An important goal of NHS policy today is to increase public involvement in health care, most notably through the Patient and Public Involvement Forums associated with NHS trusts. In the hospital sector this has led to the controversial establishment of foundation trust 'membership communities', which aim to give local citizens a say in management. This is not the first attempt to introduce greater community participation in the running of British hospitals. Prior to the birth of the NHS in 1948 the hospital contributory scheme movement provided ordinary members of the public with the chance to sit on hospital management boards. This article examines the nature and extent of Britain's earlier experiment with local democracy in hospital governance. It argues that historical precedent is not particularly encouraging, either for the prospect of broadening popular participation, or for making services more responsive to local needs. It therefore points to those areas on which government should concentrate if the policy is to be implemented effectively.
NHS foundation trusts are independent public-sector organisations, created to give hospitals increased financial freedoms with more autonomy from Whitehall control. A central argument for the establishment of foundation trusts is the need for greater local responsiveness in hospital policy. The Health and Social Care Act (2003) duly established a framework of 'membership communities', whose members can vote for, and stand as, governors of the trusts. The aim is to ensure that governors genuinely represent the interests of the hospitals' users and can hold the trusts' boards of directors accountable to local populations. Guiding this strategy is the assumption that an untapped reservoir of active citizenship exists from which members can be drawn. Proponents argue that this will enhance responsiveness and reduce health inequalities through the better articulation of local needs. Doubters ask whether local consultation will be perfunctory, with central control still dominant through the machinery of national policies and priorities, exercised through target setting and the audit culture. Conversely there are fears that active localism risks surrendering policy to interest groups whose preferences could jeopardise equity.
What guidance does the history of hospital management offer on the scope for popular participation? Politicians and policy advisers regularly allude to historical precedent to justify what is regarded as a mutualist and localist approach. They suggest that membership communities are a revival of Victorian welfare initiatives such as co-operatives and mutuals. This makes them part of the labour movement's tradition: 'a rebirth of popular socialism', according to Ian McCartney M.P. (1) Before the NHS, argues Hazel Blears M.P., 'local people had ...provided the money and support to develop and maintain the hospital. The sense of affiliation felt for their local hospital was developed through a form of funding and governance that provided people with a real local relationship'. (2)
Hitherto little direct reference has been made to the experience of the mass hospital contributory schemes, whose heyday was between 1918 and 1948. Their primary goal was fund-raising, but they also provided an avenue for ordinary citizens to join management boards. So while they do not offer a direct parallel with NHS membership communities, in that participation was tied to financial support, they do provide an intriguing test-bed for contemporary claims about the scope for public involvement. An examination of their history can tell us: first, what democratic procedures existed for grassroots representation on hospital boards before the NHS; second, how extensive was citizen participation in these arrangements; third, how satisfactorily were local needs articulated and addressed under this system; and fourth, whether the attitude of the labour movement towards hospital contributory schemes confirms that this was, indeed, a forgotten labour tradition ?
With the coming of the NHS in 1948 the government took control of what had hitherto been a highly disparate hospital system. Prior to their nationalisation, some 59% of hospital beds had been administered by local authorities, but the remainder were in the independent voluntary sector. Voluntary hospitals had originally been funded by charity and were managed by volunteer boards, typically made up of professionals and industrialists drawn from the subscribers. They provided the bulk of acute care, and included the major teaching hospitals as well as general, special and cottage hospitals. As rising taxation undermined philanthropy after 1914, voluntary hospitals faced financial shortfalls and responded by developing mass contributory schemes. These had their origins in Victorian workplace collections, known as Saturday Funds, which elicited small weekly subscriptions from the working class.
In the interwar period these hospital contributions were made principally through a payroll deduction from employees, and to a lesser extent through household collections, at rates of between 1d and 4d per week. Many, though not all, schemes set income limits to exclude the middle class. The majority were comparatively small and affiliated to a single hospital, from which they were run. Others, particularly in the major cities, were large, independent organisations which supported a range of hospitals. The main benefit enjoyed by contributors was free treatment at a voluntary hospital. Non-contributors by contrast, would face out-of-pocket charges for their maintenance, and in much of England almoners were employed to means-test patients on admission. In cities with several different hospitals, schemes operated a central fund disbursing to institutions according to their rates of utilisation by members, and they typically offered additional benefits such as access to convalescent homes, nursing services and ambulance fleets.
Some contributory schemes were very large: the Hospital Saving Association (HSA) was London's main scheme and had about two million members in 1939, while Birmingham's had 690,000, and Merseyside's 350,000 (all three still operate today as health cash plans providing low-cost medical insurance). Nationally there were perhaps ten million contributors. And crucially, the schemes provided the basis for contributor representation on hospital management boards. The constitutions of some specified that in addition to fund-raising the role of these 'worker governors' was to articulate contributors' views and ensure that the service met their needs. The discussion which follows draws on the documentary archives of several major schemes to examine this side of their work.
Elaborate procedures for the representation of ordinary contributors on hospital governing boards existed in the majority of large schemes. Although there was considerable variation between places, it was usual for a representative to be elected from each contributing workplace or district who would attend the scheme's Annual General Meeting. Here delegates would elect a small executive committee to manage the fund, and choose representatives to sit on the boards of management of hospitals which they supported. In some large cities (such as Sheffield, Birmingham and Liverpool) hospital policy was overseen by a 'Hospitals Council', on which scheme contributors sat alongside members from hospitals, local government, the business community and the university. In smaller towns, with a single hospital which managed the fund directly with no separate executive, the elections were sometimes direct to the hospital board. In London, with 146 voluntary institutions by 1938, the HSA contributors did not elect to hospital management boards, but instead to an executive body on which their representatives had one third of the seats.
Although these selection procedures were scrupulously observed, evidence suggests that active participation was far from universal. In Glasgow, for example, of 790 firms entitled to nominate delegates in 1930, 300 did so, and of these 187 attended the AGM. A 1947 survey published by William Beveridge found that nationally 97% of contributors were inactive, and only 1% attended meetings quarterly or more. Moreover, much of this volunteer involvement within the schemes was geared towards fund-raising and publicity matters, rather than questions of hospital policy. On the hospital management boards or Hospitals Councils the worker governors remained in a minority position, typically with no more than one third of the seats and therefore outnumbered by middle-class trustees and doctors. Hospital leaders generally cultivated an ethos of consensual management in the broad public interest, rather than encouraging decision-making through partisan debate. For example, when confronted in 1941 by contributors' claims for a greater say in hospital management in Leeds, Alderman George Martin rebuffed them thus: 'Don't worry about representation on the hospital boards... they are not like a city council. They do not sit on each side of a table and vote according to numbers. Your representatives come to give us their best..' not to '..represent the Fund and its members.' (3) Indeed it was more common for schemes to present themselves as charitable endeavours rather than avenues of democratic engagement.
Because hospitals relied on pay-roll deductions they were obliged to seek support from local trades councils, Labour parties and trade unions. Consequently leading figures from unions and co-operative societies were ubiquitous as scheme executives and contributor representatives on hospital boards. Some were dedicated civic activists who treated hospital fund-raising as an aspect of labour's social mission. A good example is Moses Humberstone, President of Sheffield Contributors Association, 1922-1939, and also assistant secretary of Sheffield Trades and Labour Council, who declared himself: 'in love with the movement'. Trade-unionist governors occasionally used their position on hospital boards to press for improved pay and conditions for nurses and ancillary workers; sometimes they were successful, though their leverage was compromised by their dual position as hospital managers and fund administrators. More crucially they acted as intermediaries between fund and workers, ensuring that contribution rates were reasonably set in accordance with local wages.
Despite their support for their local voluntary hospitals however, there is good evidence that trade unionists favoured the interwar Labour Party's policy goal of a tax-funded health service administered by elected local government. For example, Luke Hogan, chair of Merseyside Trades Council and Labour Party, argued in 1928 that a tax-based national health service was 'the only ultimate practical solution'. However, interim support for the local contributory scheme was desirable '...in the light of present day humanities and ... of the thousands of unemployed and poor people ... dependant (sic) on these Medical Institutions ....'. (4) The labour movement then, was ambivalent about the value of the voluntary sector, regarding the schemes as a temporary expedient in the march towards a public hospital service. For Labour, local control of hospital policy could be more satisfactorily achieved through the municipal ballot box.
Advocacy by contributor representatives on behalf of patients was a regular if infrequent feature of scheme business. Many such complaints were of a generic nature and concerned issues which might worry any group of hospital users, such as waiting lists, visiting times, poor treatment of particular cases by individual doctors and the quality of accommodation. It is also notable that the degree of oversight of hospital affairs which worker governors were able to exercise was rather less than that subsequently demonstrated by the Community Health Councils. These were statutory bodies operating within the NHS between 1974 and their abolition in 2003; their records show them conducting regular ward visits followed by systematic feedback, commissioning independent research on particular issues and so on.
Only rarely before the NHS did contributor representatives voice genuinely local concerns in which a distinct policy preference was expressed. For example, in 1923, during one of Britain's last smallpox epidemics, contributors in Gloucester contested official policy of using isolation hospitals to quarantine patients, arguing instead for extra accommodation at the voluntary Gloucester Royal Infirmary. The town was a centre of 'anti-vaccinationism', the movement which challenged compulsory vaccination programmes, and here the contributors expected 'their' hospital to accommodate sufferers. However the hospital board and local doctors dismissed this appeal, which ran counter to the conventional wisdom about the optimal public health strategy in such circumstances.
The medical establishment was also at odds with worker governors in Sunderland, a town whose voluntary hospital relied principally on the contributory scheme for its funding. In the 1930s local miners were angered that doctors at the Royal Infirmary were carrying out medical work for coal owners in industrial injury compensation cases. Why, they asked, should 'their' hospital be used for work which was clearly not in the interest of local labour ? Again the protests were overruled by doctors who asserted their liberty to work as they pleased. A subsequent bid by workmen governors to increase the number of their seats on the hospital board was rejected with the admonition that all was 'quite fair' and that the board's function was 'not simply to represent a sectional interest ...'. (5)
These and other cases suggest that although local preferences were articulated, the minority representation of contributors meant they could be easily swept aside if they challenged national policy or professional interests. However, there were two areas in which strong local convictions did prevail. First, in many towns the efforts of hospital managers to raise subscription levels or impose a uniform contribution rate were rejected, and here the defence by trade unionists of workers on low incomes was the crucial factor. Second, in Scotland and the North-West contributors refused to accept the introduction of user fees and the hospital means test. Instead they argued that their subscriptions should be used to finance an 'open-door' policy, where the hospital was free to all-comers regardless of membership status. Of course, these two areas in which worker governors did successfully articulate local wishes - progressive funding which favoured poorer citizens, and free access at the point of use - later became key features of the NHS.
These findings have several ramifications for the contemporary debate. At the level of political rhetoric, it is strictly speaking inaccurate to situate foundation trusts' membership communities within a labour tradition. Certainly there was a line of interwar progressive thought, represented by writers such as G.D.H.Cole and Harold Laski, which advocated the organisation of public institutions on a co-operative model. In practice however, while labour movement activists were key players in the contributory schemes, they treated them pragmatically, while preferring the policy goal of a municipal hospital service. Ironically, the real labour tradition prior to the NHS Acts was for the expression of local choice through the conventional medium of local government, not the single service authorities favoured today.
History does not provide persuasive evidence that popular engagement in hospital affairs will be easily kindled. The majority of contributors were passive participants, while the minority of more ardent activists were motivated largely by financial concerns: the convivial and altruistic aspects of fund-raising, and, for trade unionists, the defence of workers' earnings. These findings support the contemporary judgement of the Ministry of Health: '...there is little or no sentiment surrounding membership of most of the schemes, the workers regard them as a ready way of insuring against the contingency of having to go into hospital and of avoiding inquiry .... a tolerable nuisance in default of a better organisation of hospital service.' (6) This precedent suggests that it may be difficult to ensure that membership communities today are vigorous and genuinely representative.
What has been the experience thus far? Figures from 'Monitor', the trusts' independent regulator, suggest that up to May 2005, the 31 trusts which had gained foundation status had a total membership community of about 220,000 'public and patients' members. However, some were small relative to putative catchment areas. For example, Bradford Teaching Hospitals had 897 public and 256 patient members, about half of whom voted in elections for governors; Bradford District's population at the 2001 census was 467,665. Turnout levels of public and patient members for elections to governing boards have ranged from 9% to 77%, and on average exceeded turnout rates in local government elections. However, where membership is small it is questionable whether governing bodies may be deemed genuinely representative of local communities. In Birmingham for example, where a method of constituency elections was utilised, one governor was elected to the 37-strong board with only 95 votes. Data on the make-up of governing boards are limited as yet, but preliminary findings suggest women are under-represented and that there is a bias towards retired people, who are active in other spheres of voluntarism and have previously worked in the NHS. Broadly then, the early experience of the trusts rather confirms the historical picture: a non-participating majority and a small minority of public-spirited activists. Indeed the interwar contributory schemes' system of workplace polls was in some respects better suited to ensuring that hospital governors were genuinely representative of the catchment area's population than the present method of election, which relies mainly on interested citizens choosing to opt in as members.
Nor is the historical record particularly encouraging for the prospects of local communities achieving influence over hospital management committees. Before 1948 the expression of local choice by worker governors was mostly limited to relatively minor concerns, of the sort which the Community Health Councils articulated in a more professional fashion after 1974. More significant local preferences concerned pay and conditions of hospital employees (a matter specifically designated as outside the remit of foundation trust boards of governors) and issues of contribution rates and means-testing (currently irrelevant with the NHS funded from direct taxation and free at the point of use). However, where localism led to contentious preferences which challenged the views of doctors or managers it was disregarded.
Once again the experience of foundation trusts thus far conforms fairly closely to this historical pattern. The recent legislation gave boards of governors a limited statutory role: hospital directors are obliged to consult them on forward planning and take account of their views, and the governors are able to appoint and remove the trust's chair and non-executive directors. Governors therefore have a rather vague remit to represent the local community and advise on overall strategic matters, but without the right of veto over directors if they are dissatisfied, other than the extreme recourse of removing them. Early research suggests that directors have exploited the ambiguity in this brief and that it is chief executives, rather than governors, who are 'determining the agenda'. (7) The public watchdog, the Healthcare Commission, recently concluded that 'the roles of governors were unclear beyond their statutory duties', and at present the mechanism for asserting local choice remains uncertain. (8) Policy-makers ought to signal clearly the parameters within which local choices voiced by governors can legitimately prevail, or disappointment and disillusion of members may follow. The historical limits to localism in hospital governance before the NHS lend weight to this suggestion.
Foundation trusts
Department of Health, A short guide to NHS foundation trusts, August 2003
Florin, D., & Dixon, J., 'Public involvement in health care', British Medical Journal, 17 January 2004; 328: pp.159-61
Voluntary hospitals
Abel-Smith, B., The hospitals 1800-1948: a study in social administration in England and Wales, London, 1964
Cherry, S., 'Accountability, entitlement and control issues and voluntary hospital funding c1860-1939', Social History of Medicine 9, 2, 1966, pp. 215-33
Gorsky, M., & Mohan, J., & Willis, T., 'Hospital contributory schemes and the NHS debates 1937-46: the rejection of social insurance in the British welfare state?' Twentieth Century British History, 16, 2, 2005, pp.170-92
Gorsky, M., & Mohan, J., with Willis, T., Mutualism and health care: hospital contributory schemes in twentieth-century Britain, forthcoming, Manchester University Press, 2006
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