For the Sick Poor? Payment and Philanthropy and the pre-NHS Voluntary Hospital System, c. 1900-1948

George Campbell Gosling (Oxford Brookes University)
19 June 2011

History SPOT blog post



The voluntary hospitals were widely perceived as the crown jewels of British voluntarism until they were nationalised with the introduction of the NHS in 1948. From their philanthropic foundations in the eighteenth and nineteenth centuries, they provided care and treatment for the sick poor.
By the time of the NHS medicine had changed a great deal, as had Britain. The scientific advances in medicine now meant that hospitals could do more and that treatment could not always be provided in the home. Meanwhile, the phasing out of the poor law and the rise of the lower middle classes contributed to the calls for a hospital service that could treat all classes.
How then, this paper will ask, did these philanthropic institutions, the voluntary hospitals, adapt to this new age? Fundamentally, the introduction of three types of payment will be considered. The first is the new profession of the hospital almoner, later renamed the medical social worker, who operated a means-tested system for working-class patients. The second is the hospital contributory schemes, which offered an alternative to the almoner. The third is the private wards for middle-class patients.
Historians have tended to agree that these developments amounted to a fundamental reinvention of the voluntary hospitals. This has sometimes between characterised as ‘commercialisation’, other times as ‘mutualisation’ or the establishment of ‘quasi-insurance’ system. Amongst these differing approaches there is a consensus that radical change did occur.
This paper will draw upon new research to put forward the case that such change has been overstated. Payment did not cover the costs of provision let alone a profit, nor was payment a condition of access, meanwhile income limits ensured that provision remained focused on the working classes. These practical changes were a response to changing times designed, largely successfully, to allow the voluntary hospitals to maintain their traditional mission of providing hospital care for the sick poor. Despite such change, the voluntary hospitals in their final decades were actually characterised by a remarkable degree of philanthropic traditionalism.

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