GPs hold key to new-look London health services: Judy Jones assesses the Government's long-awaited blueprint for rationalising the capital's fragmented health services, and looks at the side-effects for hospitals

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What lies ahead for each institution

THE FATE of hospitals directly threatened by the Government's programme of closures and mergers will not be sealed until autumn. However, ministers yesterday signalled their intention to consult on several options proposed in, and since, Sir Bernard Tomlinson's report. The options outlined yesterday, in a Government document responding to his recommendations, focus on these institutions:

UNIVERSITY COLLEGE/MIDDLESEX: The hospitals should merge on one site, subject to statutory consultation with a single accident and emergency department. The site eventually selected could absorb two of the smaller specialist hospitals, the Royal National Throat, Nose and Ear, and the Hospital for Tropical Diseases.

ST BARTHOLOMEW'S: Trust status, due to be assumed on 1 April this year, withdrawn. The NE Thames regional health authority to appraise three options - closure, as recomm ended by Tomlinson; merger with the Royal London and the London Chest; or retention as a smaller specialist hospital, subject to the outcome of the speciality reviews.

ST THOMAS'S and GUY'S: Merger talks, already under way, must be completed by March. If a joint Guy's and St Thomas's Trust is endorsed by ministers, a programme for consolidating services on one site should be ready six months later. Other potential uses of each site must be a factor in deciding which one is preserved.

CHARING CROSS: Plans to close the accident and emergency department will shortly be put out to consultation by Riverside Health Authority. Much of the A&E workload would transfer to the new Westminster and Chelsea hospital a mile away. The long-term future of Charing Cross will hinge on the outcome of the speciality reviews.

ROYAL BROMPTON and ROYAL MARSDEN: These should submit a joint NHS trust application, with a view to merger. The Tomlinson scheme to relocate each hospital's services to the site of the Charing Cross hospital is too costly to implement. Instead these hospitals, and their respective institutes, could form part of a new Chelsea Health Sciences Centre.

QUEEN ELIZABETH: Management of this children's hospital in Hackney should be merged with that of the nearby Homerton.

QUEEN CHARLOTTE'S: While there are arguments for relocating this maternity and gynaecology hospital onto the site of the Hammersmith, its sister hospital, the balance of advantage remains unclear.

ROYAL NATIONAL EAR, NOSE & THROAT: Statutory consultation to begin on merging management with that of UCH/ Middlesex. If approved, a similar exercise will follow to relocate on to that rationalised site.

ST MARK'S: Merge management of this Islington hospital, specialising in diseases of the bowel, with that of Northwick Park, subject to statutory consultation.

HOSPITAL FOR TROPICAL DISEASES: Statutory consultation to begin on merging the management with that of the UCH/ Middlesex. If approved, a similar exercise will follow to relocate there.

Making London Better; from Health Publications Unit, No 2 Site, Manchester Road, Heywood, Lancashire OL10 2 PZ.

DOZENS of new GP surgeries and multi-purpose primary health care centres are planned for London over the next five years, as the Government shifts resources away from acute hospitals into community services.

Experienced family doctors will be recruited from outside the capital on short-term contracts to help modernise and expand primary services. Some GPs will work with vulnerable groups such as homeless people and refugees, who often receive poor standards of primary care in London.

The Government's long-awaited blueprint for rationalising the capital's fragmented health services, following last year's inquiry by Sir Bernard Tomlinson, was presented to MPs yesterday by Virginia Bottomley, Secretary of State for Health.

An extra pounds 170m will be pumped into London's primary health services over the next six years, over and above planned spending. The first pounds 40m will be spent next year. About pounds 7.5m will be allocated to joint voluntary sector initiatives, particularly to help improve community services for the elderly and cancer patients.

Much of the extra cash will be distributed to surgeries and health centres within a new London initiative zone, serving traditionally deprived areas. The areas to benefit are: Brent, Ealing, Hammersmith and Hounslow, Kensington, Westminster and Chelsea, Barking, Camden and Islington, City and East London, East Enfield and Edmonton, Waltham Forest, Greenwich, Lambeth, Southwark and Lewisham, Wandsworth and North Croydon.

There will also be a pounds 1m challenge fund to foster the most innovative schemes that bring about better-synchronised hospital and community services .

The Government response to the Tomlinson inquiry anticipated an extended role for community nurses, pharmacists and other health workers. It went on: 'The community is the future setting for much health care. We want to see schemes . . . that introduce primary care facilities into shops, sports centres, schools and offices.'

Other ideas include the establishment of 'polyclinics' or 'community care centres'. These would be part health centre, part hospital. They would offer out- patient services, rehabilitation and nurse or GP-managed in-patient beds for people whose illnesses were not thought to require full acute hospital services.

The Government's long-term plans for the acute sector - which Mrs Bottomley was expected to clarify in full yesterday - will hinge mostly on the outcome of yet more inquiries.

But the feasibility of some hospitals that appeared to be safe as a result of the Tomlinson investigation was questioned by the Government yesterday. Any merger of Guy's and St Thomas's could affect the role of St George's in Tooting, and the Kingston and St Helier's hospitals to the south west of London.

Six separate reviews of the quality and distribution of London's specialist health services were told to report to ministers by the end of May. Teams of clinicians and managers will look at provision of cancer, cardiac and children's services; plastic surgery, renal units and neurosciences. They will be expected to identify duplication of services and recommend their concentration on fewer sites. At present there are 14 cardiac centres and 13 specialist cancer units, for example.

Their advice will shape final decisions on closures and mergers towards the end of this year. Although the prospects of the threatened hospitals will remain unclear for several more months, Mrs Bottomley yesterday underlined her intention to abide by the thrust of the Tomlinson report, if not the fine detail.

Consultant and acute bed numbers have not kept pace with advances in technology, the shift to day surgery and changing patterns of referrals, that have reduced demand for inner London teaching hospital services.

Ministers are adamant that up to 2,500 fewer acute beds - 20 per cent of the total - will be needed in inner London within five years. The response to the Tomlinson report refers coyly to job losses in the capital - estimated at up to 20,000 by some health unions.

A clearing house will be established by regional health managers to help relocate specialist staff whose jobs are threatened. 'We must make every effort to keep such skills within the NHS,' the response states. 'Redundancies will unfortnately be necessary as a last resort.'

Leading article, page 18

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