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Publication abstract

British voluntary hospitals 1871-1938: the geography of provision and utilization

This article examines the distribution of beds, staff and in-patients in voluntary hospitals in England, Wales and Scotland between 1871 and 1938. The discussion addresses two broader historical questions. First, to what extent did the uneven economic development of industrial Britain lead to regional variations in social provision? Specifically, did charity and mutual insurance deliver satisfactory levels of care across the country before the welfare state? Second, an important debate related to the coming of the National Health Service concerns the extent of voluntary hospital provision by the late 1930s. Recent revisionist work has queried whether earlier commentators such as Richard Titmuss underplayed the success of voluntarism in accounts which justified the establishment the NHS. In addition the analysis provides a case study with which to explore a theoretical framework advanced by third sector economists. This suggests that the voluntary sector is more than a residual, caught between state and market, but has positive qualities which the other two sectors lack, such as the capacity to innovate and address ‘unpopular’ issues. However, as broad support for a given social intervention grows so the extent of ‘voluntary failure’, such as amateurism in management and uneven service provision, is exposed. The findings are drawn from the Voluntary Hospitals Database and from contemporary commentaries.

The A chronology of voluntary hospital growth between the mid-eighteenth and the early twentieth centuries traces the pattern of foundations. Beginning with the great metropolitan and provincial teaching hospitals, this was followed by the development of major urban general hospitals. A few special hospitals dealing with maternity are among the early foundations, but it was the later nineteenth century which really saw the proliferation of specialist medical institutions. From the later Victorian period the movement for establishing smaller cottage hospitals in rural areas gathered pace. Some of the drivers of foundations, such as the motivations of middle class philanthropy and the professional interests of doctors are described. The obvious absence of any mechanism for matching provision to need is also emphasized.

The The analysis then turns to the levels of beds, staff and in-patients per head of population in counties, county boroughs and large Scottish burghs. This evidence suggests that despite the overall expansion of the sector and the narrowing of differences between places, considerable variations in bed provision and hospital utilization remained. Per capita bed provision was higher in London, the South West, the South East and Midlands, and comparatively lower in such areas as Cornwall, Lincoln, much of Wales and rural Scotland. Consideration of the cities reveals variation by a factor of six or seven between well and poorly provided places: Bath, Oxford and Exeter illustrate the former, St Helens, Smethwick and Gateshead the latter. The distribution of specialist medical staff was also highly uneven, ranging from more than 2 per 10,000 persons in places like Bournemouth and Brighton, to none in such towns as Wakefield, Inverness and Paisley. The discussion argues that these variations were likely to have had an impact on the health of individuals, developing the case that by the first half of the twentieth century access to hospitals services did matter. Therefore the inequitable geography of provision and utilisation arguably provides an empirical demonstration of ‘voluntary failure’. The conclusion duly traces the emergence in political and public discourse of the perception that spatial unevenness was a weakness of the voluntary system. This is not to say that the NHS rectified the situation, at least until the advent of the Resource Allocation Working Party in the 1970s.

GeoData Institute