Patient consumers in mixed economies of healthcare Kill or Cure? The History of Medicine and Health WHI176: University of Warwick

Health Minister Aneurin Bevan on the ‘appointed day’ of 5 July 1948 when the NHS came into force

Political context for historians of the mixed economy of healthcare

mixed economy: the sectors Private Sector This is what most directly correlates to the ‘medical marketplace’, here we find medical services traded on a commercial basis. Voluntary Sector Hospitals and dispensaries providing medical advice and treatment to the poor as well as funding peripheral services and research. Public Sector Historically associated with poor relief and municipal (local) government, the zenith of the central state’s involvement is the NHS. Informal Sector Often overlooked is the fundamental role played by family and community networks of care and support at times of sickness.

Hospital contributory schemes

A voluntary hospital subscribers’ ticket

Mary Fissell on the ‘articulation of social difference’ in this ‘new channel for paternalism’ “the recommendation from a hospital supporter required by a prospective patient a form of social exchange in a face-to-face society. The hospital provided an arena for the mediation of social power, both directly through individual patronage, and symbolically through civic ritual and display.”

‘Receiving day’ at the London Hospital, Whitechapel

A Sheffield almoner interviewing patients in 1922

BMA income limits for general wards c.1926 Class Limit Open to 1 £200 a) single persons over 16 years of age b) widow or widower without children under 16 years of age 2 £250 a) married couples without children under 16 years of age b) persons with one dependent under 16 years of age 3 £300 a) married couples with a child or children under 16 years of age b) persons with more than one dependent under 16 years of age

Picture credit (left): Above: ‘A Ward for Paying Patients’ at the Great Northern Central Hospital, Holloway Road in London, 1912 Left: The Baker Memorial Wing for Private Patients at St George’s Hospital in London, c.1937

International comparisons USA ‘Private patient revolution’ – Charles Rosenberg ‘The rise of hospitals offers a study in the penetration of the market into the ideology and social relations of a precapitalist institution’ – Paul Starr IRELAND Hospital Sweepstake FRANCE In local ‘mini- welfare states’, interwar hospitals were transformed ‘from refuges for the poor to medical establishments intent on catering for all but the wealthy’ as part of an agenda to ‘modernize and democratize’ – Timothy B. Smith Middle classes in hospitals led by sliding scale payments but also developments in social insurance

THE EARLY TWENTIETH CENTURY AS A TIME OF CHANGE In days gone by such conditions as appendicitis were treated with poultices and drugs in the patient’s home. Now they are treated by operation, which is more effective, but requires more equipment, a team of workers, and a larger expenditure. Such conditions as diseases of the lungs formerly received clinical examination and treatment by drugs. They may now require, in addition, the attention of the pathologist and the radiologist. This means greater efficiency, but more organisation and higher cost. Bertrand Dawson 1st Viscount of Penn

Health Minister Aneurin Bevan on the ‘appointed day’ of 5 July 1948 when the NHS came into force

Mel Calman cartoon in The Times (4 December 1981) Some depictions of the public are passive, those excluded through inability to pay – i.e. Significance increases to NHS charges in the early 1980s But many show NHS patients as economic actors, despite the central (moral) mission of the NHS to demonetise healthcare 2. Does so ironically, but the Giles cartoons do this consistently… Mel Calman cartoon in The Times (4 December 1981) Keith Waite cartoon in The Sun (6 May 1968)

John Jensen cartoon in the Sunday Telegraph (26 March 1971)