Posts Tagged ‘Voluntary Hospitals’

Fee Paying, Patronage and Bankruptcy in Pre-NHS Voluntary Hospitals

May 15, 2016

Future Medicine Pic

Yesterday I put up a piece from D. Stark Murray’s 1941 book, The Future of Medicine, which described how some patients were driven to seek medical help from the hospitals, rather than their own family doctors, because they could not afford the doctor’s fees. Murray also describes the poor state of the hospitals at the time he was writing, before the advent of the NHS. Along with the municipal hospitals were the voluntary hospitals. These were supposed to be supported by private charity, but in fact this was no longer sufficient and by his time most of them had large fundraising departments. They also raised money in other ways, through charging fees and running insurance schemes. This was, however, not sufficient, and many of the small voluntary hospitals were facing closure.

Murray wrote

Today the situation is very different, and in some hospitals almost the only part of the service which is voluntary is the work of the honorary medical staff, and only a small proportion of the income arises from gifts donated in a purely voluntary fashion. How far removed from the ideals of Christian charity are those hospitals which need a large staff of paid workers to run an Appeals Department and devise schemes for collecting money! The flag day still remains the most popular method, but serves more and more to illustrate how unreliable charity has become as a means of maintaining the health of the community. Not only are hospitals staffs kept busy finding money, and incidentally costing a very considerable portion of the money which they thus collect, but few patients obtain and service from a voluntary hospital without paying in some way. The hospital almoner, who in earlier days answered the dictionary definition and bestowed the charity of the hospital on the poor, has become instead a collector of whatever small sums even the poorest can be persuaded to pay for services received. To such an extent have the users of hospitals resented this reversal of the voluntary and charitable principles that there has sprung into being, as we have noted, a very largely supported system of insurance by regular contributions against the need for hospital care.

This is of course a better system than that which was at one time the mainstay of many hospitals, and which still exists to a very large extent – the patronage system by which wealthy subscribers earn the right to nominate so many outpatients and so many in-patients according to the amount of their subscription. the securing of such nomination-the letter, or “line” as it is called in many parts of the country-is essential before the patient can obtain hospital care, but it does not guarantee admission, which is still at the discretion of the medical staff, nor does it free the patient from the attention of the lady almoner. It may be noted that membership of hospital contributory schemes does not automatically secure admission either, but it should be sufficient to cover the patient for all charges coming with the scope of the scheme…

For our purposes it is enough to note that the yearly income of all voluntary hospitals shows a steady increase in the proportion obtained as payments from patients, by contribution schemes, and by other similar methods. We must add that local authorities now have the power to pay voluntary hospitals for services rendered, and to make considerable contributions from the rates. If all these amounts are added together, it is found that in the provinces of England and Wales only 32 per cent of the income is gained by new charitable contributions. It has been admitted that the voluntary hospitals have to maintain a constant struggle to discover new methods of raising money, and are constantly revising their system for recovering some part of the cost of maintenance from the patients.

Despite these efforts the voluntary hospitals find themselves increasingly in danger of bankruptcy. It is no exaggeration to say that a very large proportion of the time spent at meetings of hospital boards is taken up with questions which hinge on the state of the hospital’s finances. This may cause difficulties in the medical treatment of patients, for it is a common experience of all staffs of hospitals that even when the Medical Committee is unanimously in favour of certain provisions of certain procedures they may find it impossible to obtain the sanction of the Finance Committee. There are those who fear that an organised hospital service may restrict the rights of the medical staff, but at least patients should be ensured that whatever is necessary for their health and well-being can and will be provided. The voluntary hospitals themselves have realised that they are no longer able to give a service wholly in keeping with modern ideas. An attempt is therefore being made to “rationalise” the hospitals, not in the sense in which a scientist would use the term but in that familiar to business men and industrialists who reorganise great industries so that their output and financial profit may be increased. The Nuffield Provincial Hospitals Trust, generously financed by Lord Nuffield, is actively engaged in persuading voluntary hospitals that they can no longer exist as isolated units, and is setting up councils and committees to reorganise the voluntary hospitals so as to concentrate their finances, to cut out overlapping hospitals so as to concentrate their finances, and to provide a service which still contain certain features of the present voluntary system.

At the moment it looks as though the Nuffield suggestions for regionally organising the hospital services will lead to the disappearance of some of those voluntary hospitals which are of such a size that they are usually termed “cottage hospitals”. These are usually hospitals so small that they cannot possibly provide a complete hospital service, or can only provide something approaching a complete service by extravagant methods….[C]ottage hospitals usually have no resident medical officer, receive only periodical visits from the consultants of larger hospitals, and are generally staffed by local practitioners. This is of course a complete denial of whole modern conception of the function of a hospital. (pp38-41).

Margaret Thatcher also wanted to introduce greater private enterprise into the NHS, and believed also that it should also get some funding through private charity. And the Tories have gone further, and are now privatising the NHS piecemeal. The current Health Secretary, Jeremy Hunt, has even written a book in which he demands the health service’s abolition.

This shows that, contrary to what the free marketeers of the Tories and Blairite New Labour claim, charity and insurance contributions alone are not sufficient to maintain hospitals. Even under this private system, the Nuffield Trust was considering closing some down. The same is pretty much true of the modern American system. Before the introduction of Obamacare, 20 per cent of Americans could not afford medical insurance, and even with the introduction of this system, insurance contributions can be crippling. Moreover, American private enterprise is hardly cost efficient. In some hospitals, up to 40% of expenditure can be on marketing, administration and maintaining legal departments against malpractice suits. And medical fees amount to something like 1/3 of all American bankruptcy cases.

For the sake of the health of the people of this great nation, we cannot let the Tories privatise the NHS. We must stop them. Now.

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The War and Socialist Demands for a National Health Service before the Beveridge Report

February 18, 2016

This is following a debate I’ve recently had with a critic, who stated that the National Health Service had its origins in the Beveridge Report of 1942, and was endorsed by Winston Churchill and the Conservatives. This is true, up to a point, though Churchill was initially very cautious about the foundation of a National Health Service. After the War he made a radio speech denouncing the Labour party’s plans for a complete reconstruction of Britain as ‘a Gestapo for England’. However, Michael Sullivan in his book, The Development of the British Welfare State (Hemel Hempstead: Prentice Hall/Harvester Wheatsheaf 1996) also points out that before the publication of the Beveridge, there had been a long process of negotiation and demand for some kind of comprehensive, free healthcare for working people, and that this had become official Labour party policy in the 1934. He writes

Discussions about the reform of British health care had, in fact, occurred between the National Government and interested parties during the 1930s (Abel-Smith, 1984, pp. 424-7). The starting point for these discussions was the extension of health insurance rather than the position adopted by the Socialist Medical Association in the early 1930s. These latter proposals, which became Labour party policy in 1934, included the provision of free services to patients, the establishment of a corps of full-time salaried doctors and the introduction of local health centres which would be the hubs of the health care system. The discussions between doctors and government had emphasised the need to cater for the British Medical Association’s preference for the retention of a large private sector in health and the extension of health insurance to cover hitherto uninsured groups. (Leathard, 1991, p. 24).

During the early war years the departmental civil service encouraged the continuation of these discussions and received deputations from the medical profession and the Trades Union Congress. Events, however, overtook these discussions. The formation of the Emergency Hospital Service had, as we have noted earlier, the effect of providing a planned health service, albeit in the conditions of war.

By 1941, civil servants in the ministry of health, perhaps influenced by the running of the EHS, suggested a comprehensive national health system in which general practitioners would be grouped in health centres associated with local hospitals. In October of the same year, the Minister of Health, the Liberal, Ernest Brown, announced that some sort of comprehensive service would be introduced after the war. The organisational and funding arrangements of the service remained unclear, though the minister did suggest that patients ‘would be called on to make a reasonable payment towards cost, whether through contributory schemes or otherwise (Hansard, 10 October 1941). At this time, a survey of hospital provision was also set under way.

At the same time, professional interests were attempting to influence the shape of any future national health system. First, the voluntary hospitals, which had been in financial difficulties before the war, started to plan to avoid the return of financial ill-health after the war. Their suggested framework for a national health system included a closer co-operation between the two existing hospital systems in which local authority hospitals might buy service from the voluntary sector, a call echoed of course in the 1980s, if in a slightly different form and from a different source!

The British Medical Association and the Royall Colleges were also active. Charles Hill, better Known to a generation earlier than that of the author’s as ‘the radio doctor’, and later to become a Conservative Minister of Health, argued that those who planned first would be more likely to influence the final form [of the health service].’ That planning initially included an acceptance of the ideas emerging about General Practitioner (GP) health centres, as well as those of central planning and of a universal and free service. (Pp. 40-1)

He then describes how the BMA later changed its opinion, and became resolutely opposed to the idea of socialised medicine.

Of the contribution of the Conservative Health Minister, Henry Willink, he says

The White Paper, introduced by the then (Conservative) health minister, Henry Willink, conceded very little to the doctors and the voluntary hospitals. Indeed it was, at first sight, almost as radical in intent as the National Health Service came to be seen. Under this plan, a national health service was to be comprehensive and free and financed out of general taxation and local rates. A closer look at the White Paper reveals acknowledgement of some of the doctors’ concerns, however. The planned service would, as far as the ministry was concerned, be free and comprehensive. There would, nonetheless, be no compulsion for doctors or patients to use the planned public service but doctors who opted into the system would be offered the opportunity to become salaried employees of the central or local state. This latter offer, of course, flew in the face of the formal position adopted by the BMA. (p. 41).

He also points out that Willink appears to have retreated from several of his initial positions due to lobbying from the BMA:

In the succeeding months, political lobbying was intense. BMA leaders engaged in secret negotiations with Willink and appeared to have achieved a large degree of success. It seems that the minister colluded with the BMA in dismembering the proposals contained in the White Paper. First the idea of Central Medical Board was dropped to be followed by the demise of plans for a salaried service organised around health centres. Local authorities, it was now decided, would build health centres, but not control them. Instead GPs would rent the buildings, would be remunerated by capitation fee and be entirely free to engage in private practice. (p. 42).

He also argues against the view that the War was ultimately responsible for the creation of the NHS, and that it was the result of an overall consensus in which there was little left for Labour to do but decide the final details. He writes

The war cannot sensibly be regarded as the midwife of the NHS. Some account must also be taken of pressure for change in health policy during the inter-war years.

As we have already seen, the SMA were successful in placing these recommendations for a national health service on the political agenda during the 1930s. These proposals for a free and comprehensive service with a salaried staff formed the basis of Labour party policy as early as 1934. The proposals put forward during this decade by the BMA were, of course, less radical but acknowledged that there were fundamental weaknesses in available medical cover. On two occasions in the 1930s, it published reports which recommended that each citizen should have access to a family doctor and to the services of appropriate specialists. These recommendation, like later proposals from the BMA, fell far short of a national, or nationalised, health service; the financing of the service was seen as best achieved through a system of health insurance. The BMA were even unwilling to accept the recommendations of its own Medical Planning Commission about the scope of a health insurance scheme (Sullivan, 1992). Nonetheless, the BMA during the 1930sa was ready to concede that co-ordination of any post-war service was most satisfactorily located at the national level. (pp. 42-3).

He also notes that even in the 1920s there were calls for some kind of national health service.

There had, of course, been an even earlier call for a national health service. In fact in 1926 the Report of the Royal Commission on National Health Insurance was published. It acknowledged that the insurance system established in 1911 by a reforming Liberal government had become an accepted part of national life. It suggested, however, that ‘… the ultimate solution will lie we think in the direction of divorcing the medical service entirely from the insurance system and recognising it, along with all other public health activities, as a service to be supplied from the general public funds (HMSO, 1926). (p. 43).

Of the supposed consensus produced by the War in favour of an NHS, he says

While it is undoubtedly the case that the experience of war played some part in promoting ideas about changes in the principles and practices of health care (ultimately represented in the 1944 White Paper), it is far from clear that this process represented a new beginning. War may simply have achieved the acceleration of an already established process of policy movement.

Nor should we fall into the trap of seeing the development of war-time health policy as consensual, leaving a Labour government only to decide on the best way to implement agreed policy frameworks. Though many doctors, even in war time, supported the idea of a health system funded from general funds and including a salaried service, there was critical resistance to some of the measures outlined in Willink’s White Paper. that resistance, from the BMA leaderships and, it must be said, from a small majority of doctors responding to the BMA survey, included resistance to the idea of doctors as public servants and, sometimes, to the idea of comprehensive health system itself.

Even among those medical and other interests favouring the establishment of a comprehensives system, there were conflicts about other issues. While the SMA and the Labour Party and Service doctors supported the idea of financing the service from the national Exchequer, most other doctors and certain elements in the Conservative Party favoured a system of health insurance, either publicly or privately administered. While the former grouping favoured control of the health service by central or local government, many doctors opposed government activity that went beyond central planning functions. While the SMA, Service doctors and local medical officers, the Labour Party and some ministers in the Coalition government favoured a salaried service, this found very little support in the wider ranks of the medical profession.

By the end of the war there was agreement of only a limited nature, which masked a wide divergence of opinion amongst interested parties in the health field and in the wider social politics of health. (P. 44).

He concludes

War-time health policy seems, then, to be of less significance than some claim in defining post-war health policy. Though limited agreement on the need for a comprehensive system had emerged, conflict remained over the nature of that system. More than this, inter-war factors seem to be not insignificant in the growth of pressure for a comprehensive health system. War undoubtedly accelerated the acceptance as orthodoxy hitherto contested arguments. Nevertheless, as Aneurin Bevan was to find out, that orthodoxy was still some way short of a national health service.

It’s therefore clear then that sections of the civil service was aware of the defects in existing health provision in the 1920s, and that the Labour Party was demanding something like an NHS from 1934 onwards. The proximate cause of the emergence of the NHS was indeed the emergency health care system set up in the war to treat victims of bombing and evacuees. I concede to my critic the fact that Churchill was, at times, cautiously in favour of an NHS, and that Henry Willink did advocate a free health care system, although his was not ultimately as radical as that set by Bevan.

Nevertheless, ultimately it was Bevan and the Labour party that set up the NHS in 1946. Furthermore, even though there were elements in the Tory party that certainly supported the creation of the NHS and welfare state, there were still many others that opposed it.

Furthermore, the origins of the National Health Service in a fragile war-time and post-war consensus does not, unfortunately, alter the situation today. The Tory party is determined to privatise the NHS by stealth. Jeremy Hunt has said that he wants the NHS broken up and replaced with private health care. Another Tory apparatchik stated that by 2020, if his party had its way, the NHS wouldn’t exist except as a clearing house for health insurance. This was later denied by the Tory spin machine, would claimed that he instead said that the Tories would succeeded in removing unnecessary health regulations and bureaucracy. In the last government, there were 95 Tory and Lib Dem MPs with interests in private health firms, hoping to profit from the NHS’ privatisation.

The only remaining clear champions of the National Health Service as national, free, universal system are the anti-Blairite wing of the Labour party under Jeremy Corbyn.

And that’s my last word on this issue. At least for now.

The Foundation of the NHS: The Conservatives’ Reaction to the Beveridge Report

February 16, 2016

As I mentioned in my last post, I’ve been discussing the origins of the NHS with a presumably Tory critic, who took issue with my statement that Nye Bevan is the NHS’ founder. Among his other points, he argues that Winston Churchill was in favour of it, and the NHS would have happened regardless of who was in government at the time.

I have argued that Churchill was in fact highly ambivalent about it. Sometimes he was for it, at other times against. G.C. Peden, in his British Economic and Social Policy: Lloyd George to Margaret Thatcher (Oxford: Philip Allan Publishers Limited 1985) has this to say about the public and the government’s response to the report.

The focus for discussion of postwar social planning was the Beveridge Report on Social Insurance and Allied Services (Cmd. 6404). The Report appeared in December 1942, at a time when ultimate victory could be foreseen and when new incentives had to be found to maintain the war effort. Despite this, the Government was cautious, if not openly hostile, to Beveridge’s proposals for universal social insurance, without means test, against interruption of earning due to unemployment, ill health or old age. It was true that the Anglo-American peace aims in the ‘Atlantic Charter’ of 1941 had included a reference to ‘social security’ but Churchill thought that such plans should be substantially left until after the War. As Harris (1977) has shown, the Beveridge Report had been very much Sir William Beveridge’s own handiwork. His committee had been expected to deal with technical questions related to workmen’s compensation for industrial disease or injury, and with anomalies in social insurance, such as the well-known one whereby a man whose earning were interrupted because of unemployment received a higher rate of benefit than if he were sick. Beveridge, however, had gone beyond his terms of reference and had called for an attack on Disease, Ignorance, Squalor and Idleness as well as Want – the five giants on the road of reconstruction, as he called them in Bunyanesque language. In particular, he stated that no satisfactory scheme of social security could be devised unless there were family allowances, comprehensive health and rehabilitation services, and avoidance of mass unemployment. Indeed, the actuarial soundness of Beveridge’s plan depended upon the average rate of unemployment being no higher than the lowest level in the 1930s; that is 10 per cent of interwar insured labour force or 8.5 per cent of the wider body of insured employees in the new scheme (Cmd 6404, pp. 120, 154-65, 185-6). Uncertainty whether unemployment could be controlled, and memories of the political consequences of an actuarially unsound unemployment insurance fund in 1931, no doubt contributed to the Treasury’s critical reception of the Report.

Nevertheless there can be little doubt that the Report was extremely popular with the general public and, following a backbench revolt in parliament, the Government felt compelled to commit itself to Beveridge’s plan, at least in principle. Widespread support for universal social insurance without means test may have been the result of what Titmuss called a ‘war-warmed impulse of people for a more generous society’. On the other hand, the fact that so many people in the armed forces and munitions industries could not but be uncertain about their own post-war employment, in the light of post-1918 experience, must have been a factor. In the interwar years the unemployed had always been a minority of the electorate; in the war those who felt threatened by unemployment may well have been a majority. Moreover, the associated prospect of universal health insurance may well have been attractive to people had been finding the cost of private health insurance a burden.

Key interest groups were also generally in favour of Beveridge’s ideas. The evidence presented to Beveridge’s committee showed that hardly any trade unions opposed extensions of national insurance and even business witnesses generally favoured more intervention by the state in matters relating to national efficiency. The one business group clearly adversely affected by Beveridge’s proposals were the industrial insurance companies which had helped to administer national health insurance since 1912. Beveridge not only recommended their exclusion from this, but he also proposed that national insurance should cover workmen’s compensation and funeral grants, thus taking away business from the companies. These seem, however, no longer to have had the influence they had had in Lloyd George’s time, and the state no longer needed their administrative expertise. Wartime experience had created new attitudes about what the state could achieve. All this does not mean, however, that there was necessarily a consensus in favour of a ‘welfare state’ except in the most general terms. Looking at Beveridge’s five giants in turn, one finds that sometimes proposals were agreed for differing motives, or on an inadequate basis, and that sometimes there were serious disagreements between Conservative and Labour members of the Coalition government.

For all its reservations on Beveridge’s main proposals, the Government did agree in principle with his assumption that there should be a comprehensive health service available to all, without any conditions of insurance contributions. The trouble was that it proved to be impossible during the war for the details of such a service to be agreed, either between political parties or with the interest groups involved. Certainly war had increased the state’s role. Greatly exaggerated prewar estimates of numbers of casualties in air raids had led to the provision of 80,000 Emergency Hospital Service beds, compared with 78,000 beds in voluntary hospitals and 320,000 in local authority hospitals. Moreover, the Emergency Hospital Service gradually extended its operations from war casualties to treatment of sick people transferred from inner city hospitals and then to other evacuees. In discussions in 1943-45 on a future national health service, however, both Conservative ministers and the British Medical Association showed themselves to be determined to safeguard private practice and the independence of the voluntary hospitals. In particular, there were deep differences between successive Conservative ministers of health, Ernest Brown and Henry Willink, who were responsible for health services in England and Wales, and the Labour Secretary of State for Scotland, Tom Johnson, who was responsible for health services north of the border. For example, Johnson successfully opposed the idea of maintenance charges for patients in hospital. The 1944 White Paper on A National Health Service (Cmd 6502), which was signed by Willink and Johnston, left much undecided and was avowedly only a consultative document.
(pp 139-40).

The National Health Service Act of 1946, and its implementation on the Appointed Day in 1948, was a considerable achievement of Aneurin Bevan, the Minister of Health. Bevan’s original nation health proposals differed from those of Willink, his Conservative predecessor, chiefly in respect of the degree of the Ministry’s control over hospitals and doctors, and in the emphasis given to group partnerships of doctors in local health centres. Whereas Willink had wished to preserve the independence of voluntary hospitals, Bevan took over all local authority and voluntary hospitals, except those not necessary for the National Health Service (NHS). Bevan’s biggest problem was with the British Medical Association which, as late as February 1948, organised a poll of its members which resulted in a vote of 8:1 against the Act. Bevan was aware of the need to meet the medical profession on some points. In particular, he was willing to allow private beds in NHS hospitals so as to attract the best specialists into the service. He met the general practitioners’ fears for their independence by promising that there would be no wholetime salaried medical service. In the end the doctors and consultants were given a larger place in the administration of the NHS than Willink had envisaged.

(pp. 155-5). Thus, while the Tories did have a role in the creation of the NHS, the government as a whole only reluctantly accepted its necessity after it won a general acceptance amongst the electorate and parliament. Yes, Willink did play his part, but the ultimate creation of the NHS was under Nye Bevan.

There is much, much more I could write on this, but at the moment this ends the discussion.