3 Payment and the sick poor In 1935 Sir Alan Garrett Anderson, son of the pioneer of women in medicine, Elizabeth Garrett Anderson, was elected Conservative MP for the City of London. A year later he spoke in a parliamentary debate on the nation's voluntary hospitals: We have been told that they are passing through a lean time and are in competition with the municipal hospitals, but I
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.
philanthropy. In the past these class distinctions had been enacted by providing a separate, institutional space where the sick poor would receive treatment. Admission to the hospital itself had been an act of separation. As technological advances and rising costs led the middle classes to arrive in the hospital as patients, this class differentiation became an internal event. The working classes submitted to a new form of charitable assessment
, but only the latter was equally as applicable to working in the NHS. The social function of the hospital both provided the cover for the compassionate introduction of a financial dimension to the patient contract and ensured the social worker's continued usefulness after its abolition. This continued social function is inseparable from a commitment to prioritise the treatment of the sick poor. Exactly what was meant by the sick poor
, despite the fact they accounted for only approximately one-quarter of hospital beds, with many of these clustered in the large teaching hospitals. 14 The voluntary hospitals were charities, often established in the eighteenth and nineteenth centuries, to care for the sick poor. They were ‘voluntary’ in the sense they were founded and supported by philanthropic donations, though funding from other sources including public grants was growing in the early twentieth century. 15 They
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 crude financial sense of redirecting the efforts of the hospitals towards these private patients was rejected in favour of a continued focus on treating the sick poor of the working classes. Five key conclusions can be drawn regarding the patterns of provision
in so far as wage and relief levels were concerned. Not only are such details given in this survey but the numbers of weavers and winders are shown and also those who were deemed able to work but had no employment. The survey was comprehensive; 301 families were visited containing some 1,850 persons. The census of 1821 had shown the population as 2,052. The sick poor were also occasionally listed separately from other groups, usually by charitable groups. The early nineteenth-century pauper listing for Barrowford is just such a survey. It follows the model of other
theoretically serving the sick poor and primarily, indeed almost exclusively, urban-located. It embodied certain attributes of the English workhouse or house of correction but did much more besides and usually contained in excess of 100, and in the larger provincial centres could house over 1,000 inmates.7 In France, the most striking embodiment of formal relief was the large urban-located institution; in England, it was the parish-based rate that was collected in both town and countryside with equal efficacy and, as Table 3.2 shows, in the late eighteenth century, Howlett
. King, ‘“Stop this overwhelming torment of destiny”: negotiating financial aid at times of sickness under the English Old Poor Law, 1800–1840. Author Abstract’, Bulletin of the History of Medicine , 79:2 (22 June 2005), 228–60, https://doi.org/10.1353/bhm.2005.0072 ; S. King, ‘Regional patterns in the experiences and treatment of the sick poor, 1800–40: rights, obligations and duties in the rhetoric of paupers’, Family & Community History , 10:1 (1 May 2007), 61–75, https://doi.org/10.1179/175138107x185256 ; S. King, ‘Negotiating the law of poor relief in England
). 20 Barry M. Doyle, ‘Author's Response to Review of “The Politics of Hospital Provision in Early Twentieth-Century Britain” ’, Reviews in History , review no. 1733 (February 2015), www.history.ac.uk/reviews/review/1733 , accessed 25 April 2016. 21 Keir Waddington, ‘Paying for the Sick Poor