Publication abstract
London’s Voluntary Hospitals in the Inter-War Period: Growth, Transformation or Crisis ?
This article asks whether London’s voluntary hospitals were facing a crisis in the three decades preceding the start of the NHS. London is particularly important to any evaluation of the history of Britain’s health system. It contained some 25% of the nation’s voluntary hospital beds, many in respected and long-established teaching hospitals. Meanwhile, the London County Council (LCC) was the nation’s (and probably the world’s) largest municipal health authority, and its burgeoning public hospital sector posed a challenge to traditional private provision. For both these reasons the experience of London’s hospitals shaped policy makers views in a period of fundamental reform. The article uses evidence from the Voluntary Hospitals Database and from records of the LCC and of individual hospitals to establish whether the interwar voluntary sector ‘failed’, thus making state intervention more likely. The focus is finance and the scope for partnership working between public and private sectors.
Consideration of voluntary hospital current and capital accounts shows a tough situation immediately after the First World War which was rectified by government aid, then escalating hardship from the mid-1930s, again saved by state aid during the 1939-45 war. The teaching hospitals could ride out years of income shortfall due to their greater wealth, though some saw an erosion of their disposable assets. It was the smaller special and general hospitals with a weaker asset base which suffered greater hardship, though this was not universal. As in the provinces, rising costs in the metropolitan hospitals were driven particularly by heavier expenditure on salaries and wages, especially for nurses, and this reflected the pace of technological change and the need for skilled staff. The composition of income sources changed too with traditional charity gradually falling during the 1930s. Expansion was therefore driven more by the growing proportion of revenues from user fees and the capital’s mass contributory scheme, the Hospital Saving Association. That said, in contrast to the rest of the country, hospital philanthropy continued to play a large part in the mix, thanks to the involvement of the aristocracy and haute bourgeoisie, as well as the impetus of the King’s Fund.
As the voluntaries struggled to fund expansion the public sector hospitals enjoyed a period of growth. Legislation in 1929 encouraged the ‘break-up’ of the Poor Law, whose workhouse infirmaries were historically associated with stigma and lower quality care for long-stay and elderly patients. Now the LCC seized the chance to convert these into modern municipal hospitals, open to all citizens and vying for equivalent status to the voluntaries. City-wide organisation of support services and central cost savings were also possible in the municipal sector, which could pay higher wages to staff and increasingly figured in medical education. The conservative and individualistic voluntary hospitals were reluctant to treat the LCC as an equal partner, while socialists on the Council preferred to expand municipalism rather than seek public/private partnerships. Thus the two sectors did not work well together: the municipals expanded into poorly provided parts of London, and better quality public hospitals undermined support for voluntary funding. Meanwhile the voluntaries were unable to tap public funds through providing contracted services. Thus when the shocks of war came, bringing physical destruction in the Blitz, the utopian blueprint of the Beveridge Report, and ultimately a political swing to the left, the voluntary sector was in poor shape to fend off nationalisation in the NHS Act.
