Hospitals that face a fight for survival

London's teaching hospitals are bracing themselves for changes in the wake of a year-long inquiry into the capital's health services. Sir Bernard Tomlinson, whose report for ministers is expected to be published tomorrow, has already warned there must be a 'downscaling' of the large central hospitals to reflect population shifts to suburbs and growing demands for health care closer to people's homes. More medical schools should merge or be absorbed into multi-faculty scientific institutions, and there must be a rationalisation of specialist services on fewer sites, he believes. By contrast, inner-city GP and community health services should get more resources. Below, the Independent profiles four of the threatened teaching hospitals

St Thomas's: founded 12th century Projected deficit for 1992/93: nil

WHEN Florence Nightingale founded the world's first nursing school at St Thomas's Hospital, she told students to treat patients as they would honoured guests. In today's overloaded NHS, in- patients may feel more like anonymous masses of irritating symptoms, buffeted along medical conveyor belts and sent home before the ink dries on the first 'Get well' card.

But St Thomas's strives harder than most to realise the noble ideals of the woman whose own patient's charter revolutionised the care of the sick a century before Whitehall mandarins and politicians at the Department of Health alighted upon the idea.

That, at least, is the view of a large swathe of GPs in south London. They are in the best position to assess the user-friendliness and the relative performance of the area's hospitals but family doctors feel they have been marginalised in Sir Bernard Tomlinson's review of the capital's health services. More importantly, they are dismayed that St Thomas's has emerged on a hit- list of possible closures in regional health executives' plans for rationalisation.

'I would be absolutely devastated if St Thomas's were to close,' one family doctor said. 'The alternatives make me cringe. Everyone knows about the problems at King's and patients being left on trolleys for hours on end. And GPs in Southwark are deserting Guy's in droves because the service, in many specialties, just is not good enough.'

Regional health executives have told the Tomlinson inquiry that St Thomas's and Guy's, a couple of miles down river, are duplicating too many services, and that south-east London will not need both. The health authority executives say that on current trends, this corner of London can manage with 1,300 fewer acute hospital beds, about one- third of the present total.

Health policy analysts view Guy's as the more secure, if only because of its symbolic value to the Government's market-driven overhaul of the NHS. If Guy's, launched as the flagship NHS trust hospital 18 months ago, were to be holed below the water line, then so would the Government's imposition of market principles throughout the NHS.

St Thomas's is the kind of place that can disarm the most hardened hospital- phobic. Housed in bright, modern buildings, it occupies a prime 15-acre site on the south bank of the Thames. For those mobile enough to enjoy them, there are wonderful views across the river to the Houses of Parliament. Present and past members of the medical staff include Lord Owen, former SDP leader and now Europe's peace negotiator in Yugoslavia, and the singing doctors Instant Sunshine.

The atmosphere is friendly, open and calm. Women flock there to have their babies - 3,700 last year, and rising - attracted by its emphasis on choice about births and the level of medical intervention. Sandwiched between two other great institutions, Lambeth Palace and Waterloo station, St Thomas's has been treating the sick, training doctors and pioneering medical research for 800 years.

Last year, its 590 doctors carried out 294,000 operations and other medical procedures on a budget of pounds 106m. It provides medical services to the Metropolitan Police, the Foreign and Commonwealth Office, and United Nations officials based in Africa and Europe.

So why, given the critical scrutiny of the health economists, does St Thomas's continue to radiate cautious optimism? Since being named as a possible casualty of the Tomlinson review, its executives have gone to some lengths to get their retaliation in first.

The special trustees have dug deep into the funds they control to mount a pounds 160,000 survival plan, commissioning independent cross-hospital comparisons backed up by glossy brochures and a public relations consultancy.

Essentially, the plan involves a shotgun wedding with Guy's, leaving St Thomas's with most of the spoils. Guy's accident and emergency service would close, as would the Dulwich, Hither Green and Brook hospitals in south- east London, and St Thomas's would be the major provider of acute and emergency care for south and central London. Some 850 beds would close, saving pounds 37m a year.

St Thomas's points out that far from losing non-London contracts for patient care, the volume of business with health purchasers outside the capital went up by 4 per cent last year. Moreover, the 70,000 A&E patients St Thomas's treated last year is projected to rise to an annual 100,000.

Local GPs insist no closures or cuts should be contemplated before alternative arrangements have been agreed and properly funded. Dominic Costa, a family doctor in Stockwell, said: 'In certain specialties such as skin diseases and obstetrics, St Thomas's is fantastic.

'In others it is under enormous pressure and has to cancel operations at short notice because there aren't enough beds. The notion of overprovision, as far as patients are concerned, is absolute rubbish.'

Centre of excellence where silence is golden

Charing Cross: founded 19th century. Projected deficit: nil

THE ODD thing about Charing Cross Hospital, west London, is that while other vulnerable hospitals have drafted in public relations teams, it chose the opposite tack and said nothing. Senior staff have taken a vow of silence.

Loose talk could cost jobs at the hospital in Hammersmith and heighten the likelihood of its demise. That is the party line. Privately, it is a different story.

'Everybody's absolutely paranoid,' one leading consultant said. 'Consultants realise there are going to be redundancies in London. Like everybody else, we have mortgages and families. But the medical profession is no more sacrosanct than miners. Some people have got a 'sod it' mentality. Some have rolled over and are playing dead.'

Not that this is the general view. The talk, even by critics, is of the 620-bed hospital's 'bright future'. Charing Cross braced itself for radical surgery long before Tomlinson. Since the decision six years ago to build the pounds 300m, 600-bed Westminster and Chelsea hospital near by, change was inevitable.

Yet the shock was palpable when the future of Charing Cross - whose site is valued at pounds 123m - was put in doubt during the summer after North West Thames health authority suggested the accident and emergency department, with 68,678 patients last year, should shut.

Professor Roger Greenhalgh, chairman of the hospital's medical council, was quick to put a gloss on the proposals, saying they represented a 'clear vision of a bright new future', with it becoming a specialist hospital. But its position as the country's largest teaching hospital would be forfeited, with a new medical school based on Imperial College, south Kensington.

The build-up of pressure for change has forced the institution to face reality. 'People accept the need for change, but don't want too much of it on their own doorstep,' one consultant said.

'It's a very conservative place. But it has moved more in 18 months than 20 years,' another said.

But will what is left still be the Charing Cross? To the consultants it stands for a great institution at the cutting edge of British medicine. 'We are as good or better than the other teaching hospitals,' one consultant said. 'That's why doctors want to work here, even though they could be consultants three years sooner if they worked elsewhere. It's driven by ambition, piles of it. You have a collection of people that are a cut above: some are prima donnas, some are very ordinary.

'It's a bit like army regiments. It has history and tradition that stems from its original siting and its founding fathers.

'It builds a feeling like that which drives a rugby team forward. There is an esprit de corps. It's the difference between being in the Scots Guards and some lesser regiment.'

The warning to the Government is that it should not lightly dismantle the teams. 'If the Government thinks the research that comes out of Charing Cross can be recreated in Stevenage or Welwyn Garden City, it's pissing in a rainstorm.'

Yet perhaps the move in 1973 from the original site in the Strand to the current tower block deprived it of its roots. Ask the residents' campaign to save the hospital about its history and they talk of the Fulham Hospital, built on the present Hammersmith site in the 1860s.

They may invoke the institution's past and present triumphs, but they want only a district general hospital that meets the needs of the young and old. A casualty department is vital for day-to-day care. 'I think people will die if they have to travel through London traffic to another hospital,' Victoria Lynch, a GP, said bluntly. That from someone who is no great lover of the hospital. 'Some of the people I have sent to the clinics have been tended by some very low- grade nursing staff. They have been rude to them and the waiting rooms have been dirty.'

Dr Edward Shaoul, one of its sternest critics who has referred patients there for 30 years, said it would be a 'grave loss' were it to close. 'If I were a native of Norwich, I would like to know that in London there was a place with all the experts under one roof. Take cancer, for instance, your chances of surviving are four times greater than a district general hospital.'

Dr Shaoul saves his ire for their PR. 'You look for something that Charing Cross has done and you'll never find it. The publicity ethos is bloody awful.'

Discontent simmers at 'not so brilliant' service

St Bartholomew's: founded 1123 Projected deficit: pounds 5m plus

'I DON'T think Bart's is so brilliant,' one hard-pressed family doctor in Hackney said wearily. 'Some of the departments are absolutely hopeless, with waiting lists so long that some patients never get to be treated.'

The review of London's health services is expected to be similarly unsentimental about St Bartholomew's, which critics believe has rested on its laurels for too long. In its pursuit of academic excellence, they say, the needs of the people of Hackney, among the poorest in the country, have been overlooked.

The imposition of market forces on the NHS two years ago hit Bart's hard, exposing a deficit of pounds 12m and price differentials that persuaded key purchasers to send their patients elsewhere.

Managers admit that the morale among the 5,500 staff at the hospital, granted its Royal Charter by Henry VIII on his deathbed, has rarely been lower and the mood is one of 'acute anxiety'.

But in some ways, Bart's has suffered self-inflicted wounds and a kind of paralysis in the face of growing rumours of closure or merger with the London Hospital in Whitechapel.

The hospital reinforced what some would call its 'superiority complex' after its move to self- governing trust status was last year deferred by William Waldegrave, the former Secretary of State for Health, who put the transition on hold until next April so the hospital could 'benefit' from Sir Bernard Tomlinson's conclusions, as it prepared for the change.

Although still theoretically accountable to the City and Hackney Health Authority, with some management devolved to a 'shadow trust' board, the hospital has been acting as though the new arrangements were already in place. Letter headings proclaim the 'Bart's NHS Trust' as do the switchboard operators, as though its hoped-for status was already a fait accompli.

Such presumption has not endeared itself to the local Community Health Council, the statutory patients' watchdog, which views it as little more than a ruse to pull up the drawbridge and keep patients' representatives in the dark.

The duties on trust hospitals to provide information to CHCs and consult on changes are minimal. The Association of Community Health Councils for England and Wales says this has led to undue secrecy, confusion and dubious accountability.

Sir Alfred Shepperd, former chairman of the Wellcome pharmaceuticals group, now chairman-designate within the Bart's shadow trust, has been taking most of the key decisions in recent weeks, according to insiders. Ken Grant, the chief executive, appeared to have been increasingly marginalised and resigned suddenly, citing personal reasons, on 7 October.

'It's hard to know what's going on and who's running what from one day to the next,' one close associate of the hospital said.

Another decision the hospital management may come to regret was not to commission independent comparisons of its performance in relation to those in closest proximity, nor to publicise its strategy for survival. While some teaching hospitals, such as St Thomas's, have used their private funds to mount publicity campaigns to save their skins, Bart's seems to have eschewed the hard sell in favour of some subtle arm- twisting of City contacts and ad hoc patient-led campaigns to save individual services.

One pointer to the future shape and function of Bart's is the appointment this week of Professor Michael Besser, whose endocrinology department at Bart's is internationally renowned, as the hospital's new chief executive.

As a leading medical specialist who trained at Bart's in the 1950s, he would certainly be an obvious choice to refashion the hospital as a tertiary referral centre, a smaller and more specialised institution, if that is what the Tomlinson inquiry recommends.

The concentration of acute services for the local population in Hackney and south Islington at the more modern Homerton, its sister hospital, could make a great deal of sense, if only because that is where 95 per cent of them live.

'In some ways, Bart's seems to have drained resources away from the Homerton,' Janet Richardson, chief officer of the City and Hackney CHC, said. 'That's already happening with day surgery, oncology services and orthopaedics may be about to be centred at Bart's. Few local people get the benefit of day surgery - they just don't have the back-up in the community very often for same- day discharge.'

Surfeit of specialists after split-site merger

Middlesex: founded 1745 UCH: founded 1834 Joint projected deficit: pounds 13m

IT WAS an arranged marriage, not a love match when the patrician Middlesex Hospital and its rigorously scientific neighbour, University College Hospital merged.

The former was rich, well endowed, highly specialised and close to Harley Street. The latter, a mile away on the other side of Tottenham Court Road, was hard up, academically excellent, and next door to University College London itself.

Traditionally the Middlesex was establishment, public school and Anglican; a consultancy meant lots of private practice. One commentator remarked that 20 years ago 'you couldn't find a consultant in the Middlesex before lunch, they were all in their private rooms round the corner'.

UCH, traditionally, was meritocratic, grammar school, interdenominational, 'littered with Nobels'. It was and is good at 'hard' science, and its medical students still arrive with some of the best school qualifications.

The hospitals' medical schools were the first to merge in 1982, and the process was completed when the two hospitals became a single financial unit by 1988. Six years of getting to know each other better have worked pretty well. Financial adversity and the fight for survival have certainly speeded the matter and brought them even closer.

Detractors delight in pointing out that UCH and the Middlesex are losing 'a million a month'. This is an alliteration. The projected deficit for the year to March 1993 is likely to be pounds 13m, possibly more.

Drastic short-term measures are being taken to cut into this huge debt. They involve closing up to 200 beds in the run down UCH building and decanting them into the Middlesex, which, being rich, has spent pounds 40m of public and private money on upgrading and improvements.

On the UCH site, the accident and emergency department, with beds and departments to service it, will stay where it is. It treats 60,000 patients a year - a load of 170 a day - and staff believe it is pivotal to the decisions over the future of London's health services. Indeed its reputation may be the key to the future of the hospitals themselves.

Between them the hospitals also treat about 50,000 day and inpatient cases a year. But the question is not whether one hospital will survive and the other fall to Tomlinson's axe; they stand or fall together. It is more which site will be chosen to provide services in north-central London with its daytime commuting population of at least half a million and resident population of 180,000.

The decisions are not straightforward. UCH is a listed building so cannot be pulled down but it needs major modernisation. The Middlesex, however, is the more expensive hospital to run. Traditionally, it has a high level of nursing staff and is by all accounts, a good place in which to be ill. Between them there is be a surfeit of highly qualified specialists: 260 serve the hospitals - a case of both quality and quantity.

Inside UCH, where Sir Bernard Tomlinson was a medical student, and at the Middlesex there is an air of confidence about the hospitals' survival. Questions on closure are countered with astonishment. Discussions about developing one or other have been going on for a decade, so they are used to them. Plans to build a new hospital to house both have come and gone. In the meantime, they are continuing to grapple with their debt and look at options for the future.

Together they have some strong cards to play: their academic excellence and proximity of the UCH site to the university; the reputation and geographical position of the A&E department, which took the brunt of casualties from the King's Cross fire; the renown of specialist departments, notably neurology, endocrinology, and neonatal medicine; and, although no one says so, old-fashioned power and influence.

And always up their sleeve is the UCH's 'Odeon site', currently used as a car park, on the corner of Tottenham Court Road and Grafton Way - prime real estate waiting for a purpose.

Staffing levels are a problem. The hospitals have more than 700 consultants and hospital doctors. Complete marriage on a single site will mean redundancies and this nettle has yet to be grasped.

For example, the hospitals have housed three departments of urology since both had their own, and then the Middlesex took in the specialist workload of three small hospitals in Covent Garden, when they closed. Not a single consultant has been made redundant.

(Photograph omitted)