The voluntary hospitals in history
What were the voluntary hospitals?
What part did they play in hospital history?
Why did ‘voluntary’ status come to an end?
What were the voluntary hospitals?
Before the National Health Service began in 1948 many of the hospitals in England, Scotland, Ireland and Wales were within the voluntary sector. These included the major centres of general acute medicine, notably hospitals with medical schools, along with special hospitals providing care for particular groups of diseases, and the cottage hospitals which flourished in small towns and rural areas. Voluntary hospitals were characterised by their independent status and their reliance on philanthropy and other private sources of funding. They were administered by committees of lay governors serving in a volunteer capacity and were staffed largely by physicians and surgeons working in honorary and unpaid posts.
Although some of the voluntary hospitals, like London’s St Bartholomew’s (‘Barts’), could claim a medieval origin, it was in the mid-eighteenth century that the major foundations began. Early examples from the 1710s to 1730s include Guys and the Westminster in London, the Edinburgh Royal Infirmary in Scotland, and in the provincial cities Cambridge’s Addenbrookes and the Bristol Royal Infirmary. The following decades saw more founded in the burgeoning centres of industrial Britain, like the Manchester Royal Infirmary (1750s), the Birmingham General (1760s) and the Glasgow Royal Infirmary (1790s). Through the nineteenth century additional general hospitals opened in the great cities and larger towns. Special hospitals devoted to areas like maternity care, orthopaedics, eye, and ear nose and throat medicine also flourished in London, Dublin, Edinburgh, Cardiff and the other big cities. The cottage hospital movement took off from the 1860s with the aim of providing small institutions run by general practitioners in rural areas. The twentieth century saw further foundations as well as mergers and relocations of long-established institutions, like the Bath Royal United Hospital, the Aberdeen Royal Infirmary and the Birmingham Queen Elizabeth Hospital.
What part did they play in hospital history?
The voluntary hospitals had no monopoly on care, and both local government and the Poor Law also provided hospitals before the NHS. For example, asylums for psychiatric patients were overseen by the county councils, while municipal and district councils controlled the many isolation hospitals. And for those in poverty requiring long-term care in sickness and old age, the Poor Law workhouses and infirmaries were the final refuge. In the 1890s the voluntary hospitals contained about 26% of beds, rising to 33% by 1938, with 20% in the Poor Law, and 47% in local government. However, it was in the voluntaries that acute medical care was practised and most medical education was located. Until the interwar years, when general hospitals began to be opened by city councils, the voluntaries represented the cutting edge of medicine.
Why did ‘voluntary’ status come to an end?
Pressure for reform of the British health services built throughout the 1930s and early 1940s, as the ideal of a comprehensive, universal system gained support. Meanwhile the charity on which voluntary hospitals had relied began to decline in relative terms; receipts from legacies and donations remained more or less constant, but were superseded in the income mix by mass contributory schemes, which raised demand for hospital services. Uneven distribution and lack of integration between the different providers were other worries. The wartime emergency saw an extension of government control which demonstrated how a unified service might work, and Labour’s victory in the 1945 election offered the chance for sweeping reform. Aneurin Bevan’s NHS Acts brought the voluntary hospitals into public ownership, henceforth to be funded principally from general taxation and staffed by salaried consultants and professional administrators.
There are many excellent books on the voluntary hospitals and their role in the history of British health care. The classic work is B. Abel-Smith, The Hospitals 1800-1948, A Study in Social Administration in England and Wales (London, 1964)
Two excellent regional studies are: G. Rivett, The development of the London hospital system, 1823-1982 (London, 1986) and J. Pickstone, Medicine and Industrial Society (Manchester, 1985)
For works on the eighteenth and nineteenth centuries, see J. Woodward, To do the sick no harm (London, 1974), M. E. Fissell, Patients, power and poor in eighteenth century Bristol (Cambridge, 1991); G.Risse, Hospital life in enlightenment Scotland. Care and teaching at the Royal Infirmary of Edinburgh, (Cambridge, 1986); K. Waddington, Charity and the London Hospitals, 1850-1898 (Woodbridge, 2000)
For developments in the twentieth century, see S. Cherry, ‘Change and continuity in the cottage hospitals c. 1859-1948’, Medical History, 36, 1992 271-89; S. Cherry, ‘Beyond National Health Insurance: the voluntary hospitals and hospital contributory schemes’, Social History of Medicine, 5, 1992, 455-82; M.Powell, 'An Expanding Service: Municipal Acute Medicine in the 1930s', Twentieth Century British History, 8, 3, 1997; J.Mohan, Planning, markets and hospitals, (London, 2002) Abstract
Individual institutional histories abound, and some fine examples written by professional historians include J. Jenkinson, M. Moss, I. Russell, The Royal. The History of the Glasgow Royal Infirmary 1794-1994, (Glasgow, 1994), A. Borsay Medicine and Charity in Georgian Bath: A Social History of the General Infirmary, c. 1739-1830 (Aldershot, 1999) and E.Heaman. St Mary's: The History of a London Teaching Hospital (Liverpool, 2003)
