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9 January 2019

Theme Hospital: how a game inspired by NHS managers turned into an epidemic success

Despite a lack of female doctors, Theme Hospital marked a turning point for girls playing computer games. 

By Julia Rampen

As Edinburgh’s doctors dealt with rising obesity and a heroin epidemic, across the city my friend and I were taking on our own medical emergencies: bloated heads and elongated tongues. Crammed into the downstairs cupboard of her parents’ – themselves doctors – otherwise large and lovely home, we became the masters of our own hospital, Theme Hospital: a pastel-coloured, retro-patterned, pixelated dolls house in which there were counterproductive numbers of KitKat machines.

Conceived in the dying days of John Major’s Conservative government, Theme Hospital was released on PC in 1997 – the same year as New Labour’s election landslide. Tony Blair had spent the run up to the poll attacking the Tories for mismanagement of the NHS and promising to build hospitals. Perhaps it is not surprising then, that Theme Hospital’s initial press diagnosis was deeply serious. “A grisly computer game which shows a doctor operating with a chainsaw is to be used as a training aid for NHS managers,” the Evening Standard reported in the month of its release, adding that medical groups had condemned the game.

In fact, despite visiting several British hospitals and even observing surgery in research for their game, its makers decided to inject comedy rather than gritty realism. “We were seeing all these really quite horrific things that people go through in their lives and it isn’t easy to turn that into entertainment,” Gary Carr, the artist for Theme Hospital, tells the New Statesman. “So we just tried to take the comical approach. We weren’t medical people, so why not rack the whole thing up and make it ridiculous?” “This was never about taking the mickey out of the health service,” Mark Webley, the producer and designer of Theme Hospital adds. “The fun of it was because we were making a piece of entertainment, making the strange illnesses.”

In Theme Hospital players are presented with an empty hospital building, ready to be filled with clinics, pharmacies and staff rooms for their tetchy employees. The more treatments the player invests in, the more curious the patients’ illnesses, and the more eccentric the cures. A figure made up of only a hat, spectacles, a wristwatch, shoes and a walking stick glugs down a bottle of medicine and is revealed as a man cured of invisibility. The tongues of slack-tongue sufferers are placed in the slicer machine, and swiftly lopped off.  “Certainly visually, with something like bloaty head disease, my favourite bit of that is the popping of the head,” says Webley, who may have also uncovered the reason the game held so much attraction to a group of kids. Some other illnesses, like “3rd Degree Sideburns”, and “TV Personalities”, are only referenced in passing, leaving their patient avatars to the imagination.

While the makers of Theme Hospital based their research on the NHS, the hospital in the game operates as a money-making business. “People thought because you got paid we were trying to recreate an American-style hospital system,” says Carr. In fact, it was simply an easy way of giving players rewards. Recently, Webley and Carr worked on a “spiritual successor” to Theme Hospital, Two Point Hospital, released in August this year. This time, they incorporated levels where the player must meet targets, rather than simply rake in the cash. “It is actually one of the harder levels to play because you have to make decisions that will have an impact down the line,” Carr says, a sentiment many NHS managers may sympathise with.

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The combination of British-style hospital culture – complete with 1950s-style iron beds, and nods to Carry On Doctor – and American-style healthcare profiteering turned out to be an epidemic success. When pirated copies are also taken into account, the most popular market for Theme Hospital is China, where, the makers say, it is almost a household name (Russia also contains a huge fan base). “I think they like a lot of nurturing games,” says Carr. “The humour seemed to work, the British things translated.” Hospital workers themselves have always had a particular interest in the game: at the US launch, a doctor told the team: “I am just fascinated about how much you have got right.”

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But why did we, as nine or ten-year-old girls, love it so much? Shortly before speaking to Carr and Webley, I asked a friend who had been part of our pre-adolescent gaming posse about it. “I downloaded it again the other week,” she told me. And so I found myself on her sofa, drinking prosecco and watching the opening animation of Theme Hospital.

The first thing I learned about playing Theme Hospital again for the first time in 20 years is that you need to be fast. You’ve barely built your pharmacy and hired your first doctor (all male) and receptionist (female, obviously), before a VIP wants to visit and there are rats running around the hospital floor. And then, just when things are ticking over, the doctors start demanding more money, which apparently they can do, despite character traits like “baits tourists” and “furtive gardener”. When you complete the level, via a congratulatory letter that praises you for being a “golden boy” (clearly Theme Hospital was no place to be an ambitious woman), you have to start building your hospital from scratch again.

Perhaps my reflexes have slowed, but there may also be a technological explanation for the frantic pace: when played on more advanced computers, older games often do speed up (to truly recreate the leisurely pace of my childhood, I could have manually slowed it down).

Strangely, technological change is also part of the reason why Theme Hospital looks so gendered. “That’s not because we’re sexist, it’s because we had four megabytes,” protests Carr when I ask why all the doctors are male. Nevertheless, he wishes he had been more radical. “I wanted to make male nurses, I wanted female doctors,” he says. “Looking back, I wish I had been braver. But you have to make decisions and we didn’t have the memory.” The duo tried to make up for it in Two Point Hospital, in which staff are both male and female, more diverse, and have far more individualistic features. “It’s clear we have referenced all cultures.”

Theme Hospital might not have looked particularly empowering, but it was a vehicle for equality in another way. My all-girl Theme Hospital sessions were not very unusual. “Around 5-6 per cent of gamers were girls [at the time],” says Carr. “When Theme Hospital came out, it was around the 20-22 per cent mark. That was unheard of – we’d broken into something.” Three years after Theme Hospital was released, Maxis launched a game that would also be popular with female gamers: The Sims. Today, roughly half of gamers are female.

Some of them will no doubt play Two Point Hospital, which has received positive reviews, and also revels in slapstick and visual puns (patients with glowing bulbs for heads suffer from “lightheadedness”). For Carr and Webley, the enduring popularity of Theme Hospital is down to two elements of the game: the need for the player to face moral dilemmas, and the delight in everyday detail. “The secret is, don’t make something extraordinary into a game,” says Webley. “It’s much more interesting to take relatable and understandable things, and turn them into something extraordinary.”

This article was part of the NS’s “Vintage video games week”, click here to read more in the series.