Charity and change in the mixed economy of healthcare in Bristol, 1918-1948
This thesis focuses on the city of Bristol to examine the British voluntary hospital system in its
final decades. It will locate the voluntary hospitals in their final years - between the end of the
First World War and the creation of the National Health Service - within an evolving mixed
economy of healthcare and can therefore be understood as an investigation into the response
of the voluntary sector to the rise of the welfare state.
Two areas of change will be examined in particular. The first will be the voluntary
hospitals' reaction to, and engagement with, the campaign for 'co-ordination'. This was the
'reformist' agenda of the day and its advocates sought to bring about a centralised,
technocratic organisation of public services. This thesis will go beyond the existing literature,
however, in two ways. One will be by emphasising the local dimension of efforts to bring
about the co-ordination of hospital policy, funding and administration. The other will be the
assertion that the voluntary sector was actively engaged in this movement - not only a subject
of reform, but also an agent of change.
The other area of change to be considered is that of access and entitlement. Specifically,
the issue of payment will be investigated. This was a period that saw the abandonment of old
philanthropic means of gaining admission in place of medical admission and a variety of
payment schemes. These included the means-tested system of the Lady Almoner (later renamed the medical social worker), the pseudo-insurance hospital contributory schemes and
the expansion of private wards operating on a commercial basis. It will be argued here that the
existing literature has overstated such changes, emphasising instead the continuity of a system
that remained fundamentally philanthropic. The scale of exemptions from and reductions to
patient payments granted by the almoner as well the limitations of private provision will be
discussed in making this case.
Ultimately, it will be argued, the voluntary hospital system was neither left behind by the
reforms of the day nor reformed beyond recognition by the time of nationalisation in 1948.