The report received a favourable reception and it was summarised in the medical press. Burdett discussed the findings in the introduction to volume three of Hospitals and Asylums of the World, which appeared in 1893. The worst fears had proved groundless. Each group fastened on the recommendations most to its liking, although the British Medical Journal accused their Lordships of being far from thorough in their consideration of abuse of the outpatient departments, dismissing the accusation in a light and airy way.¹² The special committee of the Charity Organisation Society ceased to meet. It had finished its work. Charles Loch wrote in The Nineteenth Century about the need for action.¹³ Mouat wrote four articles in The Lancet saying that he hoped that a central board would be formed with all the power over the general hospitals that the Metropolitan Asylums Board had over fever hospitals. He repeated his proposals for five districts based upon the registrar general’s five districts.

The attempt to establish a central board

The Lords committee had agreed with the Charity Organisation Society that there should be a central board. This would act as a watch-dog, audit accounts, describe operational policies, publish and comment upon proposals to remove, expand or open hospitals, and act as a central charity for the receipt and distribution of endowments and contribu­tions. The board’s power would be limited and it would not interfere with local management; neither would it receive a government grant for this would reduce the flow of voluntary contributions. Nevertheless the Lords believed that people would heed a board’s comments on proposals to build ‘useless hospitals’, and on the quality of a hospital’s administration. A central board would help in times of financial difficulty, the Lords fearing that without one the time would come when voluntary hospitals would need government or municipal aid. Sidney Webb, in The London Programme which was prepared with London County Council elections in mind, also thought that a separately elected Board was desirable. But he saw a Board as a first step to the replacement of private hospitals by public institutions. ‘London’, he said, ‘must systematically undertake the care of London’s sick.’¹

The chairman of the select committee, Lord Sandhurst, did not consider his work complete with the publication of the report. Wishing to oversee its implementation he invited representatives of the central funds and the hospitals to a conference at Spencer House in July 1892, to consider the formation of a central board. The invitation gave rise to much discussion in hospital circles for while many were opposed to cooperation there was little desire to offend the noble Lord. Burdett, who was invited to the conference, noted ‘a want of genuine interest in the proposals, much doubt as to the practicability of devising a scheme for cooperation, and an undercurrent of desire to do nothing.’ He predicted that a committee formed by the conference to consider how a board might be established would have a ‘thorny path to traverse’. He wrote in The Hospital that a central board without the power of the purse or the authority to enforce its recommendations would probably accomplish little, whilst its power for evil might be considerable.¹⁵’¹⁶ A proposed pattern of membership was rejected by the hospitals as biased towards the medical charities and unrepresentative of the voluntary system. The opponents of a board included many who objected to centralism in all its forms. They feared an infringement of the rights of hospitals to continue to act as separate units, and wished to preserve absolute individual freedom.

Nevertheless Louisa Twining, a veteran campaigner, said that she was convinced that there was something in the hospital system which could be made more in accordance with modern needs and modern ideas.¹⁷

Regular meetings were organised by the Charity Organisation Society and in January 1897 its secretary outlined the principles he believed to be generally accepted:

i    Any board should be representative of the main interest groups. 

ii   Reliance should be placed upon cooperation and publicity rather than on legal measures and compulsion. 

iii  A central fund should be formed as a permanent endowment of the hospitals. 

Opponents of a central board were given the chance to make their case at a meeting called to consider the proposition, but as those present were largely the protagonists the vote in favour of a board was 121 to 12. The view of the majority was that a board was necessary to maintain the health of the voluntary system, and it was the only way to ensure that London’s hospital and medical needs were considered as a whole.¹⁸

The Society established a sub-committee to produce a new scheme giving the hospitals the increased representation they demanded. Each hospital would have direct representation, with additional seats for the central medical charities and general practitioners. The result was a board so big that an executive committee would also be necessary. Deputations to the hospitals received little encouragement. Few hospital representatives turned up at the meeting convened to consider the scheme. A central board with two hundred members seemed so impracticable that they were not prepared to spend time discussing it. Those seeking autonomy for the hospitals believed that if a board controlled funds it would be dangerous, and if it did not it would be useless. Instead, the twelve hospitals with medical schools met separ­ately at the Westminster Hospital and formed a Central Hospital Council for London, to consider matters in which they had a common interest and promote joint action.¹⁹

The Hospital Reform Association

Much of the pressure for a central board came from the general practitioners. The Hospital Reform Association, formed in 1896 ‘to concentrate medical opinion on reforming hospital administration’, was largely a general practitioner body. The president had been president of the British Medical Association. The British Medical Journal was an ally, and those favouring provident dispensaries like Timothy Holmes and Charles Loch were members.

The Association set to work, organised conferences, and prepared a report on the management and financial arrangements of the special hospitals, demonstrating how much of their income came from payment by patients who did not require charity. The special hospitals were not even keeping to their own specialty. The Cancer Hospital was treating piles, fistulae, tuberculosis and syphilis, and the Chest Hospital anaemia and Lord Lister, in a private letter, described the Association as ‘a most unwieldy and heterogeneous body in which the medical profession was chiefly represented by practitioners whose names carried little or no weight and whose outcry against hospital abuse was extremely exagger­ated’.²¹ He was not alone in this opinion. Sydney Holland (later Lord Knutsford), the chairman of The London Hospital, also disapproved of it, saying that the Association was chiefly got up by some gentlemen from Wales. The reformers came to see that they could expect little support from the hospitals. Few of the hospitals’ medical staff wished to restrict the flow of patients. Hospital administrators saw no advantage to the reputation of their hospitals or their funds from turning away patients. The Royal College of Physicians declined to take any initiative.

The Charity Organisation Society had more success in achieving the introduction of a system of enquiry into the means of patients in outpatient departments. In 1895 an experienced Charity Organisation Society district secretary was appointed at the Royal Free Hospital, her salary being paid by the society for the first three months. Miss Stewart, the first of the lady almoners, was followed by others trained by the society. Soon almoners were appointed at St Bartholomew’s, The London and the Hospital for Sick Children. Some society members, also members of the council of the Sunday Fund, encouraged that Fund to regard the appointment of almoners as a ‘merit’ to be taken into account when money was distributed. The job of an almoner was not an easy one. They were faced by crowded departments seeing thousands of patients a year. The secretary of The London Hospital pointed out that the cost of employing an enquiry officer itself reduced the funds available for relieving the sick poor.^{22, 23} 

The London County Council and the Metropolitan Asylums Board

The quest for better methods of organisation was not restricted to voluntary hospitals. In 1893 the newly established London County Council asked a sub-committee to consider the overlapping activities of a number of centralised rate-supported bodies in the fields of health and education. The sub-committee’s report was considered by the Council in June 1894. It dealt with the wide range of services provided by the Metropolitan Asylums Board, which by now included fevers, infectious diseases, the mentally handicapped and even groups like pauper children who were sent to training ships. The Hospital Commission on smallpox in its 1882 report, had recommended that responsibility for the sanitary state of an area should be in the same hands as the management of hospitals for fevers. The London County Council, debating its sub­committee’s report, came to the same conclusion. The Council, of which Sidney Webb was a member, adopted the policy that all central metropolitan powers in the field of public health should be in the hands of ‘the elected representatives of the rate-payers’, and that the services provided by the Metropolitan Asylums Board should be transferred to the Council. The Lancet thought this proposal was ‘absolutely sound’.²⁴ Before the formation of the London County Council The Lancet had thought that the Metropolitan Asylums Board had the potential to become the central heath authority for London. Now that the Council was establishing a firm claim to this role it would inevitably become, sooner or later, the manager of the services provided by the Board.²⁵ 

The Prince of Wales’ Hospital Fund for London

[The Fund did not adopt its present name until the death of Queen Victoria]

Few of those who have devoted their lives to London’s hospitals can have accomplished more than Henry Burdett. Because of his long established position in the hospital world he had been associated with Lord Sandhurst’s attempts to form a central board, of which he did not altogether approve. In 1896 he was at the centre of discussions which bore more lasting fruit.

Throughout his life he was careful never to claim that he had played a key role in the foundation of the Prince’s Fund. As one of the Prince’s trusted advisers he may have believed that more is accomplished if one does not insist on claiming the credit. However many of the characteris­tics of the Fund bore Burdett’s stamp upon them, and reflected ideas he had advanced many years before.

From his early years the Prince had been interested in hospital affairs. He had accepted the presidency of St Bartholomew’s as early as 1867 and he regularly undertook to open new hospital buildings. He became patron of The Hospital Saturday Fund in 1896, and The Lancet said that scarcely a week passed without his making an effort for the public good. His interest and example ‘might be the very saving of the voluntary hospital system’. Help was certainly needed, for in 1894 the Hospital Sunday Fund said that around £300,OOO was vital to cover the liabilities of the London hospitals and dispensaries. It had taken 20 years for the Sunday Fund collections to rise from £27,000 to £40,000 a year, and an appeal by University College Hospital in 1896 produced so derisory a sum that the governors were forced to comment on the lamentable indifference in the district to a charity of vast importance to the poor of the neighbourhood. Another 50 beds were added to those already closed in London.²⁶

In 1896 the governors of Guy’s decided to launch an appeal to ‘re­endow’ the hospital and reopen beds which had been closed. Presiding at the festival dinner, the Prince thanked Henry Burdett for his efforts in the hospitals’ cause, and for his work as a steward to make the dinner a success. It was Burdett who first suggested the idea of a fund to the Prince, who initially questioned the leadership of such an appeal by a member of the royal family, and the association of the fund with Queen Victoria’s Diamond Jubilee. The risk of rivalry with Hospital Sunday arose, but at length agreement was reached.²⁷ Even before Jubilee year began rumours were circulating about the possibility of a commemora­tive fund. The Lancet expressed the hope that a group of wise and influential people might invite contributions, and that the money might go to the hospitals rather than to a district nursing fund as on the occasion of the Golden Jubilee.²⁸ By 16 January 1897 the name of the Prince was being coupled with the possibility of a hospital appeal. The rumours intensified when Sir William Broadbent addressed the Charity Organisation Society, mentioning the possibility of a gigantic scheme for collecting money for the benefit of the hospitals on behalf of the Prince of Wales. Gigantic it would be, for if its object was to provide the additional £100,000 a year the hospitals needed, either from annual subscriptions or as income from investments, the effort required would be enormous. Sir William pointed out the need for a distribution committee to obtain information from the hospitals and to allocate money on the basis of their merits. The Lancet thought that the committee established by the Charity Organisation Society to work for the formation of a central board could serve the Prince well. The Charity Organisation Society had never shown much of a tendency to help the hospitals with their financial problems, although it was ever ready with good advice. Now was the time for all to work together for the good of the hospitals.²⁹ The accuracy of the rumours became apparent when the Prince wrote to the press to launch the appeal.

Those invited to the first meeting of the general committee on 21 January 1897 at Marlborough House were mainly of high rank in the church, the City or the state. Burdett was present, and he became a member of the Organisation Committee formed in February 1897, which met two or three times a week to get the appeal under way.³⁰ Burdett was a member from the outset of every significant committee formed by the Fund, and it was said that in twenty years he never missed a council meeting. He personally undertook much of the early correspondence with the press, the savings banks and the printers, and he assisted in the selection of the first permanent officers.³¹ For these services he was awarded the KCB in June 1897.²⁷

Introducing the appeal the Prince said: ‘Public opinion has shown itself on more than one occasion, and I think wisely, in favour of the voluntary system for support for our hospitals, combined with an adequate system of representation of the body of subscribers in their control and management. It is obvious, however, that if these institutions are to be saved from state or parochial aid, their financial condition must be secured.’ The aim of the Fund was to place them on a sound financial footing with an additional assured income of £100,000 a year.³² The Prince himself took the lead in selecting the members of the general council, chairing its meetings. Lord Rothschild agreed to become treasurer, and wrote to city financial institutions seeking donations. The Lord Mayor of London pledged his support, Grocers’ Hall and the Bank of England provided premises and facilities, and two conferences of the clergy supported the appeal. Unlike the councils of the Sunday and Saturday Funds, whose members were essentially representatives of the subscribers and subscribing bodies, members of the council of the Prince’s Fund were personally selected. To be appointed to the council was a high honour and feelings might be hurt when it was not forthcoming. Sydney Holland at one time considered himself to have been passed over.

Hospital stamps were printed by De la Rue free of charge, for sale to small contributors. The plates from which the stamps were printed were smashed ceremonially when the run was completed. Each stamp bore the Prince’s signature and a picture of Charity, after a painting by Sir Joshua Reynolds. The 1/- stamp was blue, the 2/6 orange, and they could be stuck in a small book which contained a message from the Prince. A second issue of charity stamps the following year was less successful, and this method of raising money was abandoned.

The development of the Fund’s policies

There was widespread acceptance of the Prince’s view that state control of the hospitals should be avoided. Even the radical and reforming Lancet had ceased to advocate the establishment of state hospitals, believing that patients were cared for better under a charitable system, that the management of individual hospitals was better than ‘local municipal wisdom’ and that state control would lead to the loss of charitable money.³³ The council of the Prince’s Fund appreciated at an early stage that the great difficulty would be who was to administer the fund. If a board was constituted, the great hospitals, and probably the lesser ones as well, would claim representation on it.³⁴

The Fund received much free advice. The secretary of the Royal Westminster Ophthalmic Hospital suggested that the Coal, Corn and Finance Committee of the Corporation of London would distribute the money sensibly. C S Loch wrote to The Times to urge the Fund not to use the method adopted by Hospital Sunday, which had showed little inclination to use its power to stamp out hospital abuse. The Lancet

wanted the Prince to limit the duration of his appeal to avoid undermining the existing central funds. Distributions should also be made in a way which would discourage abuse by those above the poverty line, doctors should have a say in the way the money was distributed, and the opportunity should be taken to initiate a central board. The British Medical Association believed that monies as vast as those of Hospital Sunday and the Prince’s Fund should be distributed by a committee which worked in public, including representatives of the hospitals themselves, akin to the central board for which the Charity Organisation Society was pressing. It would then become the parliament of hospital

finance in London.³⁵’³⁶ The views of Stephen Coleridge, treasurer of the Victoria Street Society for the Prevention of Vivisection, were predictable. In a letter to the Prince, released to the press, he asked that hospitals whose medical schools conducted experiments on ‘helpless dumb animals’ should be excluded from the distributions. On 8 May 1897 Sir Francis Knollys replied in His Royal Highness’ name that there was no intention of devoting any part of the Fund towards the support of medical laboratories.³⁷

The Prince decided that the appeal should not be limited in its duration but to avoid trespassing on the sources of money of the Hospital Sunday and Saturday Funds appeals would not be made from the pulpit or in factories. Many feared that money given to the new fund would merely be diverted from the other central funds, or from the hospitals themselves. Because of the controversial nature of the Charity Organisation Society’s proposal to establish a central hospital board, to which the hospitals were opposed, the Prince’s Fund decided that it would be inexpedient to be associated with that movement, or with the Hospital Reform Association.³⁰ The Lancet came to believe that this was a sensible decision, for even the protagonists of the idea could not agree on the form a board should take.

As soon as the appeal had been announced letters began arriving; some enclosed donations, small and large, others asked for assistance. The Mayor of West Ham wrote saying that his borough was really part of London; he would launch a local appeal for the Fund if he was assured that West Ham’s hospitals would be eligible for a grant. Less subtle correspondents, like some from Finsbury, were told that it was too soon to enter into questions of distribution.

Allocating the money 

Amongst the Prince’s advisers was Lord Lister, who was asked to give his views on the way the money should be distributed. Lister thought that while examining the management and financial needs of the hospitals would be a considerable task, the greater problem would be to decide which hospitals were run on a sound professional basis; poor decisions would bring the Fund into disrepute. An authoritative group of advisers was necessary and Lister thought that the Central Hospital Council, formed by the teaching hospitals after the outcry against ‘hospital abuse’, would serve the purpose. Its chairman, Sir Trevor Lawrence, agreed it should assist if asked.³⁸

To turn to outside bodies for advice was not what the Prince had in mind. Following a memorandum on methods of allocation written by Burdett³⁰, a distribution committee was formed which in turn appointed a visiting committee to inspect the hospitals. The visiting committee consisted of physicians and surgeons of wide experience, with an equal number of laymen who were interested in hospital management.

In the first year the Fund sought the assistance of Hospital Sunday, and in June 1898 asked the advice of the Central Hospital Council on the management of certain small and special hospitals. After that it relied entirely on the advice of its distribution committee, chaired by Lord Lister, and the visiting committee under Sir Trevor Lawrence. Hospitals lying within seven miles of Charing Cross were divided into four groups: north-west, north-east, south-east and south-west, and underwent ‘thorough inspection and enquiry’.

The report on The London Hospital showed that much needed to be done, and it was agreed that if the hospital would spend up to £100,000 of its own capital on the necessary work, the Fund would make an annual grant of £5,000 — well above the level any other hospital received. Money was usually distributed for specific purposes, to open closed beds and to improve facilities, as well as a general grant-in-aid. The Prince wished capital sums to be allowed to accrue, only the income being distributed. The distribution committee was therefore able to provide more support year by year, and annual grants were reasonably secure. While the Sunday Fund’s grants were used for general maintenance, those of the Prince of Wales’ Fund were an instrument of change, strengthening the hospitals and the voluntary system. Hospitals were given a clear idea of what was expected of them, but the visitors’ remarks were confidential as the Fund did not wish them used as evidence of need when an appeal was to be launched. Grants were in danger if the next report from the visitors indicated that no action had been taken. It became Fund policy to make grants of considerable size for major schemes of great importance. Guy’s asked for assistance in the reconstruction of its outpatient department, and St Bartholomew’s itself sought a contribution to its rebuilding fund.

Sir Savile Crossley, speaking about the new Fund, said that its work ‘as an intelligence department, obtaining and collating information and statistics relating to the hospitals, was of the first importance’. By degrees the examination of figures which had been verified by visits would enable the Fund to form useful opinions on many questions relating to hospital management. There was hope that this would be a means of preventing many of the mistakes and extravagances of the past.³⁹

From an early date the Fund made it clear that hospitals receiving grants were expected to maintain high standards of efficiency in organisation and equipment, and it was soon involved in advising hospitals on financial and architectural aspects of building schemes. Plans were sent to the Fund for comment in the hope that a capital contribution would accompany approval. When the annual accounts were submitted, the Fund would draw attention to above average expenditure. A patient’s complaint or a press report which painted a voluntary hospital in a bad light would lead the Fund to ask the chairman of the hospital concerned for comments.

After Queen Victoria died the Fund became known as King Edward’s Hospital Fund for London. The new Prince of Wales assumed the presidency but King Edward VII remained the patron, and donated the money which had been collected as his coronation gift. Further endowments in 1902 from Lord Mount-Stephen and Lord Strathcona brought the Fund to within striking distance of its target income of £100,000 a year. Regrettably by this time few still believed that even a sum of this size could keep London’s hospitals solvent. In 1907 the Fund received a charter, under a private Act of Parliament, which established the constitution and governance. The royal presidents remained active in its affairs, approving minutes and expressing views on matters of significance. From the start the Fund was not merely a source of money but of good advice.

The Central Hospital Council for London 

The Central Hospital Council, formed in November 1897 to defend the interests of the teaching hospitals, consisted of representatives of the management bodies and medical staffs, but proved to be ineffective and unable to influence events. It did not have the resources of the King’s Fund, nor did it always command the support of its constituent members. It fought for a reduction in hospital rates (1898), considered ‘hospital abuse’ (1899) and discussed the anti-vivisection campaign (1900). It opposed the creation of a central bed bureau when the Hospitals Association proposed one, as inexpedient and lacking ‘practi­cal utility’ (1903). It opposed state registration of nurses (1904), and considered the charter of the King’s Fund unsatisfactory (1907). It gave evidence to the Royal Commission on the Poor Laws (1908) and commented on the National Insurance Bill (1911). However the hospitals took little interest in its work, and the chairman, Mr Harben of St Mary’s, resigned in 1910 because the council seldom gave a lead, preferring to delay discussion until the hospitals had already decided what should be done. Harben said that the council tended to shrink from the questions addressed to it, and he doubted if it could serve any useful purpose. Indeed major problems like the question of hospital relocation and rebuilding were not considered at all by the council. Nevertheless it continued to meet until the 1914—1918 war.¹⁹

Money and the medical schools 

Because the London medical schools were essentially part of their parent hospitals the financial arrangements between school and hospital were close and complex. For example at the Middlesex the school had been incorporated into the hospital in 1895, and placed under the management of a council of lay governors, medical staff and medical school teachers. At Guy’s, Herbert Eason the dean wrote in 1904 that the medical school had no corporate existence and no property. Out of the students’ fees a fund was formed, but without doubt this belonged to the governors.⁴¹ Stephen Coleridge, Hon Secretary of the Victoria Street Society, became interested in the schools’ accounts and their sources of income. He examined the accounts of Guy’s in 1897, and it is probably significant that when the Prince of Wales opened the hospital’s new medical school laboratory that year he said that the experiments conducted on animals were performed under anaesthetic and in the interests of suffering humanity. In May and June 1901 Stephen Coleridge and the British Medical Journal disputed whether teaching hospitals like Guy’s, the Middlesex, The London and Charing Cross, which had received sizeable grants from the King’s Fund, had thus been enabled to increase the sum they made over to their schools. Coleridge believed that contributors to hospital charities did not wish their money to be spent on animal experimentation. He raised the question of ‘the appropriation by the medical schools of money raised for other purposes’ at an annual meeting of the Sunday Fund.

The Metropolitan Radical Federation also petitioned the Prince of Wales in 1900, objecting to the contributions voluntary hospitals made to medical schools, and implying that hospitals engaged in human experimentation.⁴² Sir Henry Burdett had little time for the anti­vivisectionists, but he agreed that it was wrong for a hospital committee to devote any portion of the funds subscribed for the relief of the sick to the purposes of medical education. He regretted that some hospitals had ‘very weakly’ given grants to their schools. The hospitals had suffered financially from Coleridge’s attacks, and had it not been for the education issue the antivivisectionists would have had no case against the hospitals.⁴³

In the light of the pledge that the Prince of Wales had given³⁷, the King’s Fund established a committee in 1904 chaired by Sir Edward Fry and including the Bishop of Stepney and Lord Welby, to determine whether any money subscribed for the relief of the sick poor to any of the twelve teaching hospitals had been contributed to the hospital medical schools. The Fund gave the teaching hospitals less than a month to produce their accounts, and to comment on the mutual benefits the hospitals and schools gained from their association. At Guy’s, the dean maintained that it was impossible to separate the provision made for the relief of the sick from the steps taken in the furtherance of medical education.  Every dressing and every examination had as its chief purpose the treatment of injury or disease, but was also of educational value. 

When he came to give evidence Stephen Coleridge tried to raise the vivisection issue, saying that had he not discovered that medical schools undertook vivisection he would never have become interested in their finances or started the agitation against them. He again insisted that the medical schools were only receiving support from their hospitals because the King’s Fund had increased their income.

The committee worked rapidly and within a few weeks reported that two hospitals were not subsidising their schools out of hospital funds, two others were not clearly deriving a benefit from their hospitals, but that the remaining eight were receiving direct or indirect cash benefits. The report drew attention to the ‘intimate and complex relations’ between the schools and the hospitals, which made it impossible to draw up a cash balance of the more intangible benefits given and received by each. The committee felt that the mutual benefits balanced, and the hospitals should not, in addition, make cash contributions to the medical schools, save for specific services the schools performed to assist the treat­ment of patients.⁴⁴ Mr Perry, writing from the Counting House at Guy’s to Danvers Power of the King’s Fund, said that whatever action the Fund proposed to take on the report should be taken promptly, at the next distribution. Otherwise Stephen Coleridge would have a reasonable grievance and would be on the warpath again, drawn sword in hand.⁴⁵

The Fund did not ignore the great importance of medical education, believing that the facilities afforded by the voluntary hospitals placed the whole community under a heavy obligation, but it became the Fund’s policy to ensure that its grants were used solely for the purpose of patient care. Each year the hospitals had to submit a statement that no payment had been made to or on account of the medical school out of the general funds for the relief of the sick poor. Hospitals and schools were asked to keep separate accounts. During a dispute that rumbled on for a number of years the King’s Fund withdrew its annual grant to St George’s because the hospital appeared to be paying the medical school laboratories far more for their services than other hospitals.⁴⁶ Some hospitals wished to continue to assist their schools, not least because the schools annually supplied them with junior staff. The hospital authorities sometimes approached subscribers asking them to agree that in future their contributions could be paid into a ‘discretionary account’. They could then be passed to the school if the house committee wished.²²

The King’s Fund was always careful to maintain the distinction between the finances of the hospitals and those of the medical schools. Many years later it was still found necessary to produce a printed policy statement to issue to hospitals. In 1929 when St Bartholomew’s launched a joint appeal for hospital and medical school it came into conflict with the King’s Fund.⁴⁷ Yet medical school staff were not lacking in supporters. When the Research Defence Society was formed by the medical profession, Sydney Holland of The London Hospital became its chairman. He made it his business to satisfy himself that the research workers at his own hospital were not ‘cruel monsters Thereafter he defended medical research in private, in public and later in the House of Lords. Year after year he fought a bitter controversy with Stephen Coleridge in the press, although in private they were good friends respecting each other’s point of view. And when Stephen Coleridge himself lay ill, Sydney Holland made a point of visiting him. 

University reform

The medical course became considerably stiffer during the second half of the nineteenth century. The facilities for scientific and clinical instruction were improved, at considerable cost. The private medical schools disappeared, and the medical schools of the great hospitals reigned supreme. The number of students entering the hospitals each year could be calculated from the information supplied to the Royal College of Surgeons, which collected the numbers for the Government Inspector of Anatomy Schools. The figures showed that the intakes rose progressively between 1850 and 1880, but thereafter the numbers fell.

London medical school intakes 1857   353 new students — total    1,038 1867   355 new students — total    1,155 1877   597 new students — total    1,879

By the early 1900s the London intake had fallen below 300 a year. While all the country’s medical schools were affected, those in London were particularly hard hit. The financial viability of some of them was threatened. The dean of Charing Cross Medical School attributed this fall in numbers to the developing competition of provincial medical schools, the abolition of pupilage as a method of entrance to the profession, the effect of lengthening the course in 1894 from four to five years which had greatly increased the cost of a medical education and bad publicity resulting from the continuous campaigns in the latter years of the nineteenth century to reform medical education in London.⁴⁸ A long standing problem faced by London medical students was the difficulty of the examination for the degree awarded by the University of London. The standard was recognised to be higher than that of the provincial and Scottish universities. Most medical schools therefore prepared their students for the more practical diplomas of College and Hall, or Conjoint. Only a small minority of students proceeded to take the university degree and schemes for university reform generally aimed to make it easier for students to obtain degrees, as well as to enable the university to teach in addition to examining.

Some reformers, believing that it would never be possible to change the way in which the University of London operated, proposed the establishment of a second university in London or the granting of the right to award degrees to the Royal Colleges.^{49, 50} The evidence given to the Select Committee of the Lords (1892) revealed the differences between those wanting a central academic establishment and those seeing medical education in more practical terms. Some favoured a degree of amalgamation of the smaller schools, particularly of their pre­clinical departments, and the Lords had recommended that if schools affiliated like the colleges of a university they might form a teaching institution able to afford and secure good lecturers. Much of the pressure for a ‘teaching university’ came from the need felt by the teachers to have some control over the content of examinations. Medical schools sometimes maintained that they were forced to follow a syllabus drawn up by university staff who might be less experienced than the schools’ own teachers.

The constitution of the University of London was altered by Act of Parliament in 1900. The university rapidly established a faculty of medicine and appointed teachers, but the formal links established did little to alter the independence of the hospitals’ schools. The curriculum was becoming crowded because of the pressure to include new subjects, and the expense of pre-clinical instruction was continuing to rise; indeed the cost of the pre-clinical course had trebled because of the need for laboratory facilities. As the schools had no financial reserves the teachers of pre-clinical subjects had to rely on the generosity of their clinical colleagues, or work largely at their own expense in the hope of future advancement. There was increasing recognition of the desir­ability of separating the pre-clinical subjects for which laboratories and specialised staff were required from the clinical years when students were mainly taught in hospital.⁵¹ In 1902 the faculty of medicine drew up a ‘concentration’ scheme for an Institute of Medical Sciences, to be located in South Kensington, which would teach physics, chemistry, biology, anatomy and physiology to all students, whichever hospital they proposed to enter and whatever examination they wished to take. An appeal was launched the following year and £70,000 was collected. However the concentration proposals met with opposition, notably from St Mary’s, St. Bartholomew’s and The London. King’s College and University College also saw it as a threat to their well established science faculties. In 1907 the faculty of medicine changed its mind, and the money collected had to be returned to the donors. Meanwhile, Sir Donald Currie gave £80,000 to University College Hospital to provide a new medical school and, at the suggestion of the university, agreement was reached in 1905 that Westminster Hospital students would receive their pre-clinical education at King’s College, and those of St George’s either at King’s or University College. Charing Cross made a similar arrangement in 1911, the students beginning their studies at King’s College, ‘enjoying the advantage of becoming University students in the true meaning of the term’.⁴⁸ Vacated space in a hospital seldom remains empty. As the students moved out of the laboratories the Charing Cross pathologists moved in.

The new constitution of the University of London was in the nature of an experiment, intended to reconcile conflicting interests by creating a body on which all were represented and which had supreme authority. It proved unable to conciliate the interests or exert authority - certainly not in medicine. Only three medical representatives sat on the senate, so nine schools had only the most indirect contact with policy making. In 1908 the possibility of a royal commission began to be discussed.^{52, 53}  A commission was established the following year under the chairmanship of R B Haldane, the Liberal politician and a life-long friend of the Webbs. The remit of the commission covered all faculties, but medicine received particular attention. Three of the most important witnesses were the physiologist Professor Starling, Abraham Flexner and Sir William Osler.

Sir William Osler was a strong supporter of the university ideal of combining teaching with the advancement of learning. He had been concerned with the development of the Johns Hopkins Medical School and had precise ideas about the organisation of teaching, research and professorial clinical units. ‘The hospital’, he wrote, ‘should become part of the university system. It is a great laboratory in which we collect for rectification the experiments which nature makes upon us. The study of disease is just as much part of university work as is the study of mathematics, and a close affiliation of the two institutions (school and hospital) is the best guarantee of that combination of science and practice which is the right of people at the present day to demand.’⁵⁴’⁵⁵

Abraham Flexner, whose account of European medical education had been influential in the reform of medical education in the USA, drew attention to the unevenness of laboratory development, good at University College, reasonable at King’s, Guy’s and The London, but otherwise inadequate. Flexner said that in the clinical departments the typical English physician was still of the intelligent empirical type; once on the staff he gave up the laboratory and with it the laboratory state of mind. Teaching offered incidentally by hospital staff could not be of university quality. The relationships of London students to their hospitals deserved to be copied, but the merits of the system were used as excuses for not attempting anything better.⁵⁶

The closely reasoned report of the royal commission appeared in 1913 and the unanimous conclusion was that the organisation of the university was fundamentally defective and that it could not develop into the type of university the capital city of the Empire should have. The report stated that the university had signally failed to gain the sympathy of the medical schools. The commissioners wished to see preliminary scientific studies undertaken at school and they did not want the pre­clinical sciences concentrated into a few institutions; Flexner had criticised the separation of pre-clinical laboratory sciences from the wards of a hospital. Radical changes were suggested for the clinical years. While paying tribute to the practical experience of London students, the royal commissioners said that such ‘professional’ training could never substitute for university education and the stimulus of working with teachers selected for their academic achievements, actively engaged in research. A consultant in busy private practice could not devote enough time to the development of his subject or serve adequately as a university professor. The main theme of the report was, therefore, the excellence of the London clinical tradition but the extraordinary inadequacy of support for laboratory work and the research required for the promotion of medical education.⁵⁷

The remedy proposed was to institute chairs in clinical subjects, form university medical colleges and introduce academic staff into the hospitals. A professor with a staff of assistants would control wards and an outpatient department, and would have laboratory accommodation for investigation and research. Students would be attached to the academic unit in the same way as they worked for consultants in active practice. It was suggested that perhaps three of the medical schools, with their attached hospitals, should be incorporated completely into the university.

These far reaching proposals aroused great controversy. How would the university obtain financial and educational control of one or more of the medical schools which were in fact part and parcel of the hospitals? It would mean controlling the hospitals themselves while the hospital administration would have to continue to raise the money to keep the hospital going. The decision of the King’s Fund following the report of the Fry committee to withhold grants from hospitals which made contributions to their schools from the general funds was an added complication. To run a medical school was no longer a profitable occupation. In many schools the staff had looked to the hospital for assistance in maintaining its viability. This had been the reason for the scheme to concentrate the pre­clinical sciences. House governors could see the economies which would result if every hospital did not have to support an expensive pre­clinical department.⁵’

The process of selecting three schools out of twelve for full incorporation into the University was likely to be controversial. It would largely limit the selection of academic staff to those already working in the chosen hospitals, and there was more than a suspicion that the University would look no further than King’s College and University College Hospitals. To divide the teaching hospitals into sheep and goats in this way was to few people’s liking. It would also prove difficult to persuade governors, whose primary objective was the treatment of the sick poor, to continue to finance a hospital under university domination. Finally, if academic units were to be established they would require as many as two hundred beds to cover medicine, surgery and gynaecology. Only a very large hospital could provide this number if any room was to be left for the existing honorary staff.

The staff in many of the teaching hospitals did not accept that the picture was as black as Haldane had painted it, and teachers recoiled from the thought of entirely science-based and laboratory-educated doctors. The medical faculty of the university disagreed with the proposal that professorial units should be concentrated into three constituent colleges and thought they should be distributed amongst all the medical schools. The faculty concluded that it was undesirable to limit the scope of university influence by confining university medical education to three colleges. 8 However the Board of Education accepted the main thrust of the Haldane Commission and established a committee to consult on practicalities.

One new source of money appeared. In 1908 St Mary’s Medical School successfully applied to the Board of Education for a grant under the Regulations for Technical Schools. In 1909—19 10 eight schools in London received grants. Sir Robert Morant at the Board of Education considered that medical schools were just as entitled to financial aid as courses in engineering, architecture and mining. The state now regulated the qualification of the profession through the General Medical Council, and directly or indirectly was increasingly becoming an employer of doctors. It had need of adequately trained medical men. 

Postgraduate study

By the 1890s there was increasing recognition that the development of postgraduate study would benefit both doctors and their patients.⁶⁰ At first postgraduate education was mainly tailored to those with specific needs, for example those proposing to take up a post in the colonies. Jonathan Hutchinson started a series of afternoon demonstrations at his personal clinical museum in Great Portland Street and soon after, in 1899, obtained a building in Chenies Street. In association with some of the medical schools he organised the Medical Graduates College and Polyclinic. The West London Hospital was also early in the postgradu­ate field, beginning courses in 1893. These proved so popular that the hospital provided library and lecture theatre facilities in a new building specially erected in 1901.

At much the same time the London Postgraduate Association was founded ‘to make the wealth of London’s clinical material available to practitioners’. The Association made arrangements with Charing Cross, Guy’s, King’s College Hospital, St Mary’s, St Thomas’s, the Westmin­ster and University College Hospital, as well as with some of the special hospitals like the Brompton, Great Ormond Street, the National Hospital for the Paralysed and the London School of Tropical Medicine. For ten guineas a ticket would provide admission to all of them for three months. Other courses became available at the North East London Postgraduate College at the Prince of Wales’ Hospital in 1902, and the London School of Clinical Medicine (the Seamen’s Hospital) in 1906. The value, and in some circumstances even the necessity, of postgraduate education, was so widely recognised that there was no need to dilate upon it, said the British Medical Journal in 1908.61 The rapid progress of medicine called for a system which would enable all experienced practitioners to keep up to date. There was more to know, a more widespread desire to know, and a greater readiness on the part of those who knew to teach.

Most of the courses did little more than provide local practitioners with an educational stimulus. The contribution made by the University of London to postgraduate study was even less than to the undergradu­ate course and organised postgraduate education was hardly a success story considering facilities which were available. An article by Haw­thorne suggested that there should be at least be a central bureau to provide information on the courses available, and cooperation in time-tabling.⁶² The erection of a new hospital as a postgraduate clinical centre might not be a practical possibility, but some general hospitals had very few undergraduate students. Might not one see that it would do better as the clinical centre of postgraduate education? It would need to be in the middle of town so that it could work with the special hospitals which were valuable sources of clinical experience, often with schools of their own. Such a development would make London the centre of postgraduate education in the English-speaking world, but in The Lancet’s view there were problems in Hawthorne’s plan. A hospital which welcomed all the best teachers in London would place the existing medical staff in an invidious position, and ill-feeling would be inevitable. Nevertheless, said The Lancet, all practitioners had a right to expect facilities which would help them keep abreast of the strides being made in scientific medicine.⁶³

The distribution of hospitals

The clustering of hospitals in the middle of London had been the subject of adverse comment for fifty years. The point had been made by Florence Nightingale, for the third edition of Notes on Hospitals contains maps showing the concentration in the centre of London and Paris. A fall in the population of central districts occurred in every decade from 1871, partly as a result of slum clearance schemes and the development of railway and tram systems, exacerbating the problem. The 1891 census showed a dramatic change in demography of London and other major cities, see Figure below.⁶⁴  Growth in London was concentrated in an ‘outer ring’, in places like Leyton, Willesden, Tottenham and West Ham. The population of the Cities of London and Westminster, the Strand, and St Giles, showed a marked decline. Ten years later a further census confirmed the trend and the realities of metropolitan development became widely recognised. No more than a third of the growth which had occurred within fifteen miles of Charing Cross had taken place within ‘London proper’.

In April 1902 Mr Peyton Beale, a surgeon at King’s College Hospital, wrote to The Lancet that before the twentieth century was far advanced the problems of hospital accommodation in London would have to be faced. The residential areas had changed and cheap and rapid transport facilities had been developed. The sick poor should be able to obtain relief near where they were living; those seeking medical education should go to the places where the sick poor were, and not expect the sick to come to them from afar off. The alternatives were to transfer great general hospitals away from the centre of London, or to build new general hospitals further from the centre.⁶⁵

It was said that hospitals needed rebuilding every hundred years, as developments in medical science outstripped the facilities available. The clinical activities of the hospitals were changed out of all recognition by anaesthesia, antisepsis, specialisation, the growth of outpatient depart­ments and subsequently radiology. St Thomas’s had been rebuilt and, as a result of the generosity of Sir Blundell Maple, University College Hospital was being reconstructed. But Charing Cross, the Westminster, King’s College Hospital, Gus’s, St George’s, St Bartholomew’s and The London all faced problems. The question of relocation was frequently raised but governors of a hospital had no obligation to areas other than their own. There was a fear that a new district might not give adequate financial support. A hospital might also lose its traditional supporters.

In spite of pressure from the King’s Fund, Charing Cross Hospital held to a decision taken in 1896 to expand into new buildings in King William Street. The Fund’s visitors reported in 1898 that nothing could make the present building suitable for hospital purposes, and that in their view it should be pulled down and rebuilt elsewhere. ⁶⁶  the hospital did not agree.  Alfred Saxon-Snell, son of Henry Saxon-Snell, was appointed architect and fund-raising began. 

Population trends in the metropolitan boroughs, 1899.

Members of the theatrical profession, with which the hospital was closely associated, gave their services and a grand bazaar was held at the Albert Hall. The report of the King’s Fund for 1902 included a request that any proposal for a new hospital, or for reconstruction or a major extension of an existing one, should be submitted to the Fund before definite action was taken, in the hope of improving the distribution of beds. The Fund’s distribution committee adopted a policy of supporting amalgamations, setting aside £5,000 to assist in the process. During 1903 discussions were held with orthopaedic, ophthalmic and ear, nose and throat hospitals. The report for 1904 suggested that those hospitals which devoted themselves entirely to one disease should work ‘under as few roofs as possible’. It was implied that a judicious reduction in the total number of small hospitals might be advantageous. The prince referred to the high sense of duty of those hospitals which, by amalgamating, subordinated their private interests to those of the whole system.

The argument for relocation was taken up in 1902 by the newly formed Hospital Officers Association*, a group within which ‘progressive ideas and practical information about hospitals’ could be disseminated to arouse keener interest in the medical charities. Its inaugural lecture was given by Mr Adrian Hope, secretary of the Hospital for Sick Children, and was concerned with the future of the voluntary hospitals. Hope believed that the King’s Fund would become increasingly influential. He also thought that some hospitals would have to consider selling their present sites and using the money to rebuild better premises on less expensive land. Many London hospitals were in need of rebuilding to modern standards, reflecting the demand from doctors for better conditions. Decisions should take account of rehousing; for instance, the London County Council was moving 40,000 out to Tottenham.⁶⁷

The medical press paid little attention to Hope’s lecture, but the proposal to relocate hospitals was picked up by the Daily Mail which published a map showing the value of the existing sites of the hospitals, and where they might be moved to on Thursday 27th November 1902.

. ‘Control and organisation is necessary in any case’, commented the Mail. An active correspondence followed.⁶⁸ Correspondents were virtually unani­mous that relocation was a financially viable proposition. The Westminster Hospital stood in Broad Sanctuary, opposite Westminster Abbey, on a site worth £750,000. If the sale could raise only half a million, the two hundred and twelve beds could be rebuilt for £168,000 at Tottenham on a site four times as large, leaving adequate money to endow beds and meet running costs. Charing Cross could be rebuilt to serve the new population around Woolwich for £145,000, providing 175 beds. St Bartholomew’s, because it was ‘a large hospital and could not be moved so far’, might go to Clapham - ‘a good central position’.⁶⁹ The relocation would cost £550,000 but the sale should raise £1 million. Costs of rebuilding were estimated to be £700 per bed.

The secretaries of hospitals which had been relocated supported the proposal but the great hospitals, whose removal was being proposed, were rather less than enthusiastic. Sir Edmund Hay Currie of The London Hospital and the Sunday Fund told the Hospitals Association that the transplantation of ancient charities must be approached in the most gentle manner possible.⁷⁰ Sir Trevor Lawrence, treasurer of St Bartholomew’s, wrote to the Daily Mail to point out that the dense local population, the ever increasing workload, and the need for West End physicians and surgeons to be near at hand — impossible if the hospital moved to Battersea, Greenwich or Tottenham — made its present position absolutely necessary. ‘No greater injury could be infficted upon the sick and suffering poor of the City of London than to move it from the site where it has done incalculable good.’

In reply the newspaper analysed the population of the City, Finsbury and Holborn and showed that it totalled 200,000; ‘on the accepted basis of one bed per thousand inhabitants’ the district was over bedded. Guy’s, King’s, Charing Cross and the Royal Free with a further 1,200 beds lay within one and a half miles of Bart’s. They were able to serve a population of two million where barely half a million lived. The paper also ran a news item about an aged plate-layer who broke his legs on Bexley station and had to be transported to Guy’s, fourteen miles by rail.

The secretary of the Metropolitan Hospital, which had already been relocated, wrote to say that his staff had no difficulty in reaching the hospital as they were on the telephone. The matron at Tottenham said that their surgeon could ride his cycle rapidly through the quiet streets at night. The correspondence had served to emphasise what those working in hospitals had known for twenty years: that the population which had been moved as a result of slum clearance or the construction of new buildings was often poorly served; the economics of removal might often be sound; and that hospitals which had been moved were generally content. There was no doubt that they had gained in usefulness and in most cases the costs of rebuilding had been paid off. The Times carried two articles on 7 and 8 January 1903, commenting on the cramped site of St Bartholomew’s and the need for better accommodation if the future of the hospital and its school was to be assured.

An editorial in The Hospital referred to the press coverage and stated that some pains had been taken to ascertain the facts. However much was spent on reconstruction at St Bartholomew’s the hospital could never be brought up to the standard of a newly planned building. In any case the census showed that the population of the City was falling. It would seem better to sell the site and rebuild in Old Street on the site of the old St Luke’s Hospital, next to the City of London Lying-in Hospital.⁷¹

In March 1903 Sir Henry Burdett addressed the Hospitals Associ­ation on the removal of large hospitals to congested districts or to the country. Sir Henry gave bed ratios for five concentric districts: 

City of London	1:40
Stepney, Shoreditch, Finsbury, Holborn, City of Westminster, Southwark and Bermondsey	1:418
Poplar, Bethnal Green, Hackney, Islington, St. Pancras, St.Marylebone, Kensington, Paddington, Battersea, Lambeth, Camberwell	1:1.054
Stoke Newington, Hampstead, Fulham, Wandsworth, Lewisham, Greenwich and Deptford	1:1,877
West Ham and Romford, Tottenham, Edmonton, Barnet, Hendon, Brentford, Croydon, Kingston, Richmond, Bromley and Dartford.	1:2.482

 

Taken as a whole the ratio was 1:922, which is remarkably close to the usual estimate of the needs of a population — 1:1,000. South London, Battersea and Tottenham had the greatest problems. Burdett con­sidered it difficult to define hospital districts, for many patients would travel long distances to a hospital which commanded their confidence. Yet the London County Council’s policy of slum clearance, housing residents outside its own area, created difficulties in places like Tottenham. Burdett believed that the London County Council should finance Tottenham hospital, as its planning had created new demands for care. In the event it was the King’s Fund which came to the rescue by responding to the hospital’s requests. Very large grants were made to assist expansion. Soon over 50 per cent of the hospital’s income was derived from the King’s Fund. Burdett also referred to a report of a scheme to supply South London with beds by moving King’s to Camberwell, mentioned the possibility of moving the Westminster to Battersea, and hedged on the question of St Bartholomew’s. In the lively discussion which followed one speaker said that though City sites might be costly, there could be no better use for valuable land than the saving of human life. Sydney Holland of The London supported the amalga­mation of King’s and the Westminster on a suburban site, but when Burdett was asked what the attitude of the King’s Fund might be to this proposal, the question was ruled out of order.^{70, 72}