Whither London's health care? - government policy for health care in UK

Contemporary Review, Dec, 1993 by David Gladstone

Those who are interested in the hospitals of London

and their future cannot ignore their past.[1]

THE future pattern of London's health services has received considerable and continuing publicity since the publication of the Tomlinson Report in autumn 1992.[2] Not surprisingly, much of that publicity has centred on the issue of hospital closures and amalgamations. But the issues involved go much further. What is the future role for hospital care? Is primary care set on an inevitable upward curve? Can the improvements and expansion of primary care be adequately funded simply by diverting resources from the hospital sector? Is London inevitably a special case in matters relating to health care?

These are major issues relating not only to London, but to the future of health care in the United Kingdom towards 2000 and beyond. The dangers of moving both too slowly and too quickly are also obvious. On the one hand there is a risk of lowering staff morale and creating blight if change proceeds too slowly. But if the pace is too fast there may be insufficient time to consult as widely as necessary and to consider the options for the future sufficiently thoroughly. In his recent speech to the British Association, Sir Bernard Tomlinson himself argued that there was a case for special government funding to be made available over a limited time period in order to prevent piecemeal disintegration and to create the conditions for a planned rationalisation of the hospital service.[3] But, as his Report made clear:

The development of primary and community health services ... must go hand

in hand with the nationalisation and reduction of capacity in the hospital

sector.[4] Much less public attention seems to have focussed on that recommendation. And how far does the Department of Health see the changing relationship between the sectors as a complementary objective of its policy for London's health care future?

The publicity that has surrounded at least some of the Tomlinson recommendations may give the impression that the special situation of health care in the capital is something new. That is not the case. The Lancet pointed out as long ago as 1920:

The embarrassing position of London in matters of health administration has

always been recognised by those who study local organisation, and the problem

of developing, and where necessary remodelling, that administration when the

health of so vast and heterogeneous a population is concerned, is admittedly

one of continuing difficulty.[5]

That this has continued to be so is seen in the number of attempts over the past twenty years to create change in the system of London's health care. That change has been of two kinds. The first has concerned the delivery of health care to patients. The second and, in some sense, related change has been about the pattern of medical education and has involved a succession of activity by the University of London. Adaptation, co-ordination and rationalisation have been recurrent themes in both sectors. Tomlinson is much in keeping with that tradition; but, uniquely, his Report addressed both the issues of future patient services and the structural arrangements for medical education and training. Both these aspects were contained in the remit he was given which was, inter alia; to advise the Secretaries of State for Health and Education ... on the provision of health care for inner London ... taking account of ... the need to maintain high quality patient care and, as a foundation for this, high standards of medical teaching research and development.[6]

Earlier attempts at change

Prior to the Tomlinson proposals, potentially one of the most significant changes to the delivery of patient care in London was the recommendations of the Resource Allocation Working Party (RAWP). This Working Party was set up within the Department of Health and Social Security ~to ensure, through resource allocation, that there would eventually be equal opportunity of access to health care for people at equal risk'.[7] Its concern was with how, in a situation of tighter control on public spending such as characterised the mid-1970s, some progress could none the less be made in the direction of a more equitable distribution of health care resources. The answer lay in re-defining the historic formula on which resource allocation decisions had been taken. Rather than being based on the costs of services currently provided or the formula that had determined the allocation of resources since the creation of the National Health Service, the RAWP Report recommended that each Regional Health Authority should receive funding based upon the size of its population weighted by standardised mortality ratios and a set of other factors. Such a method of attempting to overcome the inequities of Julian Tudor Hart's much publicised Inverse Care Law -- where health needs were greatest, fewest resources were available -- posed a considerable threat to the hospital service in London.

On the basis of the new RAWP formula, each of the four Thames health regions was considerably over target and, in consequence, their financial growth rate was to be set below the national average. This at once raised the issue of the concentration of specialist hospitals in London and the services which they delivered not only to residents of the capital but to patients from throughout the United Kingdom and, indeed, from other countries as well. A reduced level of funding also threatened to reduce the position of London's teaching hospitals as centres both of high technology medicine and of excellence in medical research. If it had done nothing else RAWP had brought to the fore the distinctiveness of London's specialist hospital service and sharpened the debate about its future.