The Development of the London Hospital System,
1823 - 2015
The Overview, originally written in 1984/5 has been rewritten in the light of the many changes in the past twenty-five years.
Attempting to draw together the many threads of London health care and its hospitals, which have always played a prominent and even a dominant role, is difficult. This overview has been re-written in its entirety. The book has traced the way in which a multitude of hospitals that differed in their aims, their finance and their management have increasingly come together within a system that, as Lord Lawson has wryly suggested, is the closest thing the English have to a religion. It is hard to develop a mental model of what is going on. It is even harder to improve matters. From Sir Henry Burdett in the 19th Century to Dame Ruth Carnall and Sir David Nicholson in the 21st bright and devoted people have struggled with this Sisyphean task. Their consolation is that it is not really an eternity of useless efforts and unending frustration. We have not reached perfection but much good has come of their efforts.
A complex system and a wild problem
London medicine is an incredibly complex system that few if any really understand. It presents a wild problem, difficult to define, ever changing and just as a solution is apparently in sight, the problem alters. Often the law of unintended consequences seems to prevail.
Hospitals are part of the wider economy. With the NHS spending some 8% of the gross national product, and health spending is nearer 17% in the USA, the political view that a vibrant health service depends on a vibrant economy must be correct. The health service has over a million staff so that merely as an employer it is a substantial component of the economy. In some localities it is near dominant. At one time the number of doctors who were to be trained in the UK was geared to the likely speed of economic growth, not the need for their services. In the 19th century an agricultural depression devastated voluntary hospital finances, and hard times increased the strain on the workhouses. Our current economic problems are at the root of many issues in the NHS. Kenneth Clarke maintains that there are positive advantages in stringency, forcing as it does reappraisal of how the system is managed.1 Not everyone would see matters in this way.
The desire to mitigate the effect of social inequality on health, a Sisyphean task if there ever was one, adds to the complexity. From Charles Booth to Brian Jarman and Sir Michael Marmot, managers have been reminded of its importance. Voluntary hospitals, for example The London, attempted to shoulder this burden. Awareness that social services play a key role in health care lay behind the drive for coterminosity of health and social care in the 1974 reorganisation, and remains on today’s political agenda. The Resource Allocation Working Party (1976)2 redistributed money partly with this in mind, London losing money to the north, to the shire counties and to long stay specialties previously grossly under resourced.
Clinical care is ever changing. Old killers, the fevers and tuberculosis, do not dominate health services as they once did. New methods of diagnosis and imaging have changed the shape of hospitals, altering the balance of inpatient and ambulatory care, modifying the functional content of hospitals and leading to an increase in the number of patients. Fifty years ago Sir Max Rosenheim at UCH joked that a health person was someone who had been inadequately investigated. Joint replacement, transplantation, minimally invasive surgery and better anaesthesia have changed the business of the hospitals. Genetic medicine doubtless will do so in the future, and most advances modify the site of health care delivery between the community and the hospital in one direction or another.
Research is the life blood of a developing service. A hundred years ago in his rather arcane style, Sir William Osler talked about what was essentially translational medicine when he said that ‘the hospital [specialist] units mint, for current use in the community, the gold wrought by the miners of science. This is their first function.’ Today we have the academic health science centres that ‘make the most of the synergies between research, education and health services to translate research into better care and increase the speed at which research is taken from bench to bedside and back again’.
Additionally there has always been an international angle, from the time that Florence Nightingale studied continental hospitals and nursing systems, to today’s clinical trials. No country’s hospital system stands alone. Its staff and their skills move between countries.
The modification of health systems
Changes in systems are seldom radical and are usually firmly based on what has previously existed. They are evolutionary, not revolutionary. Whether one looks at Bevan or Obama, the systems they have influenced are founded on what went before. The appointed day, 5th July, brought not one extra doctor or nurse. The unfolding story in the book is this evolutionary change, although it is true that a major upheaval such as the 1939-1945 war makes a new and radical departure easier. ‘Never waste a good crisis’ has become a management doctrine. Some saw in the Darzi proposals of 2006-20083 an attempt to tear up the hospital service and primary care and start again. ‘Brilliant in conception, clinical in slant, but a recipe for turbulence,’ said the Guardian; it was a blueprint for radically different NHS. In the event that did not happen, although some useful change did.
Centralisation and devolution
For two hundred years there has been a continual strain between centralisation and devolution. Governance and management have always been contentious issues. Initially decentralisation dominated. Hospitals were managed either by ad hoc bodies, established specially for that purpose such as the committees of the voluntary hospitals, or by elected authorities and their committees. The result was confusion, gaps, overlaps and chaos.
When the pressure for centralisation came, for example with the need for poor law hospital reform and a system of fever hospitals, or for removing London hospitals to the places where the poor had come to live, the trouble started. The argument for devolution partly rests upon the need for hospitals to be sensitive to local opinion and local needs. The centralist argument was expressed by the Royal Commission on smallpox hospitals, commenting on the Metropolitan Asylums Board in 1882.4
‘It will bring to a focus, and will be able to give instant and extended effect, to all the experience which will otherwise be scattered with various results, among a variety of bodies not always actuated by broad or accurate views. It will also be able to make the different parts of a large system work into each other, not only for the advancement of practical efficiency, but also for the careful observation, collection and publication of facts systematically observed over the large field which their operations cover. Finally, it will probably be able, from its dignity and importance, to command a higher class of administrators. The Board, if it is one, will be the picked men of the metropolis, instead of the picked men of a parish.’
An uneven and incoherent hospital service had developed in London. The voluntaries could not raise enough money, either individually or jointly, to expand to meet the increasing demand for hospital care as medical science developed. So the rate-supported hospitals moved into acute care, compounding the problem of competitive and overlapping services.
The confusion led to repeated calls for economy and efficiency, for cooperation and rationalisation by the Select Committee of the House of Lords (1892), 5 the King’s Fund (1897), the Cave Committee (1920), by Neville Chamberlain as Minister of Health, the Sankey Commission (1937) 6, and the Nuffield Provincial Hospitals Trust (1941). Unfortunately, because of the multitude of authorities with different perspectives, agreement on issues of a fundamental character could seldom be reached.
The NHS ultimately provided a broader framework for planning, but it too chose to function with many independent authorities, each separately accountable to the Minister. Planning within a single organisation is always simpler than coordinating the planning of separate bodies. The creation of ‘joint planning’ and ‘liaison’ committees is frequently a sign of a basic organisational fault. Progressive reorganisations sometimes tried to mould the London authorities into a pattern which would make major change possible. The establishment of a single region for London (2002) had this aim.
Ara Darzi (2008) believed that one should centralise when essential, for example to improve outcomes, and decentralise where possible to improve access.3 Whatever the advantages and disadvantages are for centralisation in clinical and management terms, the situation differs in research and development. From the special hospitals or the 19th century, through the postgraduate teaching hospitals in the 20th to our new Academic Health Science Centres networks, the need for local autonomy is clear. London’s three AHSCs will almost certainly develop an accent on different medical problems, playing to the strengths of their staff. They have to if they are to fulfil their function.
Merger and Reconfiguration
Hospital buildings have a limited life span. The services needed change. Reconfiguration is continually needed. In 1946 the local hospital management committees began the process of reshaping the local hospital provision, a process that has continued ever since. Amalgamation as a method of rationalisation had always been favoured. It is less drastic than closure and therefore more acceptable. It preserves valuable strengths and traditions and a role can be found for supporters in the new organisation. It is argued with little evidence that larger units may be more economical to run, and more convincingly that they will provide a better basis for medical education and research. Finally the merger can be combined, if desirable, with a judicious reduction in bed numbers. The efforts of the King’s Fund to achieve amalgamation of small hospitals have been followed ever since by mergers, a process continuing fuelled by budget cuts, the migration of population, the falling duration of inpatient stay and the need to create larger units to ensure clinical effectiveness. Sadly while in the business world a merger almost always has a clear objective, obtaining a brand name, reducing over capacity or developing a new line, recently in the NHS this has not always been the case. Merger has sometimes been seen, in the face of the evidence of failed past mergers, as the way to resolve a managerial problem. However as the Americans say, however, three turkeys do not make a hawk as has recently been evident in south London (2013).
Whether it was the King’s Fund, the LCC, Lord Dawson’s Interim report in 1920 9 or in the NHS, the wish to provide an equitable service at a reasonable cost has always been there. The King’s Fund relied on friendly persuasion, the LCC on a clear management hierarchy, and at times it is hard to see the principle behind NHS management. The clash of the populist, the political, the professional and managerial is only too evident. It is an axiom that in a wild problem those whose duty it is to find a solution are frequently themselves part of the problem. This shows no sign of ceasing to be the case. It is hardly surprising that initiatives such as the London Health Planning Consortium, Tomlinson,7 Turnburg 8 and Darzi 3 seldom achieve more than 20% of their potential.
Lead time to change
As a result, the time taken to achieve necessary changes is protracted.
Sometimes it seems as if there is a thirty year rule that from the
perception that an advance necessary to its implementation is that length of
time. Whether it is the
relocation of hospitals, the merger of medical schools or the development of
clinical networks coordinating services across hospitals rather than purely
within them, this delay seems only too common.
To make it even worse, time after time, a group has become
knowledgeable, expert and effective but before the full results of their
efforts are harvested, the group has been dismantled, as after the London
Health Planning Consortium, Tomlinson and Turnberg.
A central hospital board for London was suggested 150 years ago.
Only recently did we achieve one in NHS London and it too has gone.
If there is any lesson to be drawn from the history of London’s
hospital and health system it is that nobody gains in the long run from the
absence of a central focus for London’s health problems that operates openly
and transparently. The complexity of the arrangements from April
2013 suggest a measure of instability.
The complexity of the arrangements from April 2013 suggest a measure of instability.
There remain great strengths in London hospital medicine, which by any standard should be preserved as foundations for the future. Working in London’s hospitals, and managing them, has never been easy, nor will it be in the future. It is a memorable experience.
1 Clarke K. In The Wisdom of the Crowd. 65 views of the NHS at 65. (Ed. Nick Timmins) London. Nuffield Trust, 2013.
2 Department of Health and Social Security. Sharing resources for health in England. Report of the Resource Allocation Working Party. London: HMSO, 1976.
3 Darzi A. A framework for action. Healthcare for London, 2007. and A local hospital model for London. Healthcare for London. 2008.
4 Hospitals Commission on the smallpox and fever hospitals of London. London, HMSO, 1882
5 First and second reports from the select committee of the House of Lords. London, Hansard and Son 1890, HMSO 1891.
6 Report of the Voluntary Hospitals Commission. (Sankey Report). London, British Hospitals Association, 1937
7 Department of Health. Report of the inquiry into London's health service, medical education and research. (Chairman: Sir Bernard Tomlinson.) London: HMSO, 1992
8 Health Services in London – a Strategic Review. (The Turnberg review). London. Department of Health. 1997.
9 Ministry of Health, Consultative Council on Medical and Allied Services, Interim Report. (Chairman Lord Dawson) London HMSO 1920 Cmd 693