Turmoil 1982-2006

From 1982 onwards there were repeated and major changes in the organizational superstructure of the NHS in London and in the rest of England. Scotland, Wales and Ireland where the structure of the NHS had always differed from England diverged further, as a result of devolution. At an operational level plans for service rationalisation that had been developed over many years were brought to fruition, particularly where the medical schools and the hospitals used for teaching interacted. These plans inevitably had centred upon central London. The outer swath of hospitals, for example Barnet, Hillingdon, West Middlesex, Croydon, and Basildon were less fortunate. Planners had largely ignored the need for long term strategic planning, a problem compounded with developments in the hospital service, for example downsizing of beds and the development of independent/ambulant care treatment centres.

No other period had seen the hospitals of London affected so much by the alterations in managerial or political philosophy, the views of the incumbent Secretary of State for Health or the search for cost-effectiveness and efficiency. Organisation change in London's hospitals had always been driven by money, usually financial shortages. The perception of an imbalance of services, acute and chronic, had been a more recent factor, but for the first time since Aneurin Bevan launched the NHS, political doctrine now held sway.

The economy was expanding in the early eighties and though 1989 saw a recession, by the mid nineties the economy was once more healthy. London saw substantial change with the development of Docklands as a major financial and residential centre. London had always been a multi-ethnic city; never was this more apparent as new populations from east and west Africa moved into south London. London and the southeast saw a boom in housing, and central areas such as the City of London saw a rise in population as not only the young but families and retired people made their homes in developments such as the Barbican.

Until the mid 1990s it was still possible to maintain that London's hospitals provided too many beds and it was appropriate to reduce the number of acute beds. However as the health service came under ever increasing financial pressure as a result of developments in medical science, this view became untenable. Hospital closures and bed closures continued under both political parties but against an ever increasing public anger that the NHS was no longer what it had been, and that rising expectations were far from being met. In 1997 a report on London by Turnberg concluded that there was now no evidence that London was over bedded, and the subsequent NHS Plan (1997) accepted that a substantial increase in capacity was needed. The second Labour administration accepted that the NHS was not the best health service in the world, and that there was a significant problem - too few beds, doctors, and nurses. Yet some form of consensus had emerged about the pattern of medical education in the capital, and the hospital services cared for the population and its match to the educational needs.

For most of their history London's hospitals had largely ignored general practice. It was commonplace for hospital consultants to be dismissive even if not rude about it. The hospitals had provided open access to the sick, and many people liked it that way. London students who went into practice generally did so a long way from London, for with shining exceptions general practice in London and other inner cities was not as good as in the shires. London’s difficulties were found elsewhere, but London seemed unique in its failure to resolve them. Its size encouraged isolation among the general practitioners, lack of awareness of good practice elsewhere and a feeling of impotence. The mobile young, a multitude of ethnic and immigrant groups, an intelligentsia, users of drugs and alcohol - they all congregated in London. With a few exceptions, academic general practice also developed late in London. London had fewer innovative GPs, and incentives to better care that were offered nationally were not readily taken up. Modern premises were largely non-existent. Compared with the rest of the country, team working was poor, with fewer practice nurses and attachment schemes. Without reasonable accommodation it was hard to develop teams. The combination of high land values, unsavoury locations and planning problems made it almost impossible to find a good site in the right place. Recruiting young doctors of high quality was a perennial problem. The archetypal inner city doctor faced high population morbidity and nearby teaching hospitals were slow to provide access to laboratory and X-ray facilities, and few provided in vocational training and postgraduate centres. Inner city GPs were thought to send too many people to hospital, if only because that was what the patients expected and demanded. They were, on average, older, often single-handed and many had trained overseas. Young doctors seldom wished to enter such practices, and when single-handed vacancies were advertised became available, under the rules energetic young GPs often lost out to older colleagues, perhaps less innovative. ‘Better’ doctors went to greener pastures where, because they were further from specialised services, practices provided a wider range of care and it was easier to develop a good practice. Good country practices, unlike city ones, seldom had problems recruiting new blood. Professor David Morrell, based at St Thomas’, however, toured his inner city area in the 1970s to see what might be done. Most of the premises were totally inadequate and many GPs saw no way of improving matters. There was an impression that the doctors had been lulled into accepting second best, and were not inclined to rise up and demand something better. He persuaded St Thomas' to attempt to improve matters.

If the domination of London’s health services by acute hospital-based medicine was to be reduced, primary health care had to play its part, as it did elsewhere. In a report (Primary Health Care in Inner London, 1981) commissioned by the London Health Planning Consortium, Donald Acheson provided an analysis of the problems. It made 115 recommendations, some directed towards government. Kenneth Clarke, at the time Minister of Health, said they were a maze and a minefield, difficult to handle.

Among those providing evidence was Professor Brian Jarman, of St Mary’s Hospital Medical School, later Sir Brian of Imperial College Faculty of Medicine. He had developed a measure of the social characteristics that in London GPs’ opinion most increased their workload or the pressure on their services. His index of deprivation used eight census variables and correlated with other indices that attempted to measure deprivation or the levels of illness in different areas.

Changes to the GPs' contract in 1990 used this index to increase the money paid to doctors practicing in areas of deprivation. After the Acheson Report it was no longer possible to discuss health services in London without taking note of the condition of primary care and making at least a symbolic gesture towards the solutions of its problems. When Labour came to power in 1997 there were high hopes for the London Initiative Zone, established in 1993. Projects aimed to improve GPs' premises, recruit a new cadre of GPs, introduce innovative approaches to old problems and develop cost-effective care outside hospital. A review of achievements five years later showed that many projects had improved premises but in some areas the standards of many surgeries remained unacceptably low. London still had fewer young GPs, more single-handed practices and larger lists. There were more practice nurses, but although primary care in the capital was improving, it was doing so no more rapidly than elsewhere in the country. Services still lagged behind. The initiative was terminated. The Turnberg strategic review panel (1997), which included Jarman, reiterated the extent of the problem and made further recommendations on support for GPs and the need to improve recruitment and retention.(1997)

It could, however, be argued that the pattern of general practice that worked excellently elsewhere in the country was unsuitable for inner cities, and the introduction of a new pattern of contract, An alternative contract for GPs emerged, Personal Medical Services, which made salaried service practicable, seemed particularly appropriate to the inner cities. New national initiatives aimed at the improvement of access to the NHS, for example walk-in centres and NHS Direct, were seen another way of handling problems of access.

Organisationally primary health care was in the ascendant. First GP fundholding, and later the establishment of primary care trusts, increased its leverage.

The nature of acute hospitals was being reshaped by the changes in clinical methods and management and the progressive separation of sub-specialties from the mainstream of general medicine and surgery and from each other. In the 1960s there was a clear concept of the nature of a DGH. Now matters were more complex, and one possibility involved a marked reduction in the number of hospitals, leaving a smaller number strategically placed that offered a full range of secondary and tertiary services, coupled with more local supporting facilities. Developments in specialty provision, the need to provide specialised expertise 24/7, medical staffing issues and the restriction of the total hours worked now transformed the criteria for judging the size a hospital should be to carry out clinical services safely. National Service Frameworks proposed clinical networks of hospitals varying in the sophistication of their services. A report of the BMA, Royal College of Physicians (RCP) and Royal College of Surgeons of England echoed the thinking of the Bonham-Carter Report (1969), suggesting that a single general hospital now should serve populations of not less 500,000. (The provision of Acute Hospital Services, London, RCS 1998) Such hospitals should have access to a tertiary service provided on a population base of around a million and in a sense resembled those large department stores that provided individual boutiques, but in the case of the hospital independent departments of super-specialty clinical care.

Smaller areas with populations of fewer than 150,000 might be unable to sustain a viable DGH. A new tier of large hospitals was emerging, alongside the university teaching hospitals, with advanced skills and substantially better equipment than smaller DGHs. Sub-regional centres, serving a population of a million or more often had a substantial academic base. Such hospitals could become cancer centres, dealing with the more complex tumours. They could accommodate the emerging specialties, such as diseases of the lower bowel and rectum (coloproctology), and vascular surgery, which was becoming distinct, dealing with the repair of aortic aneurysms, lower limb ischaemia and carotid artery stenosis. How many highly specialised hospitals London needed was open to question.

The growth of specialisation could be accommodated in a large hospital alongside a rota for emergency admissions, but not so easily in smaller DGHs. If patients were admitted to any one of a number of wards their care might be fragmented and poorer. Whereas many younger doctors continued to see the need for a generalist approach, in practice consultants might be so specialised that they lacked the broader skills necessary to provide emergency care and resuscitation. A surgeon spending the majority of the week on cancer of the breast was unlikely to be able to operate successfully on an emergency aortic aneurysm. Many specialist physicians and surgeons no longer participated in on-call rotas, which depended increasingly on those retaining a generalist approach, for example the geriatricians. The RCP examined different models of care. Half of the hospitals surveyed had adopted an emergency admission ward, perhaps of 20 beds, with a system of assigning patients to specialist units. Alternatively, all consultants might combine interest in a particular field with more general clinical work, although this would dilute specialist skills. Or there might be a hybrid approach in which there was a combination of specialists and generalists. The RCP suggested that Acute Medicine was itself a separate specialism, required by each hospital taking acute admissions.

Under pressure to improve the volume and quality of services without higher costs, some trusts, for example the Central Middlesex introduced process re-engineering. If the stages in the delivery of care were examined, was there a better way of designing the system? Given better drugs and anaesthetics allowing more speedy recovery, state-of-the-art diagnostics and imaging, minimum intervention techniques and better information systems, could any stages be omitted, or be arranged more economically to save the time and money of both patients and staff? The development of ambulatory care centres became a feature of government thinking. Increasingly, efficiency was sought through the improvement of clinical practice.

The drive for economy, and the introduction of the principles of an internal market in the late 1990s, led to the separation of "purchasing" and "provision" and as a result placement of contracts between health authorities and hospitals. The high costs of central London hospitals, compared with the lower tariffs of those on the periphery, looked likely to reverse the traditional flow of patients into central London. Contracts could, in the days of the NHS Reforms, be circumvented through a system of extra-contractual referrals, but this became near-impossible after 1997 when a system of out of area referrals was introduced. Health authorities could negotiate a better price under block contracts than they could for individual cases, and as these were now tracked by billing systems they could be embargoed. As a result the freedom of clinicians to take patients living some way off but who would benefit from their expertise, and the freedom of patients to use hospitals a little way away was restricted. For example those living in the City, north of London Bridge, might find themselves barred from crossing the Thames to Guy's Hospital. Patients now generally had to receive care from a list of preferred providers.

Because so many of the changes were dependent upon the priorities of the Secretaries of State for Health, they are listed

For many years ministers had pursued the vision of stretching scarce resources by improving management. Norman Fowler turned to business for advice. In 1983 he asked a small team of businessmen under the leadership of a senior manager in the food marketing industry, Sir Roy Griffiths, to advise on the effective use and management of manpower and related resources in the NHS. Griffiths met many people and regularly dined with senior staff at St Thomas’ on whom he tried out his ideas. Coming from business it was hard for him to avoid the criticism that he was unused to the idea of professional responsibility, and that his definition of management excluded the informal systems that existed in the NHS. Probably the NHS did not, at the time, devote enough of its resources to proper and disciplined management, but it would have been surprising if Griffiths had not immediately identified the absence of general management as the main difference between the NHS and the business world. In a memorable sentence he said, ‘if Florence Nightingale was carrying her lamp through the corridors of the NHS today, she would almost certainly be searching for the people in charge’. It was not the first time a chief executive had been proposed; Bradbeer had suggested it for hospital management committees in 1954.

Griffiths believed that the lack in the NHS (and indeed in the DHSS) of a clearly defined general management function was responsible for many of its problems, that the development of management budgets was vital. Consensus had to go. The government rapidly accepted the general thrust of the report. The BMJ was, at first, guardedly welcoming. The recommendations were not based on an analysis from which they could be logically deduced. Like all newcomers to the health service, Griffiths was dismissive of the differences between the NHS and private industry. Private industry was about competition in conditions of surplus, while the NHS was all about rationing scarce resources on criteria of needs, as defined by professionals, rather than demands, as expressed by consumers. The NHS did not have a single pyramidal structure, with Parliament, a Minister or the district management team at the apex. Clinical freedom created a political dimension outside any normal managerial framework. As quickly as efficient management reduced long-established queues, medical science opened new ones. Clinical freedom allowed consultants to make decisions affecting resources, and consultants had to be persuaded if they were to make their clinical demands more modest. While there was opposition to general management it was soon overcome. The implementation of the general management function made subsequent alterations in NHS structure easier, and the linking of performance to pay meant that there was a ready tool to hand to ensure that alterations Ministers of any persuasion might desire, were delivered. General managers were steadily appointed, and the hierarchical relationships now in place, and the power that they enjoyed, facilitated further structural reorganisation.

The basic structure of the NHS had not been altered greatly by the reorganisation of 1974 and restructuring in 1982 and was the same throughout England. Society, however, had changed and the Conservatives were consumer-oriented. People who increasingly expected attentive help in other fields could hardly fail to notice the absence of ‘customer-led’ services in the NHS. In the 1980s the Conservative government explicitly repudiated consensus and partnership with the professions in policy making. The public interest was no longer seen as achievable in this way and the professions were increasingly regarded as just another lobby, rather than carrying a special imprimatur derived from the nature of its expertise and values. That there were problems in the NHS was beyond debate. They were presented graphically in an article about the King’s College Hospital accident and emergency department. If Mrs Thatcher was to retire to her home in Dulwich, that was where a sudden illness would bring her. The conditions were third-world. Nurses rather than domestic staff cleaned up the vomit and blood. ‘If you don’t get it while its wet it’s twice as hard to clean up afterwards and if anybody slips over then it’s you who answers for it.’ Patients bled onto the floor; lumps of plaster fell from the ceiling. The picture was Hogarth. How long were people prepared to stick it? The broadly bipartisan approach to the NHS ended after the Conservative victory in 1987. It was said that, if there was a third term, Mrs Thatcher’s motto would be ‘the customer comes first’. Among the political beliefs underpinning the coming changes were: the paramount importance of a sound economy and strong currency, without which public services could not be funded; the view that there was little the public sector could do that the private sector could not do better; and that managerial inefficiency was rife throughout the public sector, whether in the utilities, the schools or the health service. The changing approach in the NHS was only part of a wider ideological battle about society, industry and public services, although many in the NHS did not appreciate this. If an insurance-based system was ruled out, because of the additional overheads, reform had to be on the supply side. GP budgets had already been considered in the context of the review of primary health care. Redwood and Willetts lunched at the Nuffield Provincial Hospitals Trust with Alain Enthoven, a leading expert on the economics of health care, who was on a preliminary visit to Britain before holding a fellowship funded by the Trust. The thinking of the Centre for Policy Studies was discussed, but all the main ideas that later appeared in Enthoven’s Reflections on the management of the NHS were current in radical-right circles

Working for patients published in January 1989 was Kenneth Clark's document. It was a challenge to the status quo, the rigidity of organisation and the assumption that the employment of highly trained health professionals would ensure that users got what they wanted. Yet the Review accepted many basic principles of the NHS, to the surprise of the left that had predicted a move towards health insurance to provide additional money. The NHS would continue to be funded centrally from taxation, the simplest and cheapest way of raising money. It would remain largely free at the point of usage. There was no suggestion of major organisational change at the top of the management hierarchy. The idea that a major injection of funds was all that was needed was rejected. Instead reforming incentives and management and the introduction of a ‘market’ would improve productivity. The purchasing function would be separated from the provision of services. Health authorities would concentrate on the assessment of needs and contract for services; hospitals and community units would provide the services. Good performance would be rewarded, for money would follow the patients. It was clear, although not stated, that once contracts were in place any limitation of services for financial reasons would be laid at the door of the purchaser, and no longer at that of the hospital. It was a model well suited to elective surgery, but less appropriate for elderly people and for psychiatric services. Markets have winners and losers; would the poor, deprived and handicapped be at risk?

Kenneth Clarke made the running, changing little or nothing as a result of the doctors’ opposition, and demanding a rapid timetable from his officials. Politically he was the right person to argue, explain and defend the policy day after day. The electoral timetable meant that the reforms had to be implemented faster than NHS management believed possible. Implementation depended on regional and district managers; loyalty was demanded and dissent was discouraged.

The necessary legislation passed in 1990. In November of that year William Waldegrave replaced Kenneth Clarke; less combative, he maintained the momentum in a quieter way. The reforms were implemented in April 1991. It was soon appreciated that they would have substantial and unexpected effects o n London's hospitals. The new system of contracts had to be in place and there was anxiety that purchasers would make radical changes, avoiding high cost hospitals in the centre. Ministers thought that the whole point of the reforms was to increase efficiency, but to minimise crises it was agreed to go slow in the first year, with a ‘smooth takeoff’ and the maintenance of existing patient flows. The Chancellor of the Exchequer allocated an additional 4.5 per cent in real terms to help. The election was fought in April 1992, health being a central issue. The Conservatives won against the odds, and the new Secretary of State Virginia Bottomley redefined the NHS as the provision of care on the basis of clinical need regardless of the ability to pay, not by who provided the service, a concept not adopted by her successor Frank Dobson but by his - Alan Milburn - ten years later. She said that central strategic command could, with benefit, be replaced by a local dynamic. Clinically effective intervention, local innovation, use of new technology to reduce or eliminate the need for hospital admission and the move to community-based care would take root fastest if those taking the decisions were, like fundholders, close to the public and the patients concerned.

Throughout her period in office, and that of Stephen Dorrell her successor, Ministers continued the implementation of the NHS reforms, defending them tooth and nail until, with the election of 1997, the Conservatives lost power. Industrial concerns had been removing middle management, ‘downsizing’ and producing ‘flatter’ organisations. Only a few foresaw that regions might be treated in this way. Their last major task was to oversee the implementation of the NHS reforms, managing the fundholding scheme and supporting districts in their purchasing functions. Many politicians and managers, and some consultants, wanted to abolish regions because they were controlling. Others saw professional advantages in their co-ordination of services, and political ones as they acted as a buffer between local problems and the Secretary of State. Desperate attempts were made to retain their function. However, a review of the relationship of the 14 RHAs with the centre in 1993 recommended that regions should be slimmed, and then amalgamated into eight in April 1994. London would have two, one for north and one for south of the Thames. Finally they were abolished in favour of eight regional offices of the DoH. To the government this proposal was ‘simpler and sharper’; to Labour at the time it was ‘highly centralist and undemocratic'; later it adopted the idea wholeheartedly. The Conservatives had done what Kenneth Robinson had proposed in the 1968 Green Paper. After 48 years the regions that had been central to the development and evolution of the NHS were disbanded, the Health Authorities Act (1995) providing the statutory authority and opening the door to further and continuous organisation change.

Regional outposts had less power, they had few staff and money no longer flowed through them. The Act also enabled the formation of 100 single health authorities by merging the residual 105 DHAs and 90 FHSAs. These inherited the statutory functions of DHAs and FHSAs. They would commission a range of services within their allocated funding, provide and secure the provision of services, work with GP purchasers, and make arrangements with GPs and other contractors. While the NHS reforms had aimed to increase competition and patient choice, they brought with them a reduction in the freedom of GPs to refer patients to any UK hospital. GP fundholders, because they controlled the money, could still do so. However health authorities set contracts with local hospitals and discouraged "extra-contractual referrals". These contracts were progressively tightened so that ultimately districts had preferred providers and it was near impossible for a patient to obtain care, save in an emergency, in other places. Districts were to agree strategies, monitor purchasing and support primary health care. As trusts were established, districts ceased to have responsibility for hospital management. Combining a residual management function with purchasing was, in any case, difficult. By 1995 the number of health authorities had halved as the authorities lost managerial control of the hospitals. Being under financial pressure, authorities looked for economies, pressed trusts to merge to reduce their overheads, and for the concentration of care in fewer hospital. Subsequent legislation, the NHS (Primary Care) Act 1997, had substantial bipartisan support and provided new opportunities for the transfer of resources between primary and secondary health care, and the development of comprehensive packages of primary care by new ‘provider’ organisations such as community trusts.

In place of the traditional authorities with a membership of 20 or more, an industrial model of governance was substituted. This was technocratic and, while it might promote efficiency and responsiveness, it also increased insecurity, the authority of the centre and short-term decision-making. Each trust had a smaller board of directors including non-executive ones who brought skills from the business community. Key interest groups traditionally on the board were excluded, e.g. local authorities, trades unions and the clinicians, medical and nursing. Local authority members who in theory spoke for the electorate on management bodies might have been seen as a nuisance but they added an authority to the decisions that were taken. New chief executives from outside the NHS did not always share the ethos of public service. They often improved the use of resources, and they challenged established practices, not always correctly. On fixed term contracts, sometimes as short as a year, their eyes were on the immediate problems rather than the development of long-term collaborative arrangements with others, whose assistance was essential to a good service.

Trusts were able to employ staff, negotiate terms and conditions of service, own and dispose of their assets, retain surpluses, and borrow money from the government and the private sector. They generated their revenue from contracts with districts, commissioning agencies and GP fundholders. They needed good financial information for their business plans and needed it rapidly, but much of the information required to compare relative costs did not exist; the necessary systems were not in place even at the resource management sites. Many hospitals had no price list. Block contracts, notional costs and wild price variations were commonplace. It took much work and a long time to sort things out. Extra-contractual referrals maintained the GP’s right to send the patient to the most appropriate unit, but generated substantial administrative costs. Relationships between the ‘purchaser’ district health authorities and the ‘provider’ trusts were initially tense. The health authorities had to learn to work with the trusts as equals, not subordinates. Over the first few years there was little change in the pattern of patient flows, perhaps 5-10%. Where changes were made, it was usually to create a local service for patients. District hospitals might provide services previously available only at a regional centre and purchasers wished to develop these if the price was right. In the case of city hospitals, particularly those in London, peripheral purchasers would do their utmost to restrict central flow in favour of their local hospitals, many of which were new, with young staff and spare capacity. Teaching hospital trusts were at a disadvantage because of their high overheads and managerial complexity. Sometimes they treated purchasers with disdain and lost market share. Their countervailing advantage was that a high proportion of their medical and surgical consultants had sub-specialty expertise. This made them the natural place for junior medical training. Some trusts progressively expanded their work and their catchments, others floundered. Acute trusts sometimes developed outreach services; community trusts looked at hospital-type day care. The borders could blur. Purchasers at first were poor at contracting and hospitals had the clinical expertise to run rings round them. Contracting slowly became more sophisticated and more firmly based in an assessment of local needs.

Doctors were now employed by the trust, and not the RHA, so they began to think in a more local way. Each trust could define its organisational pattern. Clinical directorates, seen early on at Guy's, were often established under medical control on the ‘Johns Hopkins’ model. Decisions could be taken more rapidly, new patterns of staffing could be introduced and services could be improved without bureaucratic delays. Because their unit budgets were determined by contracts with purchasers, it was easier to persuade consultants to change their patterns of work. Nurses, when they were appointed as directors, were in a dilemma. While they wanted to see the ‘big picture’ and to contribute to strategic planning, the chief executives looked to them primarily to run an effective nursing service and ensure that quality assurance worked.

The need for hospital trusts to generate income led to visible changes. Lilac coloured carpeting and easy chairs, smiling receptionists, a florist’s stall bursting with blooms, a bistro coffee bar and a newsagents would appear. Trusts spent money on glossy pamphlets on their services, and on logos. Acute hospital trusts established private patient units to compete with private hospitals. Between 1988 and 1992 income from private units increased by 40% to £157 million and the proportion of the UK private health care market (itself expanding) in NHS hands continued to rise. Private hospitals in their turn treated NHS patients referred by fundholders. The boundary between the NHS and private medicine was becoming blurred and the phrase ‘internal market’ seemed increasingly inappropriate.

Initially the Labour Party opposed the reforms in their entirety; however, after electoral defeat in 1992 it slowly accepted some of the concepts. Brian Abel-Smith and Howard Glennerster urged Labour to resist gut reaction, believing that many reforms moved in the right direction. FHSAs had ceased to be provider-dominated, long overdue. Fundholders were able to get a better deal for their patients, and making hospitals compete kept them on their toes. It made sense to build on what had been achieved. A division between purchasers and providers was sensible, and the substantial autonomy of trusts made it easier for them to adjust to what was wanted. Trusts could easily have a change of membership to incorporate democratically elected representatives.

There were many oddities about the distribution and organisation of medical schools and hospitals, the result of history, local pride and ethos, and anxiety about what change might bring. Who, asked the BMJ in the early eighties, would have the courage to bell the cat? Rationalisation, already underway, increased in tempo following the 1982 restructuring of the NHS, spurred by financial pressure that demanded major mergers across existing authority boundaries. Because the four Thames regional health authorities planned in different ways, after the demise of the London Health Planning Consortium the chairmen of the twelve teaching districts jointly examined what was happening. They found it impossible to say with any confidence what London medicine might look like in a few years. The Conservative internal market of 1990 had a major effect on central London and the existing pattern of services was not sustainable. The market could have been allowed to refashion London’s hospital service but this would have been unpredictable in its effects. There were two major planning exercises, one by the King’s Fund and one later initiated by government. The impetus for further rationalization stemmed from the second enquiry into London hospital medicine carried out under the Conservatives, Tomlinson. That of the King's Fund, led by Virginia Beardshaw, had some, but less, impact.

The King’s Fund appointed a Commission in 1991 to develop a broad vision of services that would make sense in the early years of the next century. It spent £500,000 commissioning 12 research reports on which the conclusions, published in June 1992, were based. However, the Commission spent less time on data analysis and its examination of educational issues than had the London Health Planning Consortium (LHPC). Substantial attacks were mounted on its findings because of a belief that it was working towards a pre-determined conclusion and that some of its members had little sympathy for London or for specialists. The report accepted the case for substantial change and reduction in acute services with a complementary build-up of primary health care. It did not consider the paucity of back-up beds in nursing and residential homes, which barely existed in the metropolis. It reported that at least 5,000 beds must be closed if the capital were to be guaranteed a good standard of health into the next century. ‘Costs in London are not just expensive, they are extremely expensive . . . change is inevitable . . . Inner London hospitals are top-heavy with doctors and the rate of patients going through is slower.

The Conservatives, though committed to market solutions, embarked in London on strategic planning and consultation. William Waldegrave, then Secretary of State, announced his review at the 1991 Conservative Party conference. Sir Bernard Tomlinson, Chairman of the Northern RHA, would form a strategic view of the future needs for service, education and research in London. The Times said that Mr Waldegrave was ‘wringing his hands’ over what should be done in London. However, he needed to be convinced that major decisions were intellectually based. UCH/Middlesex, strongly supported by the scientific community because of the quality of its work, wanted a new building and this would require other hospitals to close. Already expansion had been approved at Guy’s, the Chelsea and Westminster was established and St Mary’s was being developed. On the Tomlinson team was Dr Mollie McBride, Secretary of the RCGP, a nurse and a psychiatrist. Tomlinson was asked to consider the provision of health care within the framework of a reformed NHS, including the balance of primary health care services, and the organisation and provision of undergraduate medical teaching, postgraduate medical education, research and development. The team should advise Ministers as the inquiry progressed, focusing on management action. By commissioning the inquiry, Willaim Waldegrave had delayed the need to take action before a forthcoming election.

Tomlinson reported in October 1992 and was influenced by the King’s Fund Commission. He emphasised the need to improve primary and community care, bringing primary care up to national standards and providing services for people with special needs such as the homeless. This prescription was widely accepted, for there was a general belief (without much supporting evidence) that improved primary health care was fundamental for the degree of rationalisation envisaged for London’s acute services. An idea that had emerged at a Nuffield-sponsored meeting of professional leaders and health service managers was a ‘free-fire’ zone where normal health service rules could be modified to facilitate the development of primary health care. Tomlinson adopted this and the government provided £170 million over six years in a ‘London Initiatives Zone’ covering about 4 million people, where heath care needs were great and an innovative approach was required. Money would be concentrated on this territory and educational and management effort would be strengthened. Most people under-estimated the complexities of building new and better facilities for GPs and primary health care teams. Neither was it easy to turn a theoretically attractive plan for the teaching hospitals and medical schools into schemes on the ground. The money helped new projects and encouraged the study of long-standing problems of inner London practice. The pace of change was, however, slow and the effect on acute hospital services minimal. Neither the changes to the hospitals nor those to primary health care were universally popular and it was politically hard to fight on both fronts simultaneously. A primary care support force worked to improve matters, and was disbanded in 1997; it was hardly possible to maintain that the issues the group was set up to address had been resolved.

The Tomlinson Report (October 1992) foresaw a surplus of 2,500 beds because of the withdrawal of inpatient flows from outside central London and the increasing efficiency with which beds were used. Whole hospital sites should be taken out of use, and the resources redeployed to develop primary care and community services. Tomlinson revived earlier proposals for rationalisation. They involved change at UCH/Middlesex that had become a single, powerful and scientifically important organisation. There would be a single management unit for St Bartholomew’s and The Royal London; the loss of one hospital from among the south London hospitals of Guys’, King’s, St Thomas’ and Lewisham; rationalisation at Charing Cross/Chelsea and Westminster with relocation of specialist postgraduate hospitals to the Charing Cross site; and changes to specialist postgraduate teaching hospitals to bring them into closer relationship with general hospitals. Tomlinson supported the removal of St Marks to Northwick Park. In February 1993 the DoH’s response Making London Better, accepted the general thrust of the recommendations, and the need to develop primary health care. Specifically government announced a merger between the Trusts of St. Thomas' and Guy's Hospitals, and a review of six specialty services.

A London Implementation Group (LIG) was formed, chaired by Tim Chessells, Chairman of the then South East Thames RHA, with direct access to Ministers. Six specialty reviews were established to examine clinical requirements; the clinicians in the specialty under consideration came from outside London and could be brutal when faced with the pretensions they sometimes encountered. The reviews proposed that the best centres should be developed, the smaller ones should be closed or merged, and new ones established where they were needed as at St George’s where there was a long-standing requirement for renal replacement therapy. The specialty reviews were published in the middle of 1993. Many of the recommendations were implemented, but not all. Some were revised as a result of more general considerations, e.g. in the south east neurosurgery was not maintained at Guy's but at the Maudsley. Several initiatives now came together, making change possible. There was a research review of the London postgraduate hospitals, which pointed to the need for a wide range of skills including biophysics and molecular biology, and association with general hospitals and university facilities. Medical school deans had to play a difficult hand; most were privately supportive of the need for change and prepared to work for it, but in public they had to take their colleagues with them as far as possible. Trust chairmen had been appointed knowing there was a job to be done. They and their chief executives were heavyweights who did not fool around, although transitional funds were available to sugar the pills of change and mergers. Ministers were far more involved than they had been in the work of the LHPC; Virginia Bottomley, always in the public eye, was continuously involved in the decisions being taken. The Higher Education Funding Council (HEFCE), as a member of LIG, was involved in the various medical school mergers and amalgamations, as well as through its direct links with the institutions.

The London Implementation Group closed down in April 1995, and the then two Thames RHAs north and south of the river became responsible for co-ordinating change, though they too were facing demise. With the election of the Labour government in May 1997 Frank Dobson, who had made scurrilous remarks about Virginia Bottomley's acceptance of the east London proposals, promised a further review of the future of London’s hospitals was promised. This increased uncertainty just as some clarity had been obtained, and re-invigorated those campaigning to "Save Barts". There were four broad responses to Tomlinson: the optimistic that primary and community care could be brought up to the standards elsewhere; the realistic accepting the recipe but gloomy about the money and the difficulties; the despairing who doubted whether anything would be accomplished; and the reaction at St Bartholomew’s that was to indulge in old-style emotional campaigning against the proposals. St Bartholomew’s had come to believe its own rhetoric and dismissed any proposal not to its liking, however well founded. Its campaign was given a voice by the Evening Standard in probably the most ferocious media war ever waged against health service managers and NHS policy, unparalleled in its unstinting aggression and partiality. ‘During the past twenty years,’ wrote Lord Flowers in The Times, ‘with a few honourable exceptions every attempt to reform London medicine has been defeated by vigorous rearguard action on behalf of any hospital or medical school adversely affected. The result has been that the standing of teaching and research in London’s famed medical schools has been steadily slipping. The time has come for the government to stand firm.’ Virginia Bottomley took decisions that her predecessors had been canny enough to defer and for which her successors would be forever in her debt; she was prepared to bell the cat, as the BMJ had put it. She narrowly escaped defeat in Parliament and a rebellion of some senior London Tory MPs. Her reward was the Department of National Heritage. Robert Maxwell, Secretary of the King’s Fund, said that the creation of big medical centres across London, the main tertiary centres of service, research and education for the future, had been talked about for 50 years. Now it looked set to happen and would be Mrs Bottomley’s best legacy.

Nationally, Labour's election in 1997 brought an end to GP fundholding and a structural reorganisation. In London the new Secretary of State for Health, Frank Dobson commissioned a strategic review of inner London. Led by Professor Sir Lesley Turnberg, and with departmental support, it reported within months. Re-examination of hospital bed numbers showed that they had fallen substantially; between 1990/1 and 1995/6 1130 acute inpatient beds had disappeared from inner London, and when geriatric, maternity and psychiatric beds were included the loss across London as a whole had been 9271. Overall, Turnberg concluded that there was now no evidence that there were more acute beds available to Londoners than the England average, taking into account the use of London beds by non-Londoners. Improvements in primary care had not been able to substitute for reductions in secondary care.

The interplay between London’s hospital service and the medical schools was profound. Since the the time of the Royal Commission on Medical Education (1968) academic merger had been proposed. The Todd pairs (below) differed substantially from the ultimate pattern.

Early steps had been taken in the 1980s and the university now re-introduced proposals for medical school merger. Progress was more rapid on the academic side than the NHS for hospital closure attracted more public interest than the merger of academic institutions. A five sector arrangement was adopted (see map below). The Turnberg Report liked this approach and thought that health authorities might, in due course, merge on a sectoral basis. The academic successes indicated a way ahead for the NHS. The number of students to be admitted increased, medical schools sometimes exceeding their target intakes, and four year courses for mature entrants and graduates were slowly introduced.

The University moved towards a rationalization of medical schools in association with multi-faculty colleges. There would be four university centres, each related to a multi-faculty college, St George’s maintaining an independent position. The postgraduate institutes were finally brought within the fold, as proposed by Sir George Pickering in the 1960s. Within this structure, once the colleges became directly funded by the Higher Education Funding Council for England, the successor from 1993 to the University Funding Council, the University of London had to accept the realities of the local aims and ambitions. The colleges had gained financial and managerial autonomy, UCL, Queen Mary, Kings and Imperial being separately identified from 1993/4 and St George's two years later. The University maintained a coordinating group of the medical faculties to discuss strategy for mutual benefit but each college took a different approaches to the integration of medical schools within their fiefdom. University decisions influenced the Turnberg report, and that report impacted upon NHS organisations.

Imperial College, secure in its prestige and size, took a firm line with the medical schools now an intrinsic part of its empire. The Faculty of Medicine was established in 1997. The ethos of the component medical schools would be that of Imperial College, scientific based and of the highest standard; they would no longer have an independent identity. Following school mergers (e.g.) there was a thorough reorganization to develop an integrated medical school. There would be one organisation using the same letterheads. The Faculty was now spread over seven campuses, six the sites of major teaching hospitals. These were

University College London was less forceful. The Royal Free continued to act with a measure of independence but in August 1998 a new Royal Free and University College Medical School was formed. Imperial and UCL discussed a merger, but decided it was in the interests of neither side. However, the discussions divided the London medical schools into two camps, Imperial College and UCL neither of which were supportive of the concept of London University, and the other three. In 2003 Imperial College was awarded independent degree awarding powers by the Privy Council but did not immediately decide to invoke them. UCL and King's also had proposals in front of the Privy Council. Such moves, covering all subjects and not solely medicine, tended to undermine London University.

King's College gave Guy's and St. Thomas's room for manoeuvre. The Guy's, King's and St Thomas' School of Medicine was created on 1 August 1998 by the merger of King's College London (including the former King's College School of Medicine and Dentistry) and the United Medical and Dental Schools.

Queen Mary, University of London wished for a medical faculty, but was in a financially weak situation, as indeed were the two medical schools involved, St Bartholomew's and The Royal London. There were substantial objections to amalgamation from both the medical schools, and the merger in 1995 as Bart's and The London School of Medicine and Dentistry, the medical faculty of Queen Mary University of London, was not a happy one.

Within a national plan for a massive increase in the number of medical school places (and medical schools), London played a minor role.

In December 1997, Frank Dobson, the new Secretary of State, issued the The new NHS - Modern, Dependable, setting out Labour's initial vision for change to NHS structure nationally, conceding that some of the features of the Conservatives' internal market were worth keeping. Labour built on Conservative initiatives while denouncing them. There were three main themes of The new NHS

All built upon trends already current. The harder edges of the internal market, were softened. Fundholding went, co-operation replacing more extreme forms of competition. Health Action Zones would encourage cooperation between health and social services, an initiative that proved short-lived. ‘Partnership’ and ‘integration’ would replace the internal market and the jargon of the market was slowly replaced by that of New Labour. The Conservatives' ‘seamless services’ became ‘joined-up thinking’. The interdependence of health and social care, and joint programmes, were stressed. It was claimed that this partnership was novel, forgetting the attempts by Barbara Castle and David Owen in 1974 to integrate health and social services planning.

The new NHS - Modern, Dependable, involved substantial change in organisational structures. London had been divided into four health regions at the start of the NHS and in 1996 into two, north and south of the river as a result of a review of regional functions. In June 1998, in line with the recommendations of the London Strategic Review chaired by Sir Leslie Turnberg, Frank Dobson, announced that London would have a single NHS region instead of two - and previously four - and a single London Regional Office of the NHS Executive was established on 1st January 1999. The arguments against such a pattern, vetoed by Bevan in 1946, and rejected once more in the early seventies, were now weaker. A London region had been proposed in the Tomlinson Report (1992). Change had therefore been expected and would have ripple effects on the surrounding areas.

Trusts and health authorities continued to merge, and Labour brought fundholding to an end, its alternative, based upon commissioning by Primary Care Groups (PCGs) and later Primary Care Trusts. The number of health authorities fell and they were abolished, as their responsibility for commissioning services disappeared. Formerly autonomous GPs were organizationally brought together with community trusts and their nursing staff. InApril 1999, 481 PCGs were established in England and Family Health Services Authorities (FHSAs) disappeared. By 2005 Primary Care Trusts themselves faced a change of role, as their number was reduced in part to save money and overheads. .

Hospital trusts were far less affected by Labour's decisions than other management bodies. They became accountable to regional offices for their statutory duties, and to health authorities and later primary care trusts for the services they delivered. The separation of planning from provision and decentralization of hospital management was maintained. The number of Trusts fell through merger; 22 trusts merged in 1998 and a further 49 in 1999. Research by the London School of Hygiene and Tropical Medicine suggested that the motives for a merger were not always made explicit; reducing deficits, putting the good management of one trust into the poor management of another, and hospital closures. Financial savings were seldom as great as imagined (c.f. hospital closures in the 1970s and 1980s). Service planning was often delayed as a result of loss of managerial control, perhaps by as much as 18 months

Labour's second wave of organisational change.

The replacement of Frank Dobson in 1999 as Secretary of State for Health by Alan Milburn heralded yet more changes. Alan Milburn wished there to be great change, fast and over a broad front. Labour's second policy document was issued in July 2000 - the NHS Plan. The Conservative reforms of ten years previously had stressed organisational change and incentives. In sharp contrast Labour had consulted the professions which had been deeply and often enthusiastically involved. Labour believed that a radical shake-up was necessary if the NHS was not to run into the ground. The Plan was a lengthy document with details and targets aplenty within the four main themes of increasing capacity, setting standards and targets, supervision of the way the NHS delivered services, and 'partnership'. Initiatives varied from "bringing back matron", to the improvement of hospital food by consulting celebrity chefs. The dates set for the achievement of the Plan's targets were beyond the end of the administration setting them and achievement would depend on the performance of the economy. Against the odds,substantial progress was achieved for example in terms of waiting times and waiting lists, where history gave reason for considerable scepticism.

Key points of the NHS Plan

	More doctors, nurses and medical students by 2004
	Consultants to commit their first seven years to the NHS
	7000 more beds and 100 new hospital schemes by 2010
	All patients to see a GP within 48 hours by 2000
	Booking systems to replace waiting lists
	A patient advocacy service for each trust, replacing Community Health Councils
	A UK council to coordinate the profession’s regulatory bodies.
	A new level of primary care trust to provide even closer integration of health and social services

Source : BMJ 2000, 321: 317

Structural reorganisation.

The NHS Plan's structural reorganisation took place on 1 April 2002 and had a major impact on the NHS in London. Area authorities were replaced by Strategic Health Authorities, in advance of legislation to establish them formally. The new Strategic Health Authorities, nationally 28 in number with five for London, were established by merger. The London StHAs reflected the recommendation in the Turnberg strategic review that services of a specialised nature should be commissioned at a level of the five sectors into which London could be divided, each relating to the new University of London medical school groupings. On the board of each of the London StHAs was a representative of of the local higher educational institutions.

Turnberg recommended that health authorities (later primary care trusts) should work together at sectoral (later StHA) level. These sectors were not unlike the inner parts of the old Regional Health Authorities (for the shire counties had been separated) and reflected not only the five sector scheme of Tomlinson (and the five sector radial plan considered in 1946 before the number of the metropolitan regions was settled as four) but the five university medical school segments identified by the University and by the Turnberg strategic review. Radial organisation had been referred to in the sixties as a "starfish" pattern, because the intelligence was in the centre and the communication pathways spread outwards. The more egalitarian term of Pizza slices was now applied, and within the slices PCTs, Trusts and the educational authorities had a commonality of interest that led them to work with each other, and seldom with other pizza slices. The London StHAs related to a smaller number of PCTs than was common elsewhere, and in London there was mandatory co-terminosity between PCTs and one or more of the local authority boroughs. Each of the five London medical schools was associated with a StHA, and every Dean sat on an StHA underlining the importance of the association.

The five sector system and the local authority boundaries Source: Turnberg strategic review 1997

Sector map of London from Turnberg Report

Strategic Health Authorities would

develop a coherent strategic framework
prioritize major capital developments and do so on a London-wide basis.
manage PCTs and Trusts (including those of postgraduate hospitals) and agree annual performance agreements
build capacity and support improvement of performance
relate to the Workforce Development Confederations responsible for virtually all manpower planning, increasing staff numbers

They would develop 'clinical networks' (much as the Regional Hospital Boards in 1948 had taken advantage of universities and university medicine). Should they wish, StHAs could associate at a higher level to discharge functions better fulfilled together. In London the opportunity was taken to make the pattern of StHAs fit with the educational sectors outlined by Tomlinson.

Department of Health
Permanent Secretary/Chief Executive		4 Directors of Health & Social Care
	Annual Delivery Agreement
I I Strategic Health Authority
I	Annual Performance Agreements	I
Primary Care Trusts	---Service agreements---	NHS Trusts

London Strategic Health Authorities	Acute NHS Trusts and 2002 star ratings
North East London Health Authority *Matching Queen Mary University of London* Eight Primary Care Trusts	Barts and The London NHS Trust** Whipps Cross University Hospital NHS Trust* Homerton University Hospital NHS Trust* Plus two non-teaching acute trusts, Newham and Barking, Havering & Redbridge,* and two mental health care trusts
North Central London Health Authority *Matching University College London* Five Primary Care Trusts	Barnet & Chase Farm NHS Hospitals Trust University College London NHS Hospitals Trust* Great Ormond St Hospital for Children NHS Trust Moorfields Eye Hospital NHS Trust* North Middlesex University NHS Hospitals Trust Royal Free Hampstead NHS Trust Whittington Hospital NHS Trust Great Ormond Street Hospital for Children NHS Trust and three mental health NHS trusts
North West London *Matching Imperial College* Eight Primary Care Trusts	Chelsea & Westminster Healthcare NHS Trust Ealing Hospital NHS Trust Hammersmith Hospitals NHS Trust Hillingdon Hospital NHS Trust North West London Hospitals NHS Trust* West Middlesex University Hospital NHS Trust* Royal National Orthopaedic Hospital NHS Trust Royal Brompton and Harefield NHS Trust St. Mary’s NHS Trust* and two mental health care trusts
South West London Health Authority *Matching St Georges Hospital Medical School* Five Primary Care Trusts	Epsom & St Helier NHS Hospital Trust Mayday Healthcare Trust St George's Healthcare NHS Trust Kingston Hospital NHS Trust Royal Marsden NHS Trust*** London Ambulance Service, Surrey Oaklands Trust and two mental health care trusts
South East London Health Authority *Matching Kings College London* Six Primary Care Trusts	South London and Maudsley NHS Trust King's College Hospital NHS Trust* Guy's & St Thomas NHS Trust*** Bromley Hospitals NHS Trust* The Lewisham Hospital NHS Trust* Queen Elizabeth Hospitals Trust Queen Mary's Sidcup NHS Hospitals Trust* and two mental health care trusts

The five London StHAs appreciated the need for the coordination of services on a London wide basis, because of the characteristics of primary care, patient flow within London and to and from surrounding areas, and teaching and research. They decided to share out the lead London roles for major service improvements including National Service Frameworks, with a ‘cabinet’ approach across London, the five StHA Chief Executives meeting regularly with the Director of Health and Social Care at Departmental level. The 'London Health Cabinet' would take decisions on the priority of major capital schemes across London, developing a coherent development programme. One of the London Health Cabinet's objectives was to play an influential role in the development of policy at national level. However the abolition of the regional directorates in 2003 left the five strategic health authorities without a form of coordination that had teeth, other than the regional directorate of health and social care within the Department*, should the StHAs begin to drift apart like tectonic plates. The London Modernisation Board that had been established in 2000 was taken over by the five authorities, North West London being the lead authority. The Board was large in size, representative of the five authorities, local authorities and professional groups, but seemed to lack a co-ordinating role in the sense that had existed previously.

[* In the 1980s there was similarly a Regional Liaison Group within the Department concerned with the London regions]

Strategic HA	Lead responsibilities across London
North East London	Cancer Services and Health and Regeneration
North Central London	Specialist Commissioning, Children’s services, Coronary Heart Disease
North West London	Forensic psychiatry and Mental Health London Modernisation Board
South West London	London Ambulance Service, Performance Management, Older People’s Services
South East London	Primary Care

By 2004 Ministers said that 'the unique nature and scale of health service issues facing the capital might point to a single organisation to oversee service development. The following year a review of the primary care trusts and StHAs in the capital was set in hand. The wheel was turning once more. The number of SHAs and PCTs would be reduced and from July 2006 the London strategic health authorities would be united and London would again have a single focus. For the time being the PCTs in London would remain at 31, with a strong emphasis on coterminosity with boroughs.

Capital Development

Over the two decades major changes took place in each of the five emerging sectors as substantial capital began to be spent in Central London for the first time since the war, Chelsea and Westminster, St. Mary's, University College Hospital and the Middlesex. New developments were also in the pipeline. Originally somewhat piecemeal, the acceptance of a five radial sector system provided a better framework for planning and the Turnberg strategic review commented upon a number of the projects in hand. Major developments could now proceed with less anxiety, mainly funded by the Private Finance Initiative.

In 2002 plans were announced for NHS foundation trusts. These would have less central government control and more locally responsive management. London trusts among the first to be encouraged to proceed included

Guy's & St Thomas' Hospital NHS Trust
Homerton University Hospital NHS Trust
King's College Hospital NHS Trust

Moorfields Eye Hospital NHS Trust
The Royal Marsden NHS Trust
University College London Hospitals NHS Trust
Department of Health Press Release January 2004

North East London

In north east London the quality of hospital buildings varied widely. One of the greatest planning conflicts of the eighties and nineties involved St Bartholomew's Hospital and The Royal London. As part of the NHS reforms the Government introduced the idea of self-governing hospital trusts within the NHS, and Bart’s was planning to set up such a Trust when its independent future was called into question by the publication in 1992 of Sir Bernard Tomlinson’s Report of the Inquiry into the London Health Service. This did not see Bart’s as a viable hospital and recommended its closure. The Government’s response to this report was published in 1993 and laid out three possible options for Bart’s: closure, retention as a small specialist hospital, or merger with the Royal London Hospital and the London Chest Hospital. This sparked an intense public debate and a campaign to save the Hospital on its Smithfield site. After public consultation, in April 1994 the Royal Hospitals NHS Trust was formed, amalgamating the three hospitals. Homerton became a separate Trust, and Queen Elizabeth Hospital for Children joined it, providing paediatric services to the new DGH. The Turnberg strategic review (1997) supported the case for redevelopment of a 900 bed secondary and tertiary care hospital in Whitechapel, while maintaining some tertiary services on the Smithfield site with a particular focus on cardiac and cancer services. Bart's was to remain open in this role, whilst general hospital services would be concentrated at the Royal London in Whitechapel. A billion pound PFI development was planned.

New building was proposed at Whipps Cross and Newham General (a nucleus hospital) and an entire new hospital at Romford on a new site.

North Central London

The medical schools of UCH and the Middlesex Hospital had for some time been working with each other when Patrick Jenkin, as Secretary of State in the early eighties, took the decision to unite their two districts as Bloomsbury, encouraging the University of London to merge the matching medical schools of UCH and the Middlesex. With the Royal Free Hospital, the University College London Hospitals Trust provided the main university sites. Of the UCL hospitals, the Eastman Dental Hospital, built and largely funded by an American, George Eastman of the Eastman Kodak Company was granted special health authority status and in 1996 joined University College London Hospitals NHS Trust. The Elizabeth Garrett Anderson Hospital was built in 1888 and became part of UCL Hospitals NHS Trust in 1994. The Heart Hospital was founded in 1857 and became part of the NHS in 1948 as the National Heart Hospital When its services were moved to the Brompton in 1994 the hospital, it again become privately owned, and was re-opened as a world class private hospital, featuring state of the art accommodation and equipment, and specializing in cardiac treatment. Falling into debt as a private institution, the hospital re-joined the NHS in August 2001, when it was bought by UCLH. It became the home for the trust's cardiac services, previously housed in The Middlesex Hospital but worked well under capacity as the waiting lists for cardiac surgery fell throughout the country. The Hospital for Tropical Diseases has an ancestry dating back to the Dreadnought Hospital and in 1920 became the home for the London School of Tropical Medicine and the Hospital for Tropical Diseases. The hospital eventually moved to a building in the grounds of the St Pancras Hospital and in 1948 became part of the University College Hospital Group. The Middlesex Hospital became part of the Bloomsbury District in association with UCH in the restructuring of 1982. The National Hospital, Queen Square, for Diseases of the Nervous System including Paralysis and Epilepsy, was founded in 1859. In 1948, with Maida Vale, the two hospitals were designated a postgraduate teaching group to be administered by a board of governors, directly responsible to the Minister of Health under the new NHS. The Hospital for Sick Children, Great Ormond Street, re-examined its role as part of a network of children's' services in north central London. The Institute of Neurology is now affiliated to UCH and provides undergraduate and postgraduate teaching to the medical school. The Royal London Homoeopathic Hospital, established 150 years ago, joined forces with UCLH in April 2002. Turnberg supported the proposal for capital development and ground was broken in 1999 for a rebuilding scheme; a £422 million private finance initiative that opened in 2005 to unite the University College London Hospitals on a single site and to provide a diagnostic and treatment centre. The Chief Executive was known to some of his colleagues as "Bob the Builder".

Elsewhere substantial development was also taking place. The first phase of a new Barnet General Hospital opened in 1997. A major development was under way at the Whittington, and development was proposed at Chase Farm and the North Middlesex.

North West London

Centrally the sector contained the Hammersmith, Queen Charlotte’s/Chelsea Hospital for Women, Charing Cross and, in close proximity St Mary’s, the Chelsea and Westminster and two specialist hospitals, the Royal Marsden and the Royal Brompton.

In northwest London in 1984 the medical schools of Charing Cross and Westminster hospitals united, and in the following year the districts in which they were situated were merged into one authority, Riverside District Health Authority, with plans to rebuild and reduce the number of hospitals to two. The new Chelsea and Westminster Hospital, which enabled the closure of five separate hospitals, opened in 1993. Brent and Paddington District Health Authorities had considered merger; ‘we’re huddling together for strength and warmth,’ said the district manager. In 1988 Parkside Health Authority was created, uniting St Mary’s and the Central Middlesex, leaving St Charles’ as a non-acute community hospital. The plan involved the part-rebuilding of St Mary’s and rebuilding the Central Middlesex, the first phase being a pioneering ambulatory care centre.

The Turnberg report on London's health service in 1997 called for more rational distribution of specialist services in north west London. The outcome was the Paddington Health Campus project, a variant of the proposals in the Pickering Report of the 1960s to be funded by PFI. It would bring together Royal Brompton & Harefield NHS Trust, St Mary's NHS Trust, Imperial College's National Heart and Lung Institute and north west London’s specialist children's services to share one site in Paddington. The Business Case was approved by the Department of Health in 2001, but the cost steadily escalated until it was clear to everybody that it was not viable. It was cancelled in 2005. The Hammersmith/Queen Charlotte's new maternity facility opened in 2003.

Further out the Medical Research Council (MRC), under financial pressure, decided to pull out of its Northwick Park Clinical Research Centre and concentrate at the Hammersmith Hospital. This freed modern accommodation and research space. A small specialist hospital concerned with coloproctology, St Marks, needed to move from its poor accommodation in City Road. St Marks had the foresight to realise that it had more to gain than lose from a merger and grasped the alternative, Northwick Park, with enthusiasm. Relocation in 1995 provided the hospital with immediate access to intensive care, theatres and state-of-the art imaging and service departments. St Marks had its own front door, clinical directorate and all the advantages of association with a busy district general hospital. Organisationally there was amalgamation within the North West London Hospitals NHS Trust incorporating Northwick Park & St Mark's and the Hospitals in Harrow, the Central Middlesex covering Wembley, Willesden, Edgware, Harlesdon and Stanmore.

The National Heart Hospital had closed with the transfer of its services to The Brompton; the building passed into private hands and was later sold on to University College Hospitals London. Subsequently the Royal Brompton & Harefield NHS Trust was established on 1st April 1998 as the largest post-graduate specialist heart and lung centre in the United Kingdom. It is based on two sites, one in the heart of London and one in Middlesex. The Trust provided comprehensive patient services for all age groups from infancy to old age and is associated with its multi-faculty university partner Imperial College School of Medicine within which is the National Heart and Lung Institute.

Turnberg supported the approach to collaboration in the rationalization of services that was being undertaken by the hospital trusts and Imperial College.

South West London

In south west London the position of St George’s was secure, and the plans to relocate the Atkinson Morley Hospital to the St George's site, and further developments there, were supported by Turnberg. The neurosciences and cardiac centre, the Atkinson Morley Wing, opened in October 2003.

South East London

In southeast London the medical and dental schools at Guy’s and St Thomas’ had merged as the United Medical and Dental Schools. There was protracted discussion and much in-fighting about the future of Guy’s and St Thomas’, whether one or the other site should close, where the accident and emergency department should be situated, and where specialised services should be concentrated. Turnberg commented that the merger of the two Trusts had allowed the development of proposals for rationalizing services across the two sites and St Thomas' became the main centre for A and E. There had also been discussion about the distribution of specialised services between St Thomas', Guy's and King's College Hospital. A new wing at King's College Hospital opened in 2003 and a new Children's Unit is planned. Turnberg examined redevelopment of acute services in Bexley and Greenwich, and supported the redevelopment of Queen Elizabeth Hospital to replace services at Greenwich, built under PFI at a cost of £93M, and now open.

Foundation Hospitals

In July 2002 it was formally stated that acute hospital trusts that had performed well, as assessed by the star system, could apply to be "NHS foundation trusts". Foundation trusts were expected to have greater freedom in terms of management, relations with the local community, and financially. The idea, anathema to many old Labour supporters, was watered down in its passage through the House, but a number of London hospitals appeared in the first wave, and more subsequently.

London foundation hospital trusts established during 2004 included

Basildon and Thurrock University Hospitals NHS Foundation Trust
Homerton University Hospital NHS Foundation Trust
Moorfields Eye Hospital NHS Foundation Trust
The Royal Marsden NHS Foundation Trust
Guy’s and St. Thomas’s NHS Foundation Trust
University College London NHS Foundation Trust

University

Target 1997

London total