The most dramatic change the NHS made to most people's everyday lives was not to provide them with medical care free at the point of use. Before 1948 hospitals had arrangements in place for this to be guaranteed to anyone for whom paying would cause financial hardship; and beyond the hospital it was not uncommon for a doctor's conscience to render him (or occasionally her) unable to charge poorer patients. Across working-class communities many who would have been expected to pay something turned to mutual aid schemes to ensure doctors’ visits or hospital stays without a bill, while National Insurance made a similar arrangement compulsory for a growing number of workers in certain industries. Nor did the NHS open up greater provision. No new hospitals were built for more than a decade and the ‘appointed day’ did not herald the end of the dreaded waiting list. What the NHS changed was that it removed entirely questions of payment from the doctor–patient encounter. Moreover, it enshrined within commonly held notions of British citizenship that this should be so.

Just as the absence of payment after 1948 was deeply imbued with meaning, so too was the act of paying the hospital before the NHS. It was an act firmly embedded in the social relations that had always governed medical 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, practical changes that moved away from what we might expect of philanthropy were accompanied by others that safeguarded and even reinforced various core principles. While direct payments became the norm, the almoner granted notable reductions and exemptions on a means-tested basis. Although the middle classes accounted for a growing proportion of the patient base, provision for them was limited across the hospital sector, marginal within the institution and largely restricted geographically to the south of England. Even the radical break supposedly offered by mutualist contributory schemes looks rather less radical when we focus on their place within the hospital. Despite the image of insurance, membership conferred no new rights. Paying in to a contributory scheme was an opt-out of the almoner's assessment, which determined the term of access, but not access itself. Admission continued to be a medical decision regardless. However, the almoner system did more than provide a philanthropic safeguard to limit the growing commercial activities in the voluntary hospitals. It was, in fact, a reassertion of the social dynamics than underpin philanthropy itself.

The common expectation that money has a corrosive effect – that economic concerns will ultimately trump all else – was not borne out.2 Yet payment and philanthropy did not merely find an accommodation. These new developments were incorporated into a revised understanding of medical philanthropy. In considering this, two dimensions of the hospitals’ patient payment schemes will be focused upon in this chapter. The first is the social relations within which they were embedded. Some old and persistent ideas about the social function of money in the modern world tell us we should find a great levelling when payment enters a social encounter. Social distinctions should fall by the wayside in favour of those between able and unable to pay. On the contrary, instead of an anonymous and inflexible price tag attached to care, arrangements for payment were grafted on to the social classifications of patients. The distinctions in payment served to reinforce the differential (if not always deferential) class relations at the core of 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 or demonstrated thrift to secure the terms of their admission. The middle classes paid at a rate that not only covered the cost of their treatment but also served as a donation to support that of poorer patients. Payment in the doctor–patient relationship continued along traditional class lines, with working-class patients treated on an honorary basis and middle-class patients agreeing a fee. In many ways, the old social order survived.

Moreover, the payment schemes were a means to instil a moral-financial code around the use and abuse of the voluntary hospitals. A notable insight of anthropologists and sociologists has been that moral schemes are broadcast by economic activities – not only those designed to make a profit, but also spending, saving, lending, gifting, begging, accepting and refusing monies.3 The almoner's mediation of the complex boundaries between payment and philanthropy did exactly this. The new system was not only embedded in social relations but also in social attitudes and values, including the different expectations of working- and middle-class patients. This is rather different from the democratic ideal of the NHS – comprehensive and universal – where working- and middle-class patients are treated together and on the same terms. Middle-class patients may have entered the hospitals during the interwar years, while local reforms provided something akin to a comprehensive service in some areas, including Bristol.4 However, working- and middle-class patients were neither treated alongside each other nor on the same terms. The physical and ideological division of patients on grounds of class (assumed to be unproblematically equivalent to levels of household income) held out against a gradual move towards universalism.

The principle, termed here economic reciprocalism, is the second dimension. The moral code of Victorian philanthropy was one of moral reform, while the scientific charity movement sought to focus efforts on changing recipients’ behaviours while stamping out indiscriminate giving.5 The early days of the almoner profession seem to be characterised by this same mission, weeding out the ‘abuse’ of the middle classes seeking free treatment at the expense of the hospital, encouraging provident saving amongst those who were otherwise socially and morally deserving of free or subsidised care. However, this made way for a reformulation of medical philanthropy more in keeping with the coming collectivist age. Just as charitable provision was differentiated rather than exclusively for the poor, the expectation became that paying in was the civic duty of all but the poorest. As hospital provision became a mass operation, less deeply rooted in the communities being served, there was less hope of reforming social conduct in familiar ways.6 Payment, however, offered a new opening into household management. Making a financial contribution was a shortcut to wider habits of saving and spending, while the almoner's assessment opened up the family's habits to the scrutiny of a philanthropic professional. Paying in, or more importantly being prepared to, became the new staple for demonstrating deservingness in medical charity.

In order to reform philanthropy in this manner, however, it was first necessary to forge a new and broader definition of the deserving sick poor – one that could encompass the new class of patients seeking treatment at the voluntary hospitals.

The sick poor and the new poor

The argument typically advanced today in favour of private social provision, and mimicked in the public sector, is that it empowers the service user through granting them a degree of consumer choice.7 In the interwar hospital system it does appear that in some cases ordinary ward patients could upgrade if they could find the money. One woman in Lancashire recalled her sister being offered this option to avoid a waiting list:

Far from empowering working-class patients who went private, the memory at least, is of a continuing paternalism governing the voluntary hospitals. For the middle classes it was not a matter of opting to go private, as income limits to the ordinary wards ensured private treatment was their only option. Rather, the concern was that those who could afford to pay might try to go public by seeking admission to the ordinary wards to save money – something widely seen as an ‘abuse’ of charity.

Abuse and the diversion of charity

When Dr Thomas Bickerton was writing his medical history of Liverpool, either side of the First World War, he gave considerable prominence to the contemporary issue of ‘hospital abuse’. By which he meant ‘the exploitation by the unscrupulous and parasitical members of the community of the services’ of the voluntary hospitals. ‘No one grudged to the destitute the treatment which they received gratuitously at the hospitals and dispensaries’, he insisted, ‘but it was a grave abuse of charity when those of moderate income expected to receive advice and treatment for which, without hardship, they could afford an adequate fee’. He decried this behaviour as ‘the chief form of hospital abuse’ and ‘disastrous to all concerned’.9 To demonstrate this, one local report cited the shocking example of a woman ‘who openly boasted in the ward that she would have been treated at home if she had not bought a seventy-guinea piano!’ 10 This condemnation of those who made unnecessary use of charity was an important moral pillar of late-Victorian paternalism, and one which lived on well into the twentieth century.11 One almoner who entered the profession in the 1930s recalled this, with a fellow almoner not so much weeding out abuse as defending a patient against the charge:

Although this doctor's concerns were shared by the likes of Bickerton, Burdett and the Charity Organisation Society, the initial investigations of newly appointed almoners at London hospitals in late 1890s did not reveal any significant abuse of medical charity. At the Royal Free Hospital, only around 1.5 per cent of outpatients were ‘considered able to afford the usual fees for private advice’ and were therefore told they would not receive treatment in future.13 The almoners at St Mary's Hospital also found that the outpatient department had ‘not been abused on a large scale’, with only 2 per cent being deemed ‘unsuitable’.14 This came as no surprise to some. The governors of Guy's Hospital insisted their outpatient department ‘was seldom improperly taken advantage of, and that, with few exceptions, the people attending … were fit recipients for charitable relief’. The appointment of an almoner provided evidence to support this assertion. Her function was therefore not to stamp out abuse but to serve as a ‘pledge’ by the governors, ‘a further assurance to the public … of their desire to prevent any abuse’.15 The moral outrage therefore appears to have been somewhat disproportionate: the middle classes were not a major element of the voluntary hospital patient base at the turn of the century as some feared. Yet those fears were real and they continued into the twentieth century.

Interwar concerns of diverting charitable efforts away from the sick poor were expressed by Labour politicians and trade unionists – ‘we do not want the provision of paying beds to be the means of cutting down services for poor people’ – and were also found in the hospitals themselves.16 By 1927 the St John's (skin) Hospital in London had ended its private provision, having found ‘there was occasionally a little difficulty with the patients as, naturally, they required more personal attention and the Staff was not large enough to give such extra attention’.17 Similarly, one interwar GP found the different expectations of his working-class and middle-class patients required him to spend twice as long with the latter.18 Equally, at the West End Hospital for Nervous Diseases they had found it ‘undesirable, both from the Hospital's and the patients’ points of view, to have “Hospital” and “part-paying” or “semi-private” patients in close proximity to each other’.19 Such a statement suggests there may have been some merit to one Scottish MP's concerns that the preferential treatment of private patients was in ‘danger of creating class distinction and snobbery’.20 To avoid these difficulties, it was often the case that the establishment of private wards was part of a wider scheme of hospital extension or reconstruction, or room was made for these wards by clearing a floor of the nurses’ home, a part of the hospital site not being used for the treatment of sick poor.21

The typical response to such concerns was for hospital governors and administrators to insist that private wards had the opposite effect. At the Bristol Royal Infirmary it was claimed in 1937 that ‘the small profit derived from the private patients helps to maintain the beds in the general wards’.22 However, beyond such claims there is little evidence in Bristol or elsewhere to support the idea of any redistributive effect of private provision.

Expanding the definition of the ‘sick poor’

Those who supported the admission of middle-class private patients – whether administrators within the hospitals, reformers in organisations such as the King's Fund, or supporters in parliament – all adopted a strikingly similar rhetorical strategy. This involved an enlarged redefinition, rather than an abandonment, of the notion of the sick poor. This term was commonly used by doctors and administrators in interwar hospitals to mean anyone who could not afford the private fees of being treated in their own home. After the First World War major changes of two kinds – advances in medical technology and broader economic changes – brought significantly more people into that category. Technological change meant the hospital could deliver something beyond even the most expensive care at home.23 This reasoning could easily have been used to support the idea that the modern hospital could no longer be a site for the medical care of the poor exclusively, but rather that it must be a resource for all classes.

This line of argument seems to have had some purchase in the municipal sector. Indeed, two emergent principles of healthcare were promoted by Section 13 of Health Minister Neville Chamberlain's 1929 Local Government Act. One was universalism, by means of granting local authorities the power (if securing Ministry of Health approval) to appropriate poor law infirmaries in order to provide general hospital services to the community as a whole. Meanwhile, co-ordination across the mixed economy was also promoted by stating that there should be consultation with the local voluntary hospitals on such developments.24 Although not all local authorities took up this opportunity Bristol did, making the appropriation of Southmead Hospital a flagship policy. To some extent this was a matter of reinforcing an established commitment: ‘Some time ago’, the city's medical officer of health declared in 1930, ‘the Board of Guardians opened the doors of Southmead for the treatment of sick persons of all classes.’ 25 Yet we also know ordinary and private patients were treated in different wards and paid different amounts.26 If other areas went further in adopting a universalist approach, Bristol did not join them.

In the voluntary hospitals there was no such change. They did not abandon philanthropy as their organising principle. What did change, or at least what reformers sought to change, was who was seen as a deserving recipient of medical charity. A 1923 Court of Chancery ruling had established the precedent ‘that a hospital for “poor” persons could provide pay beds’ because they defined the poor as ‘persons unable to afford [the] full cost of private treatment’, which it estimated at a rather high five guineas.27 This could therefore include patients drawn from ‘the blackcoated poor of the middle and professional classes’, with incomes too high to gain admission to the ordinary wards or to receive financial assistance from national insurance, but for whom meeting the costs associated with illness and treatment was still a challenge.28 Lord Castlerosse wrote in the Sunday Express in 1927 that ‘this class suffers in the same way as Farmers do, from not combining together in their own interests’.29 He supported the conclusion of a report by H.L. Eason that the solution lay in middle-class insurance. Yet Eason did not see this being achieved simply by insurance schemes to cover treatment in the odd private bed: ‘Until private hospitals are built for this purpose, it will still remain the truth that in England the only people who get properly treated are the rich and the poor, while those of limited means have to put up with an inferior service.’30 Although the transition was more timid, this echoes the situation whereby the American hospitals ‘had gone from treating the poor for the sake of charity to treating the rich for the sake of revenue and only belatedly given thought to the people in between’.31 Meanwhile the less radical Lord Macmillan, chairman of the Voluntary Hospitals’ Parliamentary Committee, insisted it was a philanthropic principle of the established hospitals ‘that nobody should be unable to benefit merely because he is embarrassed with regard to money’.32

A notable voice making the case that private wards catered for this unfortunate group was the King's Fund. Founded by Henry Burdett in 1897 as the Prince of Wales Hospital Fund for London, it was established to encourage both donations from the middle and upper classes and support the modernisation of the hospitals. This meant introducing the latest systems of accountancy, greater co-ordination between institutions and, increasingly in the interwar years, making provision for private patients.33 The King's Fund was behind legislation passed in 1936 making it considerably easier for private wards to be introduced at the minority of older hospitals whose trust deeds explicitly referred to catering exclusively for the poor. Where before it took an Act of parliament for these hospitals to be able to establish private wards, afterwards it required only the approval of the Charity Commissioner. In their confidential briefing for the promoters of the Bill, discussed in the previous chapter, the King's Fund presented a picture of private provision somewhat at odds with other evidence now available – one in which private wards were common and the rate of charges was low.34 Payment, they were implying, was not crowding out philanthropy.

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 arguments of both supporters and opponents rested on the assumption that the traditional mission of the voluntary hospitals – understood to be both philanthropic and paternalistic in character – remained essentially unchanged. Indeed, on the ground we see this embodied in arrangements designed to ensure that, even when middle-class patients were treated, it was not on the same terms as working-class patients. The guiding principle of middle-class exclusion gave way to what we might term class differentiation.

Class differentiation

The inclusion of middle-class patients fell far short of heralding the advent of some version of social democratic citizenship in the hospital wards. As early as the 1870s, Burdett sought to legitimise middle-class treatment by separating it from that for the sick poor. He proposed separate private hospitals, beds or wards, operating on a commercial basis, while the working classes would remain as the only patients in the ordinary wards.35 However, instead of receiving ‘free’ treatment, he envisaged the ordinary wards operating ‘a system of small payments, according to the means of the applicant’.36 What he was advocating was the adoption of two key principles, which we will here term economic reciprocalism (to which we will return) and class differentiation. The latter involved the separation of patients into two groups – those who could and those who could not afford to pay for medical treatment themselves – with different sites of and terms of treatment for each.

There was some delay, however, before such ideas were put into practice. Following the 1891 investigation of a House of Lords committee into the over-crowding of voluntary hospital outpatient departments, the Royal Free Hospital in London sought to reassert their focus on treating the sick poor. In order to do so, they appointed an Enquiry Officer, who was quickly replaced by Miss Mary Stewart, a St Pancras social worker employed by the Charity Organisation Society.37 Thereafter, Stewart trained future almoners for her own and other hospitals before the task was taken over by the COS.38 With the arrival of the almoner the hospitals had someone who could put into practice this separation of the classes, leaving only the matter of where to draw the dividing line to be settled.

Drawing the line

Initially it appears that Mary Stewart simply used the COS categorisations of applicants for charitable assistance: those who could afford to join a provident association, those unable to afford such payments, and those in need of non-medical assistance.39 Thus, from the beginning the separation was entirely financial, relating to those who could or could not afford to pay for treatment. By the mid-1920s, this had become standard practice and the BMA suggested where the income limits for ordinary ward treatment might be drawn (see table 5.1). The BMA recommended progressive limits of between £200 and £300 annual income, depending on the size of the dependent family.40 Corresponding income limits were a feature of the hospital contributory schemes. Indeed, amidst local contributory scheme tensions in 1942, the Bristol Royal Hospital (the merged Royal Infirmary and General Hospital) was said to be insisting upon making enquiries into the circumstances of patients even when they were members of a contributory scheme, if that scheme had not ‘given a written pledge to observe the BMA scale of income limits’.41

A major study of the contributory scheme movement suggested that Bristol's income limit, set at £312 per annum (or £6 per week), was typical.42 On average this covered 84 per cent of those living in English county boroughs, but inevitably a little less in Bristol as the city had a large middle-class population. Charles Madge, co-founder of the Mass Observation movement, surveyed Bristol in 1940 and found 81.8 per cent to have incomes below £7.43 The same dividing line had been drawn by Henry Tout in his 1937 social survey of the city, which was ‘concerned only with incomes which fall below middle-class levels’, which he said was ‘four-fifths of all Bristol families’.44 These clear class divisions, drawn according to income levels, were therefore not only evident in social comment but also in the administering of statutory welfare and the mechanics of admission to the city's voluntary hospitals and membership of its hospital contributory schemes. This system of class differentiation meant that different services were provided on different terms to different sections of society.

However, some caveat should be offered to the idea there was a simple means test separating working-class and middle-class patients. Steven Cherry has identified a ‘gradation’ in rates of payment, though the relationship between this and the separation of the classes has gone uncommented upon.45 In a 1935 meeting between the King's Fund and the Ministry of Health, Lord Luke explained:

Such a gradation can be seen in the Bristol Royal Infirmary's patient payment scheme, discussed in chapter three. In 1922 there were not only the 15 per cent of patients paying the set amount of twenty-one shillings, the 28 per cent paying various reduced rates and the 55 per cent paying nothing, but also the small 1.5 per cent who paid the set amount plus a donation to the hospital.47 This suggests a wide gradation, even before the more obvious separation of working-class and middle-class patients with the arrival of private wards later in the decade.

This in fact proved to be an issue in the early 1940s, as the BHF found itself out of line with the British Hospital Contributory Schemes Association's policy of bringing about a national flat rate income limit of £420.48 Evidently gradation was a resilient feature of hospital payment schemes, despite pressure at the national level to simplify practices in favour of a two-tier split. Both the BMICS's middle-class ‘section 2’ scheme and the BHF's provident scheme provided access to private wards for those over the income limits of £312 per annum.49 However, the BHF also had an intermediary scheme which created an additional category of those who were narrowly over the income limit for the general wards, having annual incomes between £312 and £420. Those between the two limits did not receive a superior private alternative; rather, they gained access to the same ordinary ward provision, although to do so they had to make a significantly higher contribution through their 6d weekly membership rate, which was twice that of the main scheme.50 Although there was disagreement over the particulars of the income limits, the principle that those over the limits should make their own provision and all those below them should receive the same service regardless of how much they were able to contribute was not questioned.

The means test in healthcare and welfare

We can identify a similar approach to welfare more generally during this period. Legislation in 1931 introduced a household means test for those receiving unemployment benefits for more than twenty-six weeks. As with the investigations of the almoner, this social enquiry used an assessment of the household as a whole in determining entitlement. The means test was designed ‘to ensure that the state's money would not be claimed unnecessarily’.51 Similarly, the income limits the almoner policed were designed to avoid the ‘abuse’ of free or subsidised treatment being given to those who could afford to pay for medical attention. In both cases, there were central guidelines but there was discretion in implementation, whether at local authority or institutional level.52

The means test was the iconic policy of the National Government for its opponents, who organised marches and street protests throughout the 1930s. Their criticisms were not only that it was intrusive, but that it was unfair to include pensions, savings and the income of other members of the household when judging the financial position of the individual applicant. Derek Fraser has suggested the latter ‘heightened family tension, already aggravated by the loss of patriarchal dignity and discipline consequent upon unemployment itself’.53 The whole-family assessment remained until 1941, when the household means test became a personal one under Churchill's coalition government.54 It is therefore not surprising that one Glasgow almoner should feel the need to deny that her household investigations ‘in any way smacked of the hated Means Test’.55

There is a significant difference, however, between the National Government's means test and the hospital almoner's assessment in terms of where the line was drawn. It was the job of the almoner to find, amongst the patients of her hospital, those for whom sickness did not bring with it financial hardship, those who had the disposable income necessary for medical fees. Holding this up alongside Herbert Tout's categorisation of the Bristol working classes in 1937 may shed further light here. Those below the ordinary ward income limits would include not only those described by Tout as being ‘in poverty’ or having a ‘hard struggle’, but also ‘typical Bristolians’, some of whom ‘have a small marginal for saving or pleasure if they are frugal’, and also those who he considered to be ‘very comfortable by the prevailing standards in the classes covered’.56 The ‘classes covered’ were those who were both included in his survey of working-class living standards and in the ordinary wards of the voluntary hospitals. Where the means test separated out the very poorest in order to justify public expenditure, the hospitals’ income limits were designed instead to exclude the wealthiest.

This difference aside, they were both systems which used income assessments to determine entitlement to services. The assumption behind both was that those considered not poor enough were able to make their own provisions for hard times. Entitlement to voluntary hospital services in this period should therefore be understood as more akin to the 1930s means test than going private today. By establishing a system of class differentiation governing access to the voluntary hospitals, a new patient contract was constructed for working-class patients. We now turn to the role in which this cast them.

Economic reciprocalism

Historians have long discussed the essentially subordinate role of the patient as a recipient of medical and other charity.57 Moral judgements of working-class life were bound up with the idea that patients should reciprocate by demonstrating their virtue, thereby proving themselves ‘deserving’ of treatment. We see this reflected in Lynsey Cullen's work on the first almoner, Mary Stewart, appointed to London's Royal Free Hospital in 1895. Following a home visit from her, some patients were refused treatment. Miss Stewart's record book recalls one visit on which she found ‘the mother very dirty and untidy, and gossiping in the street’. After another, she considered ‘the family to bare [sic] good character’, that they were ‘sober and hardworking, but very poor’. Free treatment was refused in the first case and granted in the second.58

This case shows the almoner could be a defender of the traditional philanthropic brand of moral reciprocalism, whereby the patient was expected to not transgress certain behavioural codes. However, it was rare for the almoner to suggest individuals be refused treatment, certainly by the time the profession spread beyond the capital. For the most part, the almoner's role was to assess the circumstances of patients and recommend an appropriate level at which they should be asked to contribute financially to the hospital. As we have seen, the arrival of the almoner and the rise of contributory schemes were important changes, and both show the old principle of moral reciprocalism was giving way to a new economic reciprocalism founded on the notion of earning the right to hospital treatment through financial contribution, as a form of what Finlayson called ‘citizenship by contribution’.59

Contribution as civic duty: rhetoric and reality

This notion of a civic duty to contribute was expressed in a number of ways. It was commonly asserted in general terms as ‘the primary duty of every good citizen’.60 This was a message that placed working-class contributions within a broader cross-class fundraising strategy. The London example offers a demonstration of this, with two major organisations established by the hospital reformer Henry Burdett. The King's Fund was designed to bring the prestige of the royal family to philanthropic fundraising amongst the middle classes. Meanwhile, the League of Mercy was established a year later in 1898 as an auxiliary of the Fund and intended to raise funds from ‘the poorer classes’ who, Burdett noted, were least likely to make charitable donations but most likely to use the services of the hospitals.61 Similarly, contributory schemes in Bristol sought to elicit donations from employers as well as employees, regardless of the fact they would have been charged as private patients if admitted to the hospitals. Promotional material for Bristol's first major contributory scheme in 1933 asked: ‘is your factory an 100% one?’ This meant, they explained, that employer, manager and staff should all contribute. ‘if not’, they asked, ‘why not?’ It was the duty of a good employer to make such a contribution.62 Likewise, the national association defined the key purpose of the schemes as raising funds for the voluntary hospitals ‘primarily from wage-earners and their employers’.63 A similar line was taken during the Sheffield Voluntary Hospitals’ Million Pound Appeal in 1938: ‘It is not healthy for any community to depend on one or two benefactors to provide the necessary money for its Hospitals; it is the duty of the community as a whole – it is YOUR responsibility.’64 In rhetoric at least, contribution was seen to be a universal duty.65

Figure 5.1 Contributory scheme membership depicted as a family duty, 1943

Membership was sometimes cast as a duty to one's family, as can be seen in figure 5.1. The same approach was taken by Mr Brookhouse Richards, founding president of the BMICS, when he ‘suggested to the wives of every wage-earner in the city that they should insist that it was the duty of her husband to her, the children, and himself, to join the contributory scheme, and so abolish all anxiety as to the future in the case of illness’.66 A decade later, he encouraged membership by appealing to a different conception of civic duty, a wider responsibility to the community as a whole of contributing to the stewardship of local institutions. Speaking in 1935 he declared:

Likewise, on the foundation of the BHF, the Bishop of Bristol said the ‘alleviation of suffering and the curing of disease is much more than the responsibility of the religious community. It is the duty of every citizen’.68 Meanwhile, contribution was also characterised in BHF promotional material as a personal responsibility, a means for a ‘self-respecting citizen’ to ‘pay their way’.69 Similar dynamics were evident in Belfast. This was evident when the lord chief justice, Sir Denis Henry, stated during the hospital's annual meeting in 1923 that the subscribers ‘did not want to be treated as paupers; they were honest, hard-working men, who were prepared, God helping them, to pay their way’.70 In the eyes of the hospital's leadership, willingness to make a financial contribution demonstrated deservingness of medical relief.

Evidence that such statements were not just fundraising rhetoric but voiced genuinely held values is clear from the reaction when it was believed patients or schemes had not paid their way. For example, Herbert Baker, president of the Bristol General Hospital, noted in reference to motor crashes that: ‘Although some victims were generous, others passing through the city did not pay what they should’.71 Similarly, there were cases where the reciprocal arrangements between schemes from different areas, so that if people fell ill away from home they would still receive the benefits of contribution, were either not adhered to or deemed inadequate. The BHF had such an arrangement with a Torquay scheme, although the BHF secretary John Dodd described their rate of payment to the Bristol hospitals as ‘absolutely absurd’. During the Second World War he commented: ‘One would think it impossible for any borough the size of Torquay, even though they have not received much attention from the enemy, to calmly go on as though they have no obligations to their neighbours in these days. I shall certainly tell them what I think of them every time they try and shift their responsibility on to Bristol citizens.’72

It is notable that those hospitals in Bristol outside of this system – where their patients were often not categorised as ordinary patients and therefore where contributory schemes were not a factor – did not undergo the same cultural-ideological repositioning. Wholesome behaviour continued to be the primary concern at two hospitals in Bristol. One was the Orthopaedic Hospital and Home for Crippled Children, which received typically less than 2 per cent of ordinary income from contributory schemes.73 The other was the Bristol Temporary Home and Lying-in Hospital, which was not affected by contributory schemes as they did not cover ‘ordinary maternity cases’. It stuck to its commitment ‘to exercise a moral and religious influence over the girls, to help them to regain their own self-respect and that of others’.74 The continuance of a moralistic premise for admission was reflected in their annual reports which until the 1940s stated the core mission of the institution as being: ‘to receive and influence for good young women who are expecting to become mothers for the first time, and who have never mixed with degraded companions; also to place the infants in charge of responsible women, from whose care they cannot be removed without the sanction of the Committee’.75 In both cases, the role of the patient appears to have been understood in socio-behavioural terms, akin to the old-fashioned moral reciprocalism. It is not possible to say whether the involvement of contributory schemes caused the shift to economic reciprocalism or vice versa, or whether the absence of both in these two institutions was caused by overriding moral concerns relating to children and mothers. What is clear, however, is that the rise of economic reciprocalism came hand-in-hand with the contributory scheme movement.

Contribution and citizenship

Even with these exceptions we can, without entirely displacing the late Victorian ‘high point of civic Liberalism’, recognise the scope and penetration of economic notions of civic duty prevalent in the voluntary hospitals and more widely in the interwar years.76 While this does imply interwar ideas of civic duty were more expansive than simply voting, the patient contract remained essentially passive.77 Patients making a financial contribution, even those middle-class patients paying a commercial rate, were not empowered medical citizen-consumers of the kind seen since the 1960s.78 They were understood as active citizens only in the sense that they acted upon their obligations to the hospital and to the community. Indeed, the only reason these were common civic duties rather than the responsibilities of the individual patient was because all working-class people, and increasingly the middle classes too, were potential patients. Meanwhile, the universal responsibility to pay in to the system was stronger than any notion of universal right to receive relief in the voluntary hospitals, although this was no longer so clearly the case by the time almoners were emphasising the social work side of their role in anticipation of the rest disappearing with the arrival of the NHS.

Wartime arrangements and the spectre of the welfare state disturbed this pattern and the almoner profession certainly saw its interests best served by realigning with social democratic notions of citizenship. Yet the systems built around older paternalistic attitudes were far from hollowed out ideologically by the advent of the postwar welfare state. Finlayson saw something similar despite the advance of the state in 1930s unemployment relief, where ‘the frontier of the state moved, but took voluntarist convictions with it’.79 This meant public assistance means testing mixed the new financial with the old moral distinctions between deserving and underserving. Meanwhile, voluntary associations continued to play a significant role in social case work with the unemployed. Hulme sees this as ‘a partnership, where voluntarism provided the personal moral impetus, and the state acted as the impersonal financial backer’.80 In the field of hospital care, the handover to the state had been less clean or complete. Consequently, the transfer of responsibility for funding relief had not been one from charity to state but rather one from charity to a diverse range of sources including the patients themselves. The end of distributing funds in one case and the beginning of collecting payments in the other produced, to some extent, the same effect. In both cases the interwar years saw social work in the voluntary sector reinterpreting and reinforcing the old social contract at the heart of philanthropy.

Contribution as insurance: rhetoric and reality

The almoner and payment systems were, therefore, far from empowering ones. As an alternative, membership of a contributory scheme did allow for a degree of control to be taken over the management of that financial contribution to the hospital. The cost could be spread out and the almoner interview, which was undoubtedly ‘resented’ by some as a ‘humiliating’ experience, could be avoided.81 Yet the schemes did not advertise themselves as offering an alternative to the almoner or effectively managing the financial contribution of a good citizen. Instead, despite the fact that membership had no bearing on the right to hospital admission or treatment, the schemes were promoted implicitly, and sometimes explicitly, as a form of medical insurance.

The notion of contributory scheme membership as a type of insurance was only reinforced by the rhetoric that had been present since the foundation of the BMICS. Indeed, the scheme's first president, Mr Brookhouse Richards, had stated its objective, as well as raising funds for the hospitals, as being ‘to assist those unable to afford it to have the treatment without burdening themselves, their families, or the hospitals. That was not charity,’ he said, ‘but pure common sense, which ought to appeal to every thinking man and woman.’82 Likewise, the Dean of Bristol described the BMICS as ‘something to enable the man not so fortunately placed as other men, for some small contribution to take away something that will free his mind of any thought of big expenses, if illness comes along’. He continued: ‘Surely this is one of the best forms of insurance that has ever been started.’83 Both Bristol's major schemes, in fact, promoted themselves implicitly as insurance schemes. The BMICS described membership as ‘A First-Class Investment for a Rainy Day!’, while the BHF encouraged people to ‘anchor’ themselves to the organisation for financial security (see figure 5.2).84 These representations are quite at odds with the more honest depiction of membership fees contributing to the fundraising efforts of the hospitals used only two years later (see figure 3.5).

Figure 5.2 Contributory scheme membership depicted as an ‘anchor’, 1946

Key to the fundraising/insurance issue is the question of whether members who had paid into a scheme had earned a ‘right’ to hospital treatment if taken ill. Quite simply, they had not. However, Martin Gorsky and John Mohan have suggested that contributory schemes ‘were perceived by their members as having the character of insurance’ and that they had, by virtue of contribution, earned a ‘moral right’ to treatment.85 Meanwhile, Barry Doyle has focused on the ways in which such a perceived right might be enforced through working-class representation in hospital governance, identifying hospital contributory schemes as arenas within which power and control could be negotiated.86 Rather than commercial insurance, this had a strong mutual character, with a ‘dual thread of self-interest and humanitarianism’.87 Indeed, William Beveridge noted approvingly in 1948 that the recent growth of hospital contributory schemes had ‘shown the driving force that emerges when local feeling can be combined with Mutual Aid’.88 Yet it is hard not to reach the conclusion that promoting the schemes as offering insurance was a rather misleading fundraising strategy.

There was some tension here between philanthropy and mutualism – what Beveridge dubbed the ‘impulse from above’ and the ‘impulse from below’89 – but they were not fundamentally pulling in different directions. Certainly, the early twentieth century did see the growth of the expectation of access to healthcare as a right and contributory schemes were pivotal in this development.90 Yet in practice they served no function in meeting this expectation for individual patients. As extensions of the hospital administration, the contributory schemes served two key functions. One was raising funds, which they provided both as payments to cover the contribution of their members when admitted and in block grants to support the general work of the institution. The other was to normalise and celebrate working-class financial contributions to the hospitals.

Accepting payment

There is some evidence that the notion of contribution as a civic duty was not just held by those running the contributory schemes and the voluntary hospitals, but amongst the working classes as well – and this is to be found in the membership figures of contributory schemes.

Contributory scheme membership

While criticising the forerunners to his own scheme, John Dodd suggested that the level of membership in Bristol compared poorly with that of other cities. He listed the impressive number of contributors in cities such as Sheffield (250,000), Liverpool (332,000) and Birmingham (600,000) in 1937.91 He did not, however, offer any membership figure for Bristol. This may have been because of an important difference between Bristol and these other cities. Sheffield, Liverpool and Birmingham all had one single, central scheme. Consequently, the membership of that scheme was in itself the total membership for the city. In Bristol, the BMICS was a central scheme operating alongside a great many smaller local and workplace schemes, while Dodd's BHF was set up as yet another scheme largely in an effort to unify the myriad schemes operating in the city. It was therefore much harder to give a reliable figure for the city as a whole. Some rough figure can be estimated from combining the stated membership figures of the Bristol Hospital Contributors League,92 which brought together the BMICS and the smaller schemes, with the published membership rates of the BHF.93 This suggests that contributory scheme membership in Bristol in the early 1940s was in the region of 150,000. Certainly this is less than those of some other major English provincial cities, but compares well with the nearby cities of South Wales. Swansea's was the largest scheme in Wales with 114,000 members in 1941, while Cardiff's had only 66,000.94 Bristol's contributory scheme membership rate may not have been amongst the highest, therefore, but it can hardly be considered low.

Charles Madge's analysis of Tout's 1937 Bristol survey suggests that a majority of working-class families were making a contribution.95 Some 62.4 per cent of all working-class families were said to contribute to hospital funds, and amongst families headed by skilled and semi-skilled male labourers, who might be considered the respectable working classes, the percentage rose to 74.3 and 78.5 respectively.96 We can safely assume these rates increased once we include the new contributors signed up to the BHF, established two years later, even if some were previously contributors to other schemes. Such membership rates amongst the city's working classes demonstrate a widespread acceptance of contribution as a civic duty, especially given the extensive exemptions from general ward payments for those on low incomes that ensured membership was not the only way to receive treatment without paying. Yet we cannot assume that everyone who joined a contributory scheme supported or agreed with the principle of economic reciprocalism. There are various other reasons why individuals may have joined.

An oral history informant described the establishment of the one-penny-per-week employees’ hospital scheme at Storeys’ mill in Lancaster: ‘You might call it voluntary because in the first place they might have called a meeting of the workers: “Have you any objections to one penny being deducted from your wage?” Then it was automatic, that was that … If you paid you did [get free treatment] and if you couldn't you couldn't.’97 We can also assume that some people joined contributory schemes out of a mistaken belief, encouraged by the schemes’ promotion, that they would be buying some otherwise unavailable guarantee of access when sick as a form of insurance. Indeed, it was a complaint at the London-based HSA, the largest contributory scheme, that they were often referred to mistakenly as the Hospital Savings Association rather than the Hospital Saving Association.98 However, given the scale of almoner reductions and exemptions, it is simply not credible to think that all those who contributed did so mistakenly. Meanwhile, if the arrangements were widely understood but also widely resented, we could expect to see some evidence of resistance or protest.

Alternatively, there may also have been some financial sense in membership for those who were not on a low enough income to be passed free, but still below the income limits. It is worth remembering that the standard charge (although only asked of a minority of assessed patients) was one guinea for a week's stay. At a common rate of 3d per week membership fee it would take over a year and a half (eighty-four weeks) for membership subscriptions to cost the same. Meanwhile, we should not dismiss the pride taken in effective management of a household budget.99 These positive explanations are more convincing than the assumption that millions of working people failed to understand what would happen if they went to hospital and were consequently duped.

Insurance normalised

It may be that such a view found easy acceptance because it felt familiar. After all, the principle of paying in to the health and welfare system you rely on also ran through both the mutual aid societies of the day and the National Insurance system established by Lloyd George in 1911. Indeed, with hospital treatment omitted from National Insurance provisions, the contributory schemes could be seen as a complementary part of the same welfare arrangements. This is not to say they were insurance schemes. Rather, in their respective areas, there was a shared premise between what we are here calling economic reciprocalism and the Liberal insurance principle. One of Lloyd George's chief civil servants summarised this when he said ‘working people ought to pay something! It gave them a feeling of self-respect and what cost nothing was not valued’.100 That said, pragmatic motivations also prompted the development of both, with financial pressures paramount for the hospitals and politics playing no small part in guiding the choices of the Liberal reformers.101

The insurance principle, however, was not universally accepted. Writing at the time, Hilaire Belloc claimed that the 1911 Act, with its class-based interference, followed ‘in every particular the lines of a Servile State’.102 He represented a significant block of opinion when, objecting to its compulsion, he termed it a ‘vile enslaving act’.103 Despite such criticisms, Lloyd George's judgement was that using insurance as the premise for his scheme made it socially acceptable and paying insurance came to be treated as any other household expense.104 A Ministry of Labour inquiry found that the combined payments of state and voluntary insurance accounted for over 5 per cent of expenditure in the average working-class household in 1937–38 (see table 5.2). That on state insurance was 2s 0¾d, while that on voluntary insurance higher still at 2s 4½d, and an additional 1s 8d was spent on ‘medical fees, drugs and hospitals’.105 With the insurance principle ingrained, not only as part of statutory and voluntary welfare systems, but also as part of the household budget, it is perhaps not surprising that such an attitude towards voluntary hospital services should develop.

Considering the impact of such an approach, both parallels and divergence can be seen between National Insurance and the economic reciprocalism of the voluntary hospitals. Lloyd George had an amendment inserted into the 1911 Bill stating ‘that medical treatment shall be given without regard to cause or nature of disease’, which Derek Fraser used as evidence that he and Churchill ‘saw no place in insurance for the concept of the undeserving poor’, but instead saw ‘universal entitlement earned by contribution’.106 Likewise, there was no notion of an undeserving contributory scheme member, but that is not to say they operated on the same insurance principle. Payment, either directly by the patient or indirectly via a contributory scheme, was in effect an act of good citizenship rather than earning the right to treatment. Moreover, for many Liberal reformers, including Churchill and Beveridge, an important characteristic of the National Insurance scheme was run on an actuarial basis: entitlements were earned by virtue of payment and they were limited accordingly.107

For an actuarial approach to be adopted by the voluntary hospitals, they would have had to make payment a condition of access, and this (at least for the ordinary wards) did not happen. However, the deservingness of the individual to receive treatment did move away from moral judgements in favour of three criteria: that they should be in medical need, that they should be unable to pay for the necessary treatment privately, and that they be prepared to make whatever contribution (perhaps none) was deemed appropriate. What the hospitals were operating therefore was closer to the practice Steven Thompson has found amongst the mutualistic welfare provisions of the South Wales Miners’ Federation. Although ‘membership conferred rights of eligibility’ for their various welfare services, ‘strict actuarial insurance principles’ were rejected in favour of responding wherever possible to the greatest need.108 This, again, is evidence of the overriding and continuing commitment to the philanthropic traditionalism at the heart of the patient contract in the voluntary hospitals.

Payment and professional identity

In his famous study on Victorian Outcast London, Gareth Stedman Jones identified what he called ‘the deformation of the gift’. By this he meant that the reciprocity at the heart of philanthropy's meeting of rich and poor was in danger if the interaction was depersonalised; for example, by the geographical separation of the classes through suburbanisation.109 Such concerns hovered over the hospital in the interwar years, less as a result of another wave of suburbanisation than as a consequence of the broadening patient base. In combating this, the almoner was a powerful figure – policing this system and promoting the principle of economic reciprocalism. Yet in doing so she appears an almost anachronistic figure. Theories of governance tell us authority in this period was diffuse, leading to the working classes being ‘steered’ towards good civic behaviours rather than old-fashioned Victorian-style ‘social control’ being exerted.110 Indeed, we might see something of this in the new style of community activity, especially that geared towards fundraising, that Nick Hayes and Barry Doyle have identified as part of an evolving hospital-orientated middle-class civic culture in the interwar years.111 While the distinction between the two is at best hazy, the almoner's ‘steering’ of working-class patients was somewhat heavy-handed for this narrative. Yet the almoner's assessment is an instructive social encounter specific to the interwar years, a ritual that gives us an unusual insight into what Tom Hulme calls ‘the actual mechanics of producing citizens’.112

The work of producing citizens was an important role for the hospital and carried great influence over the patient as a recipient of medical charity. But it was also a crucial role in building the professional status and identity of the almoner. Where our focus has been on what it meant to make a payment or to be asked to make one, it is also important to briefly consider the professional meaning of taking or refusing a payment. Indeed, the rationale for the almoner not only collecting payments but also setting their rate was that she had some specialist insight. It was her training, skill, and experience which allowed her to understand not only the social conditions of the patient but also the wider health and welfare systems to which they might turn for support. This was what allowed her to make a judgement on what was an appropriate level of payment.113 By the same logic, the almoner could demonstrate professional ability by labelling a patient ‘unable to pay’ or even refusing a payment offered – showing she had a fine enough appreciation of family circumstances to know when the money was needed at home.114 Meanwhile, providing free treatment to the poor was a professional activity doctors traded on lucratively in their private practice.115 In either case, refusal of payment could enhance professional status.

In between taking and refusing payment, a profession might distance itself from the payment taken. Indeed, that was essentially what the medical staffs of the hospitals were doing when almoners were brought in to conduct this work. For general practitioners visiting working-class homes, it had long been the ‘unwritten law’ that after the doctoring had finished a sixpence would be placed on the corner of the table and picked up on the way out.116 Finding ways to similarly keep doctoring and taking payment separate was not only a question of maintaining the traditional doctor–patient relationship, although this was certainly a factor. It was also one of managing the philanthropic conduct of the institution. We see this when almoners joined doctors in insisting on another third party to collect fees from private patients – those for medical services rather than hospital accommodation. Physicians and surgeons having to collect their own fees was a source of great dissatisfaction following the introduction of private beds at the Bristol Royal Infirmary in 1926 – a situation only resolved six years later by ‘the Secretary's kind offer to collect fees on their behalf.’117 Moreover, it was an important condition that these fees were not passed on to the individual physician or surgeon, but placed into a collective staff fund, further distancing the doctor from the payment made to them.118

For almoners, the collecting of payment in the large working-class wards was often a task undertaken jointly with clerks or administrative assistants.119 This could have served doubly to enhance professional standing by distancing from the actual collection and by putting on show their seniority over other, often male, colleagues. Where almoners were involved in collecting payments from private patients, however, this tended to be the task of the almoner herself. A 1947 questionnaire from the Institute of Almoners, responded to by 233 hospitals, found 0.5 per cent of almoner's departments collecting medical fees from private patients and none being assisted in doing so. When it came to collecting maintenance fees from private patients, almoners were much more likely to be involved. Fourteen per cent of departments collected those fees, with 9.5 per cent saying this was done by the almoner, 2.5 per cent a clerk and 2 per cent an administrative assistant.120 Given the limited scale of private provision in the voluntary hospitals, discussed in the previous chapter, this level of activity is considerable.

The eagerness for the almoner profession to abandon this aspect of their work was evident when various charges were introduced only a few years after the establishment of the National Health Service. Under Attlee's Labour government these began with charges for dentures and spectacles, and the door was opened for Churchill's subsequent Conservative government to bring in charges for prescriptions and hospital appliances. Just as the medical staff of the voluntary hospitals had been weary of directly receiving payments, for fear of sullying their hands with the dirty business of money, the almoners were adamant they would not – as some hospital administrators planned – be collecting these new charges. In February 1952, the council of the Institute of Almoners met and issued a statement declaring: ‘that any assessment or collection of charges under the national health service is not an appropriate duty of almoners’ departments and in no circumstances should almoners (or their clerks) accept such responsibilities’.121

Refusal to return to their traditional role in assessing patients also meant they sought to have no role in ‘dealing with cases of hardship’, which they saw as the business of the new National Assistance Board. In rejecting such tasks, the almoners saw themselves as fighting off a distraction from and a dilution of their real work. At their national association's annual general meeting shortly after, Miss Hornsby Smith remarked: ‘I am sure many of you rejoice in the fact that your work is no longer association with the extraction of money and that those other services which you render to the patient and to the National Health Service have assumed their proper place.’ 122 This was not merely protestation from the social workers. A month later Ministry of Health officials were stating in no uncertain terms that despite the new charges there was no be ‘no requirement whatsoever for any person in the almoner's department to assess need’ and that there was no suggestion ‘that the almoner should be responsible for the collection of money’.123

Conclusions

In the summer of 1948, every household in Britain received a leaflet introducing them to The New National Health Service. The services of which they were entitled to, free at the point of use, as a right of citizenship: ‘There are no charges, except for a few special items. There are no insurance qualifications. But it is not a charity. You are all paying for it, mainly as taxpayers, and it will relieve your money worries in times of illness.’124 This philosophy was expressed in similar terms by the Prime Minister, Clement Attlee, in a Home Service broadcast on the evening before the ‘appointed day’ when the NHS and a number of other Labour reforms came into effect. The NHS would, he said, give ‘a complete cover for health by pooling the nation's resources and paying the bill collectively’. However, this was not a state-run social insurance scheme: ‘It is not dependent on insurance, everyone is eligible’. Rather, healthcare had become a nationalised industry.125

This was not only a break in who provided healthcare, but also in its underlying philosophy of citizenship. Attlee and Bevan alike were keen to emphasise that entitlement to NHS services was neither insurance nor charity. By contrast, entitlement to treatment for the pre-NHS citizen patient was understood as both. The meaning of paying in to the hospital, either in advance through a mutualist scheme or directly when admitted, was to make a financial contribution. For the majority with working-class levels of income, admission was not dependent on payment but on medical need. To receive that treatment without making what payment was deemed appropriate would have been shameful. For the most part, therefore, patient payments were a mediated form of charitable donation.

This was different for that far smaller number of middle-class patients, for whom payment was a commercial arrangement and a necessity to receive treatment. Above all, it is the difference between the two that is telling. The very fact private patients were separate and treated differently tells us that, for all the changes, the main business of the hospitals was still understood in the same terms. The old social divisions and distinctions survived, even as they were brought within the hospital.