As London's medical sector continues to consolidate its resources, Steve Farrar considers the future of the capital's remaining independent institutions and asks whether bigger really is better When Neville Woolf, vice-dean of the faculty of clinical sciences at University College London, arrived in the capital some 40 years ago, there were 12 medical schools. Today there are just five,and Professor Woolf is a leading light at one of them.

Over five years of merger mania, the map of the capital has been redrawn. Four powerful blocs have emerged, carved from the old institutes and schools of medicine, in a quest for academic and research excellence.

It is now two decades since the Flowers report first urged the rationalisation of London's scattered medical schools, a policy that found further support in both the 1992 Tomlinson report and 1997's Turnberg report. But as the dust begins to settle, just how wise was this grand vision?

Like many of his colleagues, Professor Woolf argues that there was no other option. "A man, a boy and a few test tubes is not good enough any more - research is very expensive and medical schools need a critical mass in order to be competitive."

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Alexander McNeish, warden of St Bartholomew's and the Royal London Hospital School of Medicine and Dentistry - the emergent bloc in the east - agrees. "I am certain London will now be able to consolidate as a centre of world-class excellence for medical research."

Others, particularly those within the few remaining independent groups, believe there is room for another approach.

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The awkward and lengthy names assigned to the various blocs are testament to the painful process of amalgamating proud and historic institutions, but the strategy does appear to be starting to pay off.

In the west of the capital, Imperial College has merged with St Mary's Hospital medical school, the Royal Postgraduate Medical School and the Charing Cross and Westminster medical school.

Its Kensington headquarters, designed by Norman Foster and opened by the Queen last October, sits at the hub of nine separate sites, including the Royal Brompton, St Mary's and Hammersmith hospitals. The group has a research turnover of Pounds 137 million.

There are plans to strengthen its medical school further with the development of the Hammersmith hospital campus as an international research centre combining basic science and clinical research and including a genetics and genomics institute.

In north London, University College London has gone through a long chain of mergers, starting in 1980 with its reunion with University College Hospital medical school and taking in the Middlesex Hospital medical school, the institutes of laryngology and otology, orthopaedics, urology, ophthalmology, child health and neurology. Recently, the Eastman dental institute and the Royal Free Hospital school of medicine have joined the group.

The emergent Royal Free and University College Medical School of University College London is still expanding with the Pounds 10 million biomedical research centre located at the Cruciform Building. The centre will focus on ways of treating and preventing heart attacks, strokes and cancer.

Dominating the east of the capital, Queen Mary and Westfield College has linked up with St Bartholomew's hospital medical college and the Royal London hospital medical college.

St Bartholomew's and the Royal London Hospital School of Medicine and Dentistry's determination to combine research with servicing the people of east London, one of Britain's poorest communities, was given a major boost with the approval of a scheme for a Pounds 46 million state-of-the-art school of medicine in Whitechapel - expected to be completed in three years' time - alongside a Pounds 200 million hospital.

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Mr McNeish says: "Part of our research mission is to have multiple programmes of research at international levels of excellence but concentrated on the health problems of the people of east London."

In the south of London, King's College has formed an especially strong bloc with Guy's and St Thomas's. The group has an Pounds 80 million research budget and an intake of 350 students a year.

Advocates of the amalgamations identify a whole host of advantages.

The new blocs boast a "critical mass" of students and researchers, allowing them to tackle some of the great medical problems cost-effectively and attract some of the best talent.

As a result of its expansion, King's has been able to lure expat British scientist Adrian Hayday from Yale University to study the immunology of infection.

The strength in numbers also allows for investment in particularly expensive equipment that would normally be beyond the reach of smaller bodies.

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And mergers can also bring financial stability, says Professor Woolf: "Small units tend to go to the wall when times are hard - and they have certainly been hard over the past eight or nine years."

Students and staff also benefit from working within a university environment. The greater level of contact tends to spark ideas and initiate collaborations among experts from different disciplines, from genetics to computing, materials science to physics.

The King's mergers prompted a thorough revision of the way research was handled by the institutions, resulting in a flood of new multi-disciplinary teams across the various sites.

Adrian Eddleston, dean of medicine at King's, says: "This has been extremely successful, leading to very exciting new research groups being established, such as a team examining immunology of allergy in respiratory medicine, which is able to tackle problems from the control of antibiotic response to the impact on the airways themselves."

Crucially, the links between clinical practice and research should push patient care forward, although some remain sceptical about this. But because the links between the medical schools and the NHS are far stronger than the often uneasy relationship between private hospitals and schools in the United States, former students may be encouraged to commit themselves to the challenge of improving London's health instead of seeking research posts abroad.

While some re-search teams are already benefiting from the new working relationships, many believe it will be a few years be-fore the strategy comes to fruition.

Those independents that have steadfastly resisted being swallowed by their giant neighbours will be watching the progress with particular interest.

John Green, secretary of the Imperial College School of Medicine, notes: "Those that are left are the ones that would be particularly hard to amalgamate."

The School of Hygiene and Tropical Medicine is a good example. While its world-renowned research and teaching puts it in the highest company, alongside the John Hopkins and Harvard medical schools in the US, both Flowers and Tomlinson earmarked it for merger into UCL.

John Ackers, teaching programme director at the school, admits that some researchers believe it may be better to join nearby UCL to use the bloc's resources, but he insists: "The school feels independence is the best route at present and we are financially very strong."

The school's particular expertise and ability to attract students and researchers from across the globe - there are currently 90 countries represented - probably safeguard its future.

However, the situation is somewhat different for St George's Hospital Medical School in southwest London. Some observers believe that the merger process will not be over until St George's signs up with one of the blocs, but Robert Boyd, the medical school's principal does not agree.

"Having experienced so many mergers, we need to pause for a breath and see if they deliver the expected advantages," Professor Boyd says. "I am not against mergers and I think we are going to see some notable successes, although at a much greater cost to opportunity than many believe."

So far St George's is doing well. It has in the region of 1,000 medical students, a Pounds 16 million research budget and enjoys close links with Kingston University on the nursing side of its teaching, a collaboration that has spawned new courses in radiology and physiotherapy.

And it too can attract foreign talent. A prominent US professor is about to sign a deal bringing him to the school in a move that Professor Boyd hopes will underline St George's determination to thrive rather than merely survive.

St George's may be the litmus test for the future of the sector. If Professor Boyd is right, and results of the grand strategy are mixed, his medical school may continue to thrive in its independence.

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As for the members of the four blocs, if the grand strategy fails to deliver all of the advantages promised, they may regret their haste in trading in their own independence. Either way, the next few years will be critical ones in the future of London's medical sector.