The Development of the London Hospital System,

This is an organisational history of the development of hospitals in London over the last 180 years. It is not a history of an individual much loved institution, but the story of the development of system. As such, it deals with the types of hospital, fever, poor law and voluntary, and the influences that brought them together, charity, local authorities, and the NHS. The book considers major influences on the hospitals, such as specialization, medical education, developments in nursing, and the frequent financial crises they had to deal with. Because some owed their existence to charity and others to the poor law, the hospitals were more remarkable for their individuality than a common sense of purpose. The absence of a central organisation attracted the attention of Victorian reformers, whose criticisms and the solutions they proposed have a familiar ring to them today. Primarily an organisational story, it lacks the clinical angles that are a major part of From Cradle to Grave

This is the story of the way ideas developed that came to influence the shape of the health service in London, and of bodies like the King’s Fund and the London County Council who tried to bring order out of chaos. Institutional opposition to change was strong and the way the capital itself has developed has compounded the problems of its hospitals.

Because this book is now hard to locate it has been made available on Internet. The site is text-rich, and you may wish to print some out. Sadly many of the illustrations have had to be excluded. Since 1982 when the book was published much has happened in medicine, in London and to hospitals. I am writing a further chapter covering the period since 1982 and, in addition, adding remarks to the text where new information has become available to me and, perhaps more interestingly, where it is easier to include personal knowledge that would have been unwise when I wrote the book in 1978-82.

Foreword to the original book

This history begins with the foundation of The Lancet in 1823 and ends in 1982 with the restructuring of the National Health Service, when the management of hospitals in isolation from other health services had ceased. The territory with which it is concerned corresponds roughly with that of the old London County Council. It was during this period, and often inside London, that many ideas developed which still condition our thinking about the hospital service.

The opening chapters consider the endowed and voluntary hospitals, the poor law infirmaries and the fever hospitals in turn. Thereafter the book is chronological and it is necessary to consider a number of themes in parallel, and to return to them in each epoch. The interaction of professional developments with medical education, finance and matters of administration, makes it impossible to consider any issue independently, and the reader may find the chronology and the list of ministers helpful. I have not sought to replicate the many excellent histories of individual hospitals or wider ranging accounts of developments in the public health. Neither could justice be done to the evolution of scientific medicine, the great sanitary revolution, or the changes in the social background against which the hospitals developed. Concerned as it is with the issues and debates which affected the London hospitals as a group, and the acute hospitals rather than those dealing with long stay patients or the mentally ill, the book may seem to discount wider developments by concentrating on the capital. Regretfully I must ask those who wish to know more about individual hospitals or national events like the establishment of the National Health Service to look elsewhere.

As far as possible I have relied on contemporary material, for latter-day mythology is as common in the hospital service as in other fields. Even so, papers often conceal as much as they reveal, assume a background knowledge few now possess, and frequently stress the achievements of a body beloved by the author and its claims on the private or public purse. This account does not lead to any particular organisational or political conclusion about the principles which have governed the development of London's hospital system. This is because many of those concerned have been wrapped up in their own world. Whilst they were inevitably swayed by the concepts of their time, the interests of their hospital and patients usually came first.

Much of the nineteenth century material has been derived from the medical press, the records of certain hospitals, and to a lesser extent the files of the Public Record Office. For the first half of this century the archives of the King's Fund and the London County Council are prolific sources of material. For the period since the 1939-45 war good records have been kept in a number of hospitals and it has been possible to gain much from talking to those directly involved in the events of the time. My thanks are due in particular to Sir Desmond Bonham-Carter, Mr A H Burfoot, Sir John Ellis, Dr Clark-Kennedy, Sir Harry Moore, Mr David Noble, Mr John Pater, Dr James Fairley, Dr Malcolm Godfrey, Lady Evelyn Sharp, Professor Brian Abel-Smith, Dr Charles Webster and Dame Albertine Winner. Where opinion has been allowed to creep in it is my own. The text does not necessarily reflect past or present policies of central government departments.

My thanks are also due to the librarians and archivists who have helped me, with much patience, to locate old records, particularly those at the Department of Health, the Greater London Record Office, the Wellcome Institute, the Institute of Health Services Management, and hospitals like Guy's, St Bartholomew's, the Middlesex and University College Hospital.