From Districts to Trusts - London’s hospitals from 1982-2009

Issues affecting London

Conservative governments and NHS reorganisation (1982-9)

The review of the NHS in 1983 by Sir Roy Griffiths was the direct outcome of the chaos of the industrial action of 1982.  Thirteen unions (including the BMA and the RCN) were involved.  While the main issue was pay, the unions also felt that the current system was no way to run a health service.  Kenneth Clarke, as Minister to Norman Fowler's Secretary of State, was concerned that the steady growth of non medical manpower was adding an extra burden to the NHS. As well as the main negotiations with the 13 unions, there were less formal contacts with the TUC and Confederation of Health Service Employees (COHSE), and with the RCN.  Ministers wished to get the nurses on side and having been told that there was a possibility of a pay review body specifically for them, the College's opposition became more muted.  The other unions began to sense defeat and welcomed the ides of a management review as a component of the final offer.

The Permanent Secretary, Sir Kenneth Stowe, was asked to establish it and used contacts in the Bank of England to find a good private sector manager who could consider the application of effective management principles to the NHS.  Sir Roy Sainsbury identified Roy Griffiths as a fine manager in a customer based service.  Sir Kenneth had a difficult 45 minute interview with Griffiths who was poker faced until he smiled and accepted.  While Kenneth Clarke had wanted the review to be more about manpower than management,  Griffiths insisted that manpower was the secondary issue.  A team of four was selected, including a personnel director from BT, a finance director from United Biscuits and a regional administrator; the terms of reference were left somewhat vague, to advise on the effective use and management of manpower and related resources 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’.

Griffiths' recommendations included a small, strong general management board in Whitehall, that all day-to-day decisions should be taken in the main hospitals and other units and clinicians should be involved more closely in management decisions, should have a fully developed management budget and the necessary administrative support. A general manager should be identified (regardless of discipline) at each level and authorities should have greater freedom to organise the management structure suited to their needs. Griffiths believed that the lack of a clearly defined general management function was responsible for many problems and that the development of management budgets was vital.  Consensus had to go. The government rapidly accepted the general thrust of the report.

In addition

Regional and district authorities received funds according to the size of their resident populations, weighted for age and morbidity and for the differences in the cost of providing services. RAWP had almost established equity so it was easier to move from historic allocations to a weighted capitation system

There was an attempt to devolve decisions (through fund holding and trusts) to those closest to the people, introducing greater local diversity, competition and choice

Hospitals and community services could apply for self-governing status as NHS trusts. Between 1991 and 1995 NHS hospitals were progressively transformed into publicly owned substantially self-governing bodies. Managerially élite hospitals had substantial freedom. Seen by government as a potential flag-ship of the reforms, Guy’s believed that trust status would ensure that a major building scheme would go ahead, guaranteeing its survival.  While the idea had been developed with acute hospitals in mind, before long applications were received from mental illness and community services.  They too saw advantages in the freedom of action that trusts enjoyed.

Fund holding: GP practices could apply for their own NHS budgets to cover their staff costs, prescribing, outpatient care, and a defined range of hospital services, largely elective surgery.  Systems of medical audit were introduced to ensure quality of service

Authorities were reformed on business lines, with executive and non-executive directors

The legislation passed in 1990. There were substantial and unexpected effects on London's hospitals and anxiety that purchasers would make radical changes, avoiding high cost hospitals in the centre.  An 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 Labour successor Frank Dobson but by his - Alan Milburn - ten years later. Ministers continued the implementation of the reforms, until 1997, when the Conservatives lost power. Industry had been removing middle management, ‘downsizing’ and producing ‘flatter’ organisations. Few foresaw that regions might be abolished. Their last major task was to oversee the implementation of the NHS reforms, managing the fund holding scheme and supporting districts in their purchasing functions. A review in 1993 of the relationship of the 14 RHAs with the centre  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 Department of Health. 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 and ultimately in the return of regional organisation in the shape of Strategic Health authorities, albeit with slightly different functions.

Regional outposts had less power for money no longer flowed through them. Health authorities were formed by merging the residual DHAs and FHSAs. They commissioned services within their allocated funding and made arrangements with GPs and other contractors. As trusts were established, districts ceased to have responsibility for hospital management. Combining a residual management function with purchasing was difficult.

The new NHS - Modern, Dependable involved substantial change in London’s organisational structures.  London had been divided into four health boards at the start of the NHS (plus Boards of Governors for teaching hospitals), into 4 regions in 1974, and in 1996 as a result of a review of regional functions into two, north and south of the river.  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 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 fund holding to an end. Its alternative was commissioning by Primary Care Groups (PCGs), later Primary Care Trusts. The number of health authorities fell and they were abolished, as their responsibility for commissioning services disappeared. 

Labour's second wave of changed structures and policies. (2000)

The replacement of Frank Dobson in 1999 as Secretary of State for Health by Alan Milburn heralded more change, Milburn wished it to be fast and over a broad front.  Labour's second policy document was issued in July 2000 - the NHS Plan (10). Labour had consulted the professions which had been deeply and often enthusiastically involved. 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'. Against the predictions of many, substantial progress was achieved for example in terms of waiting times and waiting lists. The replacement of Frank Dobson by Alan Milburn and successors imposed further challenges on the NHS generally as well as in London. Milburn’s policies involved a greater role for the private sector, for example in the private finance initiative and independent treatment centres, a wider choice for patients, IT systems to underpin choice, for example Choose and Book, radical changes in funding with the introduction of tariffs and Payment by Results, and Foundation Hospital Trusts with greater freedoms.

 The NHS Plan's structural reorganisation took place on 1 April 2002, "devolution day".  Health authorities were replaced by a smaller number of Strategic Health Authorities. Nationally there were 28 with five for London.

The five London SHAs were not concerned with day to day management and needed to coordinate some services on a London wide basis.  They shared out the lead London roles including National Service Frameworks e.g. cancer, the elderly, primary care and children’s services, the five SHA Chief Executives meeting regularly with the Director of Health and Social Care at Departmental level. 

Hospital Services

A new imperative was now emerging - rationalising/reconfiguring the hospital system. The need to provide specialised expertise 24/7, medical staffing issues and the restriction of the total hours worked under EC legislation had transformed the criteria for defining the size a hospital should be to carry out clinical services safely.  The progressive separation of sub-specialties from the mainstream of general medicine and surgery added to problems. The need for rotas of  consultants in all the subspecialties could be accommodated in a large hospital but not so easily in smaller District General Hospitals (DGHs). In the 1960s there had been a clear concept of the nature of a DGH.  Now far more specialties were involved in care, and there had to be several of each type to provide a 24 hour service. It might only be possible to staff fewer major hospitals, strategically placed, that could offer a full range of secondary and tertiary services. These might be supported by more local facilities. National Service Frameworks developed for clinical specialties outlined clinical networks of hospitals varying in the sophistication of their services.  Reports of the BMA, Royal College of Physicians (RCP) and Royal College of Surgeons of England echoed the earlier thinking of the Bonham-Carter Report (1969), suggesting that a single general hospital now should serve populations of not less 500,000.(14) (The provision of Acute Hospital Services, London, RCS 1998)  Such hospitals should provide a tertiary service for a population of around a half a million.

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 treatment centres, many in the private sector, became a priority in government thinking.  In London few were developed, other than that at the Central Middlesex which itself operated under capacity. The Darzi report (2007) [19} and its successors accelerated the process.

A related problem was the provision of effective emergency care when most consultants were super-specialists. 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 specialty, required by each hospital taking acute admissions. 

Biomedical Research Centres

Service assessment and planning

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 in the early 1992, one by the King’s Fund and one later that year 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 the lesser impact.

The Conservatives, though committed to market solutions, also embarked in London on strategic planning. At the 1991 Conservative Party conference William Waldegrave, then Secretary of State, announced a review to be undertaken by Sir Bernard Tomlinson, Chairman of the Northern RHA.  The Times said that Mr Waldegrave was ‘wringing his hands’ over what should be done in London and needed to be convinced that major decisions were intellectually based. There were many bids for development.  UCH/Middlesex, strongly supported by the scientific community because of the quality of its work, wanted a new building and this might mean the closure of other hospitals. Already expansion had been approved at Guy’s, the Chelsea and Westminster was established and St Mary’s was being developed.  By commissioning the inquiry, William Waldegrave had delayed the need to take action before a forthcoming election.

Tomlinson reported in October 1992.  He emphasized 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 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. The changes to the hospitals and to primary health care were unpopular and not politically easy to fight.  A primary care support force worked to improve matters and was disbanded in 1997; few of the issues the group was to address had been resolved.

The Tomlinson Report 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 Mark's 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 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 was continuously involved in the decisions being taken. The Higher Education Funding Council (HEFCE), as a member of LIG, was involved in 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.  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.

Labour came to power and accepted the need to co-ordinate the planning of health services with changes in medical education. The new Secretary of State for Health, Frank Dobson commissioned a strategic review of inner London. Led by Professor Sir Lesley Turnberg, 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.  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. 

Turnberg felt that a five sector scheme would assist planning and that health authorities should work together at sectoral (later SHA) level.  These 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).  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 used and within the slices PCTs, Trusts and the educational authorities had a commonality of interest that led them to work with each other, rather than with other pizza slices. 

The London SHAs 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. They reflected the Turnberg review that services of a specialised nature should be commissioned within five sectors each relating to the new University of London medical school groupings.  On the board of each of the London SHAs was a representative of the local higher educational institutions. 

Imperial College, whose Faculty of Medicine was established in 1997, was secure in its prestige and size, and took a firm line with the medical schools now an intrinsic part of its empire, and indeed with the hospitals to which it related. In 2003 it was given the power to award its own degrees, outwith the University of London, but did not immediately use them. On the NHS side in 2007 St Mary's Hospital Trust, The Hammersmith Hospitals Trust, and Imperial College united to become the Imperial College Health Care Trust and was selected as one of five National Biomedical Research Centres.  Imperial thought that globally there was only room for 5-6 major biomedical research and teaching centres, perhaps two in the USA, one in the far east and two in Europe.  Imperial considered itself the natural premier league centre in the UK. 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 there was a thorough reorganization to develop an integrated medical school. There would be one organisation using the same letterheads.  The Faculty was spread over seven campuses, six the sites of major teaching hospitals.  These were

· the Hammersmith & Charing Cross (Hammersmith Hospitals Trust),  In 1988 the Royal Postgraduate Medical School merged with the Institute of Obstetrics & Gynaecology and became part of the Imperial College School of Medicine on its formation in 1997

· St Mary's (St Mary's Hospitals Trust),

· The Royal Brompton.  The Brompton and Harefield NHS Trust was established on 1 April 1998 following the merger of Royal Brompton Hospital and Harefield Hospital. The National Heart and Lung Institute (itself formed by merger in 1988, and situated next to the Royal Brompton Hospital,) became part of Imperial College in 1995, and part of Imperial College School of Medicine in 1997

· Chelsea and Westminster (Chelsea and Westminster NHS Trust) and

· Northwick Park (North West London Hospitals Trust).

University College London was less forceful.  University College London Hospitals while having only small local catchments, had substantial financial assets and an ideal academic location next to UCL, and perhaps the strongest research base in London. It too was selected as a National Biomedical Research Centre. In July 2008 UCL with Great Ormond Street, Moorfields Eye Hospital, The Royal Free and University College London Hospitals came together as UCL Partners, to create "London's leading health research powerhouse" focussing on ten areas of research each of which posed a major health challenge, e.g. children's health, cancer and women's health. 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 even though the Royal Free remained under separate NHS management.  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 2005 UCL was awarded independent degree awarding powers by the Privy Council.  Students already in courses would have the option of a degree from UCL or the University of London, those medical registering after 2007 would have a UCL degree. Such moves, covering all subjects and not solely medicine, tended to undermine London University.

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.  Barts and the Royal London had everything one could desire in terms of a local population, but the association with QMC, comparatively weak as a research institution, did them no favours.

A Single Health Authority for London

In 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. A review of the primary care trusts and SHAs left the PCTs that were largely coterminous with boroughs alone, but led to a single SHA in London in July 2006, a centre for strategic thinking covering 32 London Boroughs with a population of approximately 7.2 million.  It faced problems, for example the emergence of Foundation Trusts that had a capacity for independent action and a reduction in the number of trusts under its aegis as the number of Foundation Trusts grew. However it soon comissioned Sir Ara Darzi (as he then was) to report on a strategy for London.  In 2009 a new London Clinical and Business Support Agency was formed to support PCT commissioning, providing clinical evidence, public health intelligence, 'provider intelligence' and contracting support.   London PCTs would finance and oversee it.  The new body would take over several bodies under the SHA including Healthcare for London, overseeing reforms including the introduction of polyclinics, the London Health Observatory and the London Development Centre. London's medical director and quality observatory would work in the new Agency.

Capital Development

The Turnberg 5 sector scheme is a convenient way to consider capital developments. Some new hospitals planned in the 1970s had opened in the 1980s, e.g. the Newham Hospital (opened in 1983) and the Homerton in Hackney in 1986 on the site of the previous Eastern Hospital, incorporating Queen Elizabeth Hospital for Children.  Further development was supported by the Private Finance Initiative, and major changes took place in each of the five sectors which provided a good framework for analysis and planning.

Among the largest schemes were the Chelsea and Westminster, St. Mary's – a complex saga, University College Hospital/The Middlesex, and The Royal London/St Bartholomew’s. The advantage of PFI was that money was forthcoming that would not otherwise have been available.  The problems of PFI were the inflexibility once the building had been opened and the financial costs that stretched way into the future and sometimes closed off other possibilities.

North East London

One of the greatest planning conflicts of the last two decades of the century involved St Bartholomew's Hospital and The Royal London.  As part of the NHS reforms (1990) 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. This did not see Bart’s as a viable hospital and recommended its closure. The Government’s response in 1993 laid out three 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.  In April 1994 the Royal Hospitals NHS Trust was formed, incorporating the three hospitals. The Turnberg strategic review (1997) (commissioned by Frank Dobson) 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, mainly cardiac and cancer services.  Bart's would remain open in this role, whilst general hospital services would be concentrated at the Royal London in Whitechapel.  A billion pound PFI development began, the financial cost of which overhung the hospital and delayed its application for foundation trust status.

New building was undertaken at Whipps Cross and Newham General (an Ambulatory Care and Diagnostics Unit and an adult mental illness unit). The new Queen’s Hospital in Romford brought together the services previously run at Oldchurch and Harold Wood hospitals; built under the PFI, it opened in 2006, complementing the rebuilt St George's Hospital Ilford where lower risk and midwife led maternity care was provided. The Queen's Hospital provided a full range of non-clinical services and a managed equipment service under a 36-year concession agreement with Bovis.

North Central London

The Department of Health had stimulated discussion between the medical schools of UCH and the Middlesex Hospital, two organisations with a similar ethos, and encouraged by this Patrick Jenkin, as Secretary of State in the early eighties, united 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 (UCLH) 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 but in 1996 joined UCLH. The Elizabeth Garrett Anderson Hospital was built in 1888 and became part of the same 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 was re-opened as a private hospital, featuring state of the art accommodation and equipment and specializing in cardiac treatment. Falling into debt, the hospital re-joined the NHS in August 2001, when it was bought by UCLH to became the home for the trust's cardiac services. 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 UCLH.  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 Institute of Neurology affiliated to UCLH to provide undergraduate and postgraduate teaching. The Royal London Homoeopathic Hospital, established 150 years ago, joined forces with UCLH in April 2002.  Turnberg supported the proposal for capital development at UCLH and ground was broken in 1999 for a £422 million private finance initiative that opened in 2005 uniting most of the University College London Hospitals on a single site and providing a diagnostic and treatment centre. The old Middlesex Hospital site was sold off profitably for redevelopment as flats gaining the Trust £175 million.  With its new development commissioned, and its financial situation sound, the Trust rebuilt its obstetric hospital (the EGA wing) and looked at the possibility of bringing other hospitals, including postgraduate teaching hospitals, onto its site.

North West London

A new strategy - NHS London and the Darzi Reports

A Framework for Action  was published in July 2007.  It appeared days after he was appointed by Gordon Brown as a junior health minister with a seat in the Lords. The report was a substantial document, the product of many hands including McKinsey's. It recommended 5 principles, an individual focus on patients' needs, services local where possible and centralised where necessary, focus on health inequalities, prevention rather than cure and truly integrated care. Technical groups had looked at population trends, and the likely health problems in London over the coming years.  Clinical working groups had considered appropriate policies for care and the care pathways that seemed best suited to differing groups of patients.  On this basis a changed pattern of health service organisation was proposed 

References

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[2] London Health Planning Consortium. Acute hospital services in London. London: HMSO, 1979

London medical education. A new framework. Report of a working party on medical and dental teaching resources. (Chairman: Lord Flowers.) London: University of London, 1980.

[3] Department of Health. Report of the inquiry into London's health service, medical education and research. (Chairman: Sir Bernard Tomlinson.) London: HMSO, 1992

[4]  Health Services in London – a Strategic Review.  (The Turnberg review).  London.  Department of Health. 1987.

[5] NHS Management Inquiry. Letter dated 6 October 1983 to the Secretary of State, Norman Fowler, from Roy Griffiths, Michael Betts, Jim Blyth and Sir Brian Bailey.

[6] Parliament. Working for patients. Cm 555. London: HMSO, 1989

[7] Enthoven AC. Reflections on the management of the NHS: an American looks at incentives to efficiency in health services management in the UK. London: Nuffield Provincial Hospitals Trust, 1985.

[8] Dorrell S. The Millennium lecture. Manchester Business School, 1996

[9] The new NHS - Modern, Dependable, Cm 3807, Department of Health, London, 1997

[10] Parliament, The NHS Plan – a plan for investment, a plan for reform, Cm4818, London, 2000

[11] Primary Health Care in inner London (the Acheson report) (1981)

[12] Parliament.  Promoting better health, the government’s proposals for improving primary health care.  CM249 London.  HMSO. 1987

[13] Parliament  NHS Plan – a plan for investment, a plan for reform. Cm 4818, London 2000

[14] The provision of Acute Hospital Services, London, RCS 1998

[15] Cuts and excellence [leading article]. BMJ 1982; 284: 294

[16] London : King's Fund London Initiative, 1992  London health care 2010 : changing the future of services in the capital .   King Edward's Hospital Fund for London. King's Fund Commission on the Future of London's Acute Health Services

[17] Department of Health. Report of the inquiry into London's health service, medical education and research. (Chairman: Sir Bernard Tomlinson.) London: HMSO, 1992.

[18] Great Britain, Ministry of Health and University Grants Committee. Postgraduate medical education and the specialties (with special reference to the problem in London). (Chairman: Sir George Pickering). London, HMSO, 1962.

[19]  A Framework for Action. Healthcare for London (NHS London)  Lord Darzi. London 2007