’s Hospital (2007), Westminster Eye Hospital (2007)
Chelsea and Westminster Hospital NHS Foundation Trust (2006 FT Status)
Chelsea and Westminster Hospital (Built on site of St Stephens and opened 2003), West Middlesex University Hospital (2015)
London North West Healthcare Trust (2014)
Central Middlesex Hospital, Ealing Hospital, Northwick Park Hospital, St Mark’s Hospital
Royal Brompton and Harefield NHS Foundation Trust (2009 FT Status)
Brompton Hospital, Harefield Hospital
South West London
St George's University Hospitals NHS Foundation Trust (2015 FT Status)
(Incorporating the Atkinson Morely Hospital)
Kingston Hospital NHS Foundation Trust (2013 FT Status)
Royal Marsden NHS Foundation Trust (2004 FT Status)
Royal Marsden (Chelsea), Royal Marsden (Sutton), Royal Marsden day unit in Kingston Hospital.
South East London
Guy’s and St Thomas’ NHS Foundation Trust (2004 FT Status)
Guy’s Hospital, St Thomas’ Hospital
King's College Hospital NHS Foundation Trust (2006 FT Status)
King’s College Hospital, Princess Royal University Hospital, Farnborough Common (2013), Orpington Hospital
Lewisham and Greenwich NHS Trust
Queen Elizabeth Hospital Greenwich, University Hospital Lewisham
The State of Play, 2016
the position over the 30 years from NHS restructuring to the Health and Social
Care Act 2012 and beyond, London’s hospitals started under the management of
four regional health authorities and individual teaching districts. They were
bound into a planning system where the aspirations and the money did not match.
They had little control over their destiny; there was infighting between the
medical schools and no effective strategic planning. Thirty years later the
Department of Health was stepping back from
and there was a single strategic authority, or regional branch of NHS England,
for London. The medical schools had sorted out their
problems. Ways were being found to remedy the lack of a focus for strategic
planning, NHS England encouraging the creation of ‘Sustainability and
Transformation Plans’. Academic
were flexing their muscles, but the gospel of competition was giving way to
not only within the NHS but with local authority
Planning for services such as heart and
taking place across
metropolis, rather than within individual hospitals, with substantial clinical
involvement, and driven by commissioning. Increasingly the burden of care of the
elderly and those with multiple problems was leading to "integrated care" with
attempts to unite the work of general practitioners and hospital services.
The problems of developing, and where necessary remodelling, London in matters of health administration "is admittedly one of unending difficulty." So said The Lancet in 1920, and when this book was first published in 1986 few could have predicted the pattern of London health services and hospitals thirty years later.
Advance was coming from success in working with clinicians, whether consultants or GPs. The attempt to predict the future at this juncture would be equally silly. The trend to look at clinical services for quality and cost across hospitals and trusts is encouraging. London remains, however, with its hospitals, universities and academic health science centres a powerhouse of talent. Long may it remain so, a wild problem but, again in the words of The Lancet on 18th January 1873, "a service doing on the whole an enormous amount of good and necessarily doing also a certain amount of mischief."
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