Leading Article: Painful but necessary

VIRGINIA BOTTOMLEY'S success in winning pounds 170m for the improvement of primary health care in London is to her credit. But on the politically sensitive front of hospital closures and mergers, she has procrastinated. Instead of grasping the nettle, as she promised last October when the Tomlinson report on the future of London's health services was published, most decisions in this field are to be postponed until the autumn - that is, a full year after Tomlinson - pending the outcome of a review of specialist units.

So for several famous hospitals, including Bart's, the lobbying and the uncertainty for staff will continue. Meanwhile, those who purchase hospital services - the district health authorities and GP fund-holders - will be showing by their choices which hospitals they believe provide the best value. That will be an important guide. But the delay left Mrs Bottomley open yesterday to accusations - for example, from Labour's health spokesman, David Blunkett - of duplicity in leaving hospitals to wither on the vine.

There is a case for calling for further studies before taking decisions from which others have shrunk for much of this century: getting the decisions right is, after all, the main objective. But why were the projected reviews of specialist units (cardiac, cancer, renal and the like) not put in hand immediately after the publication of the Tomlinson report? Logically they should even have preceded it and underpinned its recommendations. Having been so unaccountably slow to commission the reviews, Mrs Bottomley has tried to compensate by setting the end of May as a deadline for their completion. Experts, such as the respected King's Fund, claim convincingly that this is not nearly long enough for an operation that should provide the building blocks for a strategic plan for London's hospitals. There are, for example, no fewer than 14 cardiac services in the capital, where no more than six may be necessary. Overprovision affects quality by spreading resources too thinly. The review will have to recommend where services should be retained, preferably without setting the clinicians of rival hospitals at each others' ears or throats.

There is no disputing Sir Bernard Tomlinson's broad findings: that inner London has too many hospital beds in relation to its population, absorbs a disproportionate share of health-service resources, yet suffers from primary and GP services well below the national average. As a result, many hospital beds are used to treat patients who outside London would be dealt with more cost-effectively in primary healthcare centres. Sir Bernard recommended that a minimum of pounds 140m be spent merely on capital projects in the primary-care sphere over the next six years, the sum that Mrs Bottomley has managed to increase to pounds 170m, and that several famous hospitals should close or merge.

Such decisions are never popular: a hospital like Bart's, which has been in Smithfield since 1123, attracts enormous sympathy when it fights for survival. But as Mrs Bottomley likes to remark, she cannot become an arm of the heritage industry. Change cannot be avoided. London's hospitals have been absorbing too high a share of NHS resources, at the expense of hospitals elsewhere and on primary care standards in the capital. The balance must be redressed. Sentiment aside, it is the patients who will gain.