“Open the Other Eye”: Payment, Civic Duty and Hospital Contributory Schemes in Bristol, c. 1927–1948

Abstract

On the appointed day of 5 July 1948, the National Health Service (NHS) came into existence in Britain. What existed before had been a complex and constantly evolving mixed economy of healthcare, within which hospital services were provided by a combination of public and voluntary sectors. The public sector accounted for the majority of hospital beds and dominated treatment of the chronic and aged sick. However, it is the voluntary hospitals that have often been seen as at the heart of this system because of their historic foundations—many having been established as charitable institutions in the eighteenth and nineteenth centuries—as well as their perceived clinical superiority.1 In fact, the move towards a national health service, which ultimately nationalized the hospitals, gave great credence to an approach Daniel Fox has described as “hierarchical regionalism”. This placed such institutions as leading specialist and teaching centres at the top of a hierarchy of regional service providers, and in doing so reinforced this view of the primacy of the voluntary hospitals.2 From their foundations in the mid-eighteenth century, both general and specialist voluntary hospitals across Britain expanded dramatically in the nineteenth century. However, the early twentieth century saw them struggling to maintain their financial foothold in the shifting sands of the mixed economy, and historians have typically seen this period as something of a fall from grace for the voluntary hospitals, with demands and costs rapidly increasing and deficits becoming commonplace.3 This was perhaps most evident in the aftermath of the First World War. During wartime, the voluntary sector had been part of a wide-scale co-ordination of hospital services under the direction of the War Office. Indeed, Geoffrey Finlayson has commented that, in the process, “Voluntarism itself became—almost—collectivized”.4 Bristol was very much part of this trend, with the Bristol Royal Infirmary's King Edward VII Memorial Wing serving as the headquarters for Southern General No. 2, the region's wartime grouping of public and voluntary hospitals.5 This successful wartime policy left in its wake a financial crisis for those hospitals involved, key to which was the £530,000 shortfall the King's Fund famously calculated in the government's reimbursement of the voluntary hospitals in London alone.6 This formed a significant element of a growing and “palpable crisis” in voluntary hospital funding at the time, which Martin Gorsky, John Mohan and Martin Powell have judged to be the only “genuine threat to the system”.7 It was one which saw the overdraft of the Bristol Royal Infirmary, financially the strongest of the city's major voluntary hospitals, increased in less than two years from £17,985 to more than £42,125 by the end of 1920.8 Although such financial troubles were common, recent views have tended to be more generous, although very few have been as positive as David Green's overtly political assessment of the pre-NHS voluntary sector as a “galloping horse”.9 Certainly the sector's provision was increasing over the interwar period, alongside the growing demands of technology, wages and consumer costs such as food prices, as well as patient numbers.10 The response to these changing circumstances was a search for new and greater income. This process, which has been seen as defining the voluntary hospitals in the early twentieth century, has been most accurately described as one of “diversification”.11 This meant that traditional sources of charitable income were accompanied by new and expanded alternatives, such as public funds and payments. It is to payments from two sources, directly from patients, and via hospital contributory schemes, to which we now turn.