Bart's may be 'saved', but the capital's health services are revealed to be still in a state of dangerous disarray.

The results of the strategic review of London's health services generated feel-good headlines about how Bart's is to be 'saved' as a specialist cardiac and cancer care centre. But the report of the review results makes pretty gloomy reading.

The team, led by Sir Leslie Turnberg, concludes that the capital's health services need more strategic planning and co-ordination. Primary care is in a 'woeful' state. Community care 'lags behind the rest of the country'. There are 'serious deficiencies' in mental health services.

These problems are familiar. The picture painted by the Turnberg report is strikingly similar to the one painted by Sir Bernard Tomlinson in Making London Better five years ago.

But while the two reports agree London is under-provided with community and primary care services, the Turnberg report does not conclude that it is over-provided with acute services.

It says London's hospitals are 'under enormous pressure' and 'further bed closures should not be planned'.

This pleases Geoff Martin, campaigns director of pressure group London Health Emergency. 'The review panel have hit the nail on the head when they say Tomlinson got it completely wrong on the question of over-provision,' he says.

But the Turnberg report does not say: 'Tomlinson got it completely wrong.'

It says the number of acute beds in London has fallen, largely as a result of greater efficiency, just as the 1992 report predicted it would. Inner London lost 1,130 acute beds between 1990-91 and 1995-96 (Tomlinson said it would lose 1,365), while London as a whole lost 2,761 acute beds and 9,271 beds in total.

As a result, 'the number of beds per 1,000 episodes of acute care has fallen from 18.4 in 1990-91 to 13.4 in 1995-96', while 'comparative figures for England nationally are 18 and 12.5 respectively'.

But the Turnberg report finds that Tomlinson's prediction that referrals to London hospitals would fall has not been borne out. It says between 2,500 and 2,800 of London's 17,400 beds are still used by non-Londoners.

Although London Health Emergency welcomes the Turnberg report's overall conclusion that 'there are no more acute beds available to Londoners than the England average', Mr Martin is disappointed that it 'does little or nothing to reinstate any of the frontline beds that have closed in the past six years'.

The Turnberg report certainly does not say London bed numbers should be increased. Indeed, with the partial exception of Bart's, all the reconfiguration plans put on hold when the government set up the review in June will go ahead.

Health secretary Frank Dobson told the House of Commons last week this meant investment worth pounds800m would now take place over 10 years.

But it means disappointment for campaigners fighting to keep accident and emergency at Guy's Hospital, stop Queen Mary's Hospital in Roehampton becoming a community hospital, and stop the closure of Harold Wood Hospital (see panel, page 14).

The Turnberg report concludes that many of these moves are needed to complete the rationalisation of London's specialist services set in train by Tomlinson and the reorganisation of medical training in the capital.

It says progress in this area has been patchy, which has 'inhibited efficiency in the acute sector'. It also says that, 'as a result HAs have been unable to invest money in primary or community services at the required pace'.

The Turnberg report expresses considerable concern at the state of primary care in London. It finds that although the London Initiative Zone set up in the wake of Tomlinson has pumped pounds265m into primary care, London GP numbers have fallen by 1 per cent in five years, while they have risen by 6 per cent in England as a whole.

It says too many London GPs are still single-handed practitioners, 50 per cent work in premises that do not meet minimum standards, and the capital has too few community nurses. It calls for more GPs and specialist nurses and the number of practice premises below minimum standards to be reduced by 10 per cent annually.

This was welcomed by Tony Stanton, secretary of six local medical committees in the capital. 'We must ensure provision of proper services to patients in London,' he says.

The Turnberg report is also concerned that London is underprovided with intermediate care facilities, such as beds for rehabilitation, recuperation and respite care.

And it highlights issues in mental health services.

It says there are too few community places to support people with severe mental illness, leading to hospital bed occupancy rates of up to 125 per cent. 'This, in turn, results in a very high threshold for admissions so that only those with the most severe forms of psychosis are admitted, leaving many vulnerable people who would benefit from a period of inpatient care unable to gain access to that care.'

The report calls for more support for vulnerable people and carers, minimum standards of service and improved hospital services 'pending more investment in and development of community services'.

Mr Dobson promised last week that pounds30m would be invested in the capital's primary care and mental health services next year, with another pounds110m to come over four years.

Neither he nor health minister Alan Milburn were saying where this money had been found.

The cash has been warmly welcomed by London lobby groups, unions and the King's Fund, which raised concerns about mental healthcare in its own report, Transforming Health in London, last July.

Sue Towns, director of the Greater London Association of Community Health Councils, says it 'welcomes the recognition of the need for improvements to and investment in primary care, mental health and community services'.

But she warns: 'Because GP and primary care services have been poorly developed in many areas, Londoners have relied on hospitals for care and treatment.

'This is not going to change overnight. It is important therefore that acute services do not diminish any further.'

The other finding of the Turnberg report that has received almost universal approval is its call for improved planning and co-ordination of health services. It says the two Thames regional offices of the NHS Executive should enhance their working relationships 'to ensure coherent strategic planning across London with a single London regional office as a longer- term aim.'

The report also calls for specialised services 'at the level of the five sectors into which London can be divided, each relating to the new University of London medical school groupings and covering populations of up to 1.5m' (see map).

It says HAs should develop and review plans in each sector, with five and 10-year targets for specialist services and training and research.

And it suggests that 'in due course' HAs could merge along sector lines.

The Turnberg report backs the government's idea of locality commissioning groups for populations of 100,000 people, and calls for these to be coterminous with local authority boundaries to 'improve joint working'.

Finally, it calls for a capitation formula review to direct resources to poorer communities and urges all health organisations to develop proper communications strategies for public consultation and involvement.

This is all welcomed by King's Fund chief executive Rabbi Julia Neuberger, who says: 'This is the time to break down all the Berlin walls between providers so the government's new ideas for primary care can take effect.

'The (pounds140m) will only be used effectively if issues in mental health and to do with older people are tackled with London-wide action.'

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