The voluntary hospitals underwent a great many changes during the interwar years. The pre-National Health Service (NHS) hospital did not become a site for generating profit. Yet payment did find a place, even as the hospital remained essentially a philanthropic institution. The idea that the working classes should pay in to the system, the various schemes that facilitated this in the community and the almoner who policed it in the hospital, and the idea of opening up the hospital to middle-class patients, were all inventions of the nineteenth century. Yet it was not until the interwar years that any of them became the norm, or even commonplace. In both principle and practice, the change brought about was more complex than a simple switch from medical charity to private healthcare, a reformulation rather than a rejection of philanthropy.
This introduction presents an overview of the key concepts discussed in the subsequent chapters of this book. The book looks at four new arrivals in British hospitals from the late nineteenth century, each of which became commonplace in the interwar years. These were: patient payments, hospital almoners, hospital contributory schemes and middle-class patients. Two core principles will be discussed as underpinning these four new arrivals in British hospitals. The first will be termed economic reciprocalism. A combination of change and continuity characterised the second principle of class differentiation. The book sets up the city of Bristol as a case study to explore the operation and meaning of hospital payments on the ground. It places the hospitals firmly within the local networks of care, charity and public services, shaped by the economics and politics of a wealthy southern city.
Payment in the doctor-patient relationship continued along traditional class lines, with working-class patients treated on an honorary basis and middle-class patients agreeing a fee. The rhetorical and political strategies adopted by advocates of private provision were based on the premise that middle-class patients needed to be brought in to a revised notion of the sick poor. By establishing a system of class differentiation governing access to the voluntary hospitals, a new patient contract was constructed for working-class patients. Payment, either directly by the patient or indirectly via a contributory scheme, was in effect an act of good citizenship rather than earning the right to treatment. In between taking and refusing payment, a profession might distance itself from the payment taken. Providing free treatment to the poor was a professional activity doctors traded on lucratively in their private practice.
This chapter examines why the voluntary sector and wider mixed economies of healthcare, welfare and public services should be so well developed in Bristol. To do so, it considers the social, economic and political factors at play in the city. The poor law was one of the two pillars of Victorian welfare. The other was philanthropy. Municipal interventionism, in both economic and social fields, was evident in Bristol from the early to mid-nineteenth century. If action was slower than many wanted from local government, there was significant activity from other sectors, including private enterprise, as can be seen from the case of private asylums. Poor Law infirmaries have sometimes been seen as the nucleus of a public hospital service. While the voluntary hospitals were leading charitable institutions in their own right, they were also deeply embedded within local networks of care.
Taking a wider view of the patterns of provision, it is clear that the relocation of middle-class patients requiring institutional care, from the nursing home to the hospital, was only partially achieved over the early twentieth century. The specialist services of Bristol's hospitals, particularly in maternity care, contributed to a dual hub split between the two cities, jointly providing hospital services to the region's middle classes. This variation in locality, size and type of hospital both explains the atypicality of Bristol and nuances the 'insufficiency' of private provision identified by Bridgen. Understanding the type of hospital (i.e. general or specialist) can help us gain some understanding of what kinds of medical treatment were being provided to middle-class patients. Placing our focus on the idea and the act of payment both heightens and diminishes the significance of 1948 as a watershed in the history of British healthcare.
This book examines the payment systems operating in British hospitals before the National Health Service (NHS). An overview of the British situation is given, locating the hospitals within both the domestic social and political context, before taking a wider international view. The book sets up the city of Bristol as a case study to explore the operation and meaning of hospital payments on the ground. The foundation of Bristol's historic wealth, and consequent philanthropic dynamism, was trade. The historic prominence of philanthropic associations in Bristol was acknowledged in a Ministry of Health report on the city in the 1930s. The distinctions in payment served to reinforce the differential class relations at the core of philanthropy. The act of payment heightens and diminishes the significance of 1948 as a watershed in the history of British healthcare. The book places the hospitals firmly within the local networks of care, charity and public services, shaped by the economics and politics of a wealthy southern city. It reflects the distinction drawn between and separation of working-class and middle-class patients as a defining characteristic of the system that emerged over the early twentieth century. The rhetorical and political strategies adopted by advocates of private provision were based on the premise that middle-class patients needed to be brought in to a revised notion of the sick poor. The book examines why the voluntary sector and wider mixed economies of healthcare, welfare and public services should be so well developed in Bristol.
This chapter seeks to answer whether the incorporation of payment into the working-class patient contract amounted to an abandonment of philanthropy. The appointment of hospital almoners to conduct what was effectively a means-test served as a double-safeguard. First, it allowed the hospital to grant reductions and exemptions to those unable to pay, ensuring this did not become a barrier to access. Second, along with the setting of income limits, the assessment of the almoner was a mechanism for weeding out those of the middle and upper classes who were not considered appropriate cases for medical charity. Prior to the First World War, Bristol's voluntary hospitals were typical in operating two well-established systems for admission: subscriber's tickets and 'receiving day'. More fundamentally, admission was not conditional on either almoner-assessed payment or contributory scheme membership.
This chapter surveys some key themes in the historiography of healthcare in early twentieth-century Britain and presents a few enlightening international comparisons. A more nuanced understanding of the place of payment in British hospitals before and after 1948 adds to a growing appreciation that it was the high-point in a longer period of kaleidoscopic change. The history of the voluntary hospital system is itself, inevitably, bound up with funding. The question of whether a hospital could remain a charity whilst taking payments from patients, the recipients of that charity, is hard to separate from a wider historiographical debate in the social histories of medicine in Britain, Europe and North America, on whether the hospital had by now lost its social function. The pre-National Health Service (NHS) citizen patient was not so much a citizen-consumer or a welfare citizen as a citizen-contributor.
The emergence of bioethics in British universities
Many of the academics who taught on new interdisciplinary ethics courses were increasingly located in dedicated bioethics centres from the late 1980s onwards. During the 1960s and 1970s, as Edward Shotter notes, 'there was no teaching in ethics in British medical education' and leading doctors believed that ethical questions were best 'discussed by consultants, with consultants and in camera'. The non-doctors who taught medical students were initially based in law, philosophy and social science departments. The pressure on philosophy departments was compounded when the government replaced the University Grants Committee (UGC) with a new Universities Funding Council (UFC) in 1988. The degree's structure and focus, with input from many staff and departments across the university, reflected the British attitude that no one profession should dominate medical ethics or bioethics.
Mary Warnock's support for assisted dying is significant in a number of respects. It shows, first, how an individual's ethical views are not fixed and can change according to what the observer called 'the lessons of life'. Secondly, and more importantly, it shows just how much authority bioethicists are thought to wield over public affairs. The fact that a philosopher fronted an episode of the BBC's flagship science series again shows how bioethicists emerged as a 'new epistemic power' in Britain from the 1980s onwards. Although the notion of moral expertise remains contested and many bioethicists refuse to acknowledge it, they are often portrayed as what the Guardian called 'ethics experts'. The legal philosopher Gerald Dworkin, working at Queen Mary University in London, highlighted the major differences in his paper on the 'delicate balance' between ethics, law and medicine in Britain and the United States.