I always bring my books to hospital appointments. Or my readings. The words are meant to distract from the bright white paint, the arguments at the reception desk, the rattling wheelchairs, the supportive relatives; but they rarely work. Instead, I sit and watch people experiencing the same building, rooms and walls in completely different ways.
The Royal London Hospital, originally named ‘the London Infirmary’ and then ‘the London Hospital’ is situated in Whitechapel. When founded, it was one of the five main voluntary hospitals in London, and the first in the East of London. Having experienced numerous relocations, redevelopments and adaptations, it proves both an interesting and valuable subject of analysis, when considering the role of institutions in reflecting the wider socio-economic environment. This paper argues that the Royal London Hospital has and continues to perform as both a palimpsest and heterotopia. As identified by Foucault, we observe changes in the political economy and cultural values of London throughout history, which alter the purpose and function of heterotopic space (1984, p5). Specifically, we argue that the built form, both external and internal to the Royal London reflects the wider social, political and cultural environment.
Firstly, the theoretical underpinning of this argument will be considered, with accompanying information on the methodologies employed. We recognise the need to avoid simplistic and teleological understandings of time. However, to ensure we consider how the political economy has influenced and been reflected in the built form of the hospital, our main body of research will chart four of the most prominent periods of architectural change in the history of the Royal London Hospital.
Prominent representations often present institutions, as isolated islands, with their own codes of conduct and rules of law. (Street & Coleman, 2012, p4). Such conceptualisations align with theoretical understandings of space as ‘the dead, the fixed, the undialectical, the immobile’ (Foucault, 1980, p177). This absolutism is often criticised, and, drawing on the work of Massey, a prominent new conceptualisation of ‘space’ within human geography is identifiable. From this standpoint, space must be recognised as a product of relations, which consequentially consists of multiple and heterogeneous orderings. In this way, space is continually constructed, and is always in process. Such logic actively undermines imaginations of the hospital as a bounded and exceptional space. Instead, we are instructed to consider the hospital as a continuation of the mainland, with non-existent to porous boundaries (Street & Coleman, 2012, p4).
This research argues therefore, that if relations rather than intrinsic qualities define a site, the hospital can be considered a counter-site and reflection of wider society (Arnold, 2013, p20). Institutions, such as hospitals, where the public-private dichotomy is disrupted, are often termed ‘heterotopic.’ Heterotopia literally means ‘other places’ – a broad translation, which hints at the multiple and contradictory meanings assigned to the term (Nelson, 2010a). With the existence of such challenges, and limited opportunity to thoroughly analyse such theoretical underpinnings, we will adopt a loose and selective understanding of heterotopia. For the purpose of this research, a heterotopia is presented as a space where social orders are continually (re)constructed, through the representation and inversion of other sites. In this way, we consider the heterotopia to emphasize lived and socially constructed spatiality as the habitus of social practice and order (Fairbanks II, 2003, p134).
We will particularly focus on Foucault’s heterotopia performing as a microcosm and mirrored reflection of a changing society and political economy (Nelson, 2010b, p12; Foucault, 1980). It will be necessary to recognise, however, that a heterotopia is not a utopia, as it is localised and tangible. However, the heterotopia may still enact the utopian ideals deemed desirable by society, for example the myriad space of the hospital is far more ordered than wider society, with triage and referral systems. Such thinking may nevertheless, produce a tendency towards a conception of heterotopia that produces ‘a very undialetical rendering of what space is and can be about,’ possibly reminiscent of Kantian notions of space (Foucault, 1980, p177; Harvey, 2007, p42) and so, drawing further on the analogy of a mirror, our adopted conception of heterotopia must embody both a static quality, and importantly one of flux (Arnold, 2013, p20).
It is common practice within sociology and anthropology to study society through the lens of institutions, but academic enquiry rarely considers the relations between society and the specific built form of an institution. This omission appears remarkable, as the built environment is a social product, and therefore reflects social, political, economic and cultural needs e.g. dominant belief systems or resource distribution. Change in the built environment, including the many relocations and redevelopments of the Royal London Hospital, thereby performs the maintenance of social forms and organisation, and consequentially reflects the distribution of power. Our conscious and deliberate decision to focus solely on the spatial organisation of the Royal London Hospital, will hopefully serve to produce a deeper understanding of the relationship between the built form of the institution and the wider political economy of London (King, 1980, p2, 11).
Our research argues that as the socio-economic environment of London experiences change, so too will the social need and theoretical positioning of the population. This, in turn, will produce new built forms or modifications to the existing built environment, as aligned with value-systems and demand (Johnson, 2006, p79). Such destructive and productive capabilities reflect society. For example, society disciplines through the market economy, as only conforming architectural designs are selected (Ballantyne, 2005, p6). In this way, we argue that architecture is ‘responsible for producing those parts of the built environment that the dominant classes use to justify their domination of the social order’ (Stevens, 1998, p86). The user of the space, and the builder are therefore subordinate to the architect (Kapp & Baltazar, 2010, p3).
Changes in the spatial structuring of the Royal London Hospital have therefore altered both the functioning of the heterotopia, and replaced one heterotopia with an alternate one. This has produced a space of palimpsest, with one heterotopia destroyed and another produced onto its spatial, as well as non-spatial memory (Barnum, 2014).
Initially, a literature review on the Royal London Hospital and, less specifically, the spatial structuring of institutions was conducted. The theories described in various published articles and books proved vital in grounding the specific institutional case in the broader language of palimpsest and heterotopia. Furthermore, certain books offered an insight from various points in history e.g. recently published books detailed the history of the NHS, whilst detailed descriptions of the London Hospital could be found in textbooks published at an earlier date.
Descriptive, qualitative observational data was further collected, through prolonged engagement in the research setting. This method of enquiry allowed the researcher to produce a ‘written photograph’ of the Royal London Hospital through ‘active looking’ and by conducting ‘detailed field notes’ (DeWalt & DeWalt, 2002, pvii). The researcher could, therefore, consider how space is used and negotiated in the present. The majority of research conducted involved unstructured observations of the natural and everyday setting of the hospital, with little to no participation, which reduced ethical concerns and ensured the environment was not disrupted.
Although, the researcher did not directly engage in the research setting, it must be acknowledged that ‘observation’ is not a passive method of data collection, but instead involves the active organization of data. In this way, such methods are often considered subjective, but Clifford argues that this is not an inherent weakness in methodology. Instead observations are a ‘source of representational tact,’ which allow the researcher to engage on an emotional and deeper level with the research setting (1986, p6-7.)
Furthermore, archival research and documentary analysis will provide a useful tool alongside primary research, as the researcher can gain insight over a prolonged historical period. Despite calls for more transparency, challenges exist in carrying-out such research. For example, limited guidance on conducting archival research is available to the researcher, and most remaining relevant articles are limited and often overly simplistic (L’Eplattenier, 2009, p68). Due to this, it was essential to ensure that the methods adopted were clear and would yield accurate and historically relevant information. Considering this limitation and following the work of Langton, the approach implemented combined a historiographic approach and ecological methodology. More specifically the method adopted, which centered on the in-depth analysis of a specific and historical institution – the Royal London Hospital, – was used to consider wider changes in the structural characteristics of London (1984, p330-332; Ventresca & Mohr, 2001, p8).
Difficulties in performing archival research often include access, however the Royal London Hospital Archives and Museum provided a wealth of information. After performing a search of the online catalogue of collections, numerous interesting and relevant records were requested. Photographic and drawn collections seemed to yield especially significant results, often detailing changes in architecture and building infrastructure. Such visual research proved valuable, revealing more than just information about the topic of capture. For example, since archival documents were not produced for the specific purposes of this research, the historical significance and circumstances of the archives creation was considered.
The Birth of the London Hospital
18th Century London witnessed great socio-political transformation, with the Hospital system consequentially experiencing both expansion and adaption. Until the early 1700’s, only two prominent hospitals existed. By 1752, however, the Westminster, Guy’s, ‘The London,’ the Middlesex and Queen Charlotte’s, amongst many others, were founded (Morris, 1910, p25). Therefore, before considering in depth the internal and external spatial ordering of the ‘The London,’ it is first necessary to acknowledge that the very existence of a built environment to analyze is hugely significant.
The ‘London Hospital,’ alike the other city hospitals founded in the 18th Century, was both a product and reflection of capitalist growth. With industrialization, followed rapid urbanization, as a vast industrial workforce was urgently required for labour in the capital city. The hospital improved the administration of this growing sick population vastly, through the economisation of the cost of care (Forty, 1980, p63). Consequentially, a direct correlation between population growth and requirements for hospitals is often assumed, but it is necessary to recognize that the hospital marks only one way to treat the sick. The rapid expansion in the hospital system, and construction of ‘the London,’ therefore requires a more complex and in-depth analysis.
It is often argued that the capitalist order defines value through monetary productivity. In this way it seeks to distinguish between two opposing categories of body: those who accumulate profit through their labour, and those who cannot (Connell, 2011, p1375). The growth of capitalism, and particular expansive industrialization in London, thereby lead to the development of a morality, which privileged waged work. This ideological turn conflicted with both the giving of personal charity to the poor and the existence of the Poor Laws, triggering a societal reorganization according to market principles (Forty, 1980, p67).
The construction of the hospital building thereby reflected sociopolitical change in London, which marked a newfound consensus that the charitable giving of food and money was responsible for a dependency culture and the disincentivisation of the poor to work. Since the provision of relief to the able negatively affected labour mobility and productivity, it was deemed necessary to distinguish those who were both poor and sick from those who chose not to contribute as waged labour (Smith, 1926, p135-140). The hospital was thus a space of reform of the poor relief system, which tested the authenticity of one’s poverty (Forty, 1980, p67, 68). In this way, the hospital served to relieve and support the deserving poor, whilst excluding those deemed ‘undeserving’ (Safley, 2004). Simply, the space of the hospital performed to separate theoretically different persons, ensuring that the capitalist system performed efficiently and economically (Scull, 1980, p40, 41). Thus the built environment reflected an ideological movement from the ‘postulate of brotherly love’ towards ‘the loveless realities of the economic domain’ within the broader cityscape (Weber, 1978, p589).
A Space of Control
Capitalism thereby witnessed (and proved the initiating force) in the shift from a paternalistic social order to one based on class and rank (Briggs, 1960, p44). An institutional based system was therefore adopted. As the wider capitalist system punished those who resisted the lure of industrialised labour and waged work, the hospital reflected this disciplining and ordered focus, enacting the utopian ideals of wider society (Scull, 1980, p40).
With premises change in 1752 and the construction of a new building, the London Hospital encompassed many of the key characteristics of a Palladian mansion (see fig 1.1). However, the internal spatial organization of the building was markedly different and is key in considering how the hospital space reflected the wider socio- political economy of London.
18th Century society within London was a ‘finely graded hierarchy, in which status distinctions were carefully defined, observed and protected’ (Heyck, 2008, p48). Such order was seen to continue through the porous borders and into the London Hospital. In the plans of the London Hospital (see fig 1.2, 1.3) numerous equal storey heights can be observed. The plans (fig 1.2 and 1.3) and index of rooms (appendix 1.4) reveals that rooms 1-3 are used for Bye Wards across both floors. These levels served the same functions, but patients represented different ranks of social importance. In a similar manner, the rooms closest to the main entrance were the least exclusionary, with patients of a higher social ranking treated in rooms further from communal areas, to ensure the most privacy. This arrangement also reflects the perceived need to control and ‘watch over’ the poorest patients, who were considered more likely to absent themselves during treatment, threatening their health and also abusing relief services (Forty, 1980, p70). Furthermore, the ‘London Hospital’ was navigated through using a system of corridors, meaning rooms were ordered dependent on social positioning e.g. nurses at the end and medical staff towards the centre.
The relief provided thereby performed to enforce work, through the regulation of marginal labour forces and the maintenance of civil order (Piven & Cloward, 2012, pxvii, xviii). The internal spatial organization of ‘the London ’works as a crisis heterotopian space, since the space worked to exclude those without privileged access – namely those deemed ‘undeserving’ (Foucault,  1984, p4). In this way, the hospital reinforced the wider exclusionary practices of London, reflecting a hierarchal and class-based system.
The ‘Envy of the World’
During the inter-war period, ideological support for the introduction of a national health service grew. On 5th July 1948, the majority of health-related services were transferred to the Minister of Health. With increasing hospital demand, a new Hospital Plan was implemented in 1961. This recommended the construction of 99 new hospitals and the upgrading of over 130. Budgetary constraints, however, meant that only one third of new builds were completed, and instead older hospitals, such as the Royal London Hospital remained, with eventual internal restructuring, and the construction of additional sites (Chambers et al, 2014, p14, 18).
Despite the generally poor condition of the hospitals inherited, Wilkinson argues that ‘the nonsimultaneity of the simultaneous… can create surprisingly cosy bedfellows’ (2014, p4180). For example, the nightingale wards (see fig 2.1, 2.2) seemed ill fitted to modern medicine and scientific advancement (Lomas et al, 2012, p81). The open- plan style of the wards, and dormitory type arrangement did however enable post- crisis state surveillance, whilst fostering a sense of community and ‘we’re-all-in-it- together-ism’ (Wilkinson, 2014, p4182). In this way, the hospital performed as a microcosm of the wider welfare state, both observing and disciplining the body of the patient to increase productivity.
However, by 1966 the ward modernisation plan was complete, with a restructuring of the hospital ward to ensure patient hygiene and privacy (appendix 2.3). The design of the wards broadly followed the ‘Rigs’ configuration, which divided beds into semiprivate bays. The beds were then ordered parallel to the walls in pairs, facing another set (Sloane & Sloane, 2003, p56) (fig 2.4). This meant that socially the poorest patients were ‘citizens of a small group rather than of the entire ward,’ alike patients of higher social status (Thompson & Goldin, 1975, p216). In this way, the internal architecture of the hospital reflected the ideologies and ideals of the welfare state. All patients were ensured equal privacy, as the internal organisation of the wards was consistent throughout the hospital (Wright, 2013, p6). However, patients were still easily observed and the wards maintained disciplining functions, which would have been compromise with single rooms.
As further evident in the archival photographs (fig 2.4) the hospital wards were white with easily cleaned surfaces. Hygiene represented a multiplicity of modernist metaphors. The most significant representation, since the inception of the NHS, presented the increasing awareness of hygiene, not just as a simple aesthetic choice, but also as a rejection of the stress and bustle of the modern city and the dirt of industrialisation (Wilkinson, 2014, p4030). The (perceived) cleanliness of the hospital wards at the Royal London, reflected wider arguments, which underpinned social and economic reform e.g. that a stable society is threatened by dirt and poverty. As early as 1842, for example, the Report on the Sanitary Condition of the Labouring population, argued that sanitary improvements were economically viable and common-sense (Saville, 1957, p10,11).
Further to the ward modernisation programme, the chronological phase map shows the addition of numerous sites between 1947 and 1996. Nutsford House for example opened in 1957, whilst building finished on the John Harrison House in 1963 (see appendix 2.5). The modern welfare state witnessed large amounts of such new construction. Often the social agenda of the mid-20th Century, produced buildings with clearly separate functions e.g. the Institute of Pathology and the Dental Institute opened in 1965. However, as the Royal London expanded and new sites were added, complexities of structures were left. In this way, a ‘wild mix of buildings and infrastructures from different times’ were left, ‘where new organisational principles had to be found’ (Zurich, 2006).
The numerous developments post-establishment of the NHS e.g. ward modernisation reveal a homogenous and varied architectural landscape, which reflects wider ideological transition, The Royal London here performs to both order and equalise, alike the wider welfare state.
Neoliberalism and Individualism
At the end of the 20th, and beginning of the 21st Century, the architecture of urban hospitals experienced both spatial and budgetary limitations. The economical skyscraper was therefore widely adopted. Although, only 17 floors high, the new 2011 development at the Royal London Hospital, reflected the same minimalist and economical form (Dominiczack, 2011, p22). The architectural form is reminiscent of the corporate office (see fig 3.1). In this way, the recognition that health is now a commodity to be consumed is reflected in the built environment of the hospital. The paradigm of modernity is here further reflected.
Neoliberalism is not a final product, but instead a dynamic process, which changes the relationship between the public, the private and the civil sector (Wright, 2013, p2). Individualism features as a central facet to neoliberalism, and has produced a continuum of inclusion for citizenship based on social and economic value e.g. economic relations of consumption and production constitute levels of deservedness amongst the population (Hague, 2008, p14; Rose, 2000, p1407). Reflecting this neoliberal environment of the hospital, the Royal London can be considered an exclusionary space. The architect Markus Schaefer, for example, argues that the construction of such spatial forms often overwhelm and threaten patients. Tellingly, the reception of the hospital (see fig 2.4) – the first experience of the site for the patient and the main interface between the healthcare provider and the user – performs as a continuation as the external environment (Pellitteri & Belvedere, 2016). The glass walls, high ceilings and bright colours, make the hospital reception a cold and confusing space for users (fig). Whilst, the external image of the building is highly distinctive and ‘embodies metaphors of strength, stature and strategy’ (Dovey, 1999, p109). The solid and vertical form of the hospital can be conceptualised as phallic, as it may symbolise male force and violence (Lefebvre, 1992, p287). The built form of the hospital, influenced by the social prominence of neoliberal thought, here disciplines the poor, female body.
The neoliberal values amongst the urban landscape of London are here reflected in the microcosmic space of the Royal London. Alike in earlier historic periods, the hospital excludes and disciplines, presenting as a crisis heterotopia.
Concluding Notes and Discussion
In conducting a thorough analysis of the Royal London Hospital (nevertheless less detailed than we would have wished,) two interesting lessons emerged:
Firstly, throughout the analysis, it was evident that heterotopic space is not always simply destroyed, but often takes on new significance and is adapted to fit the social, political and economic environment. In this way, the metaphor of the ‘palimpsest’ only proves valuable if it is broadly extended. We argue that imaginations of a chalkboard, where meaning is continually destroyed and re-wrote, are not adequate for theorising a palimpsest. Instead the palimpsest must be conceptualised as a wall of graffiti, with multiple layers of interwoven meaning.
Secondly, our unfortunately limited, timeline demonstrates themes of ‘orderliness’ throughout. Here, we find the ultimate limitation to the term ‘palimpsest’ in our analysis. The Royal London Hospital, seems to have performed the same disciplining function throughout history, producing docile and economically productive bodies, albeit whilst reflecting the dynamic and ever-changing political economy of London.
Despite this, we still find value in both the term heterotopia and palimpsest. We envisage the Royal London Hospital as a ‘crisis heterotopia,’ which has excluded those without privileged access across time, through different architectural form and internal ordering (Foucault,  1984, p4). From the very foundation of the hospital, to its redevelopment post-establishment of the NHS, the changing needs of London and ideological transformations are reflected in the built environment of the institution. Simply, the Royal London Hospital is the ultimate microcosm of London – a small smoke, within the ‘big smoke.’
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Archival Sources References
The Royal London Hospital Museum and Archives:
1.1 LH/S/2/4. Richardson, A. (1852). [Illustration of ‘the London Hospital’]. Plans of the London Hospital Presented to the House Committee by their Surveyor
1.2 LH/S/2/4. Richardson, A. (1852). [Plans of the First (One) Level]. Plans of the London Hospital Presented to the House Committee by their Surveyor
1.3 LH/S/2/4. Richardson, A. (1852). [Plans of the Second (Two) Floor]. Plans of the London Hospital Presented to the House Committee by their Surveyor
2.1LM/P/2/11 [Postcard for the London General Hospital Collection] Photograph of the Mary Ward, approx. early 1990
2.2 LH/P/2/11 [Photographs for Hospital Scheme Pre-Ward Modernisation] Photograph of the Harrison Ward, approx. 1950
2.4 LH/P/2/11 [Photograph by Ian Berle, On Behalf of the London Tower Hamlets Health Authority] Photograph of the Croft Ward, approx. 1970
Appendix 1.4 – The Royal London Hospital Archives – LH/S/2/4
Richardson, A. (1852). [Index of Rooms]. Plans of the London Hospital Presented to the House Committee by their Surveyor
Appendix 2.3 – Royal London Hospital Archives – LH/X/321
University of Manchester Archaeological Unity (1996) [Part 2: Analysis, p11] ‘Historic Environment Survey’
Appendix 2.5 – Royal London Hospital Archives – LH/X/321
University of Manchester Archaeological Unity (1996) [Chronological Phase Map] ‘Historic Environment Survey’