The Development of the London Hospital System,
1823 - 2013
|Organisational developments||The Hospital Plan 1962|
|Medical schools||Fever Hospitals|
|Postgraduate education||Redevelopment and Postgraduate hospitals|
|Hospital Planning||The district responsibilities of teaching hospitals|
|A new hospital survey||Medical school expansion|
In the nineteenth century, hospital practice had been revolutionised by the introduction of anaesthesia, aseptic technique and skilled nursing. The hospitals which the National Health Service inherited also faced the challenge of continually evolving medical techniques. Amongst the advances which had taken place between the wars were improvements in diagnostic methods, the introduction of contrast media into radiography, the isolation of insulin, the introduction of liver extract for pernicious anaemia, the first effective sulphonamide and the development of cardiac catheterisation. The war had stimulated advances in the treatment of trauma, spinal injuries, fractures and burns, and of course had brought about notable developments in plastic surgery. The introduction of penicillin, streptomycin, PAS and INAH continued to modify the work of the hospitals and the demand for beds for chest diseases and tuberculosis fell. Soon cortico-steroids and anti-coagulants were introduced. Measles, which before the war had been responsible for many hospital admissions, could now be treated more easily at home. Mastoiditis and rheumatic fever began to disappear. Immunisation against diphtheria and poliomyelitis also had its effect.
The work of the hospitals was continually changing. Clinical physiology and new methods of investigation, associated with such doctors as Paul Wood, Sir John McMichael and Sheila Sherlock, brought more diseases within the reach of curative medicine. Thoracic surgeons who had been treating cancer of the lung and tuberculosis were soon performing closed valvotomies for mitral stenosis, and then replacing aortic valves and repairing congenital heart defects with the aid of the ‘heart-lung’ machine. Renal dialysis and transplantation followed. Orthopaedic surgeons who had learned to pin fractured femurs were soon creating a new market for their skills by replacing hip-joints. The dangers of bed rest were increasingly appreciated, partly as a result of Asher’s writings1, and an active approach to the care of the elderly was fostered by men like Lord Amulree at University College Hospital. Psychiatric practice was modified by the introduction first of chlorpromazine, and then of the anti-depressants. Patients returned home more rapidly, and the possibility of an acute psychiatric unit within a district general hospital became more widely accepted. The work of the hospitals was changing, the length of stay was falling, more disciplines were involved in the treatment of the patients, and higher levels of skill were called for. The number of beds needed fell; the numbers of staff required rose.
Much had to be done between the passage of the NHS Act in November 1946 and the appointed day, 5 July 1948. Chairmen and members of the new authorities had to be appointed, and they had to select their officers. The pattern of organisation below regional level remained to be worked out on the basis of the principles published in a Ministry circular. Grouping of hospitals was to be approached from the point of view of function and character rather than size or geographical situation. Hospital management committees were to be responsible for a large and more or less self-contained general district hospital, created by grouping several hospitals and clinics together.2 Schemes for the groups had to be submitted by February 1948. Dr Macaulay, the senior administrative medical officer for the North West Metropolitan Hospital Board, completed the task while in bed with ‘flu. Grouping did not affect the teaching hospitals which had retained their own boards. But the smaller voluntary hospitals and the municipal hospitals whose traditions owed nothing to the voluntary system, were grouped together and had to develop new internal relationships. In the voluntary hospitals it had been traditional for there to be a partnership between the governing body, the chairman of the medical committee representing the visiting staff, and the matron. The new hospital management committees were less accessible to the hospital staff than the old boards. The municipal hospitals, on the contrary, had enjoyed little local autonomy. The chairman of any local hospital committee had few powers; the medical superintendent was responsible to County Hall for the running of his hospital, and the matron and the lay staff reported to him. The problems of the new situation, to which both types of hospital were having to adjust, were examined by the Bradbeer committee, established in 1950 by the Central Health Services Council.3 The committee recommended the continuation of the partnership of administration, medical and nursing staff which had characterised the voluntary system, the strengthening of the medical committee system, and a move away from medical superintendent posts.
The Goodenough report had pointed to the great variation in the constitutions of the medical schools. Two were apparently autonomous bodies, but in fact none had any real independence from their hospitals, nor any close association with the University of London. Bevan did not nationalise the schools along with the hospitals, so that the same Act which brought the health service into being established the medical schools as corporate bodies. New governing bodies were formed, with academic councils quite different from the hospital committees which had preceded them. New relationships had to be established, and in some cases there was marked distrust between hospital and school.
The medical schools were faced by large student intakes. Not only were there the students who had just reached university age, but large numbers had gone into the forces during the previous six years instead of entering the medical schools. The schools were also short of beds as a result of war damage. Goodenough had sold the idea of university teaching centres - groups of associated hospitals - to medical schools and hospitals accustomed for six years to a sector system. During those six years the staff of the teaching hospitals had come to know nearby hospitals very well indeed. Several of the teaching hospitals therefore approached the London County Council, seeking access to the clinical facilities of the municipal hospitals. Before agreeing to particular proposals, Sir Allen Daley thought it best to see what the medical schools as a whole wanted, and a conference was held at Senate House on 18 July 1946. Three types of proposal were advanced. St Mary’s and Guy’s suggested that voluntary and municipal hospitals might combine as a teaching group. Some like St George’s wished to accommodate their special units like ear, nose and throat at a nearby council hospital, and others wished to use existing wards in municipal hospitals to supplement their own resources.4 Crucial decisions had to be taken rapidly. The University, while supporting the principles of Good-enough, had no defined policy of its own, and in any case had no way of imposing its will upon the medical schools. Some teaching hospitals feared that if a London County Council hospital was taken over it might delay rebuilding on its own site, or lead to the loss of a hospital which had been closely associated with it during the war years, like The London Hospital’s branch at Brentwood. Senior medical and nursing staff might oppose the assimilation of LCC staff, or the education of medical students by council doctors. St Bartholomew’s and The London agreed that their main objective should be rebuilding on site, and that amalgamation should be played down.5
Before designating the teaching hospitals which would have boards of governors independent of the regions, the Minister was required to consult the University. The London syndicate discussed the principles to be applied in determining teaching groups in March 1947. The undergraduate hospitals designated would be those Goodenough had called ‘parent teaching hospitals’. The opportunity would also be taken to amalgamate a number of the smaller special hospitals with undergraduate teaching hospitals along the lines suggested by Goodenough. The syndicate held a second meeting with Sir Allen Daley to consider the possibility of linking London County Council hospitals with the teaching groups. Sir Allen said that two conditions must be met: London patients must not be deprived of hospital accommodation, and there must be no injustice to the staff of the council’s hospitals.
The teaching hospitals suggested various types of linkage with ·the municipal hospitals, simple association for the purpose of teaching, or full absorption with management by the board of the teaching hospital. Absorption had a disadvantage—it cut across the most cogent argument for a radial pattern of regions, that the regional boards would themselves have a substantial holding of beds in all areas.6 Bevan decided to designate only those hospitals bearing primary and major responsibilities for undergraduate and postgraduate teaching. Even though absorption would have helped the teaching hospitals to obtain adequate facilities, it would remove from the regional boards the beds they needed to fulfil their own responsibilities. The University of London was consulted on the designation of teaching hospitals in June 1947 and replied in October. Most of the proposals were approved, although the University wished to associate St Mark’s with the Hammersmith rather than St Bartholomew’s. Five medical schools asked for municipal hospitals to be designated to their associated board of governors, and the University supported their requests.7 These were the London Hospital Medical College (Mile End Hospital), the Westminster Medical School (St Stephen’s Hospital), St Mary’s (Paddington Hospital), Guy’s (St Olave’s Hospital) and King’s College Hospital (Dulwich or St Francis’ Hospital).
The Ministry asked the regional hospital boards for their comments on the University proposals, and with one accord they opposed the absorption of London County Council hospitals. The Minister agreed with the regions, but on a number of occasions Bevan preferred to amalgamate small hospitals, particularly special hospitals and those for women and children, with teaching hospital groups. In May 1948 twelve undergraduate and fourteen postgraduate groups were designated. Only one municipal hospital, St Pancras, became associated with a teaching hospital, University College Hospital. An understanding existed between the Ministry, the University and Charing Cross Hospital that the latter would move to Harrow where a new hospital was needed. With the agreement of the boards concerned, Harrow and Wembley hospitals were transferred to the Charing Cross group. Similarly the use the Royal Free Hospital made of the North Western Fever Hospital, and the possibility that it might itself move to Hampstead or Islington, led to the designation of the fever hospital to the Royal Free group.
The Goodenough report had stated that whilst facilities and men of outstanding distinction were present in London, the necessary organisation for postgraduate education remained deficient. The report suggested the establishment of a series of institutes, each based upon the most suitable special hospital in its particular field. All would form part of a federal organisation which would relate to the University of London. The British Postgraduate Medical Federation was established by the University, in accordance with these recommendations, in April 1945. Special hospitals had been discussed in some detail during the meetings of the Goodenough committee. Some were thought to be excellent, but others were not and it became University policy to establish no more than one institute in respect of each specialty, and to bring the educational facilities up to university standard.8 Sir Francis Fraser became the director of the new federation, with responsibility for the postgraduate institutes, and his membership of the London syndicate made coordination of service and academic policies easier. Appropriate special hospitals were recognised as teaching hospitals and, sometimes at their own request, sometimes at the request of the University, special hospitals in the same field were brought together under the governance of a single board. The pattern in London therefore came to differ from that in the provinces, where universities did not establish separate institutes and the special hospitals were usually grouped with the parent teaching hospital.
In February 1947 Sir Francis Fraser wrote to Aneurin Bevan to say that the committee of the British Postgraduate Medical Federation was agreed that the Postgraduate Medical School and its associated hospital were inconveniently situated, and the school should if possible be placed more centrally so that it was more accessible. Fraser thought that the ideal solution would be the association of the school with an existing hospital, perhaps the Middlesex. But as, in the view of the federation, it was unlikely that any existing school would be prepared to exchange its undergraduate role for a postgraduate one, the possibility of building a new hospital on a central site should be considered. He suggested the site of the old Foundling Hospital, where a hospital might be built to replace those likely to move from the centre of London9, and he sought Bevan’s advice on how to proceed.
The question was referred to the London syndicate which replied that, whilst the Hammersmith might indeed be inconvenient, to build a new hospital in the centre of London would seem contrary to the recommendations of the hospital survey and the Goodenough report. Instead, a development at St Mary Abbot’s might be considered. It was clear that any proposal to bring together the Hammersmith and all the specialist postgraduate hospitals would be expensive, and in view of the time it would take to acquire the land adjacent to St Mary Abbot’s it would be of a long term nature. The building situation also precluded an early start. Nevertheless the British Postgraduate Medical Federation continued to press for a decision in principle, returning to the possibility of a new hospital near Mecklenburgh Square, on the Foundling Hospital site. In March 1948, when this site was purchased by the Dominion Students’ Hall Trust, Sir Francis Fraser once more proposed a hospital development to which the nearby specialist hospitals and institutes could relate. While the Foundling Hospital site was near both Senate House and a number of existing hospitals, Sir Wilson Jameson was not enthusiastic. He reserved his position about further hospital construction in central London, and replied that the first step would seem to be the provision of suitable accommodation for a postgraduate medical school, the need for which was greater than for a postgraduate hospital.
The medical officers of health of the LCC and the home counties did not wish there to be a delay of two or three years in hospital planning, whilst the health service was established and the new regional boards set up planning departments. Sir Allen Daley, Dr Macaulay of Middlesex, and Dr Patterson of Surrey - a county which had already produced its own plan for future hospital development - wrote to the Ministry. As a result the London Hospitals Working Party was established, which met for the first time at the Ministry in June 1946. The working party discussed a wide range of issues during the following months, but as the metropolitan hospital boards had not been formed, and there were many uncertainties, little could be accomplished. Meetings between the London County Council and voluntary hospitals like the Royal Free and the Prince of Wales’ were more productive. The council made facilities available to them at the North Western and North Eastern Fever Hospitals. 10
A great fault of the new health service administrative structure was the multitude of authorities; they made effective planning virtually impossible. The nature of the services provided, rather than geography, was the basis of health service organisation. Teaching hospitals, ex-municipal district general hospitals, and mental illness hospitals might lie within a stone’s throw of each other but be managed by different authorities because, in some respects, they performed different roles. As early as 1949, the Hospitals Year Book said that there was little regional hospital boards could do in the way of planning without securing the cooperation of the teaching hospitals in their areas. As far as could be ascertained, the principle of service had been upheld, and there had been no tendency to regard management committees as administering geographical areas. The year book said that a large number of geographical boundaries had been swept away, and some of the happenings in the past which had aroused either public resentment or public ridicule should not occur in the future. There were no boundaries on the map to indicate where ‘A’ management committee area finished or ‘B’ management committee area started.
It was only human nature for the new authorities to express their individuality. They did. The house governor of a royal endowed hospital was reputed to throw any letter from the Ministry into the wastepaper basket if it did not contain a cheque. The regional boards had no control over this elite. Conversely, some of the teaching hospitals who tried to involve the metropolitan board in their planning had no response at all. The Ministry attempted to coordinate where it could, but the tense relationship which had existed between the voluntary and municipal hospitals persisted, albeit in a lower key, between teaching hospitals and regional board hospitals. The old guard remained in control, continuity had been maintained, but attitudes of separatism persisted. Although people accustomed to taking a broad view - like Dame Barrie Lambert of the London County Council and Sir Allen Daley - became members of the metropolitan boards, the problem was not solved.
Bevan had placed the ultimate responsibility for the provision of services on the regional boards and had been unwilling to designate municipal hospitals to teaching groups. In November 1947, he replied to a letter from the Socialist Medical Association saying that while teaching hospitals should in part serve their neighbourhood, the exact functions they performed must be depend on the educational needs of the schools with which they were associated. It did not seem possible to lay down any general rule as to the extent to which they should be local hospitals.1’ The same policy was expressed by the Ministry in a memorandum suggesting ‘tentative answers to questions each board must necessarily face’. The circular considered the relationship between regional centres, which included the teaching hospitals, and smaller ‘hospital centres’ providing a less extensive range of facilities. The regional centre would provide, in addition to the services found in all districts, ‘exceptional services’ like radiotherapy, plastic surgery, thoracic surgery and neurosurgery, which required the collection of cases from a large population to make full use of the medical teams. Teaching hospitals would have to select cases with their educational role in mind, and in view of their ‘special functions’ they would not be able to undertake all varieties of special treatment. They would not be district hospitals, but would provide the number of beds required to support teaching and research effectively. The memorandum, an attempt by an advisory committee of senior consultants to frame ideal standards for the future staffing of the hospitals, was republished under the title The Development of Consultant Services.
The specialties which emerged during the nineteenth century dealt with conditions which were found in considerable numbers in every district, like ophthalmology and diseases of women. Specialty development in the London hospitals between the wars had been comparatively slow, even in fields like radium treatment. Under the stimulus of war, new specialist units developed, dealing in the main with traumatic injury, but most were sited away from central London, on the periphery. The specialties developing after the 1939 - 45 war had new characteristics. They dealt with rarer conditions, and required larger catchment populations. Complex equipment and scarce skills were also needed. Physicians and surgeons with special interests, like cardiology and thoracic surgery, were keen to develop them but met with considerable opposition from the bulk of the consultant and academic staff in the teaching hospitals. They often had to do their main work in a specialist hospital, which might expand into a new, although related, field. The battle for beds was on, and the teaching hospitals ceased to be the province of the generalist - an ideal man to teach undergraduates - and became filled with special units under the control of men with rather esoteric interests.
The annual report of the Ministry of Health in 1941 commented on the trend to specialisation. ‘Through the growth of the emergency hospital scheme a new conception of hospital treatment can be seen emerging. The old, all-purpose conception of a general hospital has given way to a pattern of hospitals in which some specialise in one service, some in another. The patient goes to the hospital best suited to his needs, instead of, as would have happened before the war, remaining in the first hospital suitable.’ The London County Council also accepted the principle of centralisation in its hospital planning, and proposed the establishment of a second postgraduate hospital south of the Thames, at Lambeth. The London syndicate discussed specialty planning briefly, and as Sir Ernest Rock-Carling was a member it is understandable that radiotherapy should have been considered early in 1947.6 Plastic surgery was also discussed, but thereafter a London-wide approach to specialty planning lapsed.
Many of the deans wished for nothing more than a return to the prewar situation, but this was impossible. The report of the medical visitors of the University of London in 1950 drew attention to the incursions which specialist units were making into the beds available for fundamental teaching of medical students.14 This, combined with the effects of war damage, made for a shortage of teaching beds which was acute and severe. The principal of the University wrote to the Ministry to say that the Senate saw an urgent need for additional beds, and that the maximum number possible should be provided in the teaching hospitals. He also reopened the question of transferring regional board hospitals to the boards of governors of the teaching hospitals.
Bevan had appreciated that there would be cross-boundary problems, and had agreed to the establishment of a coordinating group. The ‘metropolitan regional hospital board liaison committee’ was therefore formed to consider matters of common concern. The first meeting was attended by the chairmen and senior officers of the London County Council and the regional boards. The transfer of municipal hospitals and liaison with the King’s Fund were discussed, but after two meetings the committee fell into abeyance. According to Sir Allen Daley the senior officers involved had little time for extra meetings, the regions were afraid that the committee would become a ‘super-board’ whose wishes they would be expected to implement, and most matters were best dealt with at a local level anyhow.
The Central Health Service Council, noting difficulties which were arising nationally from the multiple authorities, established a committee on cooperation between hospital, local authority and general practitioner services in 1949. Three years later it reported that in London the geographical problem was so complicated that it was difficult for any one authority to be conscious of its opposite numbers.15 Sir Allen Daley submitted two detailed papers. His monthly meetings for medical officers of health had been attended, since the advent of the NHS, by senior administrative medical officers and the Ministry. But London had 60 local authorities, 26 boards of governors and four metropolitan boards, as well as its general practitioners. While the problems of London were indivisible, a group to coordinate the capital would be a mammoth affair. But to break up into regional groups would not be a complete answer, although local groups would of course be needed. Sir Allen Daley suggested that there should be a home counties conference, chaired by Bevan, to set them up.16
Rebuilding the hospitals
The damage sustained in the war was vast, and there was a large backlog of maintenance work. Few of the voluntary and none of the municipal hospitals had escaped bombing. The London survey recognised that little more than minor work would be possible for some time.17 Housing, education and industry had priority for scarce building materials like steel, and all that could be done for hospitals was to improve efficiency through minor schemes involving operating theatres, outpatient departments and laboratories. Because of its poor structural condition, permission to rebuild Guy’s was given as early as 1949 but work could not begin straight away. St George’s was prepared to move to Tooting, but, in spite of the availability of the Grove/Fountain site, it was told that high priority could not be given to the scheme.
Because medical education was suffering as a result of poor facilities, the University of London wrote to the Ministry of Health asking for an assurance that it would be consulted before decisions were taken. The University’s priorities were ward blocks at Guy’s and St Thomas’s, the outpatient department at the Hospital for Sick Children, and reconstruction at St Bartholomew’s. Bevan accepted the importance of such schemes, but with limited funds and little steel there was no chance of rapid progress.18 In November1953 the Ministry of Health produced a capital investment programme for the years ahead (see Table 25, below), which included a number of hospitals for the new towns and redevelopment projects for the teaching hospitals. The programme slipped considerably, and Brian Abel-Smith wrote in 1956 that central government had proved a sterner master in terms of capital expenditure than the local authorities, or those who had directed the voluntary hospitals.19
Some expansion was possible from 1955 onwards, and major projects were selected and funded directly by the Ministry. Because the hospital surveys were becoming out of date, neither the regional boards nor the Ministry had a detailed idea of the hospital stock they had inherited. Even more difficult was the continuing uncertainty about the relocation of central London teaching hospitals. In 1948 policy had been clear and was accepted by all parties. Seven years later doubts were creeping in.
The post-war Greater London Plan had aimed to reduce the population of inner London by about 1,250,000 compared with 1938, in order to eliminate the housing shortage, ease traffic problems and improve access to leisure and recreational facilities. The projections of the fifties ultimately proved wide of the mark and the reduction of population, considered a good thing at the time, went beyond the wildest dreams of the planners.
In 1955 four Ministry officers were asked to visit all the hospitals in the Greater London area to review the recommendations of the Gray-Topping London hospital survey.20 They were asked to consider what modifications might now be appropriate on service grounds, in view of population trends. The purpose of the new survey was partly to assist the Ministry in the selection of building schemes but it was also to form the basis for discussions with London University on the relocation of teaching hospitals.21 The survey analysed the changes in the catchments of the teaching hospitals as a result of the establishment of the new towns and the hospitals developed in them. The surveyors, Clark, Winner, Barrett and Gregson, found that hospital services on the periphery of London had developed slowly and unevenly as a result of the restrictions on capital developments. In only a few of the teaching hospitals had there been a decline in the number of patients from outside London. Some, like University College Hospital, the Westminster, St Mary’s and Guy’s, still served large local populations and the percentage of their patients who lived in the County of London had increased slightly. Others, like St Bartholomew’s, the Middlesex, St George’s and The London had a falling local population and the proportion of patients from outside London had increased. It had not been possible to build hospitals fast enough outside London to cope with the population expansion. The peripheral populations were therefore increasingly dependent on central London hospitals. In general the new survey confirmed the policy of Goodenough and the hospital survey of 1945.20 There were too many teaching hospitals in central London and three should move out.
Most of the London medical schools continued to be slow to develop medical education on an academic rather than an apprenticeship basis; the university approach was adopted more readily in the provinces. The University Grants Committee consistently followed the Goodenough ideal that medical students should receive an education on broad and liberal lines. When, therefore, money became available for redevelopment in London, the University Grants Committee and the University of London restated their policy, placing emphasis on the association of medicine with the basic sciences in the undergraduate course and the development of cultural activities in the student body. The University wished to see the London schools of medicine as close as possible to the university precinct. It supported the development of St George’s Medical School at Hyde Park Corner, questioned the removal of the Royal Free to Hampstead, and refused to sanction the removal of Charing Cross Medical School to Harrow. After consultation with the University Grants Committee, Charing Cross was told by the University in January 1958 that it was not willing to agree to the siting of the medical school in Harrow. The hospital was not prepared to move without its school, and suggested that the general medical and surgical beds might be kept in the Strand whilst a new unit was developed in Harrow for specialty work. This duplication of facilities appealed neither to the Ministry, nor to the regional board, which did not see that it would solve the problems of shortage of beds in Harrow. However, the recent Ministry survey showed the need for hospital development in Fuiham. In August 1958, the Ministry suggested that Charing Cross and its school might be rebuilt there, in association with the West London Hospital. The University for its part agreed to reconsider its opposition to Hampstead as a site for the Royal Free.
During 1957 the Medical Research Council reviewed its policy on clinical research. The Council’s secretary, Sir Harold Himsworth, and a committee which included Sir George Pickering, concluded that a measure of concentration on a single site would be preferable to a larger number of widely dispersed units. The concept emerged of a clinical research centre associated with a hospital, and by June 1959 medical staff of the Ministry and of the Medical Research Council were visiting possible sites, including the Central Middlesex Hospital and Chase Farm, Enfield. Northwick Park, Harrow, was a last-minute suggestion by Sir Charles Harington, a member of the North West Metropolitan Board, just as the board was about to sell part of the site to the Middlesex County Council. A joint project to build both a hospital and a research centre was the result, building starting in 1966.
The planning of hospitals wishing to rebuild on their existing sites also suffered delays. Sometimes the hospitals themselves were responsible. Grandiose and inflexible plans might be prepared which had to be abandoned when difficulties became apparent. One hospital planned a tower block directly over an underground line; another a complex of towers which could not be commissioned in phases — the hospital would not work till the last one was in place. There were protracted discussions about hospital size, because whilst for educational purposes a hospital of a thousand beds was best, this contravened civil defence planning and a smaller hospital was better for ease of management and good staff relationships.22 Whilst the Ministry’s survey had drawn attention to the risk of overprovision, it proposed that some new hospitals should be built, and others, like St Alfege’s in Greenwich, should be redeveloped.21 Guy’s thought the Greenwich redevelopment would lead to an excess of beds in an area in which it was interested. The region was not enthusiastic, but the scheme went ahead. The existence of endowment moneys helped Guy’s, St Thomas’s and The London, for they could pay for preliminary planning and make a rapid start if money became available. It also enabled the hospital to influence the shape, design and location of the buildings on the site, and the nature of the wards - whether Nightingale or ‘race-track’. Endowment money made it possible for St Thomas’s to enlarge its site by six acres, when Lambeth Palace Road was diverted, at its expense.
National expenditure on hospital building rose slowly from £10 million in 1956-7 to £31 million in 1961-2. All three political parties included promises about hospital construction in their 1959 election manifestos; the economy was expansionary and there was a vogue for planning. Mr Enoch Powell became Minister of Health and pressed for an urgent hospital building programme. Officials worked late into the night, often with the Minister sitting in. The plan was based upon a bed norm of 3.3 acute beds/thousand, although studies like those of the Nuffield Provincial Hospitals Trust showed that more efficient use of beds was possible and it was recognised that the norm might require revision downwards. The aim was not merely to modernise and rebuild many hospitals, but to change their pattern and content, integrating them with health and social services provided in the community. The Ministry survey21 provided information about the requirements in London, enabling the plan to take account of the special requirements of teaching hospitals, and the inflow of patients into London. While it provided for a substantial reduction in London’s acute beds, the proportion in population terms would remain higher than elsewhere. Enoch Powell insisted that when a new hospital was planned, older hospitals which were to be closed should be named. Three undergraduate hospitals were to be re-sited, and postgraduate hospitals brought together in two groups, in Chelsea and Holborn. The service contribution of teaching hospitals was recognised, but it remained implicit that their size and location would be determined primarily by their educational role.
An attempt was made to ensure that the plan was financially viable, but it proved not to be and within four years a major revision was required. Mr Kenneth Robinson, in opposition, maintained that the Ministry had no idea of what it cost to build a modern hospital, and the Ministry admitted that many of the schemes were inadequately defined and imprecisely costed.24 The 1966 revision was more modest, but it too was based upon over-optimistic population projections and an under-estimate of costs. Policies were also changing;
It was recognised that fewer beds/thousand were required and the Ministry began to embrace a new philosophy - that the pattern of service should not be distorted by teaching requirements. Teaching hospitals should act as district general hospitals, the students being taught where patients required treatment - not vice versa.
Most of the building schemes in the centre of London were teaching hospital projects, handled centrally by the Ministry. The regional board schemes were generally further from the centre. One, the Northwick Park development, was the result of a tri-partite agreement made in 1960 between the North West Metropolitan Regional Hospital Board, the Ministry of Health and the Medical Research Council. It provided a new hospital for Harrow and a research centre which enabled the Medical Research Council to concentrate clinical, para-clinical and non-clinical research on a single site. A major objective was to encourage collaboration between research workers and clinicians serving the community. The Ministry participated in the planning because of the national role of the centre. Both the hospital and the research centre were integrated as one building complex, the first phase of which opened in 1970.
The remarkable fall in the incidence of the more dangerous infectious diseases left hospital accommodation for fever cases unused. The fever hospitals of the Metropolitan Asylums Board had retained their original function under LCC control until the outbreak of war in 1939. Then there were higher priorities; some beds closed as a result of the blitz, some because of a shortage of nurses. Sir Allen Daley said that of 4,000 - 5,000 beds in the fever hospitals before the war, only 800 were available afterwards. Even so, there were more than were needed and some were already being used for other purposes.
When the problem was discussed by the London County Council Hospital and Medical Services Committee in May 1945, one speaker said that the soundest hospitals structurally were those which the council had inherited from the Metropolitan Asylums Board, and they should be used to full capacity. Those in the centre could be converted to acute use, infectious diseases being sent to the periphery. The North Western, Northern, Southern, South Eastern, and Joyce Green hospitals might have a new function. Change of use was slow but progressive; solidly built and on large sites, the fever hospitals were an asset of great worth to the National Health Service. Patients with chest diseases and tuberculosis were admitted to some wards, and orthopaedic units were opened in others. Some of the hospitals began to develop into acute district general hospitals in their own right.
The 1956 Ministry survey21 complimented the regional boards on the extensive and skilful use being made of the fever hospitals at a time of restricted hospital building. Redundant accommodation was being adapted for more urgent needs, including units for poliomyelitis and regional specialties, like neurosurgery and thoracic surgery. The metropolitan hospital system was slowly being reshaped, but in a disjointed way as opportunities presented themselves. The Ministry made an attempt to regulate developments, and to concentrate regional services, as the hospital survey of 1945 had suggested. But according to John Pater it was a pretty forlorn hope. Better mechanisms were called for if unnecessary developments were to be avoided.
The Goodenough report25 and the hospital survey of 194520 had proposed that there should be a reduction in the number of specialist hospitals. A number were amalgamated with other groups at the inception of the National Health Service. It was proposed that others should be regrouped around the university area as occasion permitted. The Ministry’s new survey in 1956 said that lip-service had been paid to the concept of grouping, but restriction on capital investment had limited progress. Many postgraduate boards had made plans for redevelopment on their existing sites. The surveyors considered that whilst it was reasonable to take advantage of sites already near the university area, to relocate structurally sound hospitals was uneconomic~ to do so in the centre also ran counter to the precepts of city planning.21 Redevelopment proposals were announced by Mr Enoch Powell in the House on 27 June 1961. He suggested that as far as possible the specialist hospitals should be concentrated into two groups, one in the Holborn area and the other in Chelsea, around the Fulham Road. To make the Chelsea postgraduate centre possible the site of the old municipal St Luke’s Hospital, and the Chelsea Hospital for Women, would be used. The Chelsea Hospital for Women would be rebuilt alongside Queen Charlotte’s, which, like the Bethlem Royal and Maudsley, would remain outside the two groups. The position of the Royal National Orthopaedic Hospital would be considered at a later date.
To determine the general principles which should guide the organisation of a postgraduate centre a committee was established by the Ministry under the chairmanship of Sir George Pickering.26 The report was short. Visiting the institutes, the authors became only too aware that scientific facilities were often limited and there was sometimes an atmosphere of isolationism. In general the institutes to be associated in Chelsea were outward looking, but this was less evident in the Holborn grouping. The report stressed that institutes and their hospitals could not hope to lead in their fields if isolation continued. With the broad advancement of medicine, innovators needed access to a wide range of facilities. Independent access was impracticable on the ground of cost. Institutes might amalgamate either with each other, with general medical schools, or some might move into a relationship with the Royal Postgraduate Medical Schools at Hammersmith.
The final recommendations reflected the views of the institutes that association with a general medical school might lead to loss of identity. Amalgamation with each other was therefore favoured. It was envisaged that hospitals would be built on the periphery of an area in which joint scientific facilities and individual institutes would lie. Neighbouring institutes would communicate physically with each other and with central supporting departments. Shared facilities would include pathology, tissue and organ culture and cytology. Since close architectural and functional association was envisaged it was hardly surprising that the cost of the proposals was considerable.
The two suggested postgraduate hospital groups
The plans for the Holborn group were the first to run into trouble. The committee formed to develop the proposal found that ground adjacent to Great Ormond Street and Queen Square was not available - it was being used for new housing. An alternative site in Gray’s Inn Road was considered but the borough objected to it being zoned for hospital use. This led to some of the specialist institutes and their hospitals becoming increasingly attracted to the idea of a close association with an undergraduate teaching hospital, and in view of the many uncertainties it was decided to drop the proposal in 1966.
There was no problem finding a site for the Chelsea postgraduate centre. The sites of the old St Luke’s Hospital, the Chelsea Hospital for Women, the Royal Marsden and the Brompton were available. A project team was assembled and an outline development plan was prepared with the assistance of Llewelyn-Davies Weeks and Partners. It envisaged a series of eight-floor buildings providing about twelve hundred beds, together with accommodation for the institutes of St Mark’s, St Peter’s, St John’s, the Brompton, the Marsden and the National Heart. There were to be five phases as hospitals were demolished and rebuilt in turn.
By now rumours were beginning to circulate about the line the Royal Commission on Medical Education might take on postgraduate hospitals.27 It was the alternative option, that postgraduate hospitals and their institutes might be integrated with teaching hospitals and general medical schools. This, together with the horrific cost of the Chelsea scheme, led to the final abandonment of the policy to establish two postgraduate groups.
The Goodenough report stated that teaching hospitals should see themselves as full partners in the hospital service of the district in which they were located, and that equal emphasis should be placed upon the treatment of patients and the training of students. However, the voluntary hospitals had been founded to provide particular types of care of the highest possible quality to as many of the sick poor as possible. They were still doing so, although an increasing number of their patients were coming from further afield for specialist treatment. They could not easily accept that they should change their role to provide comprehensive care for a defined population, nor see how they could simultaneously serve patients from a distance needing specialist care, and still maintain standards. Traditionally teaching hospitals were more prepared to cut quantity than quality, to maintain the standard of their service and teaching. Most of them had insufficient beds to provide all the services now being asked of them.28 In any case the ultimate responsibility for the provision of a service had been laid upon the metropolitan hospital boards.
By 1960 the old guard of chairmen and administrators was being replaced by a younger generation. Many of the new house governors knew each other, having been trained under the King’s Fund bursary scheme. They also met regularly in a hospital discussion group. There was a new problem to be faced: the movement of the population away from central London and the improvement of hospital facilities in the peripheral areas made it more difficult for teaching hospitals to obtain a supply of ‘ordinary patients’. A ring of hospitals was being planned and developed around London, but any suggestion that a teaching hospital might find itself out of business if it did not mark out a district for itself was at first received with incredulity.
In the North West Metropolitan Region the board had particular difficulty in meeting its responsibilities to provide care, as there were few regional board hospitals in the central area. In November 1960 the senior administrative medical officer, Dr Frank Fowler, arranged to meet the secretaries of the five teaching hospitals in his region. He raised the question of accepting a district responsibility — taking all patients from a specific area if no other arrangements could be made.
He pointed out that as the board carried responsibility for providing care, it would have to make other arrangements if the teaching hospitals were unwilling to play their part. The medical committee of University College Hospital saw that the falling population might leave them without enough ‘average’ patients, and that it was undesirable for medical students to become practised merely in the more exotic forms of care. The additional load proposed would not be great and refusal was risky. The medical committee recommended acceptance to the board of governors and University College Hospital assumed district responsibilities in November 1961, becoming in its view the first teaching hospital in London to do so.29 Hammersmith was probably the last. Although it had originally been a municipal hospital with a defined catchment - albeit a hospital to which the British Postgraduate Medical School was attached - it had changed its nature considerably in the early fifties. Under the influence of men like Sir John McMichael new techniques of investigation were developed. Open heart surgery was introduced, and the creation of specialist units left little room for clinical work of a more mundane nature. In spite of attempts to alter this ethos, for some years neither the hospital nor its board saw any purpose in attempting to provide a district service. However from 1967 onwards its policy began to change, and it was appreciated that there were benefits in the application of advanced clinical and scientific techniques to common conditions found in a local community.
During the fifties the size of the medical school intake had been reduced as a result of the Willink report30, but the University Grants Committee recognised that a shortage of doctors was developing and began to plan for expansion. In 1961 the Minister of Health made a statement in the House recommending an increase of 10 per cent in the intake. In January 1964 the health departments considered that a further increase of 15 per cent was called for. The University of London sought the views of the medical schools on the possibility of achieving this. The schools stated that given the necessary resources 145 additional places could be provided within four years; within a decade an increase of 268 places was possible. However an increase of this order would involve major development at a number of medical schools and access to more beds. In February 1964 the Minister of Health, Mr Anthony Barber, addressed the Teaching Hospitals Association and referred to an agreement with the University Grants Committee that an intake of 100 students might justify a new hospital of 1,200-1,300 beds, though not necessarily all on one site. The plans for the reconstruction of St Thomas’s and St George’s were sized on this basis. Other medical schools already had loose arrangements with ex-municipal hospitals to provide them with access to beds, but with expanding intakes something more formal was called for.
Dr James Fairley, senior administrative medical officer of the South East Metropolitan Regional Hospital Board, and a governor of several teaching hospitals, believed that the transfer of regional board hospitals to teaching hospitals was the most satisfactory approach.31 Mr Mellish, the chairman of the Bermondsey and Southwark Hospital Management Committee, favoured this type of development and approached Guy’s, but the teaching hospital was not initially interested in taking over the regional board hospitals. When an alternative approach was made to King’s College Hospital, however, Guy’s reconsidered the possibility. A working party in the South West Metropolitan Region came to a similar decision, and recommended to the Minister that Lambeth Hospital should be transferred to St Thomas’s.32 This transfer took place in 1964 and St Thomas’s explicitly accepted ultimate responsibility for a population of 200,000 in Lambeth. The teaching hospital had lost the privilege of picking and choosing its patients, but had gained closer links with its neighbourhood.
Lord Inman, the chairman of Charing Cross Hospital and the London branch of the Teaching Hospitals Association, put in a strong plea to his fellow chairmen to wake up to coming problems. In April 1964 the hospital secretaries met at the Hospital Centre to discuss what might happen to the authority of the London undergraduate teaching hospitals if and when Labour returned to power. They agreed that much closer coordination of their activities was desirable, and a small subgroup was established which expressed strong but divergent views. Brian Abel-Smith suggested that a body with power to enforce budgetary control might be desirable, an idea which did not appeal to the hospitals. The chairmen, meeting in June 1964, agreed that they needed to coordinate their activities more closely, and established a working party chaired by Sir Desmond Bonham-Carter to consider how the teaching hospitals might work together to meet their district and other responsibilities. They concluded that to make economic use of their facilities, and create a well-balanced flow of clinical material, they would need to draw upon a population of 2½-3 million, and that more beds were required. They favoured designation of regional board hospitals, because it was easier to teach students in hospitals under unified medical and nursing control with similar standards, easier to obtain university funds, and easier to obtain university recognition of teaching staff in hospitals which had been designated.33
There was however an alternative form of organisation. The overlapping responsibilities of the regional boards and the boards of governors led to recurrent suggestions that teaching hospitals should lose independent status and be managed by the regions, although both the Guillebaud report on the cost of the National Health Service in 195634 and the Acton Society Trust in 195735 rejected the idea. In evidence to Guillebaud, the Teaching Hospitals Association said that any rationalisation of medical services involved a danger to professional standards. The risk was minimised, in the Association’s view, if teaching hospitals were allowed to work like universities to their own clinical and academic standards, and in their own traditions, protected from the levelling-down too often seen in large groups.36 Some teaching hospitals saw yet another possible form of management — the unification of the London teaching hospitals in a central region of their own, reducing the area of the regional hospital boards.
In October 1964, Labour came to power for the first time in thirteen years. The following February the new Minister, Mr Kenneth Robinson, addressed the Teaching Hospitals Association and called a halt to further designations of regional board hospitals whilst the policy was reviewed. The review was completed in May, and it was announced that further designations might be considered if they were in line with regional policy and the teaching hospitals would accept ultimate responsibility for the provision of a district service. The review was prompted by doubts in some quarters about the efficiency with which teaching hospitals would provide district services, because of their high degree of specialisation and their alleged bias towards ‘interesting cases'. Were they prepared to give the same weight to the needs of a local community for a balanced service as they did to their teaching functions? Some teaching hospitals certainly did see it as vital to their future to keep a close hold on a district, and easy access to its patients. Others equally certainly did not. To meet the challenges which were coming the undergraduate hospitals strengthened their London committee by adding medical representation. The deans and the chairmen of the medical staff committees were invited to join.
The Minister’s conference, July 1965
With a view to resolving some of the problems of medical education and hospital administration, Mr Kenneth Robinson spoke to the chairman of the London committee of the Teaching Hospitals Association, Sir Desmond Bonham-Carter, and called a conference of the regional boards and the boards of the teaching hospitals.
Mr Kenneth Robinson pointed to the improvements in the services provided by the peripheral hospitals, and to the reduction in patients’ length of stay which made it essential for the teaching hospitals to extend their catchment areas if they were to meet the needs of clinical teaching. The time was in sight when a large part of central London would be provided with hospital services mainly by the teaching hospitals. It was going to be of the greatest importance for them to accept full responsibility for all local hospital services as well as accepting some patients referred from greater distances. As to the final solution of the problem of hospital administration in London he had an open mind; teaching hospitals might be absorbed into regions, or a central London hospital authority might be established. For the present he proposed an interim solution which would associate boards of governors with regional boards in planning. A consultative committee might be established in each region to advise the regional board on hospital and specialist services in the central part of the region.36, 37
There was a wide measure of agreement with the Minister’s proposal although the Guy’s representative said that he was terrified of bureaucracy and that there was more harness than horse about what was suggested. Could not each region be left to work out the most suitable committee structure for itself?
Three weeks later the Minister wrote to the chairmen of the regional boards asking them to establish committees with representatives from their own boards, those of the teaching hospitals, London University and the Inner London Executive Council. The most urgent problem to be tackled was the joint provision of district services and access to sufficient beds to meet the teaching needs of the medical schools. He also asked for views about the possibility of a forum within which the problems of health and welfare services of central London as one entity could be discussed, having in mind the problem of the rationalisation of the regional specialties.
As a first stage, four regional joint consultative committees were rapidly formed. The north west committee soon submitted proposals for the designation of further regional board hospitals to the teaching groups of St Mary’s, the Royal Free and University College Hospital. Progress in the south west committee was slower. There was a serious division of opinion in the north east committee about whether the additional beds needed for teaching should be provided by designation or by a system of association, which had little appeal to the teaching hospitals concerned. The south east committee was asked to consider the catchment areas of King’s and Guy’s, in the light of the proposal to undertake major redevelopment at Guy’s. A special study was commissioned which later proved useful in determining district boundaries. In the south east committee ‘there was helpful cooperation on all sides’, and the teaching hospitals accepted full district responsibilities.
Further designation orders were soon made on the recommendations of the joint consultative committees, and the negotiations were generally amicable. St Giles’ and St Francis’ joined King’s College Hospital in 1966. Other hospitals were taken over by St Mary’s, The London and St Thomas’s. The change in management led to the appointment of new consultant medical staff with the needs of medical education in mind, and the boards of the teaching hospitals put considerable effort into the improvement of both staffing and the buildings. Not all problems could be solved by designation. There might be no suitable hospital nearby, as in the case of the Middlesex, or, as at St Bartholomew’s, there might be an unwillingness to allow students to work in a ‘non-teaching hospital’.
By the mid-sixties the hospital service in central London had largely settled down. Sir Desmond Bonham-Carter thought that the boards of the teaching hospitals were about the right size, and less fettered by regulations governing their number and composition than were the regions. Local management was near the point of activity, and the four joint consultative committees which soon encompassed postgraduate interests provided a mechanism for working together. Other problems which were being addressed included the organisation of medical work in hospitals. The developments in medical science and the growth in the size of the hospital team had not been accompanied by changes in the relationship of the medical staff with each other, or with the hospital management. The ‘Cogwheel’ working party, chaired by Sir George Godber, recommended a divisional system to overcome this problem.
The representation of senior nursing staff, alongside the doctors and administrators, and the need for chief nursing officers to have well developed managerial skills, were discussed in another report on senior nursing structure.39 However the University Grants Committee was still finding it impossible to grapple with the educational problems in London. The tripartite structure of the health service was the subject of increasing criticism, fuelled by the existence of the Royal Commission on Local Government. It was a calm before a storm.
2 Ministry of Health circular, RHB(47)l 1.
3 Great Britain, Ministry of Health, Central Health Services Council. Report of the committee on the internal administration of hospitals. (Chairman: A F Bradbeer). London, HMSO, 1954. See also Hart F and Waldegrave A J. A study of hospital administration. London, Stevens and Sons, 1948.
4 London County Council papers, PH/HOSP/1/91.
5 Clark-Kennedy A E. The London Hospital. London, Pitman, 1963.
8 Fraser Sir Francis. The British Postgraduate Medical Federation: the first fifteen years. London, University of London, 1967.
10 PRO/MH/99/39; GLRO/PI-1/HOSP/1/91 and 1/92.
12 Ministry of Health circular, RHB(48)1.
13 Ministry of Health. The development of consultant services. London, HMSO, 1950.
15 Great Britain, Ministry of Health. Report of the Central Health Services Council on the co-operation between hospital, local authority and general practitioner services. London, HMSO, 1954.
16 Daley Sir Allen. Memoranda submitted to the Central Health Services Council on co-operation, 1952.
17 King’s Fund, A/KE/242 and 243.
18 PRO/MH/93/5 1.
19 Abel-Smith B. Present and future costs of the health service. Lancet, 1956, i, p 198.
20 Gray Sir A M H and Topping A. The hospital services of London and the surrounding area. London, I-IMSO, 1945. Ministry of Health hospital surveys volume 1.
21 Clark G A, Winner Albertine L, Barrett R H and Gregson H R. Hospital survey: a survey of the hospital resources of Greater London. London, Ministry of Health, 1956. Unpublished.
22 PRO/MH/93/4; Annual report of the Ministry of Health 1948—9.
23 Great Britain, Ministry of Health, National Health Service. A hospital plan for England and Wales. London, HMSO, 1962. Cmnd 1604.
24 Hospitals in the air? British Medical Journal, 1965, i, pp 807—8; and Great Britain, Ministry of Health, National Health Service. The hospital building programme: a revision of the hospital plan for England and Wales. London, HMSO, 1966. Cmnd 3000.
25 Great Britain, Ministry of Health and Department of Health for Scotland. Report of the inter-departmental committee on medical schools. (Chairman: Sir William Goodenough). London, HMSO, 1944.
26 Great Britain, Ministry of Health and University Grants Committee. Postgraduate medical education and the specialties (with special reference to the problem in London). (Chairman: Sir George Pickering). London, HMSO, 1962.
27 Royal Commission on Medical Education 1965—8. Report. (Chairman: Lord Todd). London, HMSO, 1968, Cmnd 3569.
28 Burfoot H C. Annual reports of Guy’s Hospital, 1965, 1966. London, Guy’s Hospital.
29 Minutes of the board of governors, University College Hospital.
30 Great Britain, Ministry of Health. Report of the committee to consider the future numbers of medical practitioners and the appropriate intake of medical students. (Chairman: Sir Henry Willink). London, HMSO, 1957.
31 Fairley J. Co-operation between regional boards and teaching hospitals in planning. The Hospital, October 1964, p 595.
32 Sharpington R. No substitute for governors. London, St Thomas’s Health District, 1980.
33 Papers of the Teaching Hospitals Association. A selection is held by the National Association of Health Authorities, but many are held by individual hospitals and authorities, for example, Guy’s and Westminster Hospitals (GLRO/WI-I/A/167).
34 Great Britain, Ministry of Health and Scottish Home and Health Department. Report of the committee of enquiry into the cost of the National Health Service. (Chairman: C W Guillebaud). London, HMSO, 1956. Cmd 9663.
35 Hospitals and the state, numbers 1-6. London, Acton Society Trust, 1955-7.
36 Burfoot H C. Annual report of Guy’s Hospital 1965. London, Guy’s Hospital, 1965.
37 Great Britain, Ministry of Health. Annual report. London, HMSO, 1965. Cmnd 3039.
38 Great Britain, Ministry of Health. First report of the joint working party on the organisation of medical work in hospitals. (Chairman: Sir George Godber). London, HMSO, 1967.
39 Great Britain, Ministry of Health and Scottish Home and Health Department. Report of the committee on senior nursing staff structure. (Chairman: Brian Salmon). London, HMSO, 1966.