Martin Gorsky and John Mohan with Tim Willis, Mutualism and health care: British hospital contributory schemes in the twentieth century, Manchester and New York, Manchester University Press, 2006, pp. xii, 243, illus., £60.00 (hardback 978-0-7190-6578-1)

Autor: Keir Waddington
Rok vydání: 2008
Předmět:
Zdroj: Medical History. 52:139-141
ISSN: 2048-8343
0025-7273
DOI: 10.1017/s0025727300002167
Popis: In today's health service, the values of voluntarism, mutualism and participation embodied in the ethos of the hospital contributory schemes that emerged in the nineteenth century and came to the fore in funding voluntary hospitals in inter-war Britain are little in evidence. In Mutualism and health care, Gorsky and Mohan re-examine the history and impact of such schemes on hospital finance and policy. Sympathetic to the brand of mutualism the schemes embodied, they position themselves in the revisionist school of welfare and use the idea of the “moving frontier” of welfare and a Tocquevillian model of civil society. At the same time, they draw on contemporary concerns about the role of mutualism and participation in the NHS with the implicit aim of examining the advantages and disadvantages of different ways of organizing and delivering health care. They hence use hospital contributory schemes to explore the strengths and weaknesses of civil society, voluntarism and participation. In doing so, Gorsky and Mohan trace the evolution of these schemes from their nineteenth-century origins to their growing importance to hospital funding in the 1920s and 1930s, and to wartime debates on the health service through to the present. For historians familiar with the existing scholarship on contributory schemes or voluntarism, Gorsky and Mohan offer few new revelations. However, Mutualism and health care presents a richly researched and insightful examination of the twentieth-century history of hospital contributory schemes. By drawing on a greater range of empirical evidence than other historians, they provide clearer assessments about membership and the schemes’ influence to highlight their heterogeneity. In doing so, the authors effectively question their role in civil society and in encouraging participation and control. Starting their history in the nineteenth century, Gorsky and Mohan examine how hospital contributory schemes drew on existing models of friendly societies and a cultural shift in attitudes to risk and responsibility. They reveal how they were not the natural outcomes of working-class support for individual voluntary hospitals but were established by local elites. Like many forms of voluntary activity, committed activists, many of whom were drawn from the social and professional elites, continued to dictate how the schemes were organized and managed. Growing participation between the wars did not materially alter how the schemes were run but raised expectations and demands for treatment that were not always fulfilled. If local schemes were able to gain some concessions in the delivery of hospital care, Gorsky and Mohan show how when their demands were at odds with the wishes of the governors or medical staff they were often ignored or bypassed. However, as the authors make clear, this is not to downplay their importance. By the inter-war period, hospital contributory schemes formed a crucial component in hospital finance. They offered many institutions a route to salvation, emphasizing how the traditional conception of hospital care as a charitable dispensation had all but collapsed by this time. At their peak, such schemes could boast some eleven million members although there were substantial regional and local variations. The importance of these regional and local differences is sensitively asserted throughout the book. Localism helped maintain levels of support and identification but at the same time created difficulties in securing cooperation between schemes despite moves to develop reciprocal arrangements. The creation of the NHS made the scope for voluntary effort and insurance under the new service unclear. In taking their history beyond 1939, Gorsky and Mohan are concerned to draw lessons for contemporary policymakers. They examine how the British Hospitals Contributory Schemes Association failed to influence policy before addressing how surviving schemes developed new roles and links under the NHS whilst working to maintain their voluntary and mutual character. Social and economic change, shifts in NHS policy, and competition with private medical insurance all served to threaten the ethos of the schemes, forcing them to adapt. If Gorsky and Mohan address how schemes fit in with New Labour's vision for the NHS, they conclude that it is difficult to see how they might provide the basis for a revival of mutualism. However, what exactly this mutualism signifies during the twentieth century remains ill defined. Nor is what Gorsky and Mohan mean by civil society made clear. Some of the questions they set up are not fully examined. For example, their assessment of whether contributory schemes were perceived as a form of insurance—the most likely in their view—or as charity remains muted. Certain periods are neglected—relatively little, for example, is said about the Edwardian years or the First World War—whilst ideas of gender, voluntarism and participation are addressed in a paragraph. In addition, Gorsky and Mohan occasionally come across as partisan, especially in those chapters that address the post-1948 period. For example, they lament the “failure of the contribution schemes to act collectively and articulate a plausible alternative in the NHS debates” (p. 227). Their frustration that the schemes were unable to create a fully integrated hospital service between the wars, or that a different path was not taken in the 1940s, sits uneasily with the historical record. These points aside, the authors present a detailed examination of the nature of hospital contributory schemes. They effectively highlight their dualist nature as forms of charitable activity and insurance, in order to explore their strengths and weaknesses before and after the NHS. In so doing, Gorsky and Mohan rightly emphasize the importance of voluntary activity in health care throughout the twentieth century.
Databáze: OpenAIRE
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