Why London is the home of loss-making NHS hospital trusts

A decreasing number of NHS hospitals are run by plain old NHS trusts, simply because an increasing number are successfully applying to be foundation trusts – which requires evidence of financial stability. Those which have not yet become foundations are regulated by the Audit Commission, which therefore tends to oversee those on a weaker financial footing. It recently reported on the trusts still in its care, and found that 10 of the non-foundations were in financial deficit in 2011-12, totalling £177m. (Trusts have a legal duty not to make a loss, although this applies over three-year periods.)

Map removed as Google Fusion Tables no longer works.

The trusts in question are on the map above, with detail available when clicking on a dot. While there are usually trust-specific reasons for financial problems, such as PFI schemes, the geographic distribution is clear: six of these loss-making NHS hospital trusts are in London, with two more just outside. These include the two with by far the biggest deficits (red on the map): South London Healthcare trust, with a deficit of £65m, which has since been put into the NHS equivalent of bankruptcy (PFI played a role), and Barking, Havering and Redbridge University Hospitals, with a £50m deficit.

Healthcare is undertaking a long-term shift away from hospitals, which are often worse places to treat someone than a care home or their own home, as well as much more expensive. In many localities, travel distances make it impractical to close hospitals completely, so the alternative is to reduce the number of beds (such as at North Bristol, although it is also combining its two nearby hospitals into one). But London’s population density could allow lots of specialisation. Successful work diverting those suffering strokes to a few specialist centres in London suggests that many other services could go the same way.

Added to this, London currently has more medical capacity than the English average. NHS Information Centre workforce figures report 22,036 doctors working in the capital’s trusts last January, which is 2.81 doctors per 1,000 people – a third higher than the all-England figure of 2.08. It could reasonably be argued that London’s hospitals serve a wider area, but even considering London and the south east region as one produces an average of 2.24 doctors per 1,000.

One reason for this is historic. The NHS was born in 1948 (at Trafford in Greater Manchester, as this BBC slideshow records), but for centuries the capital has hosted what would now be called the UK’s healthcare cluster, with hospitals including the Royal Free founded in 1828, the Royal London in 1740, Bethlem Royal in 1247 (the source of the word ‘bedlam’, from its less-regulated centuries, now part of South London and Maudsley trust) and St Bartholomew’s Hospital, which was founded 889 years ago in 1123. If the NHS is our national religion, then these hospitals are its ancient churches. Indeed, when founded, both Barts and Bethlem were priories (ancient hospitals often have a religious basis).

Some of London’s ancient churches are now rather underused. That isn’t the case for the prestigious, historic hospitals just mentioned. But they and other high-profile NHS facilities make life particularly hard for less glamorous hospitals in outer London – which is where those reporting deficits are mostly located.

But people hate hospital closures. The case in London, where distances are shorter and capacity is above average, is probably as strong as anywhere in England. (And if hospitals were located on the basis of medical need, the above-average health enjoyed in many parts of London would strengthen this case further.) But the capital also has above-average numbers of politicians, influencers and journalists, as well as a lot of marginal seats, making it politically very tough to change.

Two of the deficit trusts for 2011/12, Whipps Cross University Hospital and Newham University Hospital (which had nearly broken even after a far bigger deficit in 2010/11), have just merged with ancient hospitals Barts and the Royal London to form Barts Health NHS trust – and it can be politically easier to reorganise services within a trust than between trusts. But even so, its historical legacy and its politics means that London has the potential to remain the capital of loss-making NHS hospital trusts.

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