Leading Article: The pathologist's diagnosis

FOR MOST of this century it has been evident that London has a disproportionate share of the nation's hospitals, and especially of its great teaching hospitals. In recent decades it has become ever more obvious that these institutions absorb a disproportionate share of the resources available to the London region through the NHS. So Londoners have had the pick of specialised medical care when admitted to hospital. But the service provided by their GPs has, by most indices, fallen way behind the national average. And because primary care has been so inadequate, London's hospitals have been clogged up with patients who could and should have been dealt with, much more cost-effectively, by their GPs or in primary-care centres. It is not a sensible way to use the expensive resources of hospitals.

These painful realities have been thrown into relief by the Government's reforms of the NHS. Hospital care is now purchased by health authorities and some family doctors. Both have limited budgets, for which they must account. They find that treatment in London's specialist and teaching hospitals is more expensive than in general hospitals elsewhere. So demand for those hospital beds has fallen, while the costs of training students, of keeping ahead in specialist knowledge and of being in London go on rising. In addition, migration to the suburbs and demographic trends have reduced the number of potential patients.

The last Conservative government, having been badly scarred in the long run-up to the April election by Labour's dishonest accusations that it was privatising the NHS, had the good sense to appoint Sir Bernard Tomlinson (suitably, a pathologist) to head an inquiry into this unhealthy state of affairs. His recommendation that several famous institutions should be merged or closed has already created an outcry. But London would be the loser if the inevitable protests and lobbying by special-interest groups were to obscure the central thrust of his report: that the rationalisation of hospitals and teaching facilities must be balanced by a sustained improvement of primary-health care in the capital.

Trade unions are in the business of defending their members' jobs. So it is natural that the first reaction of the health unions should be to compare the suggested mergers and closures to British Coal's proposals to close down much of the mining industry. But union leaders would do well to divert some of their energies to the obviously positive recommendations in the Tomlinson report, which would create substantial numbers of jobs at primary-care health centres and the like. More broadly, Sir Bernard's suggestion that merely bringing GPs' premises up to standard would cost about pounds 130m has clear employment implications.

The concern felt among medical practitioners is equally understandable. Some of the affected institutions have long and noble histories as centres of excellence. Smithfield Market may no longer be a significant population centre, but St Bartholemew's has been there since 1123. To those who work at Bart's, the report's recommendation for a merger with the Royal London Hospital and the closure of the site will seem no less shocking than a merger of, say, Balliol and Trinity colleges at Oxford, with Balliol closing.

Few things are harder for governments than to strike the happy mean between due regard for traditions of excellence and the inexorable pressures for change created by real shifts in demand. Famous regiments have been merged, their names obliterated. Honourable newspapers have died. Even the legal profession is being subjected to change. Hospitals cannot expect to be immune. Their practitioners have skills that are in high demand around the world. In that respect they are better placed than most professional people faced with change.

All rationalisations cost money initially, before achieving savings. The central questions are whether the Government will accept the report's conclusions; and, if it does, how it will deploy the considerable resources released by the mergers and closures. The Government must show that the outcome will produce an overall improvement in medical services, in London above all but also outside it. The natural fear, already widely voiced, is that it will accept the proposals for mergers and closures, and pay lip service to improved primary care - but fail to produce the necessary money, with the need to control public spending as justification. If there is no prospect of overall benefit, the public's sympathies will swing behind those campaigning against the merger programme.