London's primary care lags behind bed reductions

BMJ 1995; 310 doi: (Published 04 March 1995) Cite this as: BMJ 1995;310:554

The King's Fund of London has called for the pace of change in London's health service to be reconsidered. It warns that cuts in short stay services are not being matched with improvements in primary and community services. Launching its second London Monitor, Robert Maxwell, the chief executive of the fund, said, “The pacing and sequence of change must take high priority…. There should be no reduction in services—whether for those with acute conditions, for continuing care of elderly people, or for those with mental health problems—unless alternatives are in place.”

The report highlights dramatic changes over the past few years in the allocation of resources to acute and primary services and the use of services by Londoners.

Between 1982 and 1993-4 the number of short stay beds fell in England as a whole by 23%; in London the fall was 40%. Nevertheless, London still has 8% more short stay beds per head of population than the English average. The number of beds for elderly patients, however, is 4% less than elsewhere in England, and London has only 70% of the national average number of residential care places for elderly people. This lack of residential and nursing care in London is in turn reflected in higher than average figures for hospital admissions among the over 75s.

Overall, however, Londoners now make the same use of hospitals' short stay services as the rest of Britain: the standardised hospital rate is just 1% above the national average. In inner deprived areas of London the rate is 6% above the national average, but even this represents a reduction in use from previous years. This is primarily due, says the report, to the “significant reduction in the use of the general medicine specialty by London residents.”

The other service that Londoners use more heavily than average is mental health services: among 16-64 year olds in inner London the rate of use is over 70% above the national average. The need for more acute psychiatric services is seen by the report as one of the key issues for 1995.

London has only 2% more general practitioners than the rest of Britain, and the number of general practitioners per head of resident population fell slightly last year. But the number of support staff has risen. Nevertheless, the picture of underdeveloped primary care persists despite the £125m spent on developments in primary care in the capital. While expenditure per head of population by district health authorities remains higher than average, spending by family health services authorities is 3% lower.

According to the report, the Department of Health now considers that funds allocated to London in 1993-4 were only 2.6% above the fair allocation. Determining what the fair level should be is seen by the King's Fund as one of the crucial decisions for this year.

Mr Gerald Malone, minister for health, said that it was up to health authorities to manage the changes. He also confirmed that with the disbanding of the London Implementation Group the two London regions would have to ensure that the changes were managed properly (p 604). Last month a conference in London called for an independent inquiry into London's health crisis (p 604).—JANE SMITH, BMJ

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