Between his time working in the Clyde shipyards and writing a quintet of novels on the life of Robert Burns, James Barke wrote a little-remembered saga of Glasgow life called Major Operation. In this 1930s novel, two characters are brought together on the wards of the Eastern Infirmary (presumably the thinly veiled Western Infirmary, one of the city's three large general voluntary hospitals and the only one without private wards). Jock MacKelvie is an unemployed leader, rushed to the hospital after a fall at a political rally. George Anderson is an international coal trader on the verge of bankruptcy as a victim of global economic turbulence. When George suffers abdominal pain and calls out the doctor in the night, he has to ‘confess’ that he cannot afford a nursing home, but must instead ‘trust himself to the tender mercies of a public charitable institution’.1

George's expectation that ‘there would be a lot of scandal’ once ‘his friends got to know he was lying in the Eastern beside the riff-raff of the Second City’ was matched by the attitude of the nurse taking his details when admitted.2 When he gave an address in a well-heeled part of town, ‘She turned and gave him a sour look. A snob: pride and poverty.’3 Once on Ward 101, the other patients thought him a ‘toff’ and a ‘swell guy’, but found him ‘quite a decent fellow’.4 Meanwhile, the surgeon was ‘interested’ in George, who was ‘so obviously middle class. And he guessed he must have been pretty low’ for his doctor to have sent him there. As a poor patient of middle-class character, the surgeon knew ‘Anderson would get the same skill – if not the same nursing – for nothing.’ He explained the medical details ‘to the students who, recognising Anderson as one of their own class, felt slightly uncomfortable.’5

The overarching narrative of the book is of a democratic transformation, with the classes brought together and a radical change in middle-class political outlook the result. George realises he ‘had always been a snob, even if a humane one. He had always instinctively recognised the gulf that lay beneath the classes. Never under any circumstances had he made any attempt to bridge the gulf himself or allow it to be bridged from the other side.’6 The hospital serves as a democratic space within which this can happen – but only because financial difficulties remove him from his natural class. The novel is essentially utopian, in that it has to contrive an interruption in the established order to provide the premise on which the events unfold. That established order is the class differentiation we have seen to be a defining characteristic of the pre-NHS hospitals. Despite the changes taking place in the early twentieth century, the admission of patients of all classes alongside each other did not become the norm, nor were the hospitals taken over by work geared towards the accommodation or treatment of those who could pay a commercial rate, as in America. The hospital did not become a site for generating profit. Yet payment did find a place, even as the hospital remained essentially a philanthropic institution.

The idea that the working classes should pay in to the system, the various schemes that facilitated this in the community and the almoner who policed it in the hospital, as well as the idea of opening up the hospital to middle-class patients, were all inventions of the nineteenth century. Yet it was not until the interwar years that any of them became the norm, or even commonplace. In both principle and practice, the change brought about was more complex than a simple switch from medical charity to private healthcare – a reformulation rather than a rejection of philanthropy.

Philanthropy reformulated

The voluntary hospitals underwent a great many changes during the interwar years. Those in the medical technology they employed were matched by changing dynamics in relations with the local and national state, while new styles of fundraising fostered a more democratic relationship with the local community.7 As far the terms of access to the hospitals were concerned, the change can be understood essentially as the adoption of economic reciprocalism. Medical need and inability to receive the necessary treatment beyond the walls of the hospital had never been the only criteria for admission, but the early twentieth century saw a change in what the others were. In the late nineteenth century they had been focused on socio-behavioural expectations which demonstrated deservingness. The early twentieth century saw them gradually give way to financial contribution. To be a contributor not only proved that one was not a free-rider, it also denoted self-sufficiency and sound management of household finances. In short, it was the mark of a good citizen. A universal right to healthcare was beyond the reach of this notion of citizenship, even as medical provision was made to ever-greater numbers drawn from new sections of the community. Indeed, it is responsibilities rather than rights that appear to have been more prominent.

This delicate balance was policed by the almoner, and the foundation and expansion of the almoner profession was inextricably bound up with the administration of payment schemes. She arrived in the hospital to identify those who could afford to pay the cost of their treatment and assess those who might be able to make a lesser contribution. Her qualification for doing so (as well as two years of university study and a series of hospital placements) was her understanding of the patient not simply as research material or as a medical consumer, but within their wider social circumstances. She both enforced payment and acted to protect the patient against its unfair implementation. When the profession's national body changed its name from the Institute of Almoners to the Institute of Medical Social Workers in 1964 it was in fact a long-overdue recognition of the nature of their work, just as when the NHS removed their financial function it did not leave them struggling to find a new purpose. By 1948 the almoners were ready to make the case that any business related to patient payments was a distraction from their real work in the hospital, a view the medical profession had long held. Financial and social work were dual strands, each deeply rooted. Both were indicative elements of the hospitals as charities, but only the latter was equally as applicable to working in the NHS. The social function of the hospital both provided the cover for the compassionate introduction of a financial dimension to the patient contract and ensured the social worker's continued usefulness after its abolition.

This continued social function is inseparable from a commitment to prioritise the treatment of the sick poor. Exactly what was meant by the sick poor, however, was not static. The broadening of the patient base, although more limited than might have been expected, was sufficient to prompt a redefinition. While some of those admitted to the private wards fell well beyond any definition of poor, it was promoted by the champions of private practice as a philanthropic function of the hospital to leave nobody (even the wealthy) without the latest, most technologically equipped medical care at times of need. More widely and more convincingly it was understood that this coincided with demographic and economic changes that meant many of those previously able to pay for home visits from their doctor now needed to turn to the hospital. As the costs of medical care rose along with many others, the new poor of the lower middle classes, when taken sick, could now be thought of as the new sick poor. Those financially incapable of securing medical treatment, the meaning of the term sick poor as it was commonly used in the early twentieth century, was a genuinely growing category. At a time of medical, technological and socio-economic change, medical charity changed too.

Philanthropy maintained

Yet the voluntary hospitals neither adopted a commercial emphasis nor evolved a universal service, even as the hospital was opened up to patients of all classes. The pursuit of those new patients most able to benefit the hospitals financially was timid and consequently, as the evidence presented here has shown, private hospital services before the NHS never broke out from being marginal within the institution, largely restricted to the south of England and strikingly limited overall. With provision for middle-class patients no more than 3 or 4 per cent of pre-NHS hospital beds, the main work of Britain's hospitals continued until 1948 to be the treatment of the sick poor. And perhaps we should not be surprised to find the medical profession keen on maintaining this focus in their hospital work. Lucrative opportunities for private practice came from holding an honorary position at a major hospital, treating the full range of acute cases across the local population.8 This meant a hard-nosed business interest in keeping access as open as possible, but it also meant trading off the philanthropic respectability garnered for the medical profession. Yet the scepticism and sometimes, as in Bristol, outright opposition of house committees to the admission of private patients is in stark contrast to the US case where Charles Rosenberg and Paul Starr have both identified the surgical staffs as driving the change, bringing their private patients to the hospital where it was more efficient and profitable to treat them.9 There is little reason to think the same logic would not apply across the Atlantic. Yet the separation of their honorary, gratuitous hospital work from their private practice beyond was only occasionally broken. This was likely an important factor in the remarkably limited growth of the only truly commercial element of inpatient hospital provision.

Ensuring a universal service was not developed ahead of the NHS were a set of practical arrangements embodying the principle of class differentiation. These ensured that, even when the medical care of all classes was brought within the hospital, their separation and the distinction between the treatment of each was not abandoned. It was simply brought, to a limited extent, in-house. The clamour and sociability of the dormitory-style ordinary ward remained the setting for working-class hospital stays, while the middle-class experience of home treatment was, whenever possible, recreated as faithfully in the hospital as it was in the nursing home. Working-class patients continued to receive subsidised care, even when they made some financial contribution. Middle-class patients still had to negotiate a fee, but were safe in the knowledge that they would not be used as teaching material. The experiences of each, as well as their expectations and those placed upon them, were not the same and did not become so.

However, we should not regard these separations and distinctions as safeguards, limiting the move away from the traditional work and character of the voluntary hospital. In fact, the new practices associated with payment served to reinforce those traditions as they daily acted out the old class distinctions on which the social relationships of philanthropy are based. These new developments reasserting old principles served to mediate the adoption of universalism. As such, the pre-NHS practice of patient payments was rather different from today's medical consumerism, with an increasing tendency to view health as a ‘commodity’ and patients as ‘consumers’.10 Although this view is far from uncontested, debates around medical consumerism have formed an unhelpfully anachronistic backdrop to historical study in recent decades. The pre-NHS citizen patient was distinctly different, with the civic duty to contribute financially itself mediated by class. For those categorised as middle-class (a category assumed to be unproblematically aligned with higher income) there was an absolute obligation to pay. On the part of the roughly four-fifths of the population below the income limits, the most important thing was willingness to pay if possible, as demonstrated either by submission to the almoner's assessment or by membership of a contributory scheme. For the two preceding centuries, this same act of submission, demonstrating deservingness of medical charity, was played out in requesting a subscriber's ticket.11 That role was now brought on-site and taken on by the almoner. Although this increasingly became a financial rather than behavioural code, adherence was still put on display to receive free treatment at the hospital. While demonstrable deference or even gratitude were deemed proper, the new patient contract ultimately required only acquiescence. Philanthropy still mediated the terms on which admission was gained.

This was just one way in which the dual role of patient and recipient of medical charity continued to be a passive one throughout the early twentieth century. What might initially appear commercial or mutual mechanisms for seizing control in the name of the patient, were in fact medically and socially governed as before. Hospital contributory schemes operated as an alternative to the almoner's assessment, opting out of the means-test to determine the terms of admission, but not securing admission itself. Meanwhile, there was no choice involved in the middle-class patient's more luxurious parallel accommodation. It was only the working-class patient with enough savings to pay for a private ward who could break free of the social hierarchies by which the hospital was bound. Overwhelming, they were reinforced rather than escaped. Payment in the voluntary hospitals was not the adoption of a consumer model of healthcare, but a bulwark against the development of the social democratic principle of patients as citizens with a right to treatment.