They are little remembered now, but before the introduction of the NHS in 1948, some 1,000 women at hospitals across the country policed the boundaries of medical charity, public and private healthcare. It was the job of these ‘lady almoners’, as they were known, to interview patients and decide an appropriate rate. They increasingly also helped to make sure patients received the support they needed when they left the hospital (this had become their primary role by the 1960s, when they officially rebranded themselves as ‘medical social workers’).
During Victorian times, the hospital was an institution that meant very different things for people of different classes. Associated in the public psyche with poverty, those who could afford a private doctor stayed away from the hospital at almost any cost. All hospitals – whether a workhouse infirmary or an elite voluntary hospital – were institutions founded and funded by the middle and upper classes to serve the medical welfare needs of the working-class population without charge.
Despite a complete lack of evidence, there was widespread fear in the 19th century that the system was being abused. This led to the first almoner being appointed at London’s Royal Free Hospital in 1895; one Miss Mary Stewart had the task to assess those coming to the hospital for treatment. Some were to be told they were too well-off, so should be treated privately. Others were told they should make some financial contribution to the hospital. The remainder received treatment for free but were advised to join a community savings scheme to ensure they could pay their way in future.This system was copied in a number of other London hospitals and, after the First World War, was rolled out across the country. In challenging economic circumstances – when the latest treatments were becoming more expensive to provide and demand for them was increasing – the hospitals reluctantly turned to the patients themselves as a source of income.
Associated in the public psyche with poverty during Victorian times, those who could afford a private doctor stayed away from the hospital at almost any cost. This illustration from The Illustrated London News depicts a ward in the Hampstead Smallpox Hospital, c1871. (Photo by Oxford Science Archive/Print Collector/Getty Images)
Hospitals didn’t appoint financial clerks or debt collectors to administer this new system.
Instead they turned to almoners, who took into account an individual’s social background and family set-up when determining the appropriate amount that they should pay.
For this reason it was understood to be a distinctly female role. While the nurses could care for the sick and the midwife would guide the mother through birth, the almoner could advise on the practical family and financial implications of sickness. As the secretary of one hospital told a King’s Fund committee in 1912, “the Almoner’s work is ladies’ work” – but added that “ladies are usually better if they are suited for the work. I mean ladies who are really ladies”.
These class assumptions usually went unspoken. But it was assumed that the person making decisions and offering guidance over the financial aspects of treatment for working-class patients should be a respectable, educated, unmarried middle-class woman.
The first generation of these women came from the world of charity work, usually from the notoriously moralistic Charity Organisation Society. However, two-year courses were soon established that combined practical experience with social and economic studies at university.
The almoners’ payment system began in the more prestigious voluntary hospitals, but soon spread to public hospitals also. With its introduction came the separation of middle-class patients, often into a few private rooms within the hospital. These would often be on a different floor to the ordinary wards – or perhaps in a different building entirely, sometimes taking over a section of the nurses’ block. This ensured that provision for the sick poor was not being crowded out while also preventing the two classes of patients from having to ‘rub shoulders’.
The payment system was now echoing and formalising the social hierarchies and class distinctions of healthcare beyond the walls of the hospital. Private medicine was a marginal activity of the hospitals, but private surgeries were far more common. Doctors used the prestige of hospital work to build their credentials for lucrative private practice.
For most people, however, the doctor’s fee of around sixpence (let alone the cost of any medicines prescribed) would have been beyond reach. As a result, two schemes provided an alternative for working-class patients.
One was the health insurance element of National Insurance, introduced in 1911 by Liberal Chancellor of the Exchequer David Lloyd George and expanded throughout the 1920s and 1930s. This was a compulsory insurance scheme for workers in certain industries, though it generally did not cover family members. The insurance granted access to a doctor from the local panel when needed, but usually didn’t stretch as far as hospital treatment.
The other scheme was membership of one of the various community-owned mutual aid funds and medical clubs, into which working people could pay while times were good. They would receive access to a doctor, medicines and sometimes hospital treatment without having to see the almoner, by means of paying in advance.
Nurses distribute tea at St Bartholomew’s Hospital, London, in 1939. The almoners payment system in early 20th-century hospitals ensured that provision for the sick poor was not being crowded out, says George Campbell Gosling. (Photo by Kurt Hutton/Picture Post/Getty Images)
There were also some health insurance schemes available to middle-class individuals, helping them to meet what could be a substantial cost for treatment – whether in the private room of a hospital, a private nursing home or in their own home.
Unlike the working-class medical clubs, these organisations survived the creation of the NHS in 1948 by covering the fees for services that fell beyond the scope of the NHS, and for private hospital wards, which were kept as ‘pay beds’ for those who wanted to go private in NHS hospitals.
So, while we tend to think of the NHS’s defining feature being its delivery of a free health service, private wards were one element of payment that continued within the NHS. Plans to phase them out, championed in the 1970s by Labour MP Barbara Castle, were finally abandoned followed the Conservative election victory in 1979.
The idea, when Aneurin Bevan first introduced his new health system in 1948, had been to abolish most forms of payment. It was, however, an ambition that was not shared by all – even some within his own Labour party opposed it.
British minister of health Aneurin Bevan and his wife Jennie pay a hospital visit, c1950. (Photo by Keystone/Hulton Archive/Getty Images)
We sometimes imagine the NHS as being at the heart of a post-war consensus in British politics. But if there was a consensus over the NHS, it began not in 1948 but in 1951. Not with the realisation of Bevan’s vision, but with his resignation in protest at the introduction of charges for dentures and spectacles, and with the door opened for an incoming Conservative government to introduce prescription charges as well.
One of the junior ministers who resigned alongside Bevan was the future prime minister Harold Wilson. A year after he came to Downing Street in 1964, a second three-year stint of free NHS prescriptions began, designed to ensure that the new system of prescription charges included exemptions for the poorest and that sickness did not result in financial hardship – the same priorities that had guided the pre-NHS hospital almoners.
In the 21st century, under devolution, Scotland, Wales and Northern Ireland have all returned to a version of Bevan’s universalist health system by abolishing prescription charges. Yet in England we have a compromise of a free health service with elements of payment, rooted in traditions that go back even further than 1948.
Dr George Campbell Gosling is lecturer in history at the University of Wolverhampton and author of Payment and Philanthropy in British Healthcare, 1918-48 (Manchester University Press, 2017). Thanks to funding from the Wellcome Trust, this is available as a free open access e-book via the OAPEN Library.