Guest Editorial > The Development of the London Hospital System 1823-2013 by Geoffrey Rivett



The Development of the London Hospital System 1823-2013 by Geoffrey Rivett | Valerie Isles

It would be easy to dismiss this book as lengthy and arcane, says Valerie Isles; but the descriptions of the evolution of the medical and nursing professions, of early hospital management, illuminate so many of the behaviours and beliefs that lie at the heart of NHS problems today.

The Development of the London Hospital System 1823-2013 by Geoffrey Rivett



I’m going to take the unusual step of reviewing and recommending a book I have only half read. Geoffrey Rivett’s history of the hospitals in London over nearly two centuries exceeds 400 pages and I’ve made my way with interest and enlightenment through 200 of them.


Rivett introduces his account:  ‘Few things in the hospital world are accidental and virtually nothing in London is the result of chance. This book is the outcome of curiosity about why things are as they are’. His curiosity has fuelled inspection of  a mountain of relevant documents, minutes of committees, editorials and papers in journals, and much more. It is an amazing piece of work.


It would be easy to dismiss it as a lengthy, arcane and irrelevant look at the past when all  our available energy needs to be focused on meeting needs of today and tomorrow. But the descriptions here of the evolution of the medical and nursing professions,  of early hospital management, of the location and remit and status of London’s hospitals and medical schools, illuminate so many of the behaviours and beliefs that lie at the heart of NHS problems today, that without an understanding of this history we may never meaningfully address these.


How familiar seem his descriptions of tensions between caring for patients, offering education for students  and rewarding career advancement. Tensions too between GPs and ‘outpatient clinics’ in hospitals (then offering general services to patients off the street). And between special and general hospitals, between medical schools and universities, and between those with few resources desperately needing care and those insisting that offering care for free encouraged them not to try hard enough to find work. Indeed there is rarely an issue in the headlines today that does not have a parallel 200 years ago.


London hospitals, Rivett points out, were ‘in the centre of the wealthiest city in the world, but unlike the hospitals in provincial towns they were not a focal point of municipal pride.’ They were in financial competition with each other for charitable funds, and that competition could become bitter.


That was not the only competition. Senior doctors gave their time to the hospitals, but an appointment at a prestigious hospital offered them the chance of a very lucrative reputation with the wealthy who were treated privately at home. Their appearance at the hospital was often (usually)  late, and their patients and students hung on every word once they arrived.  Competition for such posts was fierce and while in a few hospitals, especially those opened later and more closely linked to universities, these appointments were openly contested, in the older hospitals (Guys and St Thomas’s for example) such appointments were given only to people already well known within the organisation, and often those who had paid handsomely to be ‘dresser’ to the senior physician or surgeon expected to be recommended when such an opportunity arose.


There are descriptions too of the origins of nursing ,and of the kind of people considered suitable , in language that would appeal today to those calling, post- Francis, for nurses with ‘good values’.  You will find here, too, direct parallels with many of today’s administrative and financial conundra, and much more.


The origins of the Kings Fund are fully described too, and its importance to the health of Londoners in its early decades helps explain its ongoing sense of itself. Fascinating. The thunderous role of the Lancet under various editors is great fun, and reminded me of how we so desperately need senior clinicians today to take on campaigning and championing roles.


Within the word limit here I cannot do justice to the spirit conveyed within the book. So why am I not finishing it? Well, my bedside table needs a respite from its weight, and I do need to put my energy into thinking about today and tomorrow.


Do I recommend it to you? I think you would benefit greatly from knowing at least some of what is in it, because in professions and organisations and systems shaped over the years through apprenticeship the past is still present, and some of today’s behaviours are rooted in assumptions so implicit they are rarely examined. An understanding of history allows a fresh look at these in ways that could be hugely helpful.


The number of those who will read it from cover to  cover will be few, but it’s the kind of book that  can be dipped into,  and this would make a terrific collaborative reading task on all sorts of post grad programmes for clinicians of all kinds and those working with them. Giving everyone a chapter to read and summarise and reflect on would enable a whole cohort the opportunity to become familiar with the history of a world they inhabit and see that world in  a new light.


Valerie  Iles    September 2013


Here is a link to the book: