Doctors wait for sign that they have a future: Consultants' influence has diminished to the point where they now expect redundancies. Judy Jones reports

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'ALL ALONG, we were led to believe Guy's would be safe if we went along with the Government's bidding and became the 'flagship' NHS trust hospital,' David Green said, banging his fist on the table, exasperated, bitter. 'Safe? We're about as safe now as the Union of Democratic Mineworkers.'

Like other consultants at Guy's Hospital, he is bracing himself for what threatens to become Britain's first large-scale redundancy programme for doctors, that could span 10 London hospitals.

The image of Sir Lancelot Spratt, strutting the corridors of St Swithin's Hospital, terrorising his obsequious juniors, lingers in the public perception of hospital medicine, 30 years after Richard Gordon's creation was immortalised by the Doctor films.

Traditionally, consultants' professional clout had enabled them to shape hospital services, to a significant extent, to their own preferences and needs. But the advent of the internal market in NHS provision 18 months ago, guaranteed that their wings would be progressively clipped.

Their powers have been diluted, often over-ridden by those of a new breed of NHS managers, accountants and marketing executives; their freedom of speech eroded. Now job security, too, is fast evaporating.

Many consultants feel betrayed to find Guy's, one of the world's most venerable teaching hospitals, named as a candidate for closure in Sir Bernard Tomlinson's blueprint for rationalising London's fragmented health services. Others say the shake-up has been on the cards for decades, waiting only for a government with the will to force through necessary changes that are bound to be unpopular. The 200 or so consultants at Guy's have been told that between 50 and 75 of them may no longer have jobs, under the recommendation to merge Guy's and St Thomas's. 'It's a hell of a way to end a career,' Dr Green, now in his fifties, said. 'I spent my first 20 years making things better, helping to improve services. I've spent the last five years cutting them back, and now this. Some of us are to be slung out. You're in your prime; you may have an international reputation in your specialty, but you're going to be slung out anyway. Consultants have become the latest encumbrance. It's an absolute disgrace.

'I don't trust anyone any more. Not the Government, not the management of this hospital, nor its medical school. I expect the British Medical Association will try to get good redundancy deals, but I don't trust them either.

'The Government says no decisions have been taken. But this hospital is blighted already. Who's going to take out big contracts with us after what Tomlinson has said? Tomlinson says there are too many hospital beds in London and more money should be put into GPs' services. But that, in turn, will create demand for more hospital beds, so you will end up with more people lying around on trolleys waiting for one.'

Jeremy Trent is another consultant who appears baffled by the course of events over the past month. 'They've only just finished the memorial garden, dedicated to the men and women of Guy's who fell in the First and Second World Wars,' he said. 'We have a brand new pounds 120m building. John Major performed the topping out ceremony only recently. When Margaret Thatcher targeted Guy's back in the early days of the NHS changes to be the flagship, and new building work was approved, we felt we would be protected in the rationalisation that everyone knew was coming.

'Rationally, it makes no sense to close either Guy's or St Thomas's. What would you replace them with? A vacuum. Here you have two world-class institutions. One is to be sacrificed. What is the effect on patient care? You won't have anything like the present standards, which even now are not adequate.

'They're sending up prayers for us in the local churches. Do you know that? It's true there is a lot of claptrap talked about a need to preserve institutions. But it's people, not buildings that matter, and I fear that a great deal of talent and expertise may be wasted.'

He continues: 'It's very hazardous to talk frankly and openly in this way these days. Consultants used to have complete freedom of speech. Nowadays in the NHS you are required to be loyal to your corporate body, to your 'company'. Already one consultant here is rumoured to be facing disciplinary action for talking to the Independent.'

Jonathan Blake, a third Guy's consultant, has no great quibble with the Tomlinson report, but fears that his hospital's management has been wrong-footed in the struggle with St Thomas's over who is to be the senior partner in the forced marriage. 'The notion has developed that St Thomas's has been shat upon from a great height, and Guy's has been silently doing the dirty on it. So I fear that St Thomas's is gaining the sympathy. The message coming down to us from the management is that it is rather infra dig to join in the megaphone diplomacy. Now St Thomas's is busy scoring goals, and we are just sitting here smiling. You can't go on doing that while someone is punching you in the nose. It makes me rather annoyed. Everyone knows that changes are inevitable. The Labour Party will be delighted to have them done for it by the present government, so that it can just moralise. But there is all the potential for a huge balls-up.

'Will they retain the most talented people, or just go for the cheapest option in cutting staff costs? What would the redundancy terms be? Do you know? I think I saw a piece in the Daily Telegraph saying the package would be half your salary up to retirement age, full pension rights and a lump sum. I can't believe they can afford to do that.'

Much has been made of the diminishing local populations served by the big London teaching hospitals in order to justify a shift of resources away from the centre towards the suburbs and provinces, and from acute to primary health care.

James Charleson, a Guy's consultant whose patients are mainly local, feels this analysis is deeply flawed. He believes that the Tomlinson exercise will do for the health service what Dr Beeching did for the railways. 'But at least Beeching didn't recommend closure of Victoria or Waterloo stations. Over 10 years in this area, they have closed St Olav's, New Cross, the Evelina Children's hospital . . . Sydenham children's hospital, St John's hospital; Hither Green is on the agenda for closure. So you are left with Guy's and Lewisham, and now maybe just Lewisham.

'What Tomlinson is suggesting is bringing back the cottage hospitals by another name, which this country has been phasing out through the 1980s. They are fine for respite admissions, but you cannot offset a cut in acute hospital beds, with all the specialist back-up, by increasing cottage hospital, or GP, beds. Otherwise you will end up with iller people in the community. The whole idea is ludicrous. It's turning the clock back 10 years.'

We have changed the names of the consultants quoted to protect them from disciplinary action. Under new guidelines, staff may be dismissed for speaking to journalists without authorisation.

(Photograph omitted)