LETTER : Pressures and fallacies that shape London's health service

From Dr Robert J. Maxwell

Sir: Your editorial (6 March) reflects a rising tide of public disquiet about the closure of London hospitals. Our own position is that the strategic objectives of current policies are largely correct, but that great care is needed with the handling, sequence and pacing of the changes. That London will have fewer acute hospital beds in 10 or 20 years than it has now is a certainty based on clear trends in hospital utilisation, medical technology and hospital costs.

The balance of beds in London is skewed towards inner London and specialist hospitals, and away from outer London and more general acute beds. London is also desperately short of nursing home and residential care for the elderly. In many instances there are too many specialist units, each handling too few cases. Hence a number of shifts are required within London's hospital and residential care system in the longer term.

London's primary care is relatively weak. It needs strengthening, as a measure in itself. In the short term this will not lead to a reduction in the demand for hospital beds, but it is a prerequisite for the eventual transfer of care from hospital to the community. In addition, there is a need to develop and test a variety of means of improving the ways in which all parts of the NHS and social services work together in the care of vulnerable groups, particularly elderly patients with multiple illnesses.

On our figures, there were 1,300 fewer hospital beds in London as a whole in April 1994 than a year earlier. This is not the result of Tomlinson, but the predictable workings of a market in which all inner London health authorities are under severe budget pressure and few patients are being referred into inner London.

We are arguing for no further overall reductions in bed numbers while the pressure on beds remains as great as it now is, and great care with accident and emergency closures. We do not seek a moratorium on change - for example, bed numbers could be increased on neighbouring sites before a site is closed - but great care in the management of the changes.

We have not changed our minds about the shape of health services that London needs for the future. It would be tragic after the misery of the past three years for the momentum for change, and the vision of what we want to create, to be lost. This vision is of a smaller number of hi-tech centres of excellence providing specialist care to larger populations, while the need for more routine acute surgical and medical care and continuing care for vulnerable groups, such as elderly people and those with mental health problems, is made more locally accessible. Returning with a vast sigh of relief to the past truly is not a feasible option.

In recalling the London Commission, which the King's Fund is in process of doing, we will look again at what pattern of health services London needs for the future. If the evidence leads us to revise our conclusions, we will do so. We will also be considering what has happened in the past three years, what can be learnt from that experience, and how to move on from here.

Yours faithfully,

ROBERT MAXWELL

Chief Executive, King's Fund

King Edward's Hospital

Fund for London

London, W2

7 March