By understanding the history of London’s hospital system, today’s healthcare leaders will help improve it, says Geoffrrey Rivett

The Lancet was founded in 1823 partly to expose evils in the hospitals in London, for which a surgical instrument was appropriate. Much was amiss, for there was a financial crisis. Nepotism reigned in the great charitable hospitals. Patients were attending outpatient clinics in their thousands, when they were not a proper object of charity and should have gone to their family doctor.

‘William Farr and Florence Nightingale were both worried about hospital mortality and the accuracy of hospital statistics’

In London’s workhouse hospitals, there were scandals of poor care. Hospitals were often badly managed, badly situated and infections spread from patient to patient. Doctors and managers sometimes fought, and the doctors felt they were not being listened to.

So what has changed?

Taking the temperature

Almost 40 years ago, as a middle ranking doctor in the Department of Health, I joined a team supporting the London Health Planning Consortium that was reviewing London’s hospitals, bed numbers, specialty services and the facilities for teaching. London seemed such a mess, a feeling often shared by incoming ministers. Why?

I began to read past reports with increasing astonishment, finding gems such as the select committee of the House of Lords in 1892. A witness had the temerity to suggest relocating Barts, only to be told by the noble Lord Thring that if he was knocked down in Smithfield, the statue of a griffin, left there in remembrance, would not be much use to him.

Before long, I gave a talk on London to colleagues. My text kept growing until Robert Maxwell, at the King’s Fund, told me that with another couple of years’ work, it might be publishable. Surprisingly, it was cleared by the Department of Health in 1986 and I sent a copy to the permanent secretary, who replied graciously, and to HSJ, which reviewed it favourably in August 1986.

A new perspective

Since then, much has happened in London: massive organisational change, huge advances in medicine, the purchaser-provider split, foundation trusts, academic health science centres and the Tomlinson, Turnberg and Darzi reports. It was time for a second edition to bring the story up to 2013.

The book provides a long term perspective on the organisation of London’s hospitals: for example, it notes how in 1939 the emergency hospital system broke down the barriers between municipal and voluntary hospitals and established a radial system that persists to this day.

‘The greatest problem by far is the absence of a transparent central board for London’s hospitals, recognised as key 120 years ago and still not in place’

Hector Gavin wrote about health inequalities in 1847. The hot topic in the 1870s was how best to recruit, train and manage nurses. Lord Lister said in 1897 that it was difficult to assess whether hospitals were run on a sound professional basis. William Farr and Florence Nightingale were both worried about hospital mortality and the accuracy of hospital statistics, when so much could be learned from them. 

From Sir Henry Burdett to Dame Ruth Carnall, thoughtful and energetic people have devoted their lives to improving London’s service. Their efforts have not been in vain because the system presents a wild problem: it is difficult to define, hard to solve (because the issues mutate before one’s eyes) and those charged with solving things are often part of the problem themselves.

Historic problems

Present issues are illuminated by the past. Nick Timmins recently listed some for the Nuffield Trust. The “tension between central direction and local responsibility” is an echo of the problems faced in the LCC and voluntary hospitals − and indeed by Nye Bevan who said regional boards “were agents on whom he wished to confer the largest possible measure of discretion. From the outset they were to feel a lively sense of independent responsibility”.

“Transparency” was an issue as the great hospitals were “irresponsible bodies” − they were responsible to no one. “Repeated reorganisations” certainly have been with us since the King’s Fund started amalgamating hospitals in the early 1900s.

The problems of general practice go back to the 19th century when hospital outpatient departments were taking the bread from GPs’ mouths. But greatest by far is the absence of a transparent central board for London’s hospitals, recognised as key 120 years ago and still not in place.

Geoffrey Rivett is an NHS historian and author of The Development of the London Hospital System and

Geoffrey Rivett’s new book is printed on demand as paperback, hardback or PDF: the text is uploaded to a server and placed on sale through The book costs about £30. It is printed within 48 hours and arrives by courier within 10 days.