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Wed 12 April
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Thu 13 April
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Sat 15 April
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Wednesday 12 April 2023 08.30 - 10.30
R-1 HEA01 Charity and the Hospital in the British Welfare State since 1945
E45
Network: Health and Environment Chairs: -
Organizer: Martin Gorsky Discussants: -
Moderators: -
Agnes Arnold-Forster : The Role of Charity in Hospital Rebuilding and Design: Guy's Hospital Tower
In 1974, Guy’s Hospital in London, UK, added the 34-story Guy’s Tower and 29-storey Guy’s House. This complex was designed by architect Watkins Gray and was, when built, the tallest hospital building in the world, standing at 148.65m (487.7ft. This paper will take this case study of hospital design, building, ... (Show more)
In 1974, Guy’s Hospital in London, UK, added the 34-story Guy’s Tower and 29-storey Guy’s House. This complex was designed by architect Watkins Gray and was, when built, the tallest hospital building in the world, standing at 148.65m (487.7ft. This paper will take this case study of hospital design, building, and rebuilding to explore the multiple actors, interdisciplinary endeavours, and often contradictory vested interests involved in the development of NHS hospitals in the middle decades of the twentieth century.

When the NHS was established in 1948, the distribution of hospitals across the country was uneven and in 1962, the Ministry of Health conducted a review of existing services. The Hospital Plan for England and Wales prompted a spate of hospital building and rebuilding and provided a new financial and political impetus for Guy’s existing plans for an additional tower.

The Hospital Plan has been the subject of much recent scholarship (DeVane, 2021; Fair 2018; Hughes, 2000; Mohan, 2011). This paper will expand on this literature and add another case study to the roster. But it will also address a hitherto neglected aspect of hospital rebuilding and design: charity. While NHS hospitals were state funded, many teaching hospitals had been allowed to retain substantial endowments, and Guy’s used that financial heft not just to pay for the part of the project, but to expedite its progress, supersede the interests of the Ministry of Health, and influence the tower’s form, use, and design.

As this paper will show, the history of Guy’s Tower exposes the various conflicts and collaborations between architects, healthcare professionals, hospital management, the Ministry of Health, and – crucially – the historical legacy of charitable provision, in the making and re-making of the hospital landscape in twentieth-century Britain. (Show less)

Rosemary Cresswell : Charitable Funding for British Mental Health and Learning Disability Hospital Care in the Era of the NHS
Hospitals entered the NHS with different rules regarding how their endowments were treated, as discussed within Bernard Harris’ paper. This left mental health hospitals and those focussing on learning disabilities in some areas of the UK, in particular Northern Ireland, to cope with very little charitable funding in comparison with ... (Show more)
Hospitals entered the NHS with different rules regarding how their endowments were treated, as discussed within Bernard Harris’ paper. This left mental health hospitals and those focussing on learning disabilities in some areas of the UK, in particular Northern Ireland, to cope with very little charitable funding in comparison with general hospitals. However, one major exception was the endowment of Bethlem and the Maudsley in South London, which had charitable funds rivalling some of the leading general teaching hospitals in the capital.

This paper compares the ways in which mental health hospitals and institutions caring for patients with learning disabilities responded to the disparities in funding from endowments, particularly looking at fundraising activities from committees, including the enthusiasm of some of the hospitals’ own staff in order to raise money to improve patients’ experiences. It contextualises these efforts within the marginalisation of mental health care within the new National Health Service. Further efforts to support hospital care were undertaken by charities including the National Association for Mental Health which combined three voluntary organisations in 1946, the Northern Ireland Association for Mental Health which was founded by Lady Wakehurst, the wife of the Governor in 1959, and charities run by parents of children with disabilities. The Retreat, in York, and St. Andrew’s Hospital in Northampton, maintained their independence outside of the NHS, as charities. The paper explores how and why charities were relied upon to support care in mental health hospitals, and in hospital settings for people with learning disabilities, during the first decades of the National Health Service. (Show less)

Bernard Harris : Repugnant to a Civilized Community: Charitable Funding in the Early NHS
This paper examines a key aspect of the relationship between charity and the establishment of the United Kingdom’s National Health Service(s) in 1948: the distribution of endowment income and the future of charitable fundraising for public health care.

Prior to 1948, the UK possessed a patchwork of different types of hospital: ... (Show more)
This paper examines a key aspect of the relationship between charity and the establishment of the United Kingdom’s National Health Service(s) in 1948: the distribution of endowment income and the future of charitable fundraising for public health care.

Prior to 1948, the UK possessed a patchwork of different types of hospital: unreformed Poor Law hospitals, municipal hospitals (including not only former Poor Law but also specialist institutions for the treatment of infectious diseases and other conditions), and voluntary hospitals. However, this patchwork came under increasing pressure during the 1930s and early-1940s, culminating in the passage of the three National Health Service Acts, dealing separately with the three jurisdictions of England and Wales, Scotland and Northern Ireland, between 1946 and 1948.One of the most important issues confronting reformers was the status and financing of the voluntary hospitals. The majority of these institutions had been established over the course of the eighteenth and nineteenth centuries as charitable institutions and they continued to derive significant proportions of their income from endowments and other charitable sources. However, when the Minister of Health for England and Wales, Aneurin Bevan, introduced the first of the National Health Service Bills in 1946, he described the hospitals’ continued reliance on charitable funding as ‘repugnant to a civilised community’ (House of Commons Debates, 30/4/1946).

The establishment of the NHS(s) therefore had two major implications for the role of charity within the health care system. In the first place, it raised fundamental questions about the status of the charitable funds which many hospitals had already amassed. Second, if it was also accepted that charity should not have a significant role to play in the provision of core health services, what role should it play? What role did the Government foresee for ‘voluntarism’ within the health service(s) once the new arrangements came into force?

This paper will endeavour to answer these questions by looking at the history of voluntarism before the NHS Acts came into operation and then examining the ways in which the three Acts addressed the problem of hospital endowments. The final part of the paper will look at the role of charity more broadly. It has often been assumed that, after 1948, the role of charity was quite tightly circumscribed but to what extent was that really the case, and what can an examination of the role of charity tell us about the prioritisation of different types of health care in the UK during the postwar era? (Show less)

Gareth Millward : The Internet as a Site of Voluntary Activity: NHS Charities and the World Wide Web since 2000
Despite being primarily financed by taxpayers, many hospitals in the British National Health Service also draw on significant sums raised by charitable trusts. This partially reflects the longer history of hospital care in Britain where many hospitals began as voluntary organisations financed by philanthropy; but it is also indicative ... (Show more)
Despite being primarily financed by taxpayers, many hospitals in the British National Health Service also draw on significant sums raised by charitable trusts. This partially reflects the longer history of hospital care in Britain where many hospitals began as voluntary organisations financed by philanthropy; but it is also indicative of major changes in the funding and capacities of hospitals, especially since the great financial crisis and the subsequent budgetary constraints imposed by successive governments. Historians intending to analyse how hospitals responded to such challenges since the 1990s must themselves contend with a new methodological question – how do we track changes in institutional activity over time in an era of mass internet usage?

This paper offers an example of how such work might be done. Drawing on our previous analysis of archived websites to write twenty-first-century histories of medicine, it presents research on four of the largest charitable trusts in London to show how these organisations used their websites since 2000 to communicate their charitable works. We begin by discussing the methodology we adopted to develop a corpus of material for analysis from the Internet Archive, and some of its pitfalls. We then present a preliminary outline of how this corpus itself reflects the growth of the world wide web, and the changing nature of web design as social media proliferated.
We next adopt a more traditional historical scholarship, offering a content analysis of the corpus to track the representations of charity within the welfare state. Delineating several common themes we examine visual and textual discourse to observe cross-cutting approaches across the institutions and to track change over time. These themes are: the border between charitable and public objects of expenditure; why charity is needed in the NHS; institutional history/philanthropic history and its meaning; medical technology; methods of giving; motives for giving; the hospital community; decolonising representations; and COVID 19’s impact. Our preliminary conclusion is that the websites have contributed to an increasing normalisation of charity in the health system, and that this process has accelerated since 2010 when ‘austerity’ politics have increasingly starved the NHS of public resources. (Show less)

John Mohan : The Dead Hand of Charity: Path Dependence in Charitable Fundraising and its Impact on the NHS
A familiar trope in discussions of the growth and distribution of charitable resources is that present-day patterns reflect (and are constrained by) the resources and preferences of past generations of donors. This might pose problems for charity law in contexts where the original purposes of a charitable bequest can no ... (Show more)
A familiar trope in discussions of the growth and distribution of charitable resources is that present-day patterns reflect (and are constrained by) the resources and preferences of past generations of donors. This might pose problems for charity law in contexts where the original purposes of a charitable bequest can no longer be met – hence the legal concept of “mortmain”, or “dead hand”) or for policy-making in circumstances where historic inheritances of resources bear no relationship to modern needs or policy frameworks. A well-known expression of the latter in the context of UK health policy is Brian Abel-Smith’s statement that the NHS’s inherited capital stock reflected the “donations of the living and the legacies of the dead”.

The establishment of the NHS in 1948 relieved communities of the necessity of raising funds to build and operate hospitals, but did not remove the dead hand: charitable contributions to the funding and delivery of health care in the UK continued in various forms. Compromises were negotiated in relation to the accumulated endowments of the hospitals: teaching hospitals were permitted to retain their own endowments as an incentive to innovation; for other institutions, endowments were pooled and formulae designed to ensure a degree of redistribution of funds that might made modest contributions to hospital facilities. After an initial three decades of restrictions on charitable fundraising, accompanied by somewhat vague understandings of the appropriate place for charitable funds in the NHS, the Thatcher government enabled statutory authorities to engage in such fundraising from 1980 onwards.

The landscape of NHS-related charity was from the start an uneven one, since it reflected a highly unequal inheritance. The contours of NHS charitable funds have been only partially charted to date, mainly through small-scale studies with a focus on some high-profile individual cases; the relationship of the patterns to historic distributions is unexplored. In this paper we link together data on the finances of pre-NHS voluntary institutions, including their endowments, information about the scale of teaching hospital endowments in the 1960s, and statistics on the resources, income and expenditure of a range of charities directly supporting NHS hospitals from the 1990s onwards. We cross-reference these sources so that, as far as possible, we deal with a consistent set of institutions (e.g. by combining data on individual hospitals for the pre-NHS era so that they approximate the modern-day multi-hospital NHS Trusts). This enables us to conduct an analysis of the degree to which the post-1948 distribution of charitable resources perpetuated the pre-NHS inheritance. We investigate this with reference to teaching hospital endowments, fundraising by the principal hospitals (both general and specialist), and community-level fundraising in the form of the activities of Leagues of Friends. (Show less)



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