Barry Doyle reflects on his experience of developing a project which compares two surprisingly different hospital systems and their historiographies.
The British National Health Service (NHS) established in 1948, was significantly different to the majority of state managed hospital systems created after the Second World War. The NHS differed in two key respects – by nationalizing all of the existing hospitals from the municipal and the voluntary sector and by opting for direct state funding out of taxation which ensured treatment was free at the point of delivery. In much of western Europe, however, a mixed economy of delivery and finance was retained with hospitals owned and managed by various agencies – mainly at a local level – and funding raised through centrally mandated insurance schemes, often with a small proportion of the cost met by the patient.
What surprised me, however, was the way British historians normalised the centrally funded, nationalised service – despite its relative rarity as a model. The widely accepted view is that the tax funded nationalised system was a political solution by Bevan in the face of resistance from the voluntary and municipal sectors to joint working. This was reinforced by Whitehall’s desire for a universal and uniform system and general fear of a funding gap that would have to be met by either voluntary contributions or private insurance. Yet it is apparent that in other countries, and especially France, these issues were not perceived as intractable – and even potentially desirable.
In an effort to understand Britain’s different path I looked for an historiography which placed the UK in an international context. Maybe we could understand Britain’s choices if we contrasted them with the route taken in France, Germany or the Netherlands. Yet it was quickly apparent that such studies did not exist. Indeed five years ago there were only a couple of books in English on the French hospital system and nothing on German inter war hospitals while comparative studies were like hen’s teeth.
I decided to embark on a comparative study myself. Easy access and my rusty French meant the choice would be somewhere in northern France. Given that my British research had focused on industrial towns in the north of England I chose Lille. For the period I was interested in (1900-40) Lille was France’s fifth city, it had an industrial structure very similar to Leeds (one of my English case studies), an important regional role, and, as it turned out, excellent hospital records easily accessible in the very efficient Archives Départementales du Nord. Since 2010 I have been making visits to the city – including the very welcoming Archives Municipales Lille – and aided by a very liberal policy on photographing material I have acquired a substantial body of documentation from which to start building my own comparative study.
The simple operating theatre at La Charite, Lille around 1900
As might be expected this is proving very challenging. First, there remains little comparative research in English on twentieth century health systems. Martin Gorsky is addressing this by both macro level studies of systems (eg in Mark Jackson’s Oxford Handbook of the History of Medicine) and his recent comparison of the UK and US – but there are no local level comparative studies of Anglo-European provision. Second, it is challenging addressing very different historiographical traditions. Much of the work on France in English is by north Americans and has been heavily focused on maternalist policies, nursing provision and other highly gendered issues. These are vitally important in a French context but they are crowding out the history of general health provision. Tim Smith’s is the sole Anglophone contribution addressing the finance and management of health care in general but it remains locked in a statist paradigm which sees the local as a block on progress rather than the central building block of a modernising system. Such whiggish faith in the state as an unequivocal force for good has few supporters in Britain these days where most historians recognise that the central state played little part in developments in the inter war period. Indeed, much radical change was initiated by the voluntary sector.
La Charite, Lille – one wing for the Catholic University the other for the City
Faith in the state and a broadly progressive narrative also dominate the French language material on early twentieth century hospital provision. This is the third challenge. Not only do I have to read and understand nuanced argument in a second language but I have also been confronted with a very different historiography. The differences are not particularly of approach – there is no grand theoretical position for example – but the state of the debate is roughly where it was in Britain fifteen years ago. Moreover, there is still very little written on hospital finance or on the inter war period, but much on maternity provision and on the impact of the laicization of the nursing profession. There is also an enduring faith in progressive science and a belief in the medicalisation of the hospital which is currently being challenged in studies of British hospitals. Obviously research by scholars such as Christian Chevandier is finessing the traditional approaches of historians like Jean Imbert but this is small scale at present.
Contrasting accounting systems, mid-1920s
Similar problems have been thrown up by the sources. Fortunately by the 1920s most of the sources from the Hospices de Lille and the City Council are printed and/or typed but how information was collected and disseminated and the purposes of that information were very different in England and France. In particular, British voluntary hospitals published increasingly voluminous annual reports providing detailed background on finance, management and control issues as well as patient data, descriptions of building work and notable events. These reports were motivated by a desire to demonstrate utility and provide accountability to a range of stakeholders who invested in the hospitals through voluntary and quasi voluntary actions. For French hospitals these do not exist. Here the key concern was robust evidence of costs to justify the day rate for patients charged for insurance cases and to reassure the council that their subsidies were needed. This has obviously raised issues of comparability of data – but I think I have come to terms with these. Understanding different accounting practices has been more challenging and I am still working on that!
As I have become accustomed to these structural variations I can see the clear distinctions in management, control and delivery of hospital services that might help me understand divergent paths after 1945. In Britain a common criticism of the pre-NHS system is the separation of ownership between the local state and voluntary providers. It is frequently suggested that this division fed in to Bevan’s decision to nationalise the hospitals in 1948. In France, however, nineteenth century legislation promoted a single administration for hospitals in the main urban centres and this had occurred in Lille in the 1850s with the establishment of the Administration de Hospices de Lille chaired by the mayor but with a majority of non-council members. This led to a planned approach to service provision especially in the super hospital project of the 1930s. More disconcerting for the secular British historian was the enduring importance of confessional differences with the large, modern La Charité hospital divided into a Catholic and a secular wing for teaching purposes. Similarly the enduring presence of nuns on the nursing staff, especially in the hospices, was surprising – although a religious order did continue to provide the nursing at the North Ormesby hospital in Middlesbrough until the early 1920s.
Benefits of a contributory scheme – Leeds, 1930
The greatest contrast was the way the two systems were financed. In the nineteenth century the Hospices de Lille depended on invested income from legacies and donations with a small regular contribution from local taxes. From 1893 these were supplemented by the first of a number of state insurance schemes designed to cover specific groups of patients. Initially Assistance Médicale Gratuite (AMG) was available only to the poorest while the addition of OA for the elderly extended the system to the type of person who filled the hospital and hospice wards of both countries. Similarly, in Britain both the voluntary hospitals and the poor law infirmaries were for the sick poor or the sick pauper, with the elderly heavily represented. However, while the poor law secured its funding from local taxation, the voluntaries relied on subscriptions, donations, legacies and local fundraising. Significantly, when National Health Insurance was introduced in 1911, with a few exceptions it excluded hospital treatment, cutting off the kind of state mandated support which was emerging in France.
In the wake of the First World War the systems in both countries were put under extreme financial pressure by inflation, a decline in subscriptions, rising cost and especially rising demand. Faced with this financial crisis the voluntary hospitals in Britain switched to a system of direct and indirect charges paid for through a range of contributory mechanisms the most important of which were the mutualist workers’ contributory schemes studied by me, Gorsky, Mohan and Willis, Steve Cherry and George Gosling. These schemes transformed the funding base of the voluntary hospitals making them more democratic in terms of the source of their income, who it was they treated and in some case who ran the institutions. Contributory schemes effectively saved the voluntaries – which provided most of the acute treatment – from bankruptcy and probably state control. Indeed, the new system was so effective the voluntary hospitals were able to expand between the wars, treating many more patients in more sophisticated environments – though rarely in new general hospitals.
In France, however, the financial crisis destroyed the traditional base of investment income derived from legacies. Yet the hospitals could not tap into new voluntary sources as they did in Britain as there were no (or only very weak) structures to mobilise voluntary or mutualist contributions. Instead, as Smith has shown for Lyon, they became increasingly reliant on subventions from the council, made more necessary in Lille where the war and occupation had further undermined investments. But subvention without control caused tensions and increasingly local and national politicians sought formal state structures. These came in 1928-30 with the extension of medical insurance to around half the population with the scheme further extended in the early 1930s and more formally in 1941. The structure introduced in 1928-30 became the basis of the contemporary French system while the exclusion of hospitals from British National Insurance forced the voluntaries to find new sources which strengthened their position in the second quarter of the century.
So international comparative history is proving very challenging but also very rewarding. Language, historiographical traditions, legal and structural diversity and distinct cultures of voluntarism have all had to be negotiated as I move towards completing my first article which I hope to submit in the next few months. The process has certainly benefitted me as a historian by broadening and deepening my understanding of both British and French history. But it has also revealed that things with the same name can be very different in different contexts – a theme which a number of us in the Centre for the History of Public Health and Medicine will be exploring in our research in the coming months.
You can hear an early paper on the contrasting response to the financial crisis of 1918-28 in Leeds and Lille here