In recent months, I’ve been working on two co-authored book chapters for edited collections. Each has been a very different experience, but both have been wonderful exercises in approaching my own research interests with a wider lens – bringing an international view to my own British history research.
With Dr Glen O’Hara (my former PhD supervisor) I’ve been working on a chapter for a textbook, largely for undergraduates studying the history of medicine. The book itself is being edited by Professor Paul Weindling and will cover Healthcare in Public and Private from the Early Modern Period to 2000 and our chapter explores ‘Healthcare as Nation-Building: The Case of the British National Health Service’.
There is a common tendency towards national exceptionalism in all writing about the NHS. Yet we can better understand the NHS by locating it within a wider tendency to use those reforms as part of nation-building and postwar reconstruction. In this way social reform has often been associated with attempts to rejuvenate ‘national spirit’ in the period after a crisis, such as war or depression. The reorganisations to which the NHS has been subject throughout its history should also be understood as attempts to reform the service in keeping with a changing nation, whether driving or following that change, most recently with the rise of a more consumer-orientated society. Our chapter will explore the ambitions, compromises, achievements and failures associated with the NHS, as well as its abiding popularity, firmly in a national and international context.
In researching this chapter I came across a host of expected and sometimes unexpected parallels. Two of them that didn’t make the final edit were Turkey and Israel.
The establishment of the NHS was, of course, part of a wave of postwar social reconstruction. I’ve written elsewhere about how this was also to be seen after the First World War, and this was not exclusive to Britain. Indeed, the war had brought about a need for nation-building anew across much of Europe. The new Turkish Republic placed preventive health, alongside education, at the heart of the corporatist agenda for the new post-Ottoman nation. In fact, the Ministry of Health and Social Relief was established in 1920, three years before the proclamation of the Republic. Throughout the 1920s, a network of dispensaries and health centres was set up across the country. The 1920 Dawson Report proposed something similar, yet the promised health centres were remarkably absent in Britain. Indeed, Lord Dawson commented in 1942 that the recommendations of his report two decades earlier ‘might well form the basis of reconstruction today’. While postwar social reform has been written off by historians underneath the flagship failure to provide ‘homes fit for heroes’, plans for the state to radically reform the provision of medical services also largely failed to materialise.
Moving on a few decades, while the NHS is clearly part of a wider European story of redrawing the boundaries of the state over the twentieth century, it is striking that other countries have generally not adopted it as a model. While 1948 saw both the NHS and the country of Israel come into existence, it did not see the creation of an Israeli NHS. Rather the new state’s role in both co-ordinating and providing health services was financed through a series of sick funds, the largest dating back to 1920. Although taking over the work of the British Mandatory Department of Health, the Israeli approach was notably different to that taken in Britain. Political advantage was not to be found in the foundation of a major public institution, but in gaining control over these community-based non-profit insurance bodies. A notable difference for those interested in why Britain’s mutual-insurance organisations did not find themselves embedded in the new health service.
An international comparison a little closer to home is that between Britain and Ireland. Professor Virginia Crossman and Dr Sean Lucey are co-editing a book on Healthcare, Voluntarism and the State in Modern Ireland. Sean and I have been working on a chapter addressing the question of payment for hospital services in interwar Ireland compared to the situation in pre-NHS Britain. I’ve recently signed a book contract to write about the British situation, so this one is closer to my usual work.
Sir Henry Charles Burdett, who would go on to found of the King’s Fund in 1897, wrote as early as 1879 that “the Irish capital has done more to give the pay system a trial than any other town in the United Kingdom”. For Dublin that’s glowing praise, indeed, from a man who saw free hospital access as part of the problem and payment as part of the solution. If true, does this mean Ireland has longer embraced commercial hospital medicine than Britain or are we simply seeing the difference between capitals and provinces writ large in medical culture? By asking these questions, looking at the Irish situation becomes for me a part of a gradual process that any case study based research project has to go through – a mix of contextualising and questioning representativeness. This is something I thought I had done during my doctoral studies, but now I’m writing a book where the local case study is a little less prominent it’s something I’m doing all over again.
At the same time, I’ve been writing a review of Brent Ruswick’s new book Almost Worthy on the scientific charity movement in late nineteenth and early twentieth-century America. Although this is largely a case study of the Charity Organization Society in Indianapolis, there is much that resonates with my own work. We see competing notions of what charity is at play and attempts to unify myriad voluntary efforts around a new and more ‘scientific’ approach. All true when looking either at American charity reformers or British hospital reformers. But this is not simply a matter of comparisons. The COS case workers, the adult education campaigners and the university settlement house residents in London and elsewhere in Britain had inspired much of the leading charity and charity reform approaches adopted in America. Developments in Buffalo and soon after all across the USA and the arrival of social workers British hospitals are both direct legacies of the London COS – an organisation which existed to ensure moral judgements over the deserving and undeserving and to rein in the indiscriminating charity that led to a culture of dependency.
To acknowledge this wider picture is crucial to making sense of any part of it. My first challenge is to embed this acknowledgement in my writing. The next is to reframe my research, to move from focusing on one chapter to the story as a whole. Adopting a transnational approach is a trendy thing to put on a job application at the moment, but as I’ve blogged before it is also a crucial part of writing history in the twenty-first century. My interest in this dimension of history has largely been kept in the past to reading. This year it seems to have moved into writing as well. Next up: research.