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Publication abstract

'The caprice of charity': a geography of British voluntary hospital finance, 1891-1947

In 1946 Aneurin Bevan, Britain's Minister of Health, suggested that a crucial argument in favour of hospital nationalisation was that 'the caprice of charity' had meant that 'often the best hospital facilities are available where they are least needed'. Most previous analyses of this topic, such as Powell's study of the wartime Hospital Surveys, have concentrated on hospital provision - the source used contained no data on finance - or utilisation. The particular contribution of this paper is to present an outline of the geography of voluntary hospital funding in the early 20th century. Findings on hospital finance, provision and activity are drawn from the Voluntary Hospitals Database, which allows extraction of consistent sets of hospitals and aggregation to the level of administrative units such as counties or county boroughs. Occasional reference is made to the finances of individual hospitals but the analysis largely relates to counties or regions.

There are several possible ways of analysing the financial position of the voluntary hospitals and the paper presents three novel analyses. First, estimates are made of variations in levels of expenditure per capita and per bed - the latter probably being more useful for comparative purposes because of the problem of defining hospital catchments. Second, an analysis is presented of changes in expenditure over time using statistics relating to a set of 412 hospitals, which appear consistently in the statistical sources at regular intervals. These are used to show whether there was convergence or divergence in expenditure between regions between 1891 and 1938. County-level statistics on this point are also presented for the 1930s. Third, an analysis is offered of variations in the income mix between different places and for individual hospitals - especially the balance between traditional philanthropy (subscriptions and donations) and workpeople’s contributions.

Findings on the geography of hospital spending show a marked urban / rural divide, with the towns more favoured, as well as other regional differences. When these differences in expenditure are set against the measure of utilisation it seems likely that they impacted on the quality of care. Not only did variable levels of expenditure affect the level of service, they were also not improving: despite the shift away from reliance on philanthropy towards user payments there was no significant regional convergence in the first half of the twentieth century. Turning finally to income, the findings show that spatial differences in revenue sources and funding mix underpinned this uneven geography of expenditure and utilisation. The conclusion contains reflections on the recent trends towards promoting greater financial autonomy for NHS foundation trusts. Is there a risk that history might repeat itself, with a similar distortion of resource distribution and a comparably detrimental impact on care?

GeoData Institute