A firm but healthy direction: Sentimentality and lobbying should not divert ministers from restructuring London's NHS care, argues Chris Ham

Virginia Bottomley's statement on the future of London's health services represents a delicate political balancing act. On the one hand, Mrs Bottomley avoided the trap that Michael Heseltine fell into over the programme of pit closures by offering the opportunity of further debate on some of the options available. In this way she was able to sidestep the charge of taking precipitate action and give the impression that the Government was prepared to consider alternatives.

On the other hand, last week's statement was important in making it clear that difficult choices on London's hospitals will not be shirked. In the debate that has taken place on the Tomlinson Report in the last few months, the Government has at times seemed willing to compromise on the proposed closure of a number of famous teaching hospitals. In fact, this is now highly unlikely. Although important issues remain to be resolved, ministers have clearly decided to endorse the greater part of the Tomlinson proposals.

This has come as a big disappointment to critics of Tomlinson. In particular, staff at St Bartholomew's Hospital felt their campaign of opposition would succeed in winning concessions. By mobilising support among sympathetic friends in high places, the defenders of Bart's believed the future of the hospital had been secured. Their hopes were sustained by the close interest shown in Bart's by Brian Mawhinney, the Health minister, and work done by the Department of Health to cost various options for its future.

In retrospect, it seems the Government's approach was intended more to demonstrate that consultation was taking place than substantially to alter the decisions. This may be dismissed as cynical political manoeuvring, but that would be to ignore the importance of due process on such sensitive matters. The reality is that there is no alternative to a radical reshaping of London's health services, and only those out of touch with the direction of health policy would have believed otherwise. Although the future of Bart's has not been finally resolved, it will not survive in its present form; its best hope probably lies in a merger with the Royal London and London Chest hospitals.

A key reason why change is inevitable is the Government's commitment to introduce competition into the NHS. With authorities receiving money to buy health care on the basis of the size of population they serve, there has been a shift of resources away from declining districts in inner London to areas of population growth in the Home Counties. Health authorities who have gained from this process have moved services to local hospitals at the expense of institutions in London. In part, this is because local hospitals are more accessible to patients, and in part it reflects the higher cost of care in London.

This means the existing pattern of service provision is untenable. The location of hospitals will have to follow the distribution of patients and resources, unless ministers decide to bale out hospitals that are unable to compete successfully. The cost of propping up London's hospitals - already pounds 50m a year - is likely to be prohibitive except as a short-term expedient. As a result, the Government has little choice but to proceed with the restructuring of London's health services. To have decided not to implement the broad thrust of the Tomlinson Report would have meant reversing the very principles on which the NHS reforms are based.

The question remains as to whether the Government's approach to London is correct. Despite the strong feelings aroused by the prospect of closing hospitals such as Bart's, it is difficult to retain the status quo. The provision of services appropriate to the needs of Londoners is a more important consideration than the preservation of particular institutions, notwithstanding the excellence of much of the work done there.

Sentiment and political lobbying should not stand in the way of a restructuring that most independent commentators would argue is long overdue. The imbalance between health needs and service provision in London is well documented and there is now a real opportunity to put this right.

As things stand, London is overprovided with specialised services, finds it difficult to deliver routine medical and surgical treatment in hospitals, and has extremely variable primary care and community health services. Analysis undertaken by the King's Fund has highlighted in particular the duplication of high-technology services and how this draws resources away from the general hospital services most relevant to the needs of Londoners.

The decision to close or merge centres of excellence should not be taken lightly. But there is widespread recognition that the existing pattern of service provision cannot be sustained. Staff at the hospitals affected are already making plans to rationalise their services on fewer sites.

In parallel, the six reviews of specialist services set up by the Government and due to report in May will help to clarify how inefficient duplication of service provision can be avoided. Action on this scale would have been unthinkable a year ago, and it reflects the air of realism pervading health services in London.

Yet if the NHS reforms have brought these issues to a head, it will require a well thought-out strategy to achieve a better fit between health needs and service provision. This applies not only to the rationalisation of specialist services but also to the development of primary care. Put simply, the signals thrown up by the internal NHS market must be linked to a coherent plan if the full benefits of managed competition are to be realised.

In the case of primary care, the announcement that pounds 170m will be spent over the next six years in strengthening GP services is a welcome first step. But imagination will be just as important as additional resources in working out ways of encouraging GPs and nurses to practise in deprived inner-city areas.

The phasing of changes is also crucial. In this respect, the sad history of mental health policy serves as a cautionary tale. If hospital services are run down in advance of the establishment of more appropriate alternatives, vulnerable patients will fall through the safety net. The realignment of hospital care should only proceed when primary care services have been significantly strengthened.

Ministers also need courage and determination to withstand the pressure that defenders of existing services are sure to exert. The combination of elite medical groups, sentimental public opinion and angry health service workers could act as a significant brake on change. Provided ministers keep their nerve, a more sensible pattern of service provision should result. The winners will include not only Londoners but also users of the NHS in the rest of the country, who should at last receive a fair share of resources.

The author is Professor of Health Policy and Management at Birmingham University.

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