Christmas is the season of charitable
enterprises. Last month, the London School of Economics commemorated the life and work of
Professor Brian Abel-Smith, the distinguished British health economics and policy analyst.
It is just over 40 years since he published his history, The Hospitals, in which he
explored the mixture of professional interests and charitable sentiments that inspired the
growth of the voluntary hospital movement in Britain.(1)
Abel-Smith was critical of
the manner in which the largely unregulated exercise of clinical discretion and undirected
benevolence sometimes distorted the ordering of priorities in the development of health care
before 1946. At the same time, he was in no doubt that charitable endeavour and medical
professionalism had always been forces for good in the enhancement of human welfare.
However, The Hospitals also stands out as a celebration of the virtues of
collective benevolence in the public sector of health care. It is a work that describes, in
lucid and engaging prose, the reasons why it was necessary to create a national health
service in 1946 and why it took the form it did. Abel-Smith also shows why the voluntary
hospital movement, despite its laudable achievements, had ceased to be financially viable
after the second world war.
In two respects, at least, we compare unfavourably with our
Victorian forebears. Firstly, in the supposed heyday of rugged individualism, successive
governments found the money and the will to launch a major building programme of public
hospitals when the need for them became apparent. They responded to this challenge in a
spirit of compassionate pragmatism rather than dogmatic attachment to abstract economic and
managerial theories.
Secondly, in defiance of the principles of less eligibility, many of
the medical staff of the poor law infirmaries gave the benefit of the doubt to patients
whose medical needs were less urgent than their need for good food, warmth, and social care.
Countless children of the poor, nursing mothers, and infirm elderly were kept on the wards
as semiconvalescent cases in order to build up their health and strength before their
discharge.
Of course, we can no longer afford to use hospitals as centres of social care
for the frail elderly and chronic sick. Nevertheless, it remains the case that--despite all
the vagaries of social reform from the Seebohm report(2) to the creation of internal
markets--there is still nowhere for many of these patients to go after hospital discharge if
they cannot afford to buy the care they need. As a result, our local authority social
service departments are being transformed into de facto destitution authorities of last
resort and minimal resource.
The Hospitals covers a subject and a period in which
the voluntary hospitals movement came to epitomise all that was best in the traditions of
charity. But from the 1870s onwards our governments came to recognise the limitations of
both charity and private markets in health care. Their bold initiatives in the public sector
did not spring out of a moral vacuum; they were as characteristic of the political culture
of Victorian society as were laissez faire and commercial enterprise. It was a time, unlike
our own, in which public servants were looked on as useful members of the community rather
than as public enemies. It was also a time in which doctors exercised perhaps too much
professional discretion, but who is to say that such a state of affairs was less preferable
than one in which they exercise hardly any at all?
Nineteenth century medical charity was
dispensed through the exercise of lay and professional discretion. The provision of health
care today is, or ought to be, grounded on the bedrock of reciprocal civil rights and
obligations. However, as voters, our rights to health care can be met only if we honour our
reciprocal obligations as tax payers. If we fail to do so, more and more categories of
patients will find that their rights to free care are diminished. As the mainsprings of
public benevolence run dry we will, once again, become increasingly dependent on the
idiosyncrasies of charitable discretion.
Robert Pinker
Professor of social
administration
The London School of Economics and Political Science,
London WC2A
References
1 Abel-Smith B. The Hospitals 1800-1948. London:
Heinemann,1964.
2 Seebohm F. Report of the committee on local authority and allied
personal social services. London: HMSO, 1968.
