Overview -

Originally written in 1984/5 it has been rewritten in the light of the many changes in the past years. 

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

This book has traced the way in which a multitude of hospitals, which differed in their aims, their finance and their management have, progressively became associated in a system that, as Lord Lawson has wryly suggested, is the closest thing the English have to a religion. From Sir Henry Burdett in the 19th Century to the managers and the ministers of the day, competent, intelligent and devoted people have struggled with this Sisyphean task. We have not reached perfection but much good has come from their efforts. In the 19th Century the great voluntary teaching hospitals, and the specialist hospitals, were developmental points. Today is it Academic Medical Science Centres

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).

Management styles

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 and the Coronavirus outbreak in 2020 the need for strategic and more centralised planning.

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

Ministers of Health from 1948

Bevan Aneurin         Labour August 1945 - January 1951
Marquand                Labour January 1951 - November 1951
Crookshank             Conservative November 1951 - May 1952
Macleod                  Conservative May 1952 - December 1955
Turton                    Conservative December 1955 - January 1957
Vosper                    Conservative January 1957 - September 1957
Walker-Smith          Conservative September 1957 - July 1960
Powell Enoch          Conservative July 1960 - October 1963
Barber Anthony       Conservative October 1963 - October 1964
Robinson Kenneth    Labour October 1964 - October 1968

Secretaries of State for Social Services

Crossman Richard         Labour November 1968 - June 1970
Joseph Keith                 Conservative June 1970 - March 1974
Castle Barbara               Labour March 1974 - April 1976
Ennals David                 Labour April 1976 - May 1979
Jenkin Patrick               Conservative May 1979 - September 1981
Fowler Norman             Conservative September 1981 - June 1987
Moore John                  Conservative June 1987 - July 1988

Secretaries of State for Health
(later "and Social Care")

Clarke Kenneth        
Waldegrave William  
Bottomley Virginia    
Dorrell Stephen        
Dobson Frank     

Milburn Alan            

Reid John                
Hewitt Patricia         
Johnson Alan           
Burnham Andy        
Lansley Andrew       
Hunt Jeremy            
Hancock Matthew
Conservative July 1988 - November 1990
Conservative November 1990 - April 1992
Conservative April 1992 - July 1995

Conservative July 1995-May 1997
Labour May 1997- October 1999
Labour October 1999 – June 2003
Labour June 2003- May 2005
Labour May 2005- June 2007
Labour June 2007- June 2009
Labour June 2009 - May 2010
Coalition May 2010 - September 2012

Coalition September 2012 December 2019
Conservative December 2019 -


Biographical Note

Sir Henry Burdett

  Sir Henry Burdett

A man of many parts with boundless energy, Burdett began his working life in a bank, but at the early age of twenty-one he was appointed hospital superintendent to the Queen's Hospital, Birmingham. He came to be well known to Joseph Chamberlain (Mayor of Birmingham 1873-5) who was notable for combining effective social reform with sound business principles. Having virtually doubled the income of Queen's Hospital in six years, he became house governor to the Seamen's Hospital, Greenwich, where he again revitalised the hospital, attracted new funds and trained a number of young but rising administrators. Though lacking the time to take finals, he entered himself as a medical student at Guy's and so impressed those he met that he was appointed secretary to the Shares and Loan Department of the London Stock Exchange in 1881, leaving Greenwich.

His book, Prince, Princess and People, a sketch of social progress exemplified by the work of the Prince of Wales (later Edward VII) attracted influential attention. An active participant in the Social Science Association, his organisation of the first hospital conference led to the establishment of the Hospitals Association in 1884. He founded, in conjunction with the Hospitals Associ?ation, a weekly journal, The Hospital, which
became his personal platform. He was one of the earliest workers in the cause of Hospital Sunday, was the author of a four volume classic Hospitals and Asylums of the World (1893), and launched Burdett's Hospitals and Charities - the Year Book of Philanthropy. This became the leading annual reference book on hospitals and it appeared until the 1990s as the Health Services Year Book.

As his reputation and influence grew, he took the precaution of taking a shorthand writer to meetings with him, for his blunt comments were sometimes misquoted. A governor of many hospitals, his long and wide ranging experience of hospital administration and finance made him a formidable adversary. He was interested in the development of the nursing profession, writing a book to help girls wishing to enter nursing, and establishing the Royal National Pension Fund for Nurses. He, and his journal, supported the establishment view of his day that a register for nurses would be disadvantageous, siding with Miss Nightingale and Miss Liickes against Mrs Bedford Fenwick. His obituary in The Lancet describes him as a kindly hospitable man whose mind moved on large lines towards large objectives, but who could never subdue the instinct for oratorial effect, the dramatic pause and gesture. His writings and criticisms were robust, and those who did not measure up to his high standards would find a caustic comment in The Hospital. He therefore made enemies as well as friends. Active in visiting hospitals and always sympathetic to appeals for advice, he had no patience with inefficiency. While he believed that more men of accomplishment were needed on hospital boards, those devoting themselves to the noble cause of the hospitals had to give their all, as he did himself. For his services he received first the KCB and later the KCVO.

Burdett recognised that hospitals must demonstrate soundness and economy of management if they were to survive, but he viewed them with something approaching reverence. `The concept of the voluntary hospitals of this country constitutes one of the noblest monuments of our Christian civilisation. We believe and hope that the day is far distant when any serious attempt will be made to substitute State hospitals for the noble medical charities scattered throughout England, charities which are at one and the same time the wonder of foreigners and the just glory and pride of the British nation.'

Burdett H C. Lancet, 1897, ii, pp 1215-6.
Sir Henry Burdett. The Hospital, 1920, ii, pp 129-147