The Development of the London Hospital System,

1823 - 2015

Geoffrey Rivett

homeshaping the systemvoluntary hospitalspoor law infirmariesmedical schoolsfever hospitalsproblems & solutionsshaping the futureInter-war yearsregions & districtsthe EMSBevanhospital developmentrationalisationstringencydistricts to trustsoverview


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The new edition of this book out of print but now updated.  For more details and

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This is an organisational history of the development of hospitals in London over the last 190 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.  It lacks the clinical angles that are a major part of  From Cradle to Grave concentrating as it does in the development of system in hospitals in London, rather than clinical and political developments.

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. Since 1982 when the book was published much has happened in medicine, in London and to hospitals.  I have written a further chapter covering 1982-2013.  I have added sections to the text where new information has become available to me and, perhaps it is easier to include personal knowledge that would have been unwise when I wrote the book in 1978-82.Copies of the original print run of 1000 copies have long been hard to find.  As 30 years have passed since it was written, I have taken advantage of modern technology to publish personally, on a print to order basis.  If you go to the link above, you can order a copy that will be printed for you within days and with you by post within a couple of weeks.


This history begins with the foundation of The Lancet in 1823 and ends in 2013 with the restructuring of the National Health Service, when the management of hospitals in isolation from other health services had ceased,the introduction of the internal market and the structural reforms of Labour and the Coalition governments.  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 Cyril Chantler, Sir John Ellis, Dr Clark-Kennedy, Sir Harry Moore, Mr David Noble, Mr John Pater, Dr James Fairley, Dr Malcolm Godfrey, Sir Robert Naylor, 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.

Those seeking information on individual London hospitals, specifically those now closed, may find information at Lost Hospitals of London


The shaping of London’s hospital systemThe background  population issues.
The voluntary hospitalsThe voluntaries, great and small; their origins and objectives
Hospitals and medical schoolsThe relationship of the voluntary hospitals and the medical schools
The development of poor law infirmariesHealth care for the indigent - the paupers.  Scandals and upgrading
Smallpox and fever hospitalsThe development of a system purely for the infectious diseases
Defining problems and debating solutions, 1860—1889Debates on how hospitals in London should be organised, and the emergence of skilled nursing
Reviewing the past and shaping the future, 1889—1914London County Council, and the King's Fund
Developments in the hospital services between the world warsAn unstable system, its financial and organisational problems
Regions and districtsThe concept of the region and the district - where they came from, and how they were integrated into the NHS
The Emergency Medical Service and planning during the warThe effect of wartime organisation  (the Emergency Medical Service), on the hospitals and the NHS that followed
Bevan and the National Health Service, 1945—1948Bevan's plan, and the build up to the NHS
Hospital development, 1947—1968The early days of the NHS, and the effect on London's hospitals
Rationalisation and reorganisation 1968-1974The effect of the political decision to reorganise the NHS in 1974
Strategy and stringency 1974-1982Resource reallocation and the hospitals; the 1982 restructuring
From Districts to Trusts - London’s hospitals from 1982-2015


Griffiths, the Conservative, Labour and Coalition's reforms. The NHS Plan and changes in the pattern of administration in London. University decisions and the restructuring of London's medical schools and hospitals.  The Ara Darzi report.  The effects of the 2013 structural changes introduced by the Coalition government and the move to hospital mergers.

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homeshaping the systemvoluntary hospitals poor law infirmariesmedical schoolsfever hospitalsproblems & solutionsshaping the future
Inter-war yearsregions & districtsthe EMSBevanhospital developmentrationalisationstringencydistricts to trustsoverview