It is well known that Englishmen are in the main opposed to any and every new system with which they are not familiar. Probably to this influence is due the fact, that, with a few exceptions, pay wards are as unknown in this country as the pay hospitals themselves.1
Sir Henry Burdett, 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 the charitable character of the institution, as will be examined in the next chapter, it became the established practice to have income limits for admission to the ordinary wards. In Bristol these rose from roughly £250 per year in the 1920s to over £400 in the 1940s, roughly in line with the threshold for income tax.2 Those above this level would have been termed ‘middle-class’ by the Ministry of Labour and hospital authorities alike, and commonly excluded from accessing hospital services through the mechanisms described in the previous chapter.3 It was only by charging higher rates to this separate class of patient that the hospitals stood any chance of turning a profit. This new category of patient would be accommodated not in the usual dormitory-style wards, but in a separate one- or occasionally two-bed room, domestic in style. These private wards would be physically separate, sometimes in entirely separate buildings. Charges for such rooms were not voluntary contributions towards the cost of maintenance, but rather compulsory fees set at a rate to cover at least the full cost of treatment. Consequently, where patients in the general wards might pay up to one guinea per week, patients in these private wards could pay up to ten guineas per week. In addition to which they would have to negotiate with the doctor a fee for his services.4
Paying the very highest rates was rare, according to confidential briefing papers produced for parliamentarians by the King's Fund, lobbying in support of more voluntary hospital services for private patients. Surveying the provision on offer in London in the mid-1930s, the King's Fund categorised the different rates charged as fitting for patients of ‘limited means’ (up to three guineas per week), ‘moderate means’ (between four and seven) and the ‘well-to-do’ (eight to ten). The vast majority (73 per cent) they classed as being for the middle group, with only 1 per cent for the highest.5 More reliable evidence has been produced from assessments based on the rateable value of given addresses in Middlesbrough hospitals, suggesting the ‘class and wealth’ of inpatients changed little with the arrival of private patients.6
The emergence of private provisions might be seen as a logical development, given the elite reputation of the larger voluntary hospitals and the common view of the alternative – poor law infirmaries – as institutions of last resort.7 Indeed, this was the view of Charles Rosenberg in identifying a ‘private patient revolution’ in American hospitals at the turn of the twentieth century.8 However, as Paul Bridgen has argued, based on King's Fund evidence for London, the British voluntary hospitals ultimately failed to become the provider of hospital services for the middle classes. He suggests that, despite the efforts of the King's Fund, a ‘voluntary hospital insufficiency’ in middle-class provision left the middle classes with ‘little to lose’ from the nationalisation of the hospitals in the NHS.9 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 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 across Britain. First, that middle-class provision remained marginal in the voluntary hospitals up until nationalisation, despite some gradual growth over the early twentieth century. In line with Bridgen, this runs counter to assumptions of a fundamental shift towards a consumer-insurance system.10 Second, that such provision was more heavily focused in the general hospitals than specialist institutions. Third, that it was more often to be found in smaller hospitals than larger ones. Fourth, entirely private hospitals were very rare. Instead, private patients were usually a small minority in the institution; while separate wards, sometimes in separate buildings, meant they were unlikely to receive treatment alongside the working classes. Finally, provision was largely provided around a few major cities, and when considered proportionately to the local population, provision appears predominantly to be a characteristic of the southern voluntary hospital sector.
As a wealthy southern city and regional medical centre, we might well expect Bristol to be a hub of private hospital provision.11 In fact, it was quite the opposite. The number of private beds in Bristol hospitals was significantly below the national average and they were atypically concentrated in specialist institutions. To understand this we must see Bristol in its regional context, especially alongside the neighbouring city of Bath. 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 aytpicality of Bristol and nuances the ‘insufficiency’ of private provision identified by Bridgen.12
The scale of private provision
Britain: the national picture
In assessing the scale of private hospital provision before the NHS, we find a problematic lack of comprehensive or reliable data, with confusion common over the term ‘pay bed’. It is a somewhat misleading phrase as it was increasingly the norm through the early twentieth century for most patients to pay something. Therefore all beds might be classified as pay beds.13 This problem seems to effect both of the main contemporary national sources we have for hospital statistics: the Hospital Year-Books (which succeeded Burdett’s Charities in the early 1930s as a compilation of annual hospital information) and the reports of the wartime regional hospital surveys conducted by the Ministry of Health and the Nuffield Provincial Hospitals Trust. In both there were confusions in recording the number of private beds for various institutions, sometimes listing all beds as pay beds. In Bristol, for example, this was seen in the cases of the Bristol Maternity Hospital, the Walker Dunbar Hospital for Women and Children, and the maternity Grove House Home.14
To avoid such confusions, we might turn to metropolitan bodies such as the King's Fund; although information from an organisation with its own policy agenda will always need to be seen in that light. The earliest available figures on the scale of private provision in the voluntary hospital sector come from a King's Fund comparison of the number of pay beds in 100 London hospitals in 1913 and 1933, provided confidentially for parliamentarians promoting simplifying the process for allowing private patients in hospitals where there were problems with the wording of their charitable trust deeds. For 1913 they record 393 pay beds and 3,225 ordinary beds (a little over 10 per cent of the total). For 1933 it was 1,389 to 4,050 (slightly over 25 per cent).15 There can be little doubt, however, that those 100 hospitals were highly unrepresentative and presumably chosen in order to present a distorted picture in which private provision for the middle classes was both a significant and rapidly growing part of hospital work in the capital. If over a quarter of beds had been private across London's 159 voluntary hospitals this would have totalled over 4,000; rather more than the 1,573 listed in the 1933 Hospitals Year-Book. This fuller source gives the proportion of voluntary hospital beds for private patients in the capital a little below 9 per cent.16 Given that the King's Fund briefing papers claimed the rate was higher than this in 1913, before twenty years of expansion, the choice of which 100 hospitals to record – unnamed and with no criteria given for their selection – appears little more than an exclusion of those institutions not sharing their enthusiasm for the admission of private patients. The King's Fund itself can hardly have been under the impression that the capital's hospitals all fitted this pattern, when they had found from a questionnaire in 1927 that forty-one were making no private provision whatsoever.
Despite all these gaps and uncertainties with various information sources, some general trends are identifiable. From 1933 the Hospitals Year-Books show a trend of growth. In absolute terms, as can be seen from figure 4.1, the number of private beds in voluntary hospitals across Britain increased by four-fifths in the fifteen years before the introduction of the NHS. The rate of this growth, however, was much greater in the 1930s than the 1940s. Between 1933 and 1938 it increased by two-thirds, while by less than one-tenth between 1938 and 1947. A modest growth was returned after a temporary wartime slowdown, when private wards were among those reallocated under the Emergency Medical Service. This growth in private beds was slightly ahead of the growth in voluntary hospital beds in general, as shown in figure 4.2. Here there was also a clear trend of growth between 1933 and 1938, from 6 per cent in the early 1930s to around 8.5 per cent. Despite a small increase in the overall number of private beds during the war, they declined as a focus of the hospitals’ work, falling back to almost early 1930s levels. Across the country the balance was restored thereafter, so the situation in the provinces on the eve of war was very similar to that on the eve of the NHS. This was not the case for the heavily bombed and evacuated capital. Although private provision was still most prominent in London's voluntary hospitals, late 1930s levels were not restored after the war either as a proportion of beds or in absolute terms.
What is harder to put a figure on is the number of private beds for middle-class patients in public hospitals. As previously discussed, the assumption that all voluntary hospital beds were private has been unhelpful. The assumption that the larger and more numerous public hospitals made no private provision has been even more unhelpful. Most directories and surveys appear to have thought this figure not worth recording, although the wartime survey of the North West region is a rare exception (discussed further below). If we treat the North West of England's private 0.27 per cent of public hospital beds as representative, we can come to a very rough projected estimate for the whole of Britain; somewhere under 4,000 private beds out of the 144,000 total in all British public hospitals. Taking this combined with the voluntary hospital figures, we can estimate that only around 3 or 4 per cent of all hospital beds before the NHS were those for the middle-class fifth of the population. While this figure should be taken only as a rough estimate, it does demonstrate clearly that provision for the middle classes was very much a fringe aspect of the pre-NHS hospitals’ work.
The scale of private provision in Bristol
Bristol did not fit this pattern. Only slightly more than 2 per cent of voluntary hospital beds in the city were private in 1933.17 In fact, the first private beds were not established in Bristol until 1926. Four years earlier, the Bristol Royal Infirmary's House Committee had prevented the introduction of private wards by accepting the opening of a new maternity ward only on the understanding that it would be exclusively for ‘such patients as can pay no more than the full cost of their maintenance’.18 Of those first private wards in Bristol, there were three double wards (two-bed rooms) charged at £5 5s 0d per week, which the King's Fund would have categorised as aimed at patients of ‘moderate means’. Meanwhile, there were a further thirteen single wards (one-bed rooms) with charges of £8 8s 0d per week, which even a decade later and in London would be classed as a level of payment appropriate for the ‘well-to-do’ patient.19 This was significantly higher than the rates suggested by the Honorary Medical Staffs, which at different times was a flat rate of five guineas per week, three-to-four guineas per week, and £3 3s 0d for double wards and £4 4s 0d for single wards.20 The implication of the higher rates put into practice is that, although limited, this earliest private hospital provision in Bristol was amongst the elite.
Figure 4.3 Growth in number of private beds in Bristol voluntary hospitals, 1933–47 Note: General hospitals in solid, specialist hospitals patterned.
From this limited but elite provision in the late 1920s, the 1930s saw an increase in the number of private beds in Bristol. Although provision at the Bristol Royal Infirmary was reduced in the early 1930s from the initial nineteen beds to fifteen, other hospitals introduced private wards, as can be seen from figure 4.3. These included four (rising to six) beds at the Bristol Royal Hospital for Sick Women and Children, with charges of £3 13s 6d. The Cossham Memorial Hospital had three (reduced to two) and the Bristol Maternity Hospital for a short time had four, all charged at £4 4s 0d. The six private beds at the Bristol Homeopathic Hospital were charged at £7 7s 0d per week. The Bristol General Hospital introduced three private beds at the same time as amalgamating with the Bristol Royal Infirmary, producing a combined eighteen beds, while the Bristol Eye Hospital opened a further twelve in the late 1930s. At the close of the decade, in 1939, a new private ward of fifteen beds was opened at the Mount Hope Maternity Home, as the hospital's coverage was extended to married mothers. These figures reveal a near doubling of private hospital provision in Bristol over the second half of the 1930s.21
A similar system to that of the voluntary hospitals was in operation at Bristol's pre-NHS public hospitals – in particular, Southmead Hospital. A Ministry of Health survey of the city's health services in the early 1930s commented on its ten ‘single wards’ for ‘paying patients’ at a charge of £3 3s 0d per week.22 There is little evidence of how private provision developed from this point, although we know one former patient was written to in 1941 by the city's Medical Officer of Health informing her ‘that the Assessment Sub-Committee, with their authority passed a Resolution requiring you to contribute the sum of £17 2s 0d in respect of Maintenance of Self’ for a period of thirty-eight days as an inpatient.23 This shows a municipal hospital operating a private system based on a distinction between a set charge for maintenance and a separately negotiated medical fee, just as in the voluntary hospitals.24 A notable difference in payment between the two, however, was the rate of payment. This was significantly lower at Southmead, suggesting the city's municipal general hospital was not catering for its wealthiest citizens.25 Another difference is who requested payment. As private wards were introduced in the voluntary hospitals it became an important point for the medical staffs that they should not directly be involved in collecting funds.26 It would appear that the city's long-serving Medical Officer of Health, Dr R.H. Parry, either had no such qualms or was convinced to set them aside. Although this might not have been standard procedure, it does suggest the provision of private hospital services was firmly embedded in the city's municipal health culture.
We might assume, given the fact that Southmead had been taken over in 1930 by the Corporation, that the introduction of this system was part of the new municipal arrangement. However, a conference organised shortly before by the Medical Officer of Health, which brought together representatives of the city's hospitals heard that, although Southmead ‘was designed for the pauper sick’, the poor law guardians had ‘found it necessary to throw open their doors to patients of all classes’.27 Of Southmead's 3,000 patients in 1929, ‘roughly one half were not pauper patients’ they heard, suggesting the patient base was increasingly similar to that of the voluntary hospitals even before municipalisation. Moreover, they were told that this change would ‘remove the stigma of pauperism’ from the hospital.28 The Council's policy for admission at Southmead was explained in remarkably familiar terms: ‘the sick poor would have first claim upon the accommodation at Southmead, but any citizen would have the right to apply for a bed at the Hospital, subject to the condition of paying all or part of the cost, if able.’ The 1929 Local Government Act reinforced this system, making it ‘the duty of the Corporation under the Act to recover the cost of treatment from all patients who are able to pay’.29
The fact that these patients were accommodated in the ten ‘single wards’ is hard to square with their aim ‘to ensure that those persons who will receive from the Council by reason of their poor circumstances assistance in the form of hospital treatment shall do so in the same hospitals and under the same conditions as the rest of the citizens’.30 At Southmead the Corporation, as the Board of Guardians before them, were aiming to provide a general hospital service with essentially the same payment system as the voluntary hospitals.
Locating private provision
Beyond the voluntary-municipal mix, there are three dimensions to the pattern of provision we should consider. The first of these is the institutional location of private beds according to the size of the hospital, which sheds light on how segregated or integrated private patients were as well as on how much private provision characterised and directed the work of the voluntary hospitals. 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. The third is the geographical spread of provision, revealing the extent to which middle-class treatment in the voluntary hospitals was a reality across the country.
Size of hospital
The key question here is whether provision for the middle classes was primarily located in those larger institutions, the mainstay of medical treatment for the acute sick in the area, or in those smaller ones focused on serving a certain group or service, or indeed whether provision might be spread across the two. Figure 4.4 shows the prominence of private wards in small hospitals (with fewer than 100 beds), medium-sized hospitals (with 100–199 beds), and large hospitals. Consistently we see private beds accounting for by far the largest proportion of all beds in small hospitals, and the smallest proportions in large hospitals. Although Bristol had very few private beds in medium-sized hospitals, it was in line with the national picture in having a majority in small hospitals. A rather different situation was evident in Glasgow, with two-thirds of its private beds found in large voluntary hospitals, and a further 10 per cent in a 185-bed institution.31 However, the largest with private beds in the rest of Scotland was the Queen Mary Nursing Home, a hospital of fifty-five beds in Edinburgh. We might assume those large proportions of beds for private patients in small hospitals added up to little, with the smaller proportions in the biggest hospitals being the most significant to look at. In fact, as figure 4.5 shows, the opposite is true. In the early 1930s there were more private beds in small hospitals than in medium and large ones combined. Even as the proportion of private beds found in large hospitals increased, and that in medium and small ones decreased, over the next decade there were still more private beds in small than large hospitals.
Figure 4.4 Private beds as a percentage of total provision in voluntary hospitals of different size in Britain, 1933–47
While the faster expansion of private wards in large hospitals in the 1940s did narrow the gap to less than 4 per cent, it is clear that middle-class patients were readily opting for treatment in smaller institutions. Evidently they did not share the view of Lord Moran, President of the Royal College of Physicians, who described hospitals with fewer than 100 beds as ‘much too small to fulfil the functions of a first-class hospital’.32 Health Minister Aneurin Bevan expressed a similar opinion during the passage of the National Health Service Bill in 1946:
There is a tendency in some quarters to defend the very small hospital on the ground of its localism and intimacy, and for other rather imponderable reasons of that sort, but everybody knows today that if a hospital is to be efficient it must provide a number of specialised services. Although I am not myself a devotee of bigness for bigness sake, I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.33
The larger share of private beds found in small hospitals might be explained by a great number of entirely private hospitals specialising in treating middle-class patients, if it were not for the fact that such institutions were exceedingly rare. There were of course a huge number of private nursing homes providing care for the sick; but only nine such institutions with resident medical officers existed in 1933.34 By 1938 their number had doubled, though remained very limited at only eighteen in all of England (see table 4.1). In Scotland there were a further four. These were a hospital for women in Glasgow of sixty-seven beds and another of forty in Edinburgh, as well as an eight-bed hospital in Wick and a four-bed maternity home in Berwickshire. Eight of the eighteen in England were general hospitals, including London's Royal Masonic Hospital in Ravenscourt Park, by some way the largest with 200 beds and no other having more than seventy-five. Combined, entirely private hospitals provided only 583 beds across England in 1938. This was a rather small 9.2 per cent of all 6,341 private beds and a measly 0.7 per cent of all 83,158 voluntary hospital beds at the time. While their number increased further to twenty-two before the introduction of the NHS, the private hospital remained in our period very much a rarity.35
|Royal Masonic, Ravenscourt Park||General||London||200|
|Forbes Fraser Private Hospital||General||Bath||74|
|The Fielding Johnson||General||Leicester||43|
|Queen Victoria Nursing Institution||General||Wolverhampton||42|
|Bromhead Nursing and Maternity Home||General||Lincoln||34|
|St Mary's Convalescent Home||Special||Somerset||34|
|Leazes House Sanatorium, Wolsingham (TB)||Special||Durham||33|
|The John Faire, Leicester||General||Leicester||30|
|St Saviours for Ladies of Limited Means (Women & Children)||General||London||21|
|Rosehill Private Sanatorium, Penzance||Special||Cornwall||20|
|Burton-on-Trent Nursing Institution and Maternity Home||Special||Burton-on-Trent||15|
|Merthyr Guest Memorial Hospital||General||Somerset||12|
|Duchess of Connaught Memorial, Bagshot (maternity)||Special||Surrey||7|
Sources: The Hospitals Year-Books (London, 1933–47); Ministry of Health, Regional Hospital Services Survey Reports (London, 1945).
On the basis of these figures, any notion that the voluntary hospitals were essentially private hospitals can be refuted outright. Sir Henry Charles Burdett, founder of the King's Fund, had long been amongst those calling for the introduction of a series of ‘Home Hospitals’. In 1879 he laid out his proposals for ‘a sort of sick lodging-house’ for the middle classes, ‘where they can, for a reasonable payment, secure all that their case requires, and that their means will allow’. This was to be ‘the pay hospital par excellence’.36 Plans in 1842 for ‘a hospital for the middle classes in London’ had failed ‘through lack of support’, and it was not until 1880 that the Home Hospital Association established such an institution in the capital. Unlike in Burdett's proposals, however, Keir Waddington has described the new institution as one where ‘The pay principle was implicit and the association endeavoured to promote the contributory system’.37 By the interwar years there was a small number of entirely private hospitals, more of the kind envisaged by Burdett. A leading example, until it was taken over by municipal authorities in the 1930s, was St Chad's Hospital for paying patients in Edgbaston, Birmingham. Its 1923 report states that they received deputations from various cities considering setting up some equivalent, including London, Glasgow, Manchester, Sheffield and Bristol.38 Clearly they did not decide to follow suit. The Honorary Secretary of the Bristol and District Divisional Hospitals Council, John Dodd, made a similar visit twenty years later, ‘in view of the urgent need for this kind of accommodation in Bristol’. However, rather than visiting an entirely private hospital, he went ‘to survey the private ward accommodation’ of the Bradford Royal Infirmary.39
The overwhelming majority of private beds were to be found in ordinary hospitals in wards of one or a very small number of beds. Far more common than an entirely private hospital, was devoting a separate floor or wing of the hospital building to middle-class patients, as with the Baker Memorial Wing of St George's Hospital in London or the 100-bed Canniesburn annexe of the Glasgow Royal Infirmary.40 These private wards very rarely became the main business of the hospital, with private beds at half or more of the total in only five cases in the mid-1930s. Combined, entirely private hospitals and those with a majority of beds for private patients reached their peak of 3.1 per cent of all voluntary hospitals by the establishment of the NHS.41 Hence, even after decades of growth in private provision, heavily subsidised working-class patients were the majority in 96.9 per cent of voluntary hospitals.
We can see this pattern in Bristol, where there were no private hospitals. Instead, middle-class patients were typically found in one- or two-bed private wards. As can be seen from table 4.2, there were only two hospitals in Bristol where private beds were more than 10 per cent of the total, and none as high as 15 per cent. This means the trend discussed above, for treating predominantly working-class patients, was strongly reflected locally. Moreover, an overwhelming majority of all private beds in the city, thirty-five of fifty-one, were located in small hospitals.42 This may have made it harder to provide the respectability afforded by physically separating the two types of ward, ensuring middle-class and working-class patients had no need to brush up against each other.
|Bristol Royal Infirmary||410||15||3.5%|
|Bristol General Hospital||266||3||1.2%|
|Bristol Children's Hospital||103||6||5.5%|
|Cossham Memorial Hospital||98||2||2.0%|
|Bristol Eye Hospital||72||12||14.3%|
|Queen Victoria Jubilee Convalescent Home||80||0||0.0%|
|St Monica's Home of Rest||80||0||0.0%|
|Bristol Homeopathic Hospital||73||6||8.6%|
|Bristol Maternity Hospital||32||4||11.1%|
|Walker Dunbar Hospital||29||3||9.4%|
Sources: The Hospitals Year-Book for 1938 (London, 1938) and V. Cope, W. Gill, A. Griffiths and G. Kelly, Hospital Survey: The Hospital Services of the South-Western Area (London, 1945).
Sources: The Hospitals Year-Book for 1938 (London, 1938); V. Cope, W. Gill, A. Griffiths and G. Kelly, Hospital Survey: The Hospital Services of the South-Western Area (London, 1945).
Type of hospital
This concentration of Bristol's private beds in smaller hospitals is more understandable when bearing in mind that, bucking the national trend (see table 4.3), over two-thirds were in specialist institutions.43 Although in the late nineteenth century private payment was far more common in specialist institutions, by 1938, after an expansion of private provision, four-fifths of private beds were to be found in general hospitals.44 Yet in Bristol's three voluntary general hospitals combined there were only twenty private beds out of a 794-bed total (2.5 per cent).45 This contrasts with the 100-bed private wards found at both the Manchester Royal Infirmary (13.5 per cent of the 740 beds) and the Glasgow Royal Infirmary (12.6 per cent of 794).46 As table 4.2 shows, nearly one-quarter of the private beds in the city's voluntary hospitals were those at the Bristol Eye Hospital, where twelve beds was 14.3 per cent of the institutional total. What continued to grow in the 1940s was maternity provision, including the fifteen-bed private ward opened at the Salvation Army's Mount Hope Maternity Home in 1939 and an expansion to twenty-five private beds at the Walker Dunbar Hospital (see figure 4.4). Meanwhile, the Homeopathic Hospital was able to boast of doubling the number of births in its private wards from eight in 1936 to sixteen the following year.47 Similarly, the private wards at the city's general hospitals may well have been used for the confinement of expectant mothers. It is clear that maternity was the driving force behind the limited private provision made by Bristol's voluntary hospitals.
This was a notable change in the decades that followed the city's first private provision at the Bristol Royal Infirmary in 1926, when mental and maternity cases were the two categories excluded.48 However, this was a time of change for the status of hospital births in general, as they grew from under a quarter of all births in the 1920s to a majority in the 1940s.49 Throughout the interwar years, however, it was the starting point for debate that hospital services ‘should be available only for those mothers whom it was felt unwise to deliver at home, whether for medical or social reasons, and for teaching purposes’.50 Yet some areas saw institutional birth become the new norm, such as Leeds where hospitals accounted for the majority of births by 1938, and for nearly two-thirds by 1946.51 That private provision catered more extensively for these increasingly common hospital births than for other types of patients might be simply a result of greater demand, which was certainly increasing at this time. The explanation for this increased demand in the historical and sociological literature has gradually shifted towards seeing this as women's choice rather than the result of coercion on the part of medical men.52 One factor that may well have made it possible to take up a preference for a hospital birth was the maternity benefit provisions of the National Insurance scheme. Subject to complex institutional arrangements, this covered up to thirty shillings for the confinement but nothing towards any fees for medical treatment.53 As few women were covered by National Insurance or contributory scheme members in their own right, exemption from finding the money was afforded by virtue of her husband's employment. Moreover, while the numbers covered by National Insurance increased between the wars, so too did the rates of payment expected, which were often notably higher than the rate of the benefit. Meanwhile, the place of women within the contributory scheme movement is striking by its absence, with ordinary maternity cases usually excluded from coverage. The deeply flawed rationale given in Oxford for exclusion was that ‘only a comparatively small number of people could qualify to receive the benefit, so that the spread of the cost over the whole body of contributors would be inequitable’.54 Furthermore, the usual income-assessed barriers to ordinary wards were accompanied for maternity patients by moral ones, with separate wards typically in the maternity hospitals for married and unmarried mothers. Overall the case of maternity suggests the balance between medical, financial and social duties was different for female patients. The social was not restricted to class, but encompassed a far more varied and complex set of moral dimensions.55
Unfortunately we have no more detailed figures on the gender mix of private patients in Bristol hospitals. However, we do know that at Addenbrooke's Hospital in Cambridge, where the proportion of private beds was a little above the national average at 8.5 per cent in the mid-1930s, 55.3 per cent of private patients were women, 36.5 per cent were men and 8.2 per cent were children.56 It does therefore appear that private provision was geared largely towards women, driven by though not limited to maternity care. While this maternity provision was not limited to specialist hospitals, it did much to ensure that Bristol bucked the wider general-specialist trend. The concentration of private beds in general hospitals was not only seen at the national level but also across Bristol's South West region, where around three-quarters of private beds were in general hospitals. This was not simply a consequence of general hospitals being larger, as private beds accounted for a greater share of all beds in general hospitals than in specialist ones. In Bristol, however, private beds were concentrated in and accounted for the greatest proportion of the total in small specialist hospitals (see table 4.3). This unusual situation can only be understood by considering Bristol's position as a hub of hospital provision within its region; and it is to regionalism and its complexities that we now turn.
The minimal private hospital provision in Bristol complicates Daniel Fox's account of ‘hierarchical regionalism’, which has proved surprisingly resilient despite fierce criticism from Charles Webster on the grounds that it was a more accurate description of interwar policy than practice.57 In most respects the city was a classic example of the regional centre for research, medical education and specialist services, around which the region's healthcare was said to be organised. This position as a clinical centre for the South West was long-established by the time it was recognised in the new regional structure of the NHS, with the Bristol Regional Hospital Board covering the entire region; not only including nearby Gloucestershire, Somerset and Wiltshire, but also reaching south to Dorset, Devon and Cornwall. Private hospital services, however, are notable by their absence. There is a clear contrast between the local and national pictures, but only by comparing the city to other regional centres and by examining the patterns of regional provision across the country can we be sure whether it was Bristol or private provision which bucked the trend. In adopting this regional view, the available data leads us to focus on voluntary hospitals and on the situation in England.
London served as a regional and national hub for medical services of all kinds, and those for private patients were far from an exception. As seen in figure 4.1, the capital was home to around one-third of all private beds in Britain and roughly one-quarter in the 1940s, when expansion in the provinces was accompanied by the significant disruptions of war. The regional surveys recorded London's South East region having four times more private beds than its nearest rival in 1938, with 3,268 to the 760 in Manchester and Liverpool's North West region.58 The fact these two regions had the most private beds was in part a result of them being the most populous (see table 4.4). Indeed, there is a difficulty, for example, in comparing what was termed the ‘London Area’ (here renamed the ‘South East’), which covered many populous areas near the south coast, with the largely rural ‘Eastern Area’ immediately to its north, which had a population more than eleven times smaller.59 It is more useful, therefore, to look at the number of beds in relation to the region's population.
|Population||General beds||Private beds||Private (%)||Private beds per 1,000|
|Berks, Bucks & Oxon||867,140||1,753||164||8.6||0.189|
Sources: The Hospitals Year-Book for 1938 (London, 1938); John B. Hunter, R. Veitch Clark and Ernest Hart, Hospital Survey: The Hospital Services of the West Midlands Area (London, 1945); L.G. Parsons, S. Clayton Freyers and G.E. Godber, Hospital Survey: The Hospital Services of the Sheffield and East Midlands Area (London, 1945); V. Zachary Cope, W.J. Gill, Arthur Griffiths and G.C. Kelly, Hospital Survey: The Hospital Services of the South-Western Area (London, 1945); Ernest Rock Carling and T.S. McIntosh, Hospital Survey: The Hospital Services of the North-Western Area (London, 1945); William G. Savage, Claude Frankau and Basil Gibson, Hospital Survey: The Hospital Services of the Eastern Area (London, 1945); A.M.H. Gray and A. Topping, Hospital Survey: The Hospital Services of London and the Surrounding Area (London, 1945); Herbert Eason, R. Veitch Clark and W.H. Harper, Hospital Survey: The Hospital Services of the Yorkshire Area (London, 1945); E.C. Beevers, G.E. Gask and R.H. Parry, Hospital Survey: The Hospital Services of Berkshire, Buckinghamshire and Oxfordshire (London, 1945); Hugh Lett and Albert Edward Quine, Hospital Survey: The Hospital Services of the North-Eastern Area (London, 1945).
This makes a radical difference to the North West, where concentrated private provision was matched by a concentrated population. In fact, the region had a lower than average 0.117 private beds per 1,000, despite having the second largest number in absolute terms. The reverse is true for Bristol's less populous South West region, where 609 private beds were roughly twice as many per head at 0.230 per 1,000. This was almost identical to the South East's 0.231, both of which were significantly greater than the nearby Oxford region's 0.189. These three southern regions stand out as having the greatest private provision proportionate to population, while the lowest were to be found in Sheffield's East Midlands region, the Yorkshire region which included Leeds, and the North East, each with less than one bed per ten thousand. This division between north (including the Midlands and East Anglia) and south appears clear and striking. The overall English rate of private provision was 0.157 private beds per thousand population, and while the three southern regions were above this, the rest were below it.
Scotland both replicates this north–south divide and fits within it. The voluntary hospitals in the South-Eastern region of Scotland, centred on Edinburgh, had a higher proportion of private beds than those in the South-Eastern region of England, centred on London (10.5 per cent to 9.4).60 Despite a few large private wards in Glasgow hospitals, the rate was far lower across the rest of Scotland: 6.1 per cent in the Western Region, 4.4 in the Northern Region and zero in the North-Eastern Region, although a sixty-bed private ward was under consideration for the Aberdeen Royal Infirmary. Scotland's overall 5.3 per cent of voluntary hospital beds for private patients is therefore significantly lower than that for England.61
Beneath this broad brush stroke there were also local oddities, such as the fact that 8.9 per cent of all voluntary hospital beds in Bradford were for private patients while there were none at all in York.62 No less odd was Bristol, a wealthy southern city and a clinical centre for its region but with very few middle-class private beds. As table 4.5 shows, Bristol had fewer private beds per head than anywhere else in the region. Instead the regional hub of middle-class hospital provision appears to have been to its south in the county of Somerset and especially in the city of Bath. Despite a population one-sixth the size of Bristol's (68,300 to 415,500 in 1938) and less than half the total number of voluntary hospital beds (680 to 1,294), Bath had more than twice as many private beds (125 to 51). This was not only a difference between two cities but also points to a clear split in this north part of the South West region, as the situation in each was echoed in their surrounding rural areas. Across the county of Somerset (including Bath) private beds accounted for 15.1 per cent of all voluntary hospital beds. Across Gloucestershire (including Bristol), it was only 5.4 per cent.
|Population||General beds||Private beds||Private (%)||Private beds per 1,000|
|Devon & Exeter||529,860||1,249||100||7.4||0.189|
Sources: The Hospitals Year-Book for 1938 (London, 1938); V. Cope, W. Gill, A. Griffiths and G. Kelly, Hospital Survey: The Hospital Services of the South-Western Area (London, 1945).
Across England private beds accounted for a smaller proportion of all beds in specialist voluntary hospitals than in general ones (4.6 per cent to 8.8 per cent), but the picture was typically different in areas serving as a regional centre. In some cases the gap was notably reduced, such as London (10.1 to 12.2). In others, such as Birmingham, it was reversed (8.3 to 7.7). In Bristol this was even more pronounced (6.2 to only 2.5). Although the former is lower than in either London or Birmingham, it was still significantly higher than the national average. Bristol was not home to a major hub in specialist hospital provision for private patients, instead it was one of a number of centres spread across the region – principally between the cities of Bristol and Bath – with notably little overlap. Beyond Bristol there were only eight private beds in hospitals for women and children in 1938, seven in Plymouth and one in Wiltshire.63 There were fourteen private beds in ophthalmic hospitals in the region, twelve of them in Bristol and another two in Bath. The only six private beds in homeopathic hospitals were in Bristol and the only twenty private beds in an ENT hospital were in Bath.64 As such, the regional picture of specialist hospital service provision for the middle classes is not one of a single regional centre for provision, but rather one of a cluster spread across two counties, within which Bristol played a major role.
When the wartime survey sought to explain the low level of private provision in Scotland's eastern region, covering an area including Dundee to the north of Edinburgh, the report explained:
The proportion of middle-class and wealthy population in Dundee is relatively small, and the total amount of private practice available for physicians and surgeons of consultant status correspondingly limited. Consultant practice in the rest of the region has mostly been divided between Dundee on the one hand, and Edinburgh or Glasgow on the other, the latter being easy of access.65
The same cannot be said of the wealthy (if unequal) city of Bristol with its large middle-class population. Three possible explanations for the extremely low level of private provision at its voluntary hospitals will therefore be considered. The first of these is simply a lack of demand for medical attention amongst the middle classes. The second is that what demand there was might have been met elsewhere – either in a non-hospital setting or at the municipal hospitals. The last is that, while the middle classes were receiving treatment in voluntary hospitals, they were prepared to travel to do so elsewhere. Given the ‘dual hub’ in specialist regional private provision between Bristol and Bath, it will be suggested that in this case the last of the three should be seen as the primary explanation for the startlingly low level of middle-class provision made by the city's voluntary hospitals.
Lack of demand
The simplest explanation for limited provision would be limited demand. In the case of private provision, the reason might be assumed to lie in a lower rate of illness amongst the middle-class population. This may go some way to explaining the overall rate of provision, though not obviously the divergence between the American hospitals’ refocusing on private provision and the continued focus in British hospitals on the treatment of the working classes. Neither would it explain why Bristol should be a city with a large middle-class population, but with far fewer hospital beds for their treatment than seen elsewhere around the country and even its own region. Consequently, for any lack of demand to serve as an explanation, it would need to be in some way specific to the city itself.
We can look to the city's hospital contributory schemes for some gauge of interest in middle-class provision. In addition to their main business of offering a form of mutual aid designed to ensure an appropriate financial contribution was made on behalf of working-class patients, in some cases they branched out and established supplementary middle-class schemes. Across the hospital contributory schemes and the medical faculty of the hospitals in Bristol, we see a common assumption that there was a middle-class demand for securing access to private treatment. The founders of Bristol's two major hospital contributory schemes were acutely aware of the need for such a service. When the Bristol Medical Institutions Contributory Scheme (BMICS) was established in 1927 and then the Bristol Hospitals Fund in 1939, both immediately gave the matter consideration.66 In 1929, a sub-committee of the Bristol Royal Infirmary's faculty was set up to consider the suggestion of a hospital insurance scheme for the middle classes, defined as those with incomes of over £300 per year. They envisaged that such a scheme would require annual payment into a central fund, entitling admission if taken ill and covering payments for both maintenance charges and fees for treatment.67 This reversed the faculty's previous stance that the admission of this class of patient ‘should be determined by the almoner on the individual merits of each case, & not on the basis of subscribing to any contributory scheme’.68
The following year the BMICS established their ‘Section II’ scheme ‘to assist those who normally, owing to income limits, are not eligible for treatment in the public wards of the Voluntary Medical Institutions’. This would cover the member or a dependant if they ‘should have to become a patient in a private ward of a hospital or a nursing home’.69 In return for an annual contribution of one guinea per annum (or two for the inclusion of a dependant), the contributor would be entitled to ‘grants-in-aid’ of up to ten guineas per year for hospital expenses.70 Over the early 1940s the Bristol Hospitals Fund would establish both an Intermediate Contributory Scheme and a Provident Fund, both offering access to private services for those earning different amounts over the general ward income limits. These middle-class schemes excluded certain categories of patient, such as the chronic sick and maternity cases, maintaining a focus on treating breadwinners and returning to them to work.71
As far as membership of the Bristol Hospitals Fund's middle-class Welfare Fund suggests, there was an interest in medical insurance for this section of the city's population. The middle-class section of the BHF's membership had grown to over 40 per cent by the introduction of the NHS, meaning a presence here twice that of the city's population at large.72 This over-representation can be partially explained by the numerous other contributory schemes in Bristol without middle-class options. We might further be tempted to look to ideas of civic duty to explain middle-class membership alongside the schemes’ fundraising efforts, as identified by Frank Prochaska in London and Nick Hayes in Nottingham.73 However, these middle-class sections of contributory schemes in Bristol appear to be so heavily framed as insurance that such an explanation does not seem fitting. Their popularity suggests there was a demand for institutional treatment in times of sickness, of the kind covered, from the city's middle classes.
Alternative sites of treatment
Our second possible explanation is that medical attention may have been sought by the middle classes beyond the hospital setting. This may mean home treatment by general practitioners, and for those not signed up to a contributory scheme there would have been a clear financial incentive to avoid hospital treatment. While £3 would be a modest charge for a private bed in a voluntary hospital (with medical or surgical fees expected in addition), the typical charge for a doctor's home visit in the 1930s would range between one-sixth and one-twelfth of that amount.74
It appears the introduction of the National Insurance panel system in 1911 and its interwar expansion, when it came to cover the majority of the adult male population, did little to diminish private practice. Although Lloyd George's ‘ambulance wagon’ speech had vividly painted a picture of the neglected working-class need for medical attention, in 1926 the BMA estimated that general practitioners made more visits to private than panel patients.75 We might assume demand for hospital treatment, at least in the leading voluntary hospitals, would be generated by their reputation as elite and pioneering institutions. While George Bernard Shaw had commented in 1911 that ‘the rank and file of doctors are no more scientific than their tailors’, by 1926 the Bristol Royal Infirmary, for example, was engaging in work of ‘immense importance’ treating ‘supposedly incurable’ cancer cases.76 Yet, with the exception of maternity cases, middle-class patients in Bristol appear to have received treatment in the hospitals only relatively rarely. The explanation perhaps rests in the fact that the city's general practitioners were well-placed to cater for the middle classes beyond the hospital. We can see this from the geographical concentration of their premises in its wealthier suburbs to the west and north, such as Clifton, Redland and Westbury-on-Trym.77 This was the opposite of the small town North American situation where Charles Rosenberg found ‘the intractable reality of longer distances underlining the hospital's appeal’, as well as supposed clinical benefits, prompting practitioners to encourage hospital treatment to their patients.78 The location of dozens of surgeries within each of the city's wealthiest areas may have acted as a buffer against such a change in Bristol.
The proximity of private surgeries to the hospitals was no coincidence. It was very much the norm for the honorary medical staffs of the voluntary hospitals to also keep private practice.79 For example, Dr Patrick Watson-Williams was the Bristol Royal Infirmary's first Honorary Aurist and Laryngologist, and later Honorary Consulting Surgeon in the Ear, Nose and Throat Department until his death in 1938.80 This was a major department, which treated around one-in-ten inpatients and nearly as high a proportion of non-casualty outpatients.81 Throughout this busy period of hospital work he maintained a private surgery a little over a mile away from the hospital, in the middle of Clifton Village.82 This was normal practice. All sixteen of the visiting consultants listed as medical officers in the Bristol Royal Hospital's 1939 report were also listed with private surgeries in the local directory's medical list for the same year.83 All of these surgeries, some shared or with shared consulting rooms, were located within a small area in the centre of Clifton. Although they worked both in the hospital and with private patients, there appears to have been little appetite for bringing the two together through middle-class admissions.
Another alternative might have been for the middle-class patient to seek care in an institution other than a hospital, specifically a nursing home. Indeed, Lindsay Granshaw has noted that the development of private hospital medicine ‘ran alongside the establishment in Britain of numerous nursing-homes’, which she describes as ‘effectively small private hospitals for the middle classes’.84 Once again, in Bristol these tended to be found in wealthy areas, with nearly one-third of all those in the city located in Clifton.85 Of the thirty-six nursing homes operating in and near Bristol in 1934, twenty-one advertised as offering medical services, nineteen maternity, seventeen chronic, seven surgical, two convalescent or rest, one acute and another nervous disease services.86 Although no figures are available for their number of beds, it is likely that combined they were far greater than those for private patients in the city's hospitals.
As with general practitioners, however, nursing homes suffered from rather contrasting reputations. In 1935, a parliamentary debate on paying patients revealed an assumption held by many in the House of Lords that there must be a demand for middle-class beds in voluntary hospitals specifically because of the poor standard of the private nursing homes. Amongst them was the Labour peer Lord Sanderson, who declared ‘many nursing homes’ to be ‘very bad and most of them very expensive’, as well as not being equipped for increasingly technologically elaborate and costly procedures.87 From the other side of the chamber, the Earl of Malmesbury spoke of a widespread and ‘increasing horror – I say it with all respect – of nursing homes’.88 By contrast, some of the elite nursing homes were commonly known as private hospitals despite having no resident medical staff, such as St Mary's and St Brenda's in Clifton. These nursing homes branded as private hospitals would have been well-positioned to meet middle-class demand beyond the wards of the voluntary hospitals.
Certainly there were very few middle-class beds in Bristol's voluntary hospitals and likely many more in the city's great many nursing homes, but we should consider what alternative hospital admissions might have been possible. If the middle classes were, in fact, being treated in hospital when sick before the NHS, then there are two remaining possible explanations. One is that it might not have been the voluntary hospitals at all where they were receiving treatment, that is to say the middle classes may have been catered for in the municipal hospitals. Indeed, we know that both before and after appropriation, Southmead Hospital was making limited provision for private patients at a moderate rate.89 With ten private beds in 1933, the city's public sector accounted for two-fifths of the total.90 Moreover, we do know that such practices continued into the 1940s.91
The scale of this later provision in Bristol or more widely, however, remains unclear. A recent major work on interwar municipal medicine makes only passing reference to public hospitals taking fee-paying private patients.92 Contemporary sources were less likely to record municipal private beds than those in the voluntary hospitals, with some of the regional wartime surveys not including any such figure and others giving only patchy coverage. This was most likely caused by the same confusion over the definition of a ‘pay bed’ as with the figures for some voluntary hospitals, suggesting payment in the ordinary wards of public hospitals was normal practice by this time. The figures that were included in these reports suggest only one region – the North West of England – fully counted private beds in municipal hospitals. They counted large wards in former workhouses (Crumpsall's thirty beds and Withington's forty-six beds in Manchester, and Birch Hill's twenty-six beds in Rochdale) as well as two municipal maternity hospitals with six beds (the Municipal Maternity Home in Warrington) and eight beds (Helm Case Maternity Home in Kendal).93 As in the voluntary hospitals, the North West figures show private provision in the municipal hospitals located typically in general hospitals and, when in specialist institutions, those were most commonly maternity hospitals.
In total this comes to 116 private beds in the North West municipal hospitals, a notable amount but still only 13 per cent of private beds in the region's voluntary and public hospitals combined. Yet we cannot be sure if Bristol (or any other part of the country) saw the same proportion of private beds located in public hospitals, since no ‘pay beds’ were recorded for any of Bristol's public hospitals (and only a scattered few in other regions) despite the fact we know Southmead took private patients. However, if the number of private beds at Southmead remained unchanged over the 1930s, then the public–voluntary split would be very similar in Bristol to that recorded in the North West. Whereas some modest growth may have gone unrecorded and uncommented upon, it is highly unlikely that Bristol's public hospitals saw an expansion of private provision on a scale adequate to explain the local shortage of private beds in the voluntary hospitals.
Travelling for treatment
Of the three possible explanations considered, only alternative admission to private nursing homes appears convincing. Yet there is no evidence that this was a bigger factor in Bristol than in other cities. We must therefore turn to our final possible explanation, which is the complex position of Bristol within the region, to can gain some understanding of this unusual situation. This suggests the middle classes of Bristol were prepared to travel to receive treatment in voluntary hospitals elsewhere.
If we look first at patients from all wards, both general and private, we find that the majority of patients at the Bristol Royal Infirmary in 1930, for example, were local to the institution: 6,173 of the year's 8,734 patients were listed as being from Bristol and District. Most of the remainder were from either Gloucestershire or Somerset, including large numbers from both the nearby areas of Avonmouth and Sea Mills (103) and Shirehampton (124). There were only occasionally patients from as far afield as Worcester, Swindon and Salisbury, and a much larger number (293) from Wales.94 Overall, patients were prepared to travel to Bristol when necessary.
For middle-class patients the necessity would have been to travel the distance of a little over ten miles, between Bristol and Bath, in both directions. While Bath might appear the regional centre for middle-class medicine from the far greater number of private beds in its hospitals, we should not overlook which hospitals had private wards. From Bristol, the nearest private bed in a specialist ENT hospital was in Bath. From Bath, the closest private bed in a homeopathic or maternity hospital was to be found in Bristol.95 Bristol was not displaced by Bath, therefore, but was in fact the junior partner in a dual hub of private hospital provision in the South West region; and this should be seen as the primary reason for the startlingly low level of middle-class provision made in the city's voluntary hospitals.
This becomes clearer still when we combine the figures (shown in table 4.5) for the counties of Gloucestershire and Somerset, including the cities of Bristol and Bath respectively, revealing 356 of this wider area's 3,369 voluntary hospital beds were private. At 10.6 per cent this proportion of beds for private patients is higher than average and not so far behind the 12.6 per cent found in London.96 With 0.276 private beds per 1,000 people in the two counties, the middle-class population was better catered for than in most parts of the country. Middle-class patients were simply not treated alongside working-class patients. We already know they were treated in separate wards, commonly on other floors or in another building, but in this case also often away from the city. Where Bristol was very much the regional centre for the hospital treatment of the working classes, the middle classes typically went elsewhere.
Pay beds after 1948
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. Despite the principle of medical services free at the point of use, patient payment has always had some role within the NHS.97 Indeed, those limited ‘pay beds’ present in the pre-NHS hospitals as the only means of securing treatment for middle-class patients were continued and became a means for those with cash to opt out of the public health service. Although private practice was entrenched and even encouraged within the NHS, it remained contentious, leading to private surgery fees being capped in 1953 at seventy-five guineas, although allowed to rise to 125 guineas in exceptional circumstances.98 As the Teaching Hospital Association commented in the mid-1970s: ‘Private practice, when conducted in hospitals, has always been a matter for controversy ever since the voluntary hospitals first began to provide beds for paying patients and so, if it continues, it will certainly and unavoidably remain so.’99
It was at this time that Harold Wilson and his Secretary of State for Social Services, Barbara Castle, launched the only serious attempt to abolish them. She instructed the new Health Services Board to phase them out, starting with those under-utilised, but with only modest success. When Labour took office in 1974 there were almost 5,000 pay beds in the NHS.100 When Margaret Thatcher arrived in Downing Street five years later there remained 3,000 pay beds in NHS hospitals across England and Wales. Less than two months after taking office it was declared:
The Government believes that people who wish to do so should be free to make arrangements for their private medical treatment and intends to repeal the legislation for the phasing-out of pay beds which was introduced by the previous Government. The Health Services Board will be abolished and the Social Services Secretary's power to allow NHS hospitals to be used for private practice will be restored.101
Despite a ‘ceiling’ on the amount of private practice and a promise of legislation to ensure, echoing the calls of the 1930s, ‘that services for private patients should not prejudice services for NHS patients’, the place of pay beds within NHS hospitals was reasserted. Yet, just as numbers had been low in Bristol before 1948, so they continued to be thereafter. By the mid-1970s there were just six under-used pay beds at the new Bristol Maternity Hospital and another three at Southmead Hospital.102 A few years later, after thirty years of the NHS, there were none left in the city.
In some respects Bristol bucked regional and national trends in its hospital provision for middle-class patients, perhaps surprisingly given its large middle-class population and clear status as a regional centre for hospital services. Yet, before the NHS, the city's general voluntary hospitals never had more than twenty private beds between them, even though such hospitals were where the overwhelming majority of private beds were to be found nationally. At the same time it was home to a higher than average share of private beds in specialist institutions, in common with other regional hospital centres, such as Birmingham. Understanding these contradictions and idiosyncrasies requires us to place the local situation not only within the national context, but also to consider the city within the regional picture.
Ultimately, however, the evidence presented in this chapter points to a relatively straightforward conclusion: treating the middle classes was a marginal aspect of the services provided by the pre-NHS hospitals, with access limited to the 3 or 4 per cent of hospital beds set aside for them. Middle-class patients were treated in voluntary hospitals more often than public ones, but even there private beds were never as much as 9 per cent of the total. While these private beds took over more of the hospital than usual in London, in Bristol it was the opposite. Placing Bristol in its regional context brings the level of private provision into line with a general southern concentration. The fact this happened away from the region's hospital centre highlights the degree to which the city's hospitals remained un-democratised in this period. The limited provision made for the middle classes, especially striking in Bristol, supports Paul Bridgen's argument that the voluntary hospitals ultimately failed to become the provider of hospital services to the middle classes.103 However, this is not to say they were conservative institutions, reluctant to adapt to a new era. The small but steady stream of middle-class patients admitted was in itself a notable change and part of a wider reinterpretation of the patient contract. What remained consistent, however, was what group of society primarily constituted ‘the hospital class of patient’.104
This traditionalism only characterised one part of a dual system that allowed the medical profession to combine hospital work and private practice. It was an arrangement to which the honorary consultants and private patients alike appear to have been wedded. Whether there was less demand amongst the middle classes than might have been assumed, they were being treated elsewhere or a combination of the two, what is clear is that the treatment of private patients was far from a central function of either the public or the voluntary hospitals before the NHS.