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A key feature of the history of health care has been the battles between practitioners over the boundaries between each occupation: who they can treat, what treatments they can use, what they can charge for. Since 1750, each and every group has sought to distinguish itself from competitors and to gain recognition as a ‘profession’. Their objective has been to transform a service into an income-yielding property by gaining control of the market. Legal rights, self-regulation and formalized training were the tools that would give a group the social and economic security it sought. These developments, which have occupied practitioners over the past 200 years, have spawned numerous organizations, many of which have been located in one small area of London: Marylebone. A walk through this district illustrates the story of how the main health-care professions—doctors, nurses, midwives, dentists—developed. The highlights of the walk are shown in Box 1.1.
In 1750 there was only one group that enjoyed the benefits of professional status: the physicians. Few in number, they were educated at the exclusively Anglican universities of Oxford and Cambridge, and had been granted a royal charter in 1518 to form a College (Box 2). In contrast, the surgeons were still a city company which had only recently separated from the barber-surgeons (in 1745). And the apothecaries, who had separated from the grocers in 1617, were intent on distinguishing themselves from druggists and chemists, so as to emphasize their role as medical practitioners. Unlike physicians, training for surgeons and apothecaries was largely by apprenticeship, soon to be supplemented by attending a private anatomy school. The other trades had no formal preparation. The forerunners of dentists (tooth-pullers) learnt by experience, often from their parents, as did midwives. And nursing hardly registered as an occupation, consisting almost entirely of unskilled, menial tasks.
Box 1 Highlights of the walk
Box 2 Royal College of Physicians
Inspired by his observations in Italy, Thomas Linacre led a group to create a College of Physicians. Their aim was to protect the interests of Oxbridge educated physicians by gaining control of the exclusive right to practice medicine. In the event, protection only covered the City of London and a seven mile radius. Despite this early success, battles with the surgeons and apothecaries (both City livery companies rather than colleges) continued until the 19th century. The claim of the physicians for exclusivity failed because they were few in number and their high cost meant few people had access to them. Their case was further weakened by the decision of most to side with the Royalists in the civil war (1640s) and their abandonment of London during the Great Plague (1665).
Initially the college was located in the City, but as the centre of medical London shifted west in the 19th century it had to follow. A site in Trafalgar Square was identified and a new home was erected, designed by Robert Smirke. With its double Doric columns facing onto Pall Mall East (opposite the National Gallery), even at the time some felt it was severe ‘almost to the point of dullness’. The addition, in 1875, of three statues to the façade (Linacre, Harvey and Sydenham) did little to allay such views. It remained there until 1964, when it moved to its present home in Marylebone.
Rather than orient the new building towards Regent's Park, the modernist architect, Denys Lasdun, had the main windows look to the right, over the college garden and the Georgian houses of St Andrew's Terrace (Figure 2). The latter were acquired in the 1980s for extra accommodation. Inside the main building, the spacious hall or atrium with a central staircase takes your eyes up towards the portraits of past Presidents, the more distant of whom would probably be perplexed by the range of modern day practitioners and the complexity of managing the professions.
Until the 1720s the area north of Oxford Street was open country. Starting with Cavendish Square, the main thoroughfares of Harley Street, Wimpole Street and Portland Place were constructed, which linked London with the newly constructed east-west bypass, the New Road (Marylebone Road). For its first 100 years this was a sought-after residential area. The affluent moved here from their homes in the City. However, by the middle of the 19th century they started vacating Marylebone for the attractions of Belgravia and Kensington; this provided the opportunity for the less prosperous to move in, in particular, doctors.
Box 3 Royal College of Nursing
The quest for improved status and conditions led to two factions in nursing: a more radical one seeking independence and self-determination and a more cautious one accepting less autonomy. The former view was first manifest by the establishment of the British Nursing Council in 1887 (which became the Royal British Nursing Association in 1899). Led by the formidable Ethel Bedford Fenwick, it formed a register to which only nurses of at least three years experience were admitted. It advocated the development of nursing as a profession independent of medicine. As such, it distinguished between specialized nursing skills requiring training and unskilled domestic duties.
In contrast, the College of Nursing established in 1916 was more inclusive, recognizing and accepting the full range of duties performed by nurses. Its aims were to promote better training, encourage uniformity across the 1500 nursing schools in England and maintain a register of proficient nurses. With the help of their greatest benefactor, Lady Cowdray, they established a benevolent fund (the Nation's Fund for Nurses) to provide for nurses whose health had been damaged by WWI. She also purchased 20 Cavendish Square from Herbert Asquith (the Prime Minister), to serve as a headquarters for the College and as a residential club, not only for nurses but also for other professional women.
The tension between the two nursing factions reached a head during the debates around the 1919 Nurses Act. Government was wary of relinquishing too much independence to nurses but, along with hospital managers, was concerned to stem the growth of trades unionism, a threat that would increase if all aspirations of professional status were denied. The College of Nursing seemed to offer the least worst option. The Act created a General Nursing Council composed of nine lay people, ten members of the College and only four members of Bedford Fenwick's Association. Nursing was the last of the main health care professions to gain legal status, some eight years after parliament granted protection for domestic animals.
The expanded role for the College led to the need for more space. In 1928-30 neighbouring properties were bought and the current building was created by retaining the finest internal features of the two 18th century houses in the square, building behind them and enveloping the ensemble in the façade you see today (Figure 3). In 1939 the college received a royal charter. However, unlike the medical royal colleges, which concentrate on professional standards and education, the RCN combined these with a trade union role which led to consideration of the use of industrial action on occasions during the last few decades. Meanwhile, the late 19th century debate about what constitutes ‘a nurse’ continues into the 21st century within the RCN.
Box 4 General Medical Council
The Medical Act of 1858 required the establishment of a register of all recognized doctors and standardization of medical education, tasks for which the General Council of Medical Education & Registration was created. Although the three strands of the emerging profession (physicians, surgeons, apothecaries) were united in supporting its establishment, serious differences existed between the hospital-based specialists and the general practitioners. The former were opposed both to a basic generic education that all practitioners must satisfy and a single register in which they would be ‘seen in the same light as those of a common tradesman’. These views did not prevail and a single register was established, though initially registration was a requirement only for doctors working in public institutions and government medical services.
The introduction of the register had the effect the doctors had hoped for; that is, restricting access to only those who were ‘properly’ qualified. By the 1870s this had resulted in a shortage of practitioners and as a consequence doctors' income and status were enhanced. The supremacy of allopathic (biomedical) practitioners had been established, and with the compulsory inclusion of midwifery in basic medical training, male doctors had triumphed over female midwives. Despite a certain amount of public rhetoric, the interests of the public were always a secondary consideration for the profession in the 19th century.
Since 1900, most of the attention the Council has attracted has arisen from its role policing the conduct of doctors. This has largely concerned sexual misconduct or drug abuse rather than poor clinical performance. Its tendency to protect doctors from patients, rather than the reverse, has in part reflected the composition of the Council, which has always been dominated by doctors—though this has decreased from 94% in 1950 to 60% today.
After occupying various buildings, in 1922 the Council moved to custom-built premises in Hallam Street, designed by Eustace Frere (Figure 4). A fine bas-relief over the entrance shows medical practice at the time of Hippocrates. It wasn't until 1951 that the organization was renamed the General Medical Council.
Up until about 1840 the centre of the medical world in London was to the east, in an area extending from Queen Square to Lincoln's Inn Fields, midway between their source of income—the homes of private paying patients in the West End—and the principal hospitals (St Bartholomew's, St Thomas's, Guy's, Bethlem) in the City. However, with changes to the social geography of London, it was vital that they did not get left behind. During the first half of the 19th century the new voluntary general hospitals (University College, Charing Cross, King's College and Royal Free) were all established to the west of the City.
Box 5 Royal Society of Medicine
In 1805 a group of members of the Medical Society of London (which had been established in 1773) objected to the high-handed behaviour of the president, Dr James Sims, who after 19 years in post showed no sign of giving up office. So they broke away and formed the Medical & Chirurgical Society of London. Among them was Dr Peter Mark Roget, later to find fame by devising the thesaurus that bears his name. Similar to the society they had left, their aim was to provide a venue ‘for the purpose of conversation on professional subjects, for the reception of communications and the formation of a library.’ They occupied several premises in and around Holborn (the centre of medical London at that time), before moving west to Berners Street (near the Middlesex Hospital). They also acquired the ‘Royal’ prefix, which must have annoyed the longer-established society they had left.
In 1890 they moved to 20 Hanover Square, a fine 1720 mansion. During the 20 years they were there their long-term future as the premier medical society was secured as a result of their incorporation of 16 specialist societies. They were renamed the Royal Society of Medicine, and larger premises were sought. This was achieved in 1910 when they moved to custom-built premises in Henrietta Place. Despite only having a side door in Wimpole Street, the members craved the social cache of a Wimpole Street address, an ambition realized after lobbying various authorities.
The building had a small though monumental façade, with four recessed giant Doric columns and a fanciful entrance, above which it was intended to place a large sculpture (Figure 5). An extra storey was added in 1952 and further expansion occurred in the 1980s when part of the postal sorting office next door in Wimpole Street was incorporated, including creating a new main entrance. The RSM continues to pursue the aims of the founders by holding hundreds of meetings each year, publishing books and journals, and providing a London ‘home’ for members from afar.
Doctors recognized the need to migrate west to stay near their sources of income. Marylebone became home not only to the leading practitioners but also to the organizations that were to play key roles in the development of the health-care professions. Hence, between about 1840 and 1920, the modern health care professions were defined and refined in this area, and to the present day this remains the political centre of the health care professions.
Granting a trade the status of a profession represents a deal between society (government) and an occupation. In return for gaining considerable freedom of self-determination and legal protection, the occupation pledges to act honestly and altruistically in the interests of the members of the public they serve and to advance both their subject and their personal knowledge and skills. Unlike other occupations, a profession controls who can join its privileged ranks by determining the entry requirements and minimum standards of practice; it receives legal protection that prevents non-members from practicing; and it is allowed to regulate and police its members. To execute all these activities, each profession has needed to establish five complementary organizations, each performing distinct functions:
Establish and maintain professional standards. Now largely the responsibility of royal colleges, though until 1930 only two existed (the physicians and the surgeons). Over the past 70 years eleven more have been established, four of which are in Marylebone: midwifery, radiology, paediatrics, and nursing (Box 3).
Guard their territories. Professions established defence organizations to fulfil this role, such as the Medical Protection Society, which was based in Marylebone. Their function was to prosecute unqualified intruders and to defend their members from unjustified or false accusations.
Police their own members. In order to do this, regulatory bodies were established by acts of parliament: the General Medical Council in 1858 (Box 4); the British Dental Association in 1879; the Central Midwives Board in 1902; and the General Nursing Council in 1919, all four of which (and their successors) have been located in Marylebone.
Advance knowledge. This function was led by professional societies. Some adopted a wide, general interest, such as the Royal Society of Medicine (Box 5) and the Medical Society of London (both in Marylebone), while others specialized. Apart from organizing lectures and demonstrations, many published a journal, some of which survive to the present day.
Just like other trades, professions are concerned with protecting and enhancing their members' financial well-being and employment rights. Initially this depended on trades establishing their own benevolent associations to assist those members and their families who faced impoverishment through death or disablement. Examples include the Society for the Relief of Widows & Orphans of Medical Men (1788), the Benevolent Fund for Dentists (1883) and the Nation's Fund for Nurses (1917). With the establishment of trades unions, unlike the doctors who created a separate organization (British Medical Association), the three other main professions chose to combine trades unionism with establishing and maintaining professional standards: the British Dental Association (since 1921); the Royal College of Nursing; and the Royal College of Midwives.
Marylebone has not only been the centre of professional development in England, it was also where private hospitals emerged. Until the mid 19th century, the affluent paid to be visited and cared for in their own homes. This extended to surgery, though the range of operations available at that time was very restricted. Three factors changed this. First, there were increasing demands from people living some distance from central London, too distant to be visited by expensive physicians and surgeons. They required a ‘home’ in central London where they could stay while being treated. Social changes also meant there were increasing numbers of single people in rented accommodation who had no family to care for them when they fell ill. Second, by the end of the 19th century medical advances (most notably the availability of anaesthesia and aseptic practices) were permitting more complex treatments that required more than a kitchen table. And third, the well-justified fear of hospitals was diminishing as a result of the improvements pioneered principally by the nursing profession. All these factors contributed to the demand for hospitals and for paying patients.
Given the increasing concentration of medical men residing in Marylebone, it was inevitable that private facilities would develop here. Initially, doctors' homes doubled up as private consulting rooms for outpatients, while other houses were used as small private nursing homes. The massive growth in medical activity in Marylebone (from a dozen doctors in the 1860s to over 1400 today) led to the area being referred to as Pill Island in the 1930s. The demand for more accommodation for clinical services combined with the changing social aspirations of doctors led them to move to live in the suburbs and home counties. Entire houses could now be given over to consulting rooms, enabling even more doctors to work here. Meanwhile, the small nursing homes gave way to private hospitals, some having as many as 200 beds and state-of-the-art high-tech equipment.
This is the last of four articles that provides the background to one of the walks in a new book, Walking London's Medical History, which aims to tell the story of how health services developed, to help preserve our legacy of buildings and to inform current debates about health care. Walking London's Medical History is available from the RSM Press website: http://www.rsmpress.co.uk/bkblack2.htm