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4 Middle-class medicine 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

in Payment and philanthropy in British healthcare, 1918–48

This book examines the payment systems operating in British hospitals before the National Health Service (NHS). An overview of the British situation is given, locating the hospitals within both the domestic social and political context, before taking a wider international view. The book sets up the city of Bristol as a case study to explore the operation and meaning of hospital payments on the ground. The foundation of Bristol's historic wealth, and consequent philanthropic dynamism, was trade. The historic prominence of philanthropic associations in Bristol was acknowledged in a Ministry of Health report on the city in the 1930s. The distinctions in payment served to reinforce the differential class relations at the core of philanthropy. The act of payment heightens and diminishes the significance of 1948 as a watershed in the history of British healthcare. The book places the hospitals firmly within the local networks of care, charity and public services, shaped by the economics and politics of a wealthy southern city. It reflects the distinction drawn between and separation of working-class and middle-class patients as a defining characteristic of the system that emerged over the early twentieth century. 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 book examines why the voluntary sector and wider mixed economies of healthcare, welfare and public services should be so well developed in Bristol.

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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

in Payment and philanthropy in British healthcare, 1918–48
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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

in Payment and philanthropy in British healthcare, 1918–48
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wealthy southern city. The options, obligations and experiences of Charley are considered in chapter 3 and then those of George in chapter 4 ; with particular attention to how the hospital payment schemes they would have navigated were introduced in our case study city. Treating the two in separate chapters reflects the distinction drawn between and separation of working-class and middle-class patients as a defining characteristic of the system that emerged over the early

in Payment and philanthropy in British healthcare, 1918–48

weeding out those of the middle and upper classes who were not considered appropriate cases for medical charity. Beyond mere safeguards, however, the new mechanisms and rituals of payment came to reinforce philanthropy in a variety of ways. Systems of admission Prior to the First World War, Bristol's voluntary hospitals were typical in operating two well-established systems for admission: subscriber's tickets and ‘receiving day

in Payment and philanthropy in British healthcare, 1918–48

women occupied in Indonesian society. Before they could train as nurses, girls were required to have finished primary school. In principle, girls from poor families did not attend school. Girls from the middle and upper classes often did but it was considered culturally improper for upper-class girls – the ones among the population who could afford to study – to live outside their parents’ home when they were of marriageable age (fourteen to sixteen). The poor reputation of the hospitals made them appropriate workplaces only for lower-class women and for women whose

in Colonial caring

items were joined by standard charges for the services of opticians and dentists and then for all prescriptions. Meanwhile, the separation of private beds continued. Where before private beds had been the sole provision made for the middle classes, they were now able to enter the free public wards and amenity and pay beds became options for purchasing a greater degree of privacy or the services of a private doctor or surgeon. Indeed, the

in Payment and philanthropy in British healthcare, 1918–48

 – represented by the central powers. It appears that volunteer nurses were more likely to use these old romantic literary tropes than their trained professional colleagues.5 This may be because they, like their middle- and upper-class brothers, were steeped in the highly romantic literary canon of the day. It may also be that their motives for nursing the wounded had more to do with their desire more to be a part of the ‘great struggle’ of war than with any wish to develop their expertise as nurses.6 Notes 1 Anne Summers, Angels and Citizens:  British Women as Military Nurses

in Nurse Writers of the Great War
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Contextualising colonial and post-colonial nursing

: Proffering middle-class hygienics against the ‘dirt’ of Africa, modesty in contrast to discourses of unrestrained African female sexuality, and the beacon of a Christian medical science in the dark face of African disease and superstition, the European nurse in the first half of this century was positioned squarely at the nexus of race, class and gender politics in the arena of empire.18 Missionary nurses unsurprisingly occupy a considerable proportion of this book as it was often the missions that first introduced and provided Western biomedical healthcare to the

in Colonial caring