Healthcare in Ireland and Britain from 1850: Voluntary, Regional and Comparative Perspectives

This collection of essays by Donnacha Seán Lucey and Virginia Crossman, which emanates from two workshops held in Dublin in 2011 and 2012, is a worthwhile contribution to the history of healthcare and voluntarism in Britain and Ireland, with chapters from a range of well-known scholars in the fields of healthcare and welfare history. Healthcare in Ireland and Britain 1850–1970 begins with an introduction by the editors which provides a useful overview of the recent historiography on voluntarism in healthcare. The volume offers to provide ‘new perspectives on the central relationship between state and voluntary healthcare provision throughout the constituent parts of the United Kingdom’ (p. 2) through the use of a variety of regional case studies. Lucey and Crossman outline some of the recurring themes in the essays: the dynamics of place in public health provision; the role of non-state providers of healthcare; the close relationship between nation-building and welfare-building; the relationship between voluntarism and other providers; and healthcare in comparative and transnational contexts. The chapters themselves are organised in a logical way and read as a cohesive set (which is no easy task with edited collections). Moreover, each chapter is rigorously researched and well-written and addresses research avenues which have been previously unexplored.

The volume is divided into four sections. The first of these, entitled ‘Historiographical directions’ contains essays by Martin Gorsky and John Stewart and provide an overview of the historiography on voluntarism in English health and welfare (Gorsky) and on healthcare systems in Britain and Ireland in the 19th and 20th centuries (Stewart). These two chapters, while a little dense, provide a useful contextual overview for the subsequent chapters. Martin Gorsky’s chapter really sets the scene for the subsequent essays, examining the historiography on voluntarism in Britain, reflecting on how, despite the fact that the voluntarism has taken on various meanings and has been applied in different ways, the basic concept itself has ‘nonetheless exerted considerable power’ (p. 58). One aspect I found particularly interesting in Gorsky’s contribution was his final question of how histories of voluntarism might speak to the present. As popular discourse has begun to centre on the issue of privatization of the National Health Service, Gorsky somewhat pessimistically comments that ‘historians so far seem ill equipped to react to this resurgence of markets in healthcare, preoccupied as they are by voluntarist pasts’ (p. 60), although perhaps this should be taken as something of a ‘call to arms’ for historians working in this field. John Stewart’s chapter on healthcare systems in Britain and Ireland provides a thorough overview of the historiography on this theme. Stewart argues that in recent years, historians have provided a ‘more nuanced historical picture of welfare provision’ (p. 78) and that themes such as the importance of the mixed economy for welfare and the fact that ‘modes of funding are about more than simply the choice between social insurance and general taxation’ have been highlighted. Stewart also points towards new directions for scholarship in the field, suggesting that scholars need to direct more attention to the ‘international and sub-national contexts and frameworks in which healthcare has been historically formulated’. Arguably, the subsequent chapters in this collection develop this area of research, with their focus on what Stewart describes as ‘historic patterns of diversity and the role of particular individuals in particular local circumstances’ (p. 78).

The three sections which follow deal with voluntary hospital provision; healthcare and the mixed economy; and public health, voluntarism and local government. As mentioned, each essay provides a case study on a particular aspect of voluntary or regional healthcare in Britain. Of the nine case study chapters, five are case studies focusing on regions in the island of Ireland, two are case studies of England, one of Scotland and one of Wales. The chapters on Ireland and Northern Ireland are a particularly welcome addition to our understanding of developments in healthcare in the Irish context, an area of research which has developed significantly over the past decade, and, as Lucey and Crossman point out in their introduction, these essays effectively ‘contextualise Irish healthcare within local, regional and national frameworks’ (p. 18).

Lucey and Gosling’s chapter explores the place of fee-payment and contribution schemes in inter-war healthcare in Ireland. It takes a comparative approach, examining the topic in the context of Northern Ireland and the Irish Free State after 1921. Such an approach is useful and as the authors argue, ‘offers insights into the differing trajectories in health policy that emerged across inter-war Britain and Ireland’ (p. 81). Contribution schemes ultimately failed to emerge as significant forms of voluntarism in the Irish Free State where patient payment was derived partly from the commercialization of medicine. Yet, at the same time, there remained a commitment to traditional philanthropic healthcare although voluntary hospitals were not agents for voluntary action. In Northern Ireland, where the case study of Belfast is utilised, a different picture emerges, and the authors suggest that there, contribution schemes became vital to the finances of the two general voluntary hospitals, although in the Royal Victoria Hospital, the contribution scheme ‘lacked the mutualistic, quasi-insurance or democratizing features that have been identified in schemes in Britain’ (p. 99). Peter Martin’s chapter, on the Mater Infirmorum Hospital in Belfast, highlights the symbolic role that this hospital played in the construction of Catholic identity in Belfast. Martin argues that the Mater ‘offered a physical manifestation of Catholicism, a showcase for Catholic professionals and a model of the religious tolerance which Catholics believed was denied them in Belfast’ (p. 114). Interestingly, through an exploration of discussions about the status of the hospital, Martin shows how ownership and identity dominated these debates, and his case study of the Mater also illustrates some of the problems in the devolution of healthcare. The third chapter in this section by Julia Neville, examines the topic of cottage hospitals and communities in East Devon in the inter-war period. Cottage hospitals have received little attention from historians, except in the context of the overall voluntary hospital movement and Neville’s chapter utilises the case study of East Devon in order to explore this aspect of the mixed economy of hospital provision. The chapter draws attention to the hierarchies within the hospital management. Interestingly, although women were involved in setting up the hospitals, they were not allowed to be committee members until 1924, and even then, were confined to particular roles relating to patient experience, domestic economy or fundraising (p. 131). Neville ultimately suggests that cottage hospitals in East Devon became a ‘focus for gradual democratization among their rural communities in the inter-war years’ but that this process was slow and had limited effect on the ‘power structures associated with decision-making’ (p. 138).

The third section explores the theme of ‘Healthcare and the mixed economy’ with case studies from South Wales, Ireland and Scotland. Steven Thompson’s essay examines the theme in the context of South Wales, which he argues ‘offers a fascinating case study to test ideas about regional variations in the mixed economy of care’ (p. 141). Thompson illustrates how the ‘specific social, economic, political and cultural contexts of the South Wales coalfield’ resulted in a distinctive version of the mixed economy of care, arguing that within this framework philanthropy, employer paternalism and Poor Law institutional provision were unsubstantial (p. 159). Working-class self-help and mutualism, and later public provision by local authorities helped to fill this gap, but significantly, the mixed economy of care in South Wales did not meet the requirements of the coalfield communities there. (p. 159) Returning to the Irish context, Ciara Breathnach’s chapter explores the theme of religion, provincial politics and district nurses in Ireland, 1890–1904. Apart from research by Gerard Fealy, the history of nursing in Ireland has received limited attention and Breathnach’s chapter is a welcome contribution to this field, and like previous chapters, it shows the importance of looking at regional case studies. Like most of the chapters which focus on Ireland, the theme of religious sectarianism is prevalent. Drawing on an impressive array of sources, including the archival records of Queen Victoria’s Jubilee Institute for Nurses and District Nursing Association Records Breathnach shows how the introduction of district nursing to Ireland ‘raised a host of political, social and ecumenical tensions’ (p. 179), with the fear of proselytism often outweighing concerns for the health of the Roman Catholic poor. One aspect I particularly liked about this chapter was Breathnach’s use of letters written by the district nurses and doctors involved in the disputes, which allows us to see how these religious and professional tensions affected the individuals involved, although she suggests that there is plenty of scope for further investigation of this aspect. Moving to Scotland, Janet Greenlees’ essay explores the provision of healthcare by the Established Church of Scotland and how this provision fitted within the mixed economy of Scottish healthcare. This essay is also impeccably researched, and draws primarily on the reports of the joint committee on Social Work to the General Assembly of Scotland. Greenlees argues that the decision of the Established Church of Scotland to enter into formal health and welfare provision was not a sudden or rash one and was not a response to a particular influence or person or an attempt to counter the labour movement (p. 196). Instead, ‘concerns about religious competition, social reform, moral behaviour, political aspirations and the changing position of the church within traditional health and welfare provision’ all influenced this decision, and the services provided filled significant gaps in Scotland’s health and welfare markets while also enabling the Established Church to become the National Church. (p.196). There are parallels here with Martin’s chapter in that the provision provided by the Established Church arguably only made a minor contribution to the problems of urban and rural poverty. Moreover, Greenless shows how the Church succeeded in incorporating a moral agenda into its policies, for instance, in the case of ‘rescue’ homes established to save ‘fallen’ women (pp. 191–2).

The fourth and final section of the collection examines the theme of ‘Public health, voluntarism and local government’ and these three chapters are especially complementary to each other. Ciarán Wallace’s chapter looks at the smallpox outbreak in Dublin, 1902–3 and the role of Dublin City Council in averting catastrophe in this instance. Ultimately, Wallace’s essay suggests that the containment of the smallpox epidemic would not have been possible through the use of established voluntary hospitals or through the actions of the state. The 1898 Local Government Act was significant – it ‘enabled the L.G.B. to provide prompt loans for the Municipal Council to build an emergency isolation hospital and to conduct and intensive vaccination campaign’ (p. 215). Wallace’s case study of Dublin thus shows the increasing importance of local government in the tackling of such outbreaks. There are parallels between Wallace’s chapter and Ida Milne’s study of the Spanish flu in Ireland, 1918–19. Interestingly, in the case of the Spanish flu, however, Milne shows how the Local Government Board was portrayed as ‘unhelpful’ and ‘unwilling or unable to devise a plan of action to deal with the epidemic’ (p. 217). As Milne illustrates in her engaging chapter, local authorities and voluntary healthcare providers were instead tasked with dealing with the problem, and ‘criticism of the official handling of the crisis in an Irish context was inevitably coloured by the rapidly increasingly conflict between the state and the nationalist movement’ (p. 217). Milne situates the Irish story within the broader global context, explaining that ‘official responses to the influenza elsewhere in Britain and internationally were equally slow’ (p. 233). The final chapter by Sally Sheard returns to Britain and examines the topic of municipal medicine from the Local Government Board to the Dawson Report. Using Liverpool as a case study, Sheard explores municipal hospitals in the late 19th century. Although many studies of the Local Government Board have suggested that it was an important determinant in the course of local authority development, Sheard shows how the case of Liverpool illustrates ‘that it took many years of repeated criticism to achieve an expansion of the municipal hospital scheme’ (p. 251). Furthermore, she opines that an analysis of municipal hospital services can also be used as a lens to investigate a myriad of issues, such as the expansion of regional systems of service provision, and the ideological tensions between Poor Law, municipal and private provision for infectious diseases (p. 253).

Personally speaking, I would have liked to have seen more discussion in some of the chapters of how developments in healthcare impacted on the experiences of those they were targeting and of what patients and practitioners thought about these developments. However, this is a very minor criticism and admittedly stems from my own bias as a social historian. Overall, the two editors have done an impressive job in assembling such a strong, cohesive collection of 11 rigorously researched and complementary chapters. Each of these chapters individually represents a valuable contribution to the field. Healthcare in Ireland and Britain 1850–1970: Voluntary, Regional and Comparative Perspectives will appeal to those interested in the history of healthcare and welfare, and significantly it highlights the importance of regional case studies to our broader understanding of voluntarism in healthcare.

The editors are happy to accept this review and do not wish to comment further.