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In the 1970s, university funding, which had risen progressively over the preceding years, began to plateau. The University of London was especially afflicted. There was a need to rationalize resources and the vice-chancellor of the day, Lord Annan (previously provost of University College London), saw opportunity and advantage in tackling medicine first. At the time the Faculty of Medicine comprised 12 so-called undergraduate medical schools, 13 exclusively postgraduate medical institutes, 5 dental schools, 2 schools of pharmacy and the school of veterinary medicine. Its excellence was not much in dispute. In the main, these schools were academically, geographically and financially separate from the University multifaculty institutions. London academic medicine attracted postgraduate students from around the world much in the way that Vienna had a century before. But its academic foundations were becoming less secure in that the schools were often divorced from mainstream sciences within the University at large. With financial imperatives in mind it was also apparent that maintenance of a large number of adjacent but administratively separate and small medical schools was especially expensive. Hidden agendas may have included ideas surfacing in two of the major multifaculty institutes, ultimately to break away from the federal University and take segments of academic medicine with them. It was also felt that, if London academic medicine could be rationalized, the process might serve as a model for dealing with other Faculties. At this time the Faculty of Medicine within the University was an active body, largely in the hands of clinical academics, determining academic standards and coming to involve individual medical schools somewhat more robustly. A working party was set up with Sir Brian Flowers (rector of Imperial College and subsequently Lord Flowers) as its chairman.
The working party saw its task as securing the long-term excellence of London academic medicine. It dealt exclusively with University matters and its concerns with clinical services were restricted to ensuring that they were, or shortly would become, good enough to sustain clinical teaching into the foreseeable future. Such teaching had often been vested historically in one or other adjacent and famously named ‘teaching hospital’ which had given that name to the related medical school. It soon became apparent, with recent population shifts and more academic emphasis on social and community aspects of medical education, that some excellent central London schools in particular were at risk of asphyxiation.
The Flowers Report1, published in 1980, provoked a stormy reaction. It had proposed the consolidation of the 12 undergraduate schools into five blocks, with four of these embedded respectively in multifaculty colleges—namely, Imperial College, King's College, Queen Mary College and University College. The postgraduate medical schools and schools of dentistry were also woven into this fabric. The exception was St George's Hospital Medical School which was too geographically isolated to be easily absorbed, having recently moved from central London to a densely populated part of outer London. Lively discussions persisted through the following year and only slowly did things change.
Mergers and loss of independence are seen as threatening in many walks of life even when logic demonstrates their advantages, and proud names carry a treasured sense of identity even when the implied self-sufficiency is long lost. At stake for the London Medical Schools was that valuable asset an established sense of community, linking both staff and students in a common enterprise. Theirs was a long tradition and for a Barts man or a Guy's man, for instance, the primary loyalty was to the hospital and its medical school; even if they took its degrees London University was often seen as in essence an examining body. In the mergers the coupling between hospital and medical school was often to be lost; the hospital name would of course be kept, but with pooling of staff, and students attending many different centres, some new focus of loyalty would be required. It could be that the huge multifaculty college of which they were to be part would seem as remote as the University itself had been.
For the institutes of the British Postgraduate Medical Federation the situation was rather different. They had grown from London's ‘special hospitals’, which, though originally despised by the medical establishment, had over the course of a century achieved high international reputations. These were still regarded with disfavour by many in the general medical schools, accused of creaming off the resources, staff and clinical material which should properly have been devoted to undergraduate education. The institutes feared that they were to be engulfed by these envious giants and would lose the integrated approach to their special interests built up over so many years. The special hospitals were still of vital importance to them and talk of incorporating these in larger new general hospitals was frightening; but, if the hospital survived, at least the institute would remain coupled to it and retain its old loyalties. In the event, this was the outcome for some but not all of the institutes.
Indeed, 23 years later, the new pattern, in terms of the Faculty's undergraduate and postgraduate institutions, is now almost exactly as ‘Flowers’ recommended. The new medical schools, as part of more powerful academic blocks and also because of their internal academic evolution, now largely run their own courses and examinations on a looser rein, though still with ultimate central university governance. The degrees for the moment remain those of the University of London.
There is one aspect of the Flowers Report which has sunk without a trace. The working party, foreseeing the possible implementation of its recommendations, suggested that new academic identities would emerge and that new names for the schools might come to be welcome. This was ‘one bridge too far’. Schools were not accepting of the reassurance that the old teaching hospital names would often survive and remain linked to them, unaffected by the renaming of the medical school. They wished to preserve them in their own titles. But, in the event, many of the old medical school names have now been submerged beneath new descriptive titles that reflect the new linkages. These names, linked though they also are, in four instances, to the distinguished names of their respective multifaculty colleges, are not always totally meaningful and agreeable in themselves.
Relationships between medical education and universities can be especially complex. Universities without a medical faculty often crave one. Those with such a faculty sometimes bemoan its cost and troublesomeness. London has been no exception. The University of London, as we now know it, was created in 1836. Before this (apart from University College, which had claimed the title in 1826) London was very unusual amongst the leading European cities in not having a formalized university. But medical education had been going on in London for centuries. Following the foundation of St Bartholomew's Hospital in 1123, Fitz-Stephen felt able to comment2 that, in the 1170s, there were several ‘famous schools’ in medieval London. Subsequently, within the text3 celebrating in 1986 its 150 years of existence, the University acknowledged that ‘Antedating the University was a range of preexisting institutions, some of them important enough for it to be plausibly held that there already existed an unformed university of London. The longest roots of the University of London in its twentieth-century form are to be sought not so much in the teaching of law in London as in the teaching of medicine’. Indeed, in 1923, Gordon Wilson4 had been unable to resist the comment that such learned instruction had been part of the London scene ‘when Oxford was an obscure Saxon village and Cambridge noted only for eels’.
But the medical schools remained reluctant bedfellows. As Logan5 pointed out, it was only in 1900, when the University was reconstituted, that formally they became part of it. The Faculty of Medicine of the University, destined rapidly to become the largest in the English-speaking world, was thus born. However, the schools' aloofness persisted, even after the creation of the University Court in 1929, which thereafter came to channel their funding. In 1944 the influential Goodenough Report6 recommended that the medical schools should ‘take all possible steps to make their associations closer, more active and more mutually advantageous’. The National Health Service Act of 19467 had the effect of disconnecting the governance of the medical schools from their parent teaching hospitals and entrusting it to the University. By the late 1940s, all medical students were required to take a centrally prescribed course of study and usually to qualify with a university governed degree. In 1968 the Royal Commission on Medical Education made further recommendations8 regarding integration and laid the foundation for the Flowers Working Party.
Swept along by this tide, the medical schools continued to cherish their traditions. It had not required the University to kindle their pride. They had long been aware that they owed their existence largely to the vision and philanthropy of individuals, based as they still were on the hospitals that had conferred their names upon them. The foundations of some went back many centuries (not only Barts but also St Thomas's, which was accustomed to claiming origins in the first millennium). In the absence of a formal multifaculty university, teaching of medicine had for long assumed a bedside apprenticeship form (which finds its present expression in the emphasis still given in the UK and Eire to undergraduate clinical training). This approach had been formalized by the Apothecaries Act of 18159, which required attendance at specific courses as well as six months' attendance at a hospital. From the beginning of the seventeenth to the end of the nineteenth century such teaching, sometimes led by physicians, surgeons and obstetricians of great professional stature and lasting fame, provided the basis of medical education in London. Despite this, standards of medical practice as experienced by the public at large became an increasing source of public concern. This culminated in the 1858 Medical Act10 and formation of the General Medical Council and its Education Committee, destined to determine the standards and hence the form and content of undergraduate medical education thereafter. Thus such education became ever more standardized, thereby possibly ensuring that the schools up and down the country, and perhaps especially in London, did everything else possible to retain their individual identities. Most recently the Education Committee of the GMC, first having spelled out in considerable detail11 what attributes it requires of the present day fully trained doctor, has recommended12 that henceforth there can be a greater degree of freedom in the undergraduate curriculum within a generally accepted examinable framework. This once again, after more than a century of increasing constraint, allows greater individuality to schools—particularly in respect of elective special study modules, which invite student initiatives and draw upon the particular strengths of each school.
There may be a special message here for the reorganized and sometimes bruised medical schools in London. It is perhaps an opportunity to build on tradition in an accessible way. And what better than to identify a name from the past which communicates that intangible sense of identity and discovery, expressing at once continuity and an intellectual and clinical adventure?
‘Flowers’ had the temerity to make some suggestions at the time. It proposed that, over the centuries, London medicine had spawned people whose contributions to the field were huge, pivotal to new understanding and thus enduring. Names that were respected worldwide. Did the Viennese schools now regret not having named their schools and institutes after their own great pathologists, clinicians and others? ‘Flowers’ put such names as Harvey, Jenner, Lister and Fleming into the arena. Others abound.
Naming some of the new school combinations after such locally appropriate historical medical giants could have several advantages. If the name were well chosen it would add a halo to the institution that could endure and consolidate. The institutional profile of London medical education could once again be rooted in its traditions. Medicine, in its study and practice, is inseparable from its history and from the historical process applied daily within the clinical consultation. Aspirants to medical studies and London medical students of all ages might thus be inspired and their academic curiosity aroused by such associations. Part of our major medical heritage in London would also be enshrined for the public at large.
We wished to resurrect this idea from the past, at this time of change. Others may be thinking about it anew.
We thank David Eames, secretary and registrar for Medicine in the University of London and the archival staff of the University of London Library for their help. We also wish to acknowledge the extent to which we have drawn upon the text of Negley Harte's The University of London 1836-1986, Ref 3.