Some eighteenth century hospitals had a very simple way of dealing with the challenge of so-called ‘bed blocking’ – they refused to admit patients who had chronic, ‘high-risk’, or incurable diseases. For example, in 1778 Addenbrooke’s in Cambridge had a rather long list of forbidden sicknesses:
…no Woman big with Child, no Child under seven Years of Age…no person disordered in their senses, or subject to Epileptic Fits, suspected to have the Small-Pox or other infectious Distemper, having habitual Ulcers, Cancers not admitting of Operation, Consumptions, or Dropsies in their last stages, in a dying condition, or judged incurable, and for the present none in the Venereal Distemper, be admitted as In-patients
Variations of this list were used in hospitals across the UK in the late eighteenth century, and may at first glance seem to exclude all possible serious or chronic diseases (‘dropsy’ here would cover swellings in the soft tissue, such as oedema, and could indicate a range of heart, liver and kidney diseases). This list is an indication of a major change in the role of hospitals that occurred in Britain towards the end of the eighteenth century, as hospitals shifted from being places where sick people were cared for, to places where the focus was on cure.
Caring in the old hospital; curing in the new
Prior to the eighteenth century most hospitals were associated with religious groups, and offered charity and care for the sick and the poor – the word ‘hospital’ deriving from the same root as ‘hospitality’. While doctors, surgeons and apothecaries would be called in to diagnose, operate on, or give drugs to patients, hospitals were also there to care for people who could not care for themselves: ‘foundling hospitals’, for example, were orphanages caring for healthy, but abandoned, children.
The distinct shift in purpose from care to cure came in the eighteenth century, with a boom in the number of Voluntary Hospitals. These were funded by donations from the wealthy, and many of the UK’s famous hospitals were built as part of this movement: The Westminster Hospital in 1720, Guys in 1720, Edinburgh Royal Infirmary in 1729, Addenbrooke’s in 1766.
There are many reasons to donate to a hospital: genuine concern for the disadvantaged, Christian piety, or the desire to improve your social status and popularity. But one crucial factor for the new Voluntary Hospitals was cost-effectiveness. As the economy of Britain began to shift with the industrial revolution, sickness was highlighted as a loss of man-power, and therefore a loss of money. As early as 1716, one campaigner for medical reform wrote that
Every Able Industrious Labourer, that is capable to Have Children, who so Untimely Dies, may be accounted Two Hundred Pound Loss to the Kingdom
Revolution!
Across the Channel, the French Revolution changed the way French hospitals were run. As the Revolutionaries overturned the institutions of Monarchy and Church, the Royal School of Medicine and church-run hospitals were in serious need of reform. Revolutionary reformers ditched the old way of learning medicine, largely from books and lectures, and instituted a new ‘egalitarian’ ‘democratic’ system of learning through experience – that is hospital-based training. Hospitals were now not only places for curing patients, but also for training new doctors, and practising new medical science.
Photograph: Wellcome Library, London
By the early nineteenth century these ideas had begun to change hospitals in Britain, where cure, training, and scientific work began to be the key features of a hospital, while care for the long-term sick, chronically or terminally ill, or ‘frail elderly’ was moved to other institutions: asylums, alms-houses, workhouses and hospices.
Co-ordinating between these institutions could be difficult, as they were funded by the state, or by donors, or run by religious groups, or combinations of these three. With the development of the welfare state and the NHS in the first half of the twentieth century, it should have become easier to coordinate between medical and social care; although the appearance of the modern hospice movement in the middle of the twentieth century suggests that the British public no longer thought hospitals were the right places for the care of the incurable.
Hospitals are increasingly judged by their performance, and that includes cure and discharge rates, which can make it difficult for them to deal with patients who have complex, long-term care needs. This is the dilemma the Voluntary Hospitals faced too, as they relied on donations. If their justification was to ‘save two hundred pounds’ for the nation by curing people who would be economically active, their response to the challenge of care was to refuse to treat those who could not be cured or returned to work. Those turned away mostly had to rely on other charities, or the workhouse, for the care they needed. It seems strange that, when both social and medical care is provided by the state, it cannot be better coordinated.
