Drawing on hospital reports, committee minutes and the local press, this article examines the changing landscape of urban civic culture and challenges the pessimistic accounts of charitable financial support for voluntary hospitals in inter-war England.Through case studies of hospitals in four of the largest cities in the country, it assesses the extent to which voluntary resources of time and money continued to underpin day-to-day institutional income, stimulate the development of the hospitals' estates and investments, and enable hospitals to cut costs through the receipt of gifts in kind. It argues that by broadening the bases of charitable income, hospitals were freed from their dependence on the wealthy thus ensuring their transformation to modern community resources for all.Any welfare history that focuses on the transition from the 'active citizen' to the 'active state' needs, as Finlayson rightly notes, to take into account the many ways in which 'past traditions survive and influence what comes after them'.1 Perhaps this was more likely still within a local rather than national environment, where identity, belonging and response were more closely interlinked.2 Yet by the end of the nineteenth century the rhetoric and practice of philanthropy as an expression of urban civic attachment was supposedly losing its appeal.3 Local association, and a sense of localism itself, arguably succumbed to a homogeneous national middle-class identity, which was in many ways anti-local and anti-working class. Cities in this rendition became essentially working-class spaces, bereft of middle-class influence, marking the beginning of the end of 'a once vibrant urban culture'.
The history of the English hospital in the first half of the twentieth century has been the focus of considerable debate from the very beginning of the National Health Service. 1In the early post-war years a powerful image was built up of the mix of voluntary and local state provision as one characterized by restricted access, over-weaning charity, stigma and inadequate coverage. Hospital services were undemocratic, inefficient, underfinanced and uncoordinated, staggering from one crisis to another yet unable to help themselves due to professional and political rivalries, which prevented rationalization.2 However, recent years have seen the development of a more thorough hospital history for the interwar period which provides an increasingly nuanced approach to the pre-NHS system. Initial revisions were provided by Steven Cherry, whose work on voluntary sector funding 3 began to suggest a less pessimistic story about the situation in the 1930s than that of Brian Abel-Smith and Robert Pinker or even Charles Webster. 4 The changes within the voluntary sector have been further examined by
Our historical case studies begin with Spain and Brazil, to observe hospital models rooted in early modern charitable practices, where politics and pace of economic development forestalled moves to universalism until quite late in the twentieth century. 10.5920/PoliticalEconomy.fulltext the Medicare programme, which until the 1980s allowed private hospitals to set their own fees. Yet she also finds examples of citizens utilizing federal programmes to demand greater access to care: the medical civil rights movement's protest at segregated hospitals in the 1960s; Medicaid recipients' law suits against hospitals that refused to accept poor patients in the 1970s; and the establishment of a right to emergency care in 1986. The chapter concludes with the impact of the 2010 Affordable Care Act ('Obamacare') which provides federal subsidies to the private health insurance industry and expands Medicaid coverage for low-income people, bringing hospitals millions of newly insured patients. It thus embodies the same public-private paradox. The book closes with China, whose case demonstrates the adoption of the biomedical hospital in a great power undergoing rapid modernisation, in conditions of intense political upheaval. Xu and Mills begin by pointing out that although China was once considered an international model for low-cost rural primary health care, this reputation was founded on a short-lived combination of factors. Over the long term, China has instead suffered from chronic concentration of high-quality resources in its hospitals, despite recurrent efforts to strengthen primary care. Their chapter analyses the historical evolution of both hospitals and primary care in China from the perspective of financing, in a study covering the period 1835-2018. It shows that the developmental trajectories for earlier models of hospital and primary care diverged between 1835 and 1949, with low-cost primary care emerging only after the establishment of relatively elitist hospitals. The divergence was consolidated, they argue, between 1949 and 1978, giving rise to two different models with contrasting fiscal space, service-finance methods and administrative policies. After 1978, market-based financing mechanisms brought direct competition for patients and resources between hospitals and primary care providers, and exposed the weakness of the latter. Pharmaceuticals and technologies became critical vehicles for 10.5920/PoliticalEconomy.fulltext
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