The Development of the London Hospital System

1823 until 2020

Geoffrey Rivett


Geoffrey Rivett

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

new edition

This account of the Development of the London Hospital System was first published in 1986 and was last updated in May 2020. For many years it has been hosted on the same website as my history of the NHS, From Cradle to Grave.  The maintenance of this, my second book, has now passed to the Nuffield Trust and is maintained on its servers at 

As a result, the text of the Development of the London Hospital System now moves to a different web address,

The current edition of The London Hospital System  in hard copy can be purchased from Blurb on print to order.    For more details and to purchase (print to order, ipad, pdf abd indeed Kindle in an old edition) click on the cover icon. It is available in soft or hard cover from £20 app, and as a pdf for £6


This is an organisational history of the development of hospitals in London over the last 200 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 and the threats to and influences on its hospitals, such as epidemics, 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 1982-2020.  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 40 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 2020, by which time the management of hospitals in isolation from primary and community health care had ceased, and the introduction of the internal market and the structural reforms of Labour and Andrew Lansley had taken place - and begun to unravel. It was during this period, and often inside London, that many ideas developed which still condition our thinking about the hospital service. Geographically, the territory with which I am concerned corresponds roughly with that of the old London County Council.

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. 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, the clinical probles that drive the shape of the service, or national events 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 George Godber, 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. That some of these have now died makes me glad to have met and talked to them. 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; I aim to record and to avoid politics and polemics..

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. The King's Fund and the Nuffield Trust have been highly supportive.

The Development of the London Hospital System, 1823-1982 by [Geoffrey  Rivett] The original 1986 edition updated by an additional decade is available as a Kindle publication.
This is an alternative to the Blurb edition on print to order (above)

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 system The background  population issues.
The voluntary hospitals The voluntaries, great and small; their origins and objectives
Hospitals and medical schools The relationship of the voluntary hospitals and the medical schools
The development of poor law infirmaries Health care for the indigent - the paupers.  Scandals and upgrading
Smallpox and fever hospitals The development of a system purely for the infectious diseases
Defining problems and debating solutions, 1860—1889 Debates on how hospitals in London should be organised, and the emergence of skilled nursing
Reviewing the past and shaping the future, 1889—1914 London County Council, and the King's Fund
Developments in the hospital services between the world wars An unstable system, its financial and organisational problems
Regions and districts The 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 war The effect of wartime organisation  (the Emergency Medical Service), on the hospitals and the NHS that followed
Bevan and the National Health Service, 1945—1948 Bevan's plan, and the build up to the NHS
Hospital development, 1947—1968 The early days of the NHS, and the effect on London's hospitals
Rationalisation and reorganisation 1968-1974 The effect of the political decision to reorganise the NHS in 1974
Strategy and stringency 1974-1982 Resource reallocation and the hospitals; the 1982 restructuring
From Districts to Trusts - London’s hospitals from 1982-2020


Griffiths (on management) 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 reports.  The effects of the 2013 structural changes introduced by the Coalition government and the move to hospital and CCG mergers. And Covid-19.

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