Response to the Tomlinson Report

The Socialist Health Association starts from the premise that health services should be planned to meet health needs.  Services for Londoners should be planned by a single strategic health authority for Greater London.  Londoners need access to high quality primary and community services and to a network of district general hospital services, comprising general medical, surgical and accident and emergency departments.  Referral and access to specialist services should be easily available when appropriate.  Funding for undergraduate and postgraduate education and research should be disaggregated from the provision of comprehensive local health services.

The Socialist Health Association deplores the introduction of market forces into the National Health Service.  Decisions should be determined not by extraneous costs (such as land values) but by effective use of resources and measured outcomes.

The Socialist Health Association makes the following response to the Tomlinson Report:

Historic underfunding and impact of the internal market

1. The financial crisis in London’s hospitals is caused by a combination of a historic pattern of provision, long-term underfunding and the impact of the internal market. The market is an inappropriate way of providing health care: it threatens hospital services in areas with high overheads and capital charges and takes no account of health care need and local
2. Funding of the NHS over many years has not matched inflation in health costs or demographic changes. The pattern of annual financial crises has forced hospital managers to take short-term measures to reduce costs, without the benefit of a broader over-view of the longer-term needs of Londoners in terms of specialist, general and geriatric beds. Capitation funding, as currently proposed, will compound the problem.
3. Primary and community services provision has continued to be inadequate and well below national averages, due to lack of investment in staff and premises. Community services have been cut during the 1980s, with significant reductions in numbers of health visitors, community nurses and other ancillary staff.

The SHA proposes a comprehensive health needs assessment

4. The terms of reference state that the enquiry should “take account of the health needs of London’s resident and day time populations”. However the Report states “… we have not seen it as part of our remit to carry out a comprehensive health needs assessment for the whole of London, we have looked briefly at various indicators” and “… the population of London presents a range of need unparalleled in the rest of England” (Tomlinson, paragraph 20, page 6). The Report fails to demonstrate that its recommendations will meet this range of needs and the depth of deprivation identified.
5. The health needs section of the Report is therefore inadequate as a basis for making judgments on the health care services required. Most of the assessment focuses on mortality, but morbidity in an inner city population is often much more important as a predictor of service demand. For instance, work in City and Hackney on the needs of elderly people shows that there is a significant population of frail elderly people living alone, who require a great deal of support from community services, also having frequent admissions to hospital for acute and respite care. The number of Londoners moved out of the capital for continuing and nursing home care is not recorded, but failure to include them in assessments for NHS and local authority community care planning distorts data on the mortality and morbidity of London’s elderly population.
6. No data is presented on infant mortality, teenage and unwanted pregnancy, vaccination and immunisation uptake rates, drug and alcohol misuse, HIV and AIDS, or cervical and breast cancer screening uptake.
7. Any enquiry into London’s health services needs to recognise that the prevalence of social deprivation in London is particularly high. According to a Child Poverty Action Group report published in November 1991 one million Londoners live on income support and 750,000 earn poverty wages. More than 25% of schoolchildren in the twelve inner London boroughs get free school meals. By the end of November 1991 unemployment in London had risen to 11.1% while throughout 1990 almost one quarter of London’s adult full time employees were defined by the Low Pay Unit as being low paid.
8. London Housing Unit statistics indicate that by the end of the third quarter in 1991, 60% of people in Britain accepted as homeless and living in temporary accommodation were in London. The total of unsatisfactory dwellings in London remains persistently high with some 34% of public sector housing and 24% of private housing either unfit or requiring repairs costing over £4,500 at April 1990.
9. The level of drug misuse and the number of people diagnosed with AIDS is significantly higher in London compared to the rest of the country. London Research Centre figures indicate that almost 50% of Britain’s regular users of notifiable drugs live in London. Figures on the number of people with AIDS reveal that the four Thames regions accounted for over 70% of known cases as at 30 November 1991, due to the concentration of specialist services in London.
10. There are many ethnic groups with different needs which must be met. They account for some 15% of London’s population, with a forecast growth of a further 6% by 2001. The diversity and mobility of the ethnic groups present challenges which need appropriate responsiveness from health as well as local authorities. This section of London’s population is often concentrated in particular areas, notably in inner London where the percentage of people of various ethnic origins reaches 33% in places. Again age distribution is changing with the number of Black pensioners in London predicted to increase by as much as 84% over the next decade.
11. The Socialist Health Association calls for an accurate assessment London’s health needs, including information drawn from the 1991 census and reports from District Public Health Departments, to be undertaken before any significant changes are made to London’s services.

SHA calls for a Greater London Health Authority

12. The Report makes frequent reference to the need for pan-London planning but rejects the concept of a London Health Authority. The Socialist Health Association proposes an elected single Greater London Health Authority to enable services to be planned across the four Thames Regions which fall within the Greater London area. Those parts of the Thames regions which would not form part of a Greater London Health Authority need to be considered in relation to other surrounding regions.
13. The impact on patients and implications for services in Greater London and in the shire parts of the present Thames Regional Health Authorities of possible acute hospital closures in inner London has not been addressed. Patient choice, so recently promoted by the government, could not be delivered in the face of the hospital closures proposed or, indeed, by the internal market.
14. The Socialist Health Association agrees that health and local authority boundaries should be co-terminous, to strengthen the link between health and social services, and with other local authority services including housing, education and environmental health. Logically, strategic health planning should be a function of an elected Greater London Authority with responsibility to co-ordinate other aspects of strategic planning, such as transport and the
15. There are references in the Report to public consultation but no mechanism to achieve it, or to involve local authorities, CHCs or users in debating the report’s far-reaching Instead, “changes are to be driven briskly by a dedicated Implementation Group”, which will be wholly unaccountable. Unless this democratic deficit is addressed, so that Londoners who use and work in the health services are able to contribute to a constructive debate there will be widespread protest at changes which are perceived to be finance-driven. What is required is a public debate with an accountable authority to ensure the use of resources to meet the health needs of Londoners.

Effectiveness and equity

16. The Report states that the forces of the internal market highlight inequity and inefficiency in the present distribution of hospital facilities (Tomlinson, paragraph 8, page 3). In fact it is the market itself which is leading to haphazard deterioration of London hospital services.  It does nothing to improve equity.
17. The Report concentrates heavily on efficiency, but does not address in any detail effectiveness, accessibility or relevance. For instance, access depends on adequate This should be a major component of a London-wide health services strategy. An inadequate assessment of local need makes it difficult to evaluate the effectiveness of existing and proposed services. Further research is needed to ascertain whether improved primary and community services reduce or increase overall requirements for hospital beds. There is a general shortage of data on outcomes from specific treatments. There is undoubtedly a large amount of unmet need.

SHA challenges the assumption that London is over-bedded

18. The Report recognises that Londoners have special health needs, but fails to base its conclusions on the analysis of health status and need for services, or to demonstrate that the proposed loss of a further 4,200 beds will solve these particular problems. The Socialist Health Association rejects the proposition running through the Tomlinson Report that London is overbedded.  Since 1979 London has already lost over 9000 NHS beds. This has taken the form of centralisation of acute services and the closure of hospitals which, though often inadequate and unmodernised, served local communities. Such small hospitals could have been adapted or rebuilt to provide much needed continuing care   Changes in mental health service provision has followed a similar pattern. Between 1984 and 1990 7273 long-stay psychiatric hospital beds were closed (51%), without sufficient alternative provision being made.  There is widespread public experience and public perception of broken promises that locally accessible services would be replaced.
19. The Report does not offer any analysis of the need for different types of beds to provide specialist, district general and geriatric care for Londoners. It concentrates on the estimated 30% of beds for elective surgery in inner London, hitherto filled by patients referred from outside London. Under the contract pricing system of the internal market, neither the non-London health authorities nor the London DHAs are able to afford to pay for their patients to be treated there.  Outer London DHAs have local district general hospitals: inner London DHAs do not.
20. Throughput predictions, based on bringing London up to national averages, do not reflect deprivation and social indicators (paragraphs 5 to 9 above and 26 to 29 below). These factors influence hospital discharge rates and the appropriateness of day surgery.
21. Figures used by the King’s Fund London Commission demonstrate that London is at present under-provided with acute hospital beds. In the words of the King’s Fund Report London Health Care 2010 (p47): “despite the generally held view that London is ‘over-bedded’, Table 4.2 shows that when inner deprived London is compared with equivalent areas elsewhere in England it is found to have slightly fewer beds per thousand resident population than comparable districts elsewhere”

Available NHS beds per 10,000 resident population by status category, all acute specialties group, 1989-90 (Boyle & Samje [1992])

Area category	London DHAs	London inc. SHAs	Non-London comparators
Inner deprived	38.8	43.6	41.6
Urban	24.5	28.9	29.0
High Status	21.4	21.9	19.0
Total	28.5	31.3	29.2
England                                  |    25.0		25.4

22         The conclusion that London is in fact not ‘over-bedded’ is reached by comparing London districts categorised as ‘inner deprived’, ‘urban’ and ‘high-status’ with equivalent districts in England, referred to in the report as ‘non-London comparators’. Although this method does not deal with absolute equivalents, it is better than comparing London to the average as a whole.  Surprisingly it is from this latter comparison that the King’s Fund reaches its final conclusions advocating major bed (hospital) closures. Through this major inconsistency in approach, a report which provides a basically sound analysis of the history and current nature of London’s health service problems, produces its unsound and contradictory proposals for future changes.

23        Although improvements in primary care would help to produce a healthier population in the longer term, this would not immediately reduce the need for hospital care and would be likely to identify further health care needs, at present unrecognised and unprovided for. Furthermore the population of London is projected to increase by 0.7% and 2.9% over the next ten years. Investment in primary care development is essential, but should not rest upon drastic cuts in acute provision.  Change takes time to implement.

Re-designation of beds

24. Hospital beds are currently not necessarily in the right places and often not in the specialties needed by Londoners. GPs consistently report problems in getting patients into hospital and waiting lists in some specialisms continue to rise. The designation of beds should be reviewed, as part of the comprehensive assessment of health needs outlined in paragraph 2 above, to make the best possible use of resources and in order to improve services to local populations, both resident and day-time. There is recognised overprovision and duplication of some specialist services and underprovision in others.
25. If the listed hospitals were to be closed there would be no guarantee or suggestion that the remaining teaching hospitals or Trusts, which are obliged to give priority to financial viability, would provide high quality, but less financially rewarding, district general services needed by their local resident and daytime users.

Developments in secondary care

26. Any significant moves towards out-patient and day-care services depend on a home to go to; someone at home to act as a carer; and appropriate transport to and from hospital. The Report makes no reference to problems such as the state of housing stock in London and the number of people (particularly elderly people) who live on their own. It assumes that bed use in inner London can match the rate of the current top 10% in the country within 5 years (Tomlinson, paragraphs 89-95).  Any such shift in medical care would therefore take longer to happen in London than in the rest of the South East. It should also reflect the views and choices of users.
27. Moves towards reducing the length of stay of people in London hospitals is similarly affected by social circumstances: many patients simply have no other place to go. Planning a reduction in beds on the information presented is not acceptable. The use of beds per 1000 episodes of acute care is not a “simple measure of efficiency”. We need to know how many of these episodes are readmissions, how many are for emergency admissions, how many are for rare conditions or complications of treatment carried out We also need to know how London, as a capital city with a large population, differs from other inner city areas: hospitalisation rates are generally high in inner cities for the reasons set out above. No attempt has been made to compare the number of beds
    used per 1000 episodes of acute care with the provision of nursing home and other residential care in the area.  “Bed blocking” by people who would be better off in an alternative care setting is responsible for anything up to 30% of bed occupancy in inner London.
28. The Report recognises this (Tomlinson, paragraphs 59-60), but its recommendation to reduce beds in inner London, far from being a solution, would aggravate the problem. For acute hospital beds to be used effectively, there has to be adequate provision by the NHS of rehabilitation, convalescent and long-term care beds within the capital. Funding for any proposed re-designation of hospital services in London must take into account these long-term needs. The West Lambeth Community Care Centre is cited for its innovative approach, but only benefits the patients of those GPs who participate in all the facilities. This scheme evolved locally and is seen as locally owned. Similar schemes in other areas would not be guaranteed with success.
29.     Such arguments also apply to the provision of care for people with mental illness and learning difficulties.  The problems outlined in paras 61-66 will continue so long as there are insufficient hostels, group homes and other alternatives to acute hospital care. Replacing hospital beds by improving community services would require greatly increased revenue funding for the foreseeable future, not just bridging funding for five years. Experience suggests that this would not be available from the present government.

Community care

30.  The development of community care policies from April 1993 demands close collaboration between social services and health authorities. The accountability of directly elected local authorities conflicts with health authorities run by managers and appointed directors with minimal local knowledge or accountability. There is an urgent need for the Secretary of State to clarify where NHS responsibility ends and where local authority responsibility begins.  The Chief Executive’s letter to the Health Service Ombudsman (January 1992) appears to retreat from what most people believe they can expect:

If in a doctor’s professional judgment, a patient needs NHS care, then there is a duty upon the Health Service to provide it.”  But this was subject to resources and to clinical priority, he said. “There is no general duty on a health authority to provide in-patient medical or nursing care to every person who needs it.” (Guardian, 30/1/92) The Report does not clarify this confusion and is therefore ill-equipped to assess the extent of services required by Londoners.  Nor does the Report address the serious impact on the public of being obliged to shift from ‘free’ NHS care to means-tested services.

Primary Care

31. The Socialist Health Association supports the need for additional resources for the improvement of primary care services. The SHA has long called for salaried practitioners, general medical, dental and ophthalmic.  It advocates the concept of core primary care teams, which should include doctors, practice nurses, district nurses, community midwives, health visitors, and community psychiatric nurses.  Additional members would include nurse practitioners, physiotherapists, occupational therapists, counsellors, social workers, interpreters and home helps.  Such teams should be resourced to plan anticipatory care, promote good health, and undertake on-going training. The SHA supports the building of purpose designed health centres.
32. Public perceptions of a right of access to A&E departments would take many years to Currently A&E departments provide many primary care functions, particularly for those not registered with GPs. Involvement of general practitioners in A&E departments only offers an interim solution. Increasingly A&E departments arrange admissions for hospital treatment for those whose conditions have become emergencies while on a waiting list, reflecting the market-induced funding problems for elective in-patient care, noted in paragraph 2.
33. The Report proposes funding and advice for upgraded or new premises, but does not address adequately the long timescale required to improve professional standards to bring them up to those few examples of excellence and so inspire public confidence in GP The effectiveness of enhanced primary and community services should be monitored in pilot schemes. As noted in paragraph 23 above, the long term improvement in primary care is likely to lead to the discovery of unmet need, with resource implications for both primary and secondary care.

Research and teaching

34. The specialist postgraduate medical institutions are unique to London. They have special status closely linked to the NHS, Department of Education and Science and the university medical schools. Their role as centres of excellence extends not only throughout London, but nationally and internationally. They have traditionally been managed separately from the rest of the NHS, but they will join the internal market in 1994. Research and teaching should be funded centrally, not from monies for local services.  A formula to preserve excellence is needed.  Certain of these postgraduate institutions could form the basis for specialist regional medical services within London, allowing other specialist units to be distributed more equitably between London and elsewhere in the country. The internal market will endanger these functions which are vital to the NHS.
35. The thrust of pure medical, and particularly pharmacological, research over past decades has altered, so that private industry, much of it based in the South East, now plays the major role, conducting clinical trials in hospital settings, particularly in London. Inevitably private interests are driven by commercial considerations. It is therefore vital that pure and applied research based in universities and medical schools should be encouraged and fully supported with independent funding, free from commercial pressure. Such research projects are more likely to be related to clinical and public health needs, such as health service evaluation, rather than to the production of a commercial product.
36. There is an overlap between the Department of Health and the Department of Education and Science in the running of university based medical research. Such co-operation
    between universities and the health service should be encouraged and more broadly based than at present.  The need for independent health services research, identified by the Report of the Royal Commission (1979), should be addressed.

Conclusion

37.  The Report does not offer the much needed health strategy for London.  In the hands of the present government it is more likely to result in hospital closures, cuts in services and in the sale of valuable NHS sites, with no guarantee that the proceeds would be deployed in London or within the NHS for the improvement of other services. The changes proposed would not achieve measurable improvement in Londoners’ health in the absence of London-wide policies to tackle health inequalities.

JM/TJ/RR 18/12/92

Socialist Health Association

The SHA was founded in 1930 as the Socialist Medical Association to campaign for the creation of a comprehensive national health service. It continues to promote discussion around the politics of health. Through its journal Socialism & Health and other publications, conferences and meetings, the SHA campaigns for the improvement of curative services and the promotion of measures to tackle inequalities in health and prevent illness. It is affiliated to the Labour Party and supported by individual members and affiliated organisations. For details about membership, activities and publication lists, contact:

SHA, 195 Walworth Road, London SE17 1RP (071-703 6838)