Hospitals and Healthcare Providers: how have they changed?

Anna Howells, Policy Intern at the Health Foundation, reflects upon the development of hospitals and healthcare providers over time.

Provision of health care is something often taken for granted today- here in the UK the NHS remains committed to providing services ‘free at the point of delivery’ (mostly), and there are a staggering number of institutions, services and companies tasked with the sole purpose of looking after our health.  But where did this tale begin? How did we end up with a system that, whatever critics might claim, goes a long way in taking care of us when we are at our most vulnerable? The Hospitals and Healthcare Providers timeline seeks to chart this fascinating history.

Given the wealth of information and resources available, we have chosen to focus primarily on hospital development. The hospital has taken many forms since the eleventh century where we start our provider journey- almshouses, poor law hospitals, voluntary hospitals, teaching hospitals, free hospitals, cottage hospitals, municipal hospitals and district general hospitals to name a few- and it is fair to argue that hospitals have evolved in a somewhat haphazard fashion over time.

The origin of hospitals in England is full of intrigue- religion, romance and the monarchy all played a part. Throughout the medieval period, leper houses, hospitals and almshouses were established, with their development closely linked to the church. But it wasn’t until Henry VIII and his desire to acquire wife number two that this system of religious provision had to change. The break from the Catholic Church and consequent destruction of the monastic system led to the widespread closure of institutions linked to the church, and levels of poverty increased. Out of these ashes St Bartholomew’s hospital was re-established, after the citizens of London successfully petitioned their King on the grounds that ‘the miserable people lyeing in the streete’ were ‘offending every clene person passing by the way’. Perhaps not the most honourable of reasons, but it was nevertheless successful, and hospitals began to increase in number from this point onwards.

The 1601 Poor Law dictated the way in which state assistance was provided throughout the seventeenth century, up until the industrial revolution. The revolution brought with it urbanisation and huge societal changes, and the cost of administering assistance through the Poor Law became too expensive for the state. The 1834 New Poor Law led to the rise of the workhouse, a justly feared institution, in which conditions were intended to be less desirable than those of the poorest labourers. Not all was doom and gloom in this period however, as the voluntary hospital movement had gained momentum and led to the building of numerous hospitals founded for philanthropic reasons.

Individual providers of healthcare- that is to say medical professions such as surgeons and nurses- became more formalised during the nineteenth century. By the early nineteenth century, hospitals in England were developing medical education, and in 1815 the responsibility of organising medical education was given to the Society of Apothecaries. While the term ‘apothecary’ might conjure negative connotations for some- thoughts of quack medicine may surface- the occupation was one of three recognised branches of the medical profession, the other two being physicians and surgeons. Those wishing to become apothecaries had to undertake a five-year apprenticeship, whereas those with surgical aspirations began as apprentices and then paid a fee to become either a pupil or a ‘dresser’ before being granted the title of surgeon.

The individuals belonging to these bodies were all men, and until the establishment of University College London in 1826 which allowed students of any race or religion to study, students of any subject also had to belong to the Church of England. Interestingly, King’s College London was founded in response to University College London, which it portrayed as ‘the godless college in Gower street’. In the same period the nursing profession grew, and the first nursing school was founded in London in 1860, supervised by Florence Nightingale. Soon after, all major hospitals had nursing schools.

The provision of care through workhouses can seem like a now-irrelevant blight in the history of England, but their role in the journey towards our modern-day health service cannot be denied. Poor law hospitals emerged from workhouse hospitals, and it was only in 1929 that local authorities became responsible for Poor Law hospitals thanks to the Local Government Act. Poor law hospitals then became municipal hospitals ‘serving ratepayers, not paupers’, and voluntary hospitals still played an important role in the provision of healthcare.

World War Two highlighted the widespread variation in the provision of care across the country, with the best provision found primarily in London. The war also led to the creation of a new branch of healthcare provider, the emergency hospital service, which later became the emergency medical service.

In 1948 the NHS was introduced as a tripartite system made up of hospital services, general practitioners (GPs) and local authorities, meaning that local authorities were no longer directly responsible for hospitals. Unification of the different hospital types was complex, and matters were further complicated by GPs who insisted on remaining independent contractors at this time. A unitary system of administration was introduced in 1973, and from this time onwards the organisation, administration and labelling of hospital services fluctuated considerably. For example, there have been regional hospital boards, area health authorities, district health authorities, self-governing hospitals (NHS trusts) and NHS foundation trusts.

The provider landscape has taken on a new angle in recent years due to the increasing focus on integration between health and social care, and the emphasis on moving care outside of the hospital and into the community. But is this really a new concept? It is telling that the following quote from Enoch Powell’s 1961 ‘water tower’ speech is just as relevant today as it was then, when he outlined his view that ‘the medical profession outside the hospital service will…accept responsibility for more and more of that care of patients which today is given inside the hospitals’. Powell recognised that this would be a ‘colossal undertaking’. This has indeed been the case and there is still a long way to go as we can see from the vision set out in the Five Year Forward View.

The provision of healthcare in England has a long, rich and complex history – much of it focused around the development of hospitals. It is perhaps indicative of the NHS focus on hospital care that the Policy Navigator timeline focuses heavily on this area of service provision. In time, we would like to expand the Policy Navigator to include a wider range of provider types including primary care and community providers.  It will remain to be seen whether during the next decade, in the midst of unprecedented financial and staffing challenges for the NHS, we will finally set out to achieve the ever constant desire to shift care outside of the hospital.