How the battle for Bart's was won: Thirteen London hospitals are facing closure or merger. But one of them has the benefit of history and the establishment on its side. Judy Jones reports

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It took eight years for Henry VIII to complete the first U-turn over St Bartholomew's Hospital, sparing it from closure on his deathbed. It has taken John Major about eight weeks to agree to the second.

If the present Government had delved a little deeper in the history books, it might have formed a better grasp of Bart's formidable instinct for survival. It could have foreseen the howls of outrage, the screaming headlines, the candlelight marches, the prayers in St Paul's, the backlash from the City.

Bart's was founded in the 12th century by Rahere, an Augustinian monk, to serve the poor and sick. That first threat came in 1539, when Henry's dissolution of the monasteries forced the closure of the priory of St Bartholomew's. A public outcry, spearheaded by the Lord Mayor of London and the City fathers, forced him to retract.

In more recent times too, warning signs have abounded for politicians and civil servants tempted to sacrifice the hospital, serving the City of London, on the altar of rationalisation. In 1977, a Department of Health medical officer concluded that its high running costs outweighed its benefits to patients. On sharing these thoughts with a senior colleague, he was warned: 'This is a battle you will lose,' the colleague told him. 'There is nothing we can do about Bart's'

Why has Bart's always appeared sacrosanct? Then, as now, the very notion that it might disappear in a shake-up of London's expensive and fragmented hospital services was unthinkable to many in charge of powerful City and medical institutions. Few doctors and NHS managers disputed the arguments for concentrating London's medical training, research and acute patient services on fewer sites.

But then, as now, attempts to agree how best to achieve this became bogged down in argument over the relative merits of individual institutions and the people running them. As the aphorism about the legendary arrogance of the hospital's medical elite has it: 'You can tell a Bart's man . . . but you can't tell him anything.'

By the early 1970s, in order to iron out historical anomalies that had unfairly favoured Londoners, central government had begun shifting resources into the regions. Between 1983-89, London had lost 3,700 of its acute hospital beds, although medical staffing remained largely unchanged.

Two years ago, Sir Bernard Tomlinson, a semi-retired academic and doctor, became the latest to try to solve the conundrum. He was to conduct an inquiry into health services in London and draw up a plan for reorganising them. His report, published on 23 October last year, was the 19th official study on the capital's health services in a century. The thrust of his recommendations bore an uncanny resemblance to one which reported in 1892: too many hospitals competing for patients in the wrong places; doctors not getting sufficiently broad experience in training.

Tomlinson urged the closure or merger of 13 inner London hospitals. More importantly, it named them. Other institutions were also threatened: Guy's and St Thomas's were recommended for merger on one site or the

other. The Middlesex, Charing Cross, Queen Charlotte's would close. The Brompton and Marsden would be brought together on the vacated Charing Cross site at Hammersmith.

Some resisted. But they lacked Bart's chutzpah and nostalgic appeal. The high-profile battle to save Bart's dominated media coverage of the saga.

'They used everything bar artificial snow and violins,' sniped one hospital chief executive. Nor did the others have the sheer range and number of City and media contacts to exploit. Bart's had served Fleet Street loyally for centuries before the news organisations pulled out.

Virginia Bottomley, Secretary of State for Health, relished the prospect of implementing the Tomlinson report. She knew she would win kudos among health economists, civil servants, managers and doctors in London and the provinces if she could bring decades of prevarication to a decisive close. She hoped to prove to Cabinet rivals that she could take difficult political decisions. On publication of the report, she told MPs she would 'grasp the nettle'.

The battle for Bart's was fought on several fronts. Bart's is both a district general and a specialist teaching institution. Tomlinson wanted to move its specialist services to the Royal London, at Whitechapel, a mile away in the East End. Routine local work would go to the Homerton at Hackney, Bart's sister hospital.

Bart's serves a resident population of no more than 5,000. But patients and the public were able to present a petition to Downing Street signed by more than 500,000 people. Secondly, the threat to a commuting population of 450,000 drove business people and the Corporation of London to protest, opening up the second line of attack. Supporters argued that Sir Bernard's plan hinged too much on the dwindling resident population.

The City, it was frequently pointed out, generates pounds 17bn a year in invisible earnings. Attracting investors is a never-ending battle. 'If we are going develop and retain a reputation as the world's leading financial centre, we need a bloody hospital,' fulminated one City source. 'How can we persuade potential investors in Japan, in Germany that we have the best location, when the City's hospital is closing down?'

On 1 December, staff marched to Downing Street to hand in their petition. Two days later, the City of London local authority formally agreed to support the campaign. The Government remained calm. Department of Health officials were encouraged by the rather muted opposition to the proposals from the Labour Party. But in the same week, the management consultants Ernst & Young concluded that far from saving pounds 10m, as Tomlinson said, it would cost up to pounds 62m to move the Marsden and Brompton hospitals. Sir Bernard himself urged the Government to commission more studies of the financial implications.

Enter Arthur Scargill. On

21 December, Lord Justice Glidewell ordered independent scrutiny of the Government's plans to close 10 coalmines, sending shivers down Whitehall spines. What if the High Court did the same for the 15 threatened London hospitals?

Encouraged, the Bart's campaign moved up a gear. Just before Christmas, the Corporation of London wrote to Mrs Bottomley asking for an urgent meeting to put the views of the business community. At this time, Mrs Bottomley was still telling colleagues there should be no fudging or retreating.

Media support for the campaign to save Bart's was now extending beyond the London Evening Standard, and some other newspapers, to some more influential Tory figures. In the Spectator of 9 January, Charles Moore raged: 'Its independent constitution, Christian traditions, high medical standards, intellectual freedom explain why Bart's has survived for nearly 900 years, whereas the NHS, with its socialism, rationalisation and bureaucracy, and domination by the producer interest, is in a crisis after fewer than 50.'

The Duke of Gloucester, the film-maker Derek Jarman, and members of the cast of EastEnders, all pitched in.

By mid-January, the Prime Minister met Mrs Bottomley and is understood to have told her he did not wish to see Bart's close. On 17 January, three Sunday newspapers, including the Independent on Sunday, reported a reprieve. Two days later, the Lord Mayor of London, Sir Francis McWilliams, and colleagues met Mrs Bottomley to plead their case.

Sir Francis, who meets the Prime Minister periodically during the course of his duties, denies that he personally lobbied Mr Major to reprieve Bart's. 'Bart's does arouse some antagonism,' he said. 'But it is a centre of excellence and we do not wish to see it destroyed.'

Brian Mawhinney, Mrs Bottomley's deputy, returned to the hospital on 21 January for a second visit. He was met by chanting protestors, including one dressed up as Rahere, Bart's founder.

Bart's partial reprieve was finally agreed at Cabinet last Thursday and will be announced this week. But the terms are not yet clear. They are likely to be based on Bart's own survival plan, presented to ministers a fortnight after Sir Bernard reported. But the Government's decision will help deflect attention from the other difficult closure decisions.

Last Friday, Professor Michael Besser, Bart's chief executive and a world famous endocrinologist, said that it had still not emerged from leaks of Cabinet discussions the previous day whether the accident and emergency department would remain open. Under the survival plan, Bart's would offer an A&E service from 8am until 8pm daily, and emergency wards.

'People keep congratulating me, but I am not celebrating yet. The question about A&E is crucial,' he said. The City authorities will not be satisfied unless the casualty unit remains open 24 hours a day. The 'reprieve' may yet turn out merely to be a stay of execution.

(Photograph omitted)

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