London's hospital trusts face a massive management shake-up after the departure of four chief executives.
Two of the chief executives - Julian Nettel at Barts and the London trust and Tara Donnelly at West Middlesex University Hospital trust - have resigned amid concerns about the performance of their trusts, which have missed financial and patient access targets. There are also question marks over when or even whether their trusts will achieve foundation status.
The resignations follow instability at NHS London after the departure of director of commissioning, improvement and innovation Paul Corrigan and provider agency chief executive Malcolm Stamp. The strategic health authority is also reported to be under pressure from the Department of Health over the performance of London trusts in general.
A spokesman for West Middlesex trust said Ms Donnelly had resigned after eight patients had needed to wait more than 12 hours to be admitted to the hospital through accident and emergency. Although no patients were harmed, the trust did not tell the strategic health authority - a crucial performance issue in the eyes of NHS London.
In a statement, trust chair Sue Ellen said: "Tara, as leader of the organisation, recognised the seriousness of this and therefore decided... to step down."
West Middlesex Hospital was categorised as a "financially challenged trust" in 2007 but was moved out of this category in 2008. It is now forecasting a deficit of around£1.5m - significantly less than the£9m it reported in 2005-06.
Like all SHAs, NHS London has attempted to assign each of its remaining provider trusts with an expected date to reach foundation trust status before December 2010. But West Middlesex has not been given a date pending the outcome of a north west London-wide review of capacity and demand for hospital services that has fuelled speculation that it could be rationalised or merged with another organisation.
Barts and the London has not been given a date either - primarily due to concerns its£1bn hospital private finance initiative will be unaffordable.
From 2013 PFI repayments will eat up some 16 per cent of its turnover in facilities costs alone, just as NHS resources are expected to get much tighter. The hospital tariff assumes that facilities costs are equal to around 6 per cent of a hospital's turnover.
Barts also faced problems with a new IT system that left thousands of patient bookings unprocessed.
A fellow London acute chief executive told HSJ Mr Nettel's decision to leave the trust after just 17 months in the post was "worrying". He said he was "highly regarded by his colleagues" so his early departure suggested no one could solve the£590m a year trust's problems.
In separate developments, Mayday Healthcare trust chief executive Helen Walley has announced her early retirement and South West London and St George's Mental Health trust chief executive Peter Houghton is to be seconded - most likely to a senior role at NHS South East Coast.
And last Thursday NHS South East Coast chair Graham Eccles announced he would resign after a memo he wrote on a confidential briefing on mixed sex wards and PFI was leaked to the Conservatives.
The Conservatives used the memo to attack the government, saying it showed the health secretary had admitted the government "got it wrong" on mixed sex wards, and that there was "no plan B" alternative to PFI.
Mr Eccles' interim replacement will be Colin Tomson of Eastern and Coastal Kent PCT.
West Middlesex University Hospital trust
February 07 - February 09
South West London and St George's mental health trust
July 06 - February 09
Barts and the London trust
September 07 - February 09
Mayday Healthcare trust
May 06 - April 09
NHS South East Coast
August 06 - January 09