Introduction

Hospitals face an uncertain future. After a century of achievement and progress, the public, clinicians, managers, and politicians are increasingly expressing concern. Currently, the UK public's principal worry is the danger of hospital acquired infection, particularly methicillin resistant Staphylococcus aureus (MRSA),1 but it also includes mixed sex wards, poor quality food, inadequate cleaning, insufficient attention from staff, and the risk of being the victim of a medical error. In 2000, 850 000 adverse events occurred a year, costing the health service £2bn ($3.4bn; €2.9bn).2 Up to 40 000 patients die each year because of iatrogenesis, with a similar incidence in other industrialised countries.3 This contributes to politicians' enduring concern: hospitals' apparently insatiable appetite for resources.

Attempts to achieve greater efficiency through economies of scale are leading to fewer, larger general hospitals.4 Ironically, this is happening at a time when public confidence in larger general hospitals is waning, with the prospect of them being avoided in favour of smaller private hospitals by those who can afford them.5 All in all, it is a fairly forlorn outlook, but we have been here before. What can we learn from the past?

Previous demise

This is not the first time that hospitals have faced such challenges. Although the affluent provided financial support for the hospitals that emerged in the industrialising cities of the 18th and early 19th centuries, none of them would have relished using such facilities (though they were also discouraged as it would have threatened the income of their private practitioners and abused the charitable purpose of hospitals). The workhouse infirmaries were a refuge of last resort for paupers while the voluntary hospitals were for the labouring …