Publication abstract
British Hospitals and the Public Sphere: the Changing Nature of Entitlement and Contribution
Jurgen Habermas’s theory of the ‘rise and transformation of the public sphere’ treated voluntary associations as the representative institutions of the classic bourgeois public sphere. Scholars such as Adrian Wilson have situated the development of the eighteenth century voluntary hospital within Habermas’s theoretical framework, and this paper extends the analysis to the nineteenth and twentieth centuries. Its focus is the development of entitlement to hospital care and contribution to its running and administration over the long run, and this provides empirical material with which to interrogate Habermas’s account.
There are potential difficulties in aligning the development of the British voluntary sector with Habermas’s exposition. In his narrative the classic public sphere was undermined from the late Victorian period as the autonomy of the family was weakened, the authority of the state expanded, media and cultural outlets were captured by the leisure industry and public debate was dominated by interest groups. However, this argument for the ‘refeudalization’ of the public sphere does not consider the subsequent progress of voluntary welfare institutions which in Britain remained strong until 1946. Habermas also ignores the persistence of voluntary social action in his later analysis of the welfare state as an instrument for the 'pacification of class conflict', an interpretation which is advanced with reference to the statutory provision of pensions and social security in the German context. His reading of the advance of state welfare is also at odds with the historical tradition in British social policy which, drawing on T.H.Marshall, emphasizes the gradual extension of rights of citizenship to all members of society. His bleak vision of a manufactured public opinion, devoid of rational-critical debate, also sits uneasily with the normative claims of historians, sociologists and political scientists who see a vigorous civil society as the bulwark of democracy. And yet Habermas’s critique chimes closely with current uncertainties about the National Health Service, such as the fears about a democratic defict which the internal market reforms sought to address and the concerns that ‘provider capture’ of the service has disempowered the patient. How does the history of voluntary hospitals fit within this framework?
There are good grounds for viewing the early voluntary hospital as an ideal typical institution of the public sphere, with its attributes of transparent accounting and subscriber democracy. Like Wilson though, the paper argues that the motivations of private citizen/trustees were more complex and multi-layered than a simple desire to further the institution’s immanent purpose of health provision. At first sight the changing nature of contribution and entitlement from the later nineteenth century also corresponds closely to Habermas’s argument for a disintegrating public sphere. Evidence is presented to document the increasing marginalisation of the private contributor in the finance and management of the hospital, superseded on the one hand by business and other institutional subscribers, and on the other by small numbers of trustees managing accumulated capital resources. Developments within the state sector also support his claim that organised interest groups undermined the public sphere by exerting pressure on the state to protect against social risk. From the 1920s, and more particularly after the Local Government Act of 1929, many municipal authorities, under the aegis of the Ministry of Health, sought to extend access to general hospitals by creating a new tier of rate-funded institutions.
However, it is not obvious that all these changes can be captured within the framework of a disintegrating public sphere. Instead the new patterns of payment and entitlement point to a broadening of participation, which Finalyson has characterised as an emergent ‘citizenship of contribution’. In the voluntary sector this involved the replacement of hierarchical charity by the growth of mass contributory schemes, many founded upon an insurance principle, and the introduction of user fees for services. The interwar period saw a resurgent voluntary hospital sector significantly increasing its bed provision on the basis of these new sources of private support. The development of municipal acute medicine was also driven less by welfare capitalism and bureaucratic rationalism than by the energies of local politicians and Medical Officers of Health intent on eradicating social division. Where previously entry to a poor law hospital had carried the stigma and disenfranchisement of pauperism, access henceforth was to be a right of citizenship and the quality of care equal to that of the voluntaries. Furthermore, the Local Government Act had sought to devolve and strengthen democratic mechanisms in hospital policy-making by fostering joint committees of voluntary hospital and council representatives.
Can it be argued then that, contrary to the expectations of Habermas’s thesis, the bouyant voluntary sector of the interwar British hospital meant a revivified public sphere ? The evidence suggests that the potential which this offered for the formulation of policy according to consensual or rational assessments of medical or social need was not fulfilled. Despite important advances, progress in extending entitlement was limited by geographically uneven provision and spending constraints. Case studies of individual hospitals, c. 1890-1939, suggest that the broadening of financial participation to involve working people failed to stimulate more inclusive decision-making; instead traditional elites clung on to control of policy. And while in some places the joint voluntary / municipal committees successfully co-ordinated activities according to the wishes of local users, these initiatives were inhibited elsewhere by local rivalries, apathy and a traditional of individualism.
The paper concludes with brief reference to the changing nature of the public sphere in the context of the NHS. There have been persistent claims that the NHS deprived communities of influence over their local hospitals and therefore systematically contributed to the degeneration of the public sphere and distortion of public debate. The recent market-led reforms of the service implicitly trade off narrowly-defined economic efficiency over community control and democratic participation, but this is a tension which goes back at least to the national Hospital Plan of 1962. There have consequently been calls for a revived voluntarism, as part of a project of associative democracy. As conceived by Hirst and others, this would return hospitals to self-governing voluntary organisations, with representatives drawn from the local community and receiving funds from a variety of sources. As with the pre-NHS system, however, this would produce variations in entitlements and access to care and it is not obvious that it would revive public interest in hospitals. The place of hospitals in the public sphere will continue to be contested by medical professionals, politicians and community interest groups. However, Habermas' concept of the public sphere continues to provide a normative standard against which the character of public debate on hospital provision can be assessed, and one which is of importance at a time of rapid retrenchment and reorganisation of hospital services.
