Publication abstract
Don't look back? Voluntary and charitable finance of hospitals in Britain, past and present
In this book we summarise the major findings of the voluntary hospitals project, concentrating on the performance and financial stability of the voluntary hospital system in its last decades. We also draw parallels with the contemporary revival of charitable fundraising in the NHS over the past three decades. The key elements of the book are the following:
Firstly we review proposals for a greater role for the voluntary sector in the provision of welfare services which have originated from various points on the political spectrum and which have various motivations.
We then reassess the record of voluntary hospital provision before the NHS and draw comparisons with the present-day. Our findings are organised around four central themes.
Charitable finance: the interwar years were a time of expansion which coincided with the transformation in the funding of voluntary hospitals, as traditional philanthropy proved insufficient, and gave way to private payment and a shift to mass contributory arrangements. However the late 1930s saw a looming financial crisis, as current account deficits multiplied, and the asset base of many institutions was eroded. The revival of charity in recent decades has posed a rather different problem: the unpredictability of charitable finance rather than its inadequacy, since charity is not being relied upon to provide core services.
Provision and utilisation: the spontaneous and localist aspects of voluntary action led to the uneven development of hospital provision. Well before the "postcode rationing" identified with the contemporary NHS, access to care was inequitable, since it was shaped by residence. In terms of the impact of charitable fundraising on the NHS it has been large urban hospitals, notably those with a glamorous national and international reputation, that have attracted the bulk of charitable funds. The tendency for charity to enhance regional variations and hence inequities has therefore persisted. The pattern of charitable endowments and income remains dominated by a limited number of institutions, mainly located in central London.
Coordination and planning: improvements in the quality and availability of hospital care depended on collaboration and partnership, both with the public sector and with other voluntary institutions. However the traditional independence of the voluntary hospitals impeded this process, and despite promising initiatives in particular localities there was no coordinated hospital system by 1939. In recent years the revival of charitable giving has proven inimical to planning. Local enthusiasms underpinning voluntary support for individual institutions can conflict with proposals to rationalise provision in order to achieve wider regional or national strategic objectives.
Democracy and participation: openness, subscriber democracy and accountability were attributes of the voluntary hospital from its inception, but participation was initially limited to wealthy middle-class contributors. The transition to mass contribution in the early 20th century strengthened popular support for institutions, but their leadership remained in the hands of traditional elites. There are some parallels here with the situation under the NHS. Although community support of health services has been widely encouraged, NHS services are largely run by organisations which have little direct input from the public, even those who make considerable commitments to raise money for their local facilities. The development of NHS Foundation Trusts can in part be interpreted as a response to this so-called democratic deficit.
The book concludes with an assessment of the extent to which the issues posed by the uneven development of charity remain with us today, as a consequence of the recent expansion of charitable fundraising. The parallels are not exact but nonetheless instructive. We end with a review of some potential policy options for striking a balance between charitable provision and social need.
