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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.
, founder of the King's Fund, 1879 There was only one area of the pre-NHS hospital system which genuinely saw private healthcare operating on a commercial basis. This was the parallel provision made for middle-class patients, the likes of ‘George’ from Your Very Good Health , in the British hospital of the early twentieth century. Since admission of middle-class patients was commonly seen as a threat to
charity, even as these underwent significant changes over the early twentieth century. The previous two chapters examined the arrival in the hospital of patient payments and the almoner, contributory schemes and the middle-class patient, and how they became commonplace in the interwar years. It is typically assumed that these changes undermined or even ended philanthropy as the organising principle of the voluntary hospitals. 1 Yet, as we have already seen
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, as well as 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
wealthy southern city. The options, obligations and experiences of Charley are considered in chapter 3 and then those of George in chapter 4 ; with particular attention to how the hospital payment schemes they would have navigated were introduced in our case study city. Treating the two in separate chapters 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
provided for its part a means of social isolation. Usually built far from the wards, private rooms for ‘paying patients’ were a rare luxury reserved for a class of people that would not have tolerated being associated with the general population (see Chapter 6 , pp. 220–4). Since the law on public charity did not explicitly forbid it, the presence of middle-class patients in publicly funded
choice between free or fee-paying services meant the middle-class patient had more choice under the NHS than before. Rejection or culmination? With the transition from a diverse patchwork of providers to a comprehensive and universal service as the dominant teleological narrative in the history of British healthcare, change looms large. Yet there is no consensus on the cause, or even the chronological scope
-middle-class and middle-class patients seeking specialised and technological treatments; in return, patient-paid revenues would constitute a significant input to the finances of public institutional medicine. Now CAPs were free to open clinics for paying customers with comfortable private rooms. 73 Paying public hospital users were charged the basic legal daily rate, plus a series of
early 1930s Ministry of Health survey noted that ‘if treated in the general wards the fee is £2.2.0’, twice the full rate at the voluntary hospitals, with higher fees again for middle-class patients in private rooms (discussed in the next chapter). 45 The principle underpinning this gradation of payment was said to be ‘that the sick poor would have first claim upon the accommodation at Southmead, but any citizen would