Brian Mawhinney, Minister of State for Health, at the eye of the storm brewed by the Tomlinson report on acute health services in the capital, has become well-acquainted with many of them.
Having spent the past two months meeting doctors, nurses and managers in 20 hospitals affected by the Tomlinson proposals, he acknowledges that some of the most ardent enthusiasts of radical change are striving to avoid its consequences.
'There has been an element of the 'not-in-my-back-yard' view. Some hospitals have welcomed the recommendations; others have expressed reservations, and a few have said 'we think Sir Bernard is wrong'. But people want ordered change,' he said.
'Sir Bernard's report on London's health services has been the 20th over the past century. Now people are saying 'this time don't funk it - initiate change'.'
However, since the report was published in October - with few financial analyses underpinning the inquiry team's recommendations - many of the most vulnerable hospitals have commissioned independent detailed costings on the proposed and alternative options.
Several of these reports appear to undermine the credibility of regional health authority estimates for projected deficits and patient flows and challenge key assumptions on which some inquiry recommendations rest. Sir Bernard has suggested that St Bartholomew's, for example, faces a pounds 10m deficit next year. Bart's says the figure is closer to pounds 4m and would fall below pounds 3m by the middle of next year as measures to improve efficiency bite.
A report prepared by Ernst & Young management consultants for the Royal Brompton and Marsden hospitals showed that moving them to Charing Cross, as proposed by Tomlinson, would cost pounds 42- pounds 62m, rather than save pounds 10m, as North-west Thames regional health executives had estimated.
What such exercises have proved beyond doubt is that the new 'managed market' in the NHS, and the contracting process between 'purchasers' and 'providers', lack sophistication. The finances of many hospitals are at best opaque, and at worst a closed book to all but a handful of executives.
Moreover, the hawkish stance adopted by health ministers towards Sir Bernard's call for the concentration of acute hospital services on fewer sites is gradually giving way to more conciliatory approach. Virginia Bottomley, Secretary of State for Health, told the Commons on 23 October that she was determined to 'grasp the nettle' of excess hospital beds in London and bring an early end to uncertainty among staff.
Significantly, Dr Mawhinney has moved to dampen expectations that the Government would be in a position to announce a comprehensive and conclusive response to the inquiry report over the next two months.
Interviewed by the Independent last week, he said: 'We are seeking to move forward with as much common ground as we can in implementing the decisions. Clearly there are very sensitive issues involved here. They affect millions of Londoners in that we are determined to see better health care as a result of this process, and there is a potential effect on jobs in the health service.
'We should take as much time as is necessary to make those judgements sensibly. On the other hand there are pressures created by uncertainty. There is a balance to be struck, and we will get our decisions out as quickly as we can, commensurate with the time necessary to get them right.'
Dr Mawhinney also signalled a fresh round of consultations would follow the Secretary of State's response to the Tomlinson report. 'If you are planning to do something fairly major to a hospital, then there must be a statutory consultation period. So in some cases the Secretary of State will be announcing decisions, and others, proposals.'
Asked to comment on appeals by family doctors' leaders for a guarantee that no hospital closures or mergers will be sanctioned until primary health care services had undergone substantial improvements, he said: 'Some people will not be satisfied or reassured until they see what is happening on the ground. The decisions announced in the new year will be our best attempt to take all these factors into account.'
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