Voluntarism as Resistance to State Control: A Case Study of the Kingston Victoria Hospital and the Fledgling NHS

TL;DR

This paper explores how a voluntary hospital was established as a form of resistance to the centralised NHS in post-war Britain.

Contribution

The paper presents a novel case study on the role of voluntarism in resisting early NHS centralisation.

Findings

The New Victoria Hospital was founded as a response to perceived threats to GP independence.

Voluntary hospitals served as a medium for debates on local democracy and state control.

Stakeholders viewed the NHS as a challenge to local autonomy in healthcare.

Abstract

With the launching of the National Health Service (NHS) in 1948, this taxpayer-funded, centralised, universal service seemingly negated the need for new voluntary hospitals to be established in Britain. Within 3 years, however, the former doctors of the Kingston and Malden Victoria Hospital (KMVH) announced a new voluntary hospital (the New Victoria) after the KMVH was closed for repurposing in the NHS. Examining this case reveals stakeholder perceptions of the early NHS, including debates over general practitioner (GP) independence, local democracy and state control which predated and permeated the founding of the Service. I argue the New Victoria was founded as a response to and revolt against centralised bureaucracy and an attempt to restore a sense of GP independence and patient control in the local hospital service. Voluntarism, in the form of a voluntary hospital, was the medium through which these debates took place.

Full text

With the advent of the National Health Service (NHS) in 1948, the vast majority of voluntary hospitals in Britain were taken into the new Service, to be funded and run by the state through general taxation rather than under the auspices of charitable effort.1 Charity and voluntarism would instead take a more marginal role in health provision, supplementing state-funded core services such as providing patient amenities and funding research.2 The need for new voluntary hospitals was seemingly over; the dawn of centralised, universal state-provided service had come.3 Yet, within 3 years, a new voluntary hospital was announced: the doctors of the Kingston and Malden Victoria Hospital (KMVH) announced they would be fundraising for a new voluntary—the New Victoria—after the KMVH had been repurposed under the NHS.4 This article examines the founding of the New Victoria, the first—and only—voluntary hospital established after 1948.

With the exception of Seaton,5 who used the case as a lens through which to examine the anti-NHS group the ‘Fellowship for Freedom in Medicine’ (FFM), the founding of the New Victoria has remained unexplored. The FFM allowed KMVH doctors to speak at their meetings, appointed some of the KMVH’s doctors as its first lay members,6 and reportedly part funded the campaign to save the KMVH.7 Seaton demonstrated how the case was cast by the FFM as an example of the ills of nationalised medicine. My analysis adds nuance to this account demonstrating how the attitudes of the KMVH’s doctors varied both over time and between public and private accounts. This paper also adds to the literature on post-1948 voluntarism, class, and patient participation in healthcare: the KMVH case reflects the different attitudes towards voluntarism in the health sector held by the Conservative and Labour parties, tensions between middle and working classes, and continued demand for patient participation which predate—and permeated—the founding of the NHS.

To fully establish the importance and meanings of this case, I first examine the post-war context in which the KMVH was repurposed and the New Victoria established, highlighting concerns from doctors, patients, and political parties over the expansion of state control that the NHS would entail. Second, I explore the case of the KMVH, investigating events and debates that took place between 1949, when the repurposing of the KMVH was announced, and 1958, when the New Victoria was opened. Through this, I identify and discuss two core themes: (i) the independence of GPs and the contribution of cottage hospitals; and (ii) patient control over hospital provision. I demonstrate that whilst the former was partially replaced within the confines of the NHS, the latter was portrayed by the KMVH’s doctors as only replaceable outside of the NHS. At no point did the KMVH’s doctors advocate specifically the benefits of voluntarism; voluntarism, in the form of a voluntary (cottage) hospital, was simply the vehicle through which debates over local versus centralised control took place. I therefore argue that the New Victoria was founded as an act of resistance to state bureaucracy and support for general practitioner (GP) independence, rather than an act of support or advocation for voluntary healthcare provision.

Context: Post-war Concerns for State Control

Prior to 1948, healthcare in Britain was characterised by ‘welfare pluralism’8 comprising: a small private sector that catered to the upper classes, capable of paying for their healthcare; voluntary hospitals founded through charitable effort and staffed by honorary staff; and municipal hospitals—predominantly former poor law infirmaries which had been taken over by local authorities after the 1929 Local Government Act, and isolation and infectious disease hospitals.9 Provision was based on history, not rational assessment of need: the distribution of philanthropists to endow voluntary hospitals, and of local authorities which chose to enact their powers to take over poor law infirmaries, created irregular and uneven patterns of provision with varying rates of accessibility and utilisation.10 Notwithstanding issues in evaluating the connections between provision and need, it appears that the two rarely lined up.11

The establishment of the NHS in 1948 brought voluntary and municipal hospitals under the remit of the Minister of Health—then Aneurin Bevan (Labour Minister and NHS architect). By funding healthcare through general taxation, Bevan believed the inequity of healthcare distribution could be reduced. Most accounts of NHS history portray its formation as widely popular and politically ‘inevitable’ with near-universal public support.12 However, key tensions arose during the debate of the NHS Bill, as GPs’ independence and patient participation in the health service were seen as potentially vulnerable to state bureaucracy. The KMVH echoes these tensions, showing how they penetrated the NHS’ founding and played out in practice.

Prior to 1948, GPs had mostly worked out of their own surgeries and cottage hospitals and were accordingly afforded a high degree of autonomy.13 Cottage hospitals were typically small (averaging 15–25 beds),14 rural institutions catering to the village or small-town communities in which they were located.15 Like other voluntary hospitals, cottage hospitals were established through local charitable initiatives.16 They were an especially popular form of the hospital, favoured amongst patients and professionals alike for the doctor–patient proximity they afforded17; cottage hospitals were often referred to as GP hospitals as patients were attended to directly by their doctor.18 Cottage hospitals provided GPs with access to patients who they could court for their private practice, and considerable social standing within the community.19

Bevan’s proposals were considered a threat to GPs’ independence. The imposition of a state-run healthcare system was viewed by critics as totalitarian, placing the Minister of Health in a dictatorial position. In 1946, former chairman of the British Medical Association (BMA), Alfred Cox, even likened the proposals to Nazism: ‘I have examined the Bill and it looks to me uncommonly like the first step, and a big one, to national socialism as practised in Germany.’20 Using terms influenced by the recently concluded War, Bevan was cast as a ‘dictator’ and doctors in support of the NHS as ‘Quislings’ (a reference to the Nazi-appointed head of the Norwegian government during the country’s occupation).21 A key area of concern was over GP’s pay under the NHS: Bevan proposed to make GPs salaried employees; GPs wanted to remain independent with many threatening to boycott the service if the plans were to go ahead unchanged.

Fearing a loss in their autonomy and status, in January 1948, just 5 months before the launching of the NHS, 84 per cent of doctors voted against the Service in a vote held by the BMA.22 At the time, most doctors in Britain—and most members of the BMA—were GPs.23 To appease doctors, Bevan had to make various concessions, such as agreeing to retain GPs as independent contractors rather than employees. By the appointed day, most concerns appear to have been allayed as 86 per cent of GPs joined the NHS. However, several tensions remained: GPs complained of increased workloads in the early years of the NHS, particularly of excessive ‘paperwork’,24 and debates over pay remained largely unresolved until 1966.25 Amidst the trend towards medical specialisation, general practice was reportedly ‘in a state of crisis’, lacking morale and sense of professional identity, increasing the division between GPs and specialists.26 The FFM embodied these medical and ideological concerns, opposing what they saw as state interference in medicine. Founded in November 1948 by a group of conservative doctors, the FFM reached a height of more than 3,000 members and had the backing of several Members of Parliament (MPs) before its eventual demise in the mid-1970s.27 As highlighted by Seaton, the FFM served as the leading voice against the NHS in the 1950s.28 The intimate ties between the FFM and the KMVH are explored later in this paper.

Alongside these debates about GP independence in the new NHS, discussions over the future of patient participation also revolved around matters of control and perceived government over-stepping. Before the NHS was introduced, patients were able to exert a degree of control and influence in their medical provision through various individual and collective channels of participation. Private patients exercised ‘the power of the purse’, deciding which doctor to use and often seeking second opinions.29 In voluntary hospitals, significant donors were offered a lifetime governorship of the hospital,30 whilst subscribers were entitled to vote in general meetings and elect members of the managing committee.31 Committee membership was a source of social status and influence for the middle classes.32 Working-class representation was afforded through contributory schemes: individuals made small weekly contributions in return for access to hospital services without further payment.33 Contributory schemes grew such that at their peak they had some 10 million members and were credited with the financial survival of voluntary hospitals during the interwar period.34 Contributory fund committees had representation on hospital boards of management, typically selected from member-elected committees of the contributory scheme, who advocated for patient concerns.35

These channels of representation and control were heralded by contemporaries and more recent proponents as making services more responsive to the needs of the communities they served,36 embedding ‘grassroots democracy’ in healthcare.37 They were also considered sites of cross-class cooperation and solidarity, as middle and working classes were represented.38 This is somewhat idealised. In practice, subscribers were typically relatively small numbers of people, drawn from elite strata within communities: only those who could afford to subscribe were afforded the benefits therein.39 With the rise of contributory schemes, voluntary hospitals became less financially dependent on philanthropy,40 yet philanthropic elites continued to hold sway over working-class representatives on hospital boards. Working-class representatives were also typically over-ruled by medical professionals when the two groups were in disagreement.41 As summarised by Hayes: ‘not all hospitals welcomed a significant working-class membership on the boards of management, nor did increased representation reflect directly the scale of increasing worker financial contribution’.42 Committees still appeared to reproduce social hierarchies as leadership positions remained ‘monopolised’ by middle-class people,43 and working-class representation remained a minority (typically limited to a third of committee seats).44

Whatever their relative merits or shortcomings, under the NHS these direct channels of participation were removed and replaced with state-appointed Regional Hospital Boards (RHBs) and Hospital Management Committees (HMCs).45 Britain’s non-teaching hospitals were divided into 15 Regions, each under the control of an RHB, which were further sub-divided into Groups to be managed by a HMC.46 HMC members were appointed by their respective RHB committee who were themselves appointed by the Ministry of Health. The patient voice in the health sector was now indirect through the election of the government. Conservatives and contributory scheme representatives, amongst others, criticised this new system for taking control of hospitals away from patients and local people and placing it in the hands of ‘remote’ RHBs too distanced from the hospitals they were responsible for.47 The result is what has been called a ‘democratic deficit’ in the NHS.48

Past literature on patient participation has typically asserted or at least implied that after 1948, demand for public representation did not re-emerge in Britain until the appearance of patient groups and consumer bodies in the 1960s and 1970s.49 These associations engaged with health consumerism, advocating for patient rights and representation. Through examining the KMVH/New Victoria case, I demonstrate that demand for public participation and channels of local accountability in the NHS predates 1960s patient consumerism: the KMVH’s doctors and patients established a new voluntary hospital in the 1950s as a means of restoring pre-NHS models of patient participation.

It was against this backdrop of concerns for the future of general practice and shifts from local to centralised control that the KMVH was repurposed within the NHS, leading to the establishment of the New Victoria Hospital. The remainder of this paper thus examines these debates in relation to the KMVH/New Victoria case.

1896–1948: Beginnings of the KMVH

Both the KMVH and its eventual successor the New Victoria were established as cottage hospitals. Surrey (the county in which the KMVH and New Victoria were established) had a particularly strong history of cottage hospitals: the first recognised cottage hospital—Cranleigh Village Hospital—was established in Surrey,50 and at least 39 cottage hospitals were established here—more than any other county.51 The decision to first establish a cottage hospital in Kingston-upon-Thames was made at a public meeting held in 1896, attended by the town’s ‘burgesses’,52 to determine how to celebrate Queen Victoria’s Diamond Jubilee.53 The Hospital was subsequently built on land donated by the Duke of Cambridge (a member of the Royal family) who opened the hospital in December 1898.

Like other cottage hospitals, the KMVH relied heavily on voluntary contributions from individuals and organisations (e.g. local businesses, schools and churches). As the hospital had to compete with various other fundraising appeals in the community,54 the KMVH also relied on subscriptions (the KMVH had over 180 annual subscribers),55 investments and patient fees.56 From the hospital’s only surviving pre-1948 annual report, in 1928, the hospital had no contributions through contributory schemes—most income came from investment interest (38.8 per cent), from subscriptions and donations (gifts, collections, legacies) (29.9 per cent) and individual patient fees for services (28.4 per cent).57 These figures and the founding of the hospital suggest the KMVH was very much a middle-class institution: the hospital was located in an affluent borough and county dominated by the middle classes, its origins bore connections to the Royal family, and there is no evidence of working-class representation on the hospital’s committees.

1949–51: Planned Conversion in the NHS

On 5 July 1948, ownership of the KMVH was passed to the Ministry of Health as the hospital joined the NHS. The KMVH fell under the Kingston Group HMC within the South-West Metropolitan RHB. In May 1949, the South-West Metropolitan RHB sent a Review Committee to Kingston to evaluate hospital provision in the Group.58 The Review Committee determined the most pressing medical need in Kingston was increasing gynaecological and maternity beds.59 They subsequently recommended repurposing the KMVH from a cottage hospital into the gynaecological and maternity unit for the Kingston and District Hospital—a general hospital situated directly opposite the KMVH.60 The KMVH had been viewed favourably in terms of its staff, equipment and facilities in multiple visits from the General Nursing Council (GNC) and the King Edward’s Hospital Fund for London (King’s Fund).61 These assessments, combined with the ‘close physical proximity’62 of the KMVH and the District hospital made the planned merger appealing to the RHB as an efficient means through which to increase gynaecological and maternity provision.

However, when the Review Committee’s report was shared with the Kingston HMC in August 1949, the HMC’s Medical Advisory Committee rejected the proposed conversion of the KMVH ‘by a very narrow majority’.63 The RHB pressed on regardless. The proposed conversion was made public when the plans were leaked to, and reported by the town’s only local newspaper—the Surrey Comet—in September 1949.64 The RHB faced immediate and strong backlash from the KMVH’s doctors, all of whom were GPs. With support from their local Member of Parliament—Conservative John Boyd-Carpenter—the doctors appealed to the RHB to reconsider their proposal, to the public for support and to the Minister of Health to over-rule the RHB. Issued with a notice of closure (so the hospital could be converted) to take effect on 31 October 1950, the KMVH’s doctors announced a ‘stay in strike’65: the hospital doors were locked, and two ex-policemen formed a picket to check the identities of anyone attempting to enter the building.66 The doctors were reportedly unanimous in the decision to defy the closure notice: the Chairman of the KMVH House Committee, Brigadier Norman Skentelbery, stated ‘all of our 26 doctors are willing to go to prison if needs be’.67

Over the next 7 months, the KMVH’s doctors led a campaign against the Hospital’s conversion (discussed more below), featuring town hall meetings, a public petition, deputations with the RHB and Minister of Health, letters published in local and national newspapers, and a televised appeal. Despite these efforts, the KMVH was eventually closed for conversion on 31 May 1951. During this period (1949–51), arguments for preserving the KMVH as a GP hospital centred on three key topics—(i) patient–doctor proximity, (ii) homeliness and (iii) efficiency—which reflect debates raised during the reading of the NHS Bill.

(i) Patient–doctor proximity

The KMVH’s doctors argued the patient–doctor proximity characteristic of cottage hospitals enabled GPs to ‘keep in touch with matters medical’, upholding their interests and standards.68 Converting the KMVH from a GP hospital into a gynaecological ward was described as ‘the biggest nail in the coffin’ of General Practice.69 Closing cottage hospitals like the KMVH was described as leaving the GP ‘in medical isolation’,70 preventing them from keeping abreast of medical developments, and further eroding their responsibilities. Given the central role of the KMVH’s doctors in defending the hospital, I argue the campaign was motivated initially by a degree of professional interest—a desire to retain GP independence, control and relevance amidst the aforementioned ‘crisis’ in general practice and trend towards medical specialisation.71

Current and former patients of the KMVH similarly expressed their support for, and desire to retain, this doctor–patient proximity. Writing into the Surrey Comet, patients argued direct attendance by family doctors provided ‘peace of mind and trust’ which ‘often brings much courage and confidence to the patient’.72 Such assurance was presented as alleviating anxiety when going into hospital—for patients and their families—which contributed to a quicker recovery.73

The Hospital’s doctors and their political supporters deliberately related the KMVH to other cottage hospitals to attract wider public support and sympathy. For instance, in a televised campaign video, the KMVH’s doctors argued their campaign ‘does not only apply to our own Kingston Victoria Hospital but to many others across the country’.74 During a House of Commons debate on the future of the KMVH, the Conservative MP for Morecambe and Lonsdale similarly drew parallels with a hospital in his constituency before adding ‘There are also 20 or 30 other towns in which this situation exists.’75 Through such comparisons, the conversion of the KMVH was portrayed as part of a coordinated effort to eradicate cottage hospitals entirely and ‘keep the general practitioner out of the hospital service’.76

(ii) Homeliness

The KMVH was also defended on sentimental grounds as a homely, warm and welcoming institution in which patients felt comfortable.77 This was contrasted by doctors against perceptions of the far larger and ‘unwelcoming’ Kingston and District Hospital: ‘If this proposal is carried out it will only be a matter of time before similar action will be taken with hospitals at Surbiton, Thames Ditton, Teddington, Epsom, etc. All these, which were started with the help of the local practitioners and residents, and maintained by them, will be swallowed up by the great Clinical Concentration Camps that are proposed.’78 Comparisons to concentration camps so shortly after the conclusion of World War Two illustrate the strength of sentiment felt at the time. Such comparisons were made not only by the KMVH’s doctors but also by doctors at other cottage hospitals in Surrey concerned their hospital faced a similar fate.

The stark contrast between the KMVH and District Hospital conveyed appears to have stemmed from three underlying issues: the different sizes of, state of facilities at and origins of the two hospitals. First, whereas the KMVH was a small cottage hospital with 44 beds, the District Hospital was a much larger institution with 502 beds.79 The ‘homely’ atmosphere described by KMVH patients was deemed impossible to attain in larger hospitals,80 an opinion seemingly widely shared and supported by patient surveys from before 1948.81 Second, the state of facilities at both hospitals also varied: the KMVH was described in reports by the King’s Fund and the GNC as being well-equipped, bright and modern82; the District hospital was in need of repairs (from war damage)83 and updating.84 Finally, social attitudes towards each hospital’s origin likely also shaped opposition towards their merger: the KMVH was established as a voluntary hospital by the town’s burgesses on land donated by the Duke of Cambridge; the District Hospital was a former workhouse infirmary built by the local authority to care for the town’s ‘paupers’ under the English Poor Law. In Kingston-upon-Thames, a royal borough and one of the wealthiest areas in the country, classist snobbery towards a former Poor Law institution may have stimulated resentment towards the RHB’s proposed merger of the two hospitals. This reflects wider class differences in pre-1948 perceptions of the British hospital system highlighted by Hayes: middle-class people were more likely to have supported voluntary hospitals, and express concerns that the ‘human touch’ of voluntary hospitals would be lost in a ‘depersonalised’ state-run system; working-class people were generally more likely to prefer collectivist solutions to health, including state-run provision.85

Sentimental arguments over the ‘homeliness’ of the KMVH were criticised by Labour politicians. As noted by Labour MP Sir Frederick Messer: ‘Anybody at a town meeting could point to his little cottage hospital and describe it in terms that would wring tears from the eyes of stone statues. […] I plead with the Minister to let the regional boards get on with their job.’86 The leader of the local Labour party in Kingston similarly stated: ‘We are trying to hang on to a little bit of sentimentality which may be hindering the progress of real medicine and a proper hospital service’.87 Sentimentality, they argued, must not be allowed to impede efficiency.

(iii) Efficiency

The perceived efficiencies of cottage hospitals were a frequent point of debate during the reading of the NHS Bill. Bevan, for example, famously argued: ‘I would rather be kept alive in the efficient if cold altruism of a large hospital than expire in a gush of warm sympathy in a small one.’88 For Labour, the ‘homeliness’ of cottage hospitals came at the cost of hospital efficiency as they were too small to provide an array of specialist services.89 In contrast, Conservatives generally acknowledged possible inefficiencies but dismissed them as a tolerable price to pay.90

During the campaign to save the KMVH, supporters maintained the hospital operated with low costs and contributed to the efficiency of the wider health service. Writing to the Surrey Comet, one Kingston resident and husband of a former patient claimed: ‘The cost per bed is lower than in any other hospital within the Kingston Group, and the number of cases per bed higher than in larger hospitals’.91 The low cost-per-bed claims were reiterated by the KMVH’s doctors, but—due to lack of surviving data—cannot be verified. However, the claims made about cases per bed appear false: there were more cases per bed at the KMVH than at the District Hospital but fewer than Richmond and Surbiton which both had more beds, and fewer than Thames Ditton and Molesey which both had fewer beds.92 The KMVH’s daily occupation rate of 31 for its 44 beds was lower than nearly every hospital in the Group.93

Notably, no supporter of the KMVH (doctor, patient or politician) acknowledged any potential inefficiencies of the KMVH or cottage hospitals more broadly. Indeed, KMVH’s doctors argued that cottage hospitals contributed to an efficient NHS (primarily by alleviating pressure on beds) and so their removal would ‘harm’ the Service.94 In contrast, the RHB and their supporters highlighted efficiency issues. For example, Dr Stark Murray—a member of the Kingston HMC, President of the Surrey branch of the BMA and President of the Socialist Medical Association (1951–70)—argued that small GP-led units could not do ‘a modern hospital job’.95 The South-West Metropolitan RHB also noted that given the proximity of the KMVH to the District hospital, absorption of the former into the latter would increase efficiency by avoiding duplication of services.96

Across these areas of debate, views typically differed along political party lines. Labour politicians (both in the House of Commons and local Labour groups) backed the RHB’s proposal from the onset, arguing it would improve the scale and efficiency of hospital provision in the area for the majority of the local population.97 They dismissed the campaign against the KMVH’s conversion as a ‘Tory political stunt’ designed to reduce Labour support in the run-up to the general elections held in February 1950 and October 1951.98 With the exception of one Liberal MP, every politician who explicitly supported the KMVH’s doctors was a Conservative.

Political support for either side of the debate largely followed the corresponding party policies. The 1945 Conservative party manifesto was built upon visions of setting people free from wartime constraints.99 Labour, contrastingly sought to build upon and in many ways extend state control with an extensive programme of nationalisation including not just health but also finance, iron and steel and transportation. Though the Conservatives voted against the second and third readings of the NHS Bill, by the 1950 general election, the Conservatives had largely accepted the NHS and did not seek to reverse it—instead pledging to ‘maintain and improve the Health Service’—but did express explicit support for ‘the position of the family doctor by restoring his freedom to practise anywhere and by offering a weighted capitation fee to doctors with small lists, especially in rural areas’.100 The Conservatives prioritised narratives of individual freedoms and decentralisation of power; Labour emphasised collective progress, community and cooperation.101

The KMVH’s doctors and the politicians who supported them reflected this shift in Conservative policy: though Kingston MP Boyd-Carpenter had, along with the rest of the Conservative party, voted against the NHS and other nationalisation efforts since the 1945 election, he and the KMVH’s doctors publicly maintained their campaign was non-political and that they only wished to see the NHS ‘preserved and extended’.102 These supporters of the KMVH were concerned with the retention of their cottage hospital within the NHS, rather than opposition to the NHS or state-provided healthcare more broadly.

The Claremont Hospital: Replacing GP Beds

Because of the outrage stirred by the plans to convert the KMVH and the portrayed threat to GP beds, the RHB offered the KMVH's GPs the Surbiton Annexe as a replacement. Originally a cottage hospital in Surbiton (one mile away from the KMVH), the Surbiton Annexe had been purchased by the Kingston and District Hospital in 1935 to accommodate chronic patients.103 More than £6,000 was spent converting the Annexe between 1950 and 1951, restoring it to a GP hospital.104 It opened as ‘Claremont Hospital’ on 31 May 1951—the same day the KMVH was closed for conversion.105

The KMVH’s doctors protested the Annexe was too small and inadequate, opening with 28 beds compared to the KMVH’s 44. Even an expenditure of £6,000, they argued, would ‘fail to convert the sow’s ear into a silk purse’.106 These criticisms seem to have been justified given later evaluations of the Claremont. A review from the GNC in February 1952 reported issues with Claremont’s layout including narrow corridors and isolated positioning of two wards,107 and a King’s Fund report from 1954 questioned whether the hospital was even necessary.108 Despite these objections, the Claremont was accepted by 140 GPs in the Kingston Group and then Minister of Health Hilary Marquand described it as a ‘reasonable alternative’ to the KMVH.109 The 26 KMVH doctors remained unsatisfied.

1951–58: Establishing the New Victoria

On 1 June 1951, the day following the closure of the KMVH (and the opening of Claremont Hospital), the former KMVH doctors announced at a press conference the formation of a charitable trust—the Kingston and Malden Victoria Medical Foundation. Brigadier Skentelbery was the Foundation’s first President, and former KMVH doctor Dr Bernard Lake was the first Chairman. The Foundation was intended to fundraise £40–50,000—the amount calculated as needed to establish and run a new voluntary hospital for at least 2 years.110 The appeal for funds was shared not only with local residents, but also with every GP in Britain. As argued by Dr Lake: ‘although the immediate issue is a local one, the implications of the scheme may affect doctors everywhere’.111

Over the next 7 years, £35,000 was raised from 5,000 contributors through public donations and subscriptions of three pence per week.112 By October 1954, enough funds had been raised to purchase a property—Coombe Manor—on the same lane that the KMVH had been situated on.113 Following the development of the property, the New Victoria was opened by the Duchess of Sutherland in May 1958.114 It was the first voluntary hospital founded since the NHS was established.

During the dispute over the fate of the KMVH, the hospital’s doctors painted the hospital’s conversion as part of an attack on GPs and cottage hospitals. Their campaign aimed to retain the KMVH within the NHS. During this period, there was no sense that the KMVH as a cottage hospital was antithetical to a free-at-the-point-of-delivery, tax-funded, national system. Quite the opposite—cottage hospitals were considered a vital element of an efficient NHS. Only once it was clear the conversion of the KMVH would go ahead did the doctors push to replace the hospital outside the system. These doctors, and their continued political supporters, argued the most important thing that had been lost through the process of the KMVH’s conversion was a sense of democracy. As noted by the vice-Chairman of Surrey Liberal Organisation: ‘Quite apart from the pros and cons regarding the immediate future use of the hospital, I feel convinced that the overriding factor is a grave infringement of the democratic rights of individuals and groups of individuals.’115

Whilst the subsequent effort to establish the New Victoria still centred on restoring GP autonomy, unsatisfied by the Claremont offering, the campaign narrative also focussed on restoring a sense of local control over hospital provision after feeling thwarted by NHS bureaucracy. A new cottage hospital set up as a voluntary outside the NHS was not advocated as a better type of healthcare but as the only viable option for reinstating local public and patient control over their healthcare provision. Throughout the dispute regarding the KMVH (i.e. 1949–51), the RHB was criticised for (i) going against local public opinion; (ii) being unrepresentative of local public opinion; and (iii) refusing to hear local public opinion. Such concerns similarly reflect middle-class opinion from before 1948: ‘The middle classes, too, just as they more strongly favoured voluntary hospital provision, were equally resistant to officialdom and intrusive state interference’.116

(i) Going against local public opinion

First, the RHB was portrayed by its doctors and political supporters as going against near-total consensus in the Kingston and neighbouring Malden and Wimbledon communities. As summarised by the Conservative MP for Wimbledon Cyril Black: ‘we have here almost the position of the Regional Board versus the rest of the world, so strong, so unanimous and so complete is the objection on the part of all other sections of the public’.117 The most significant evidence supporting this claim is the public petition delivered to the Minister of Health in February 1951. The petition appealed: ‘that this retrograde step in the development of the National Health Service should be remedied by general practitioner hospitals, such as the Kingston and Malden Victoria Hospital, being established as an essential factor in the Service’.118 The petition was signed by 40,780 people119; the combined adult population of Kingston and Malden was roughly 50,000 at the time.120 Notably, Labour had advised its members in Kingston and Malden not to sign the petition.

In November 1950, some 2,000 people attended a public meeting about the proposed conversion of the Hospital. 1,500 people attended inside—more than 300 people over the venue’s capacity.121 A further 500 people attended outside the venue where the speeches from local MPs and Mayors were broadcast via speakers.122 According to the Surrey Comet, it was the largest meeting held in Kingston’s history and the overwhelming majority opposed the KMVH’s conversion.123 Labour representatives who spoke in support of the RHB were reportedly ‘drowned out’.124

Various local councils and committees also backed the campaign to maintain the KMVH as a GP hospital. Both the Kingston and Malden Conservative-run town councils made official appeals to the RHB and Minister of Health to at least delay, if not repeal, the decision.125 Additionally, the Conservative MPs for Kingston (a constituency which included Malden) and neighbouring Wimbledon both supported the campaign in Parliament, appealing directly to the Minister of Health on several occasions, including a personal deputation. The campaign against the conversion of the KMVH was also officially and unanimously supported by various small groups in the area including the Kingston Chamber of Commerce (representing 550 local businesses),126 the Malden Rotary Club,127 the Kingston Public Health Committee,128 and even the Malden United Housewives Association,129 all of which were largely middle-class institutions.

Given this widespread support, the KMVH’s doctors, local political representatives and even the BMA accused the RHB of ‘flouting public opinion in the district’.130 When Kingston MP Boyd-Carpenter raised this matter in Parliament he was told it would be ‘inappropriate’ for the Minister of Health to intervene. Boyd-Carpenter subsequently criticised the ‘apparent immunity to democratic process with which regional hospital boards were endowed’.131 Notably, this ‘immunity’ was a result of political compromises made during the establishment of the NHS to insulate the medical profession from local authority control. As recalled by Labour MP Messer, during a debate on the KMVH: ‘when the Act, as a Bill, was debated, the Opposition [the Conservatives] had insisted that there should be no interference from Whitehall’.132 Calls for overturning or intervening in the RHB’s decision on the KMVH were therefore dismissed as hypocritical exceptionalism.

(ii) Being unrepresentative of local public opinion

Second, the KMVH’s doctors and their supporters portrayed the RHB as being unrepresentative of the local public and GPs. Given the South-West Metropolitan RHB—an unelected body—consistently rejected the appeals of elected representatives (e.g. town councils, Mayors, MPs) and did so without any GPs on the Board, the RHB was criticised as ‘undemocratic’,133 ‘remote from the practice of medicine’ and ‘remote from the views of the individual patients’.134 Doctors—both at the KMVH and other GP hospitals—deplored the ability of this non-elected board to act against the wishes of such an overwhelming majority of the local community. As argued by one critic when writing to The Times: ‘the service has set up large corporations, in this case, the regional hospital boards, which administer the hospitals over a wide area according to the well known traditions of a nationalized industry, i.e., with little or no regard to the wishes of the consumers – in this case the patients.’135 These strongly echo concerns raised during readings of the NHS Bill regarding the transfer of control from local patients to remote government-appointed boards.136

Health authorities countered that the KMVH did not itself represent the medical needs of the majority of the community: ‘Who are deserving of the greatest consideration – the women resident in our area who are sorely in need of these extra gynaecological beds, or whether a small minority should continue to enjoy a special advantage, if indeed it be a special advantage, of receiving treatment at the Victoria Hospital?’.137 Given only a minority (5 per cent) of patients in Kingston were treated at the KMVH, the RHB and their Labour party supporters argued this minority should not be allowed to continue their ‘special privilege’ at the cost of a larger number of patients with more pressing needs.138

Debates over the representativeness of the RHB were amplified when several members of the Kingston HMC were not reappointed to the Committee. When the proposed conversion of the KMVH was first revealed in 1949, the Kingston HMC voted against the proposal, calling for delay and reconsideration. In March 1950, during regular HMC appointments, the RHB did not reappoint four of the HMC members who had been most critical of the proposals, including the Committee Chair.139 These were replaced with new members who were more amenable to the RHB’s plans, including a Chairman who explicitly stated he did not believe the Committee had the power to stand against the RHB.140 This new HMC voted to accept the RHB’s proposal in December 1950.

The non-reappointment of these Committee members was described by the KMVH’s doctors and their political supporters as ‘totalitarian’,141 ‘dictatorial’,142 ‘Hitler methods’ and a ‘violent attack’143 aimed at ‘beheading’ the opposition.144 Such an ‘attack’, critics argued, was a threat to democracy. As summarised by Skentelbery: ‘What I am most anxious and most incensed about is the fact that a board can pay lip service to democracy and depart from it as soon as ever it is opposed’.145 To address these concerns, Skentelbery argued RHBs should be elected in order to embed local opinion: ‘The whole thing should grow from the bottom, the public choosing the house committees, the hospital choosing their representatives and the latter choosing representatives for the Board’.146 Such views are based on an idealised recollection of pre-1948 hospital management—as outlined above, pre-1948 mechanisms were not wholly representative or democratic. Furthermore, Bevan had initially favoured a more localised model of the NHS but had been thwarted by the BMA’s opposition. As noted by Daunton, the 1948 founding structure of the NHS was not so much an outcome of Labour’s commitment to such structures as it was of the medical profession’s resistance to alternatives: ‘Multipurpose local government was more of a threat to their position than nationalization’.147

Responding to these criticisms, the RHB argued their decision bore no relation to the KMVH dispute. Instead, they maintained, they were guided by a recent ministry circular that advocated the potential benefits of appointing new members to HMCs.148 The RHB reported that they had been ‘dissatisfied with the Kingston Hospital Management Committee whose administration has not been particularly satisfactory or economical’.149 In particular, the RHB criticised the lack of attendance of some of the replaced Committee members,150 and saw advantages in having a Chairman who was ‘not directly connected with the local affairs of the Group and thereby able more easily to adjudicate on any contentious matter.’151

It is notable that Kingston was not unique in such complaints over HMC appointments: during the initial establishment of HMCs, Bevan received hundreds of letters from various hospitals, political and religious groups and councils complaining about their perceived lack of representation.152 All were informed in response that HMC appointments were a matter for the RHB and not the Minister. Likewise, when HMC members were not reappointed to their positions, they had often also written to the Minister to complain153; it was not unique either for members to not be reappointed, or for those members and/or their supporters to voice their complaints to the Minister of Health.

(iii) Refusing to hear local public opinion

Third, the RHB was criticised for withholding key discussions and plans from the public and refusing to hear public opinion. The initial proposals for the conversion of the KMVH were revealed to the public by the press, not the RHB, and after objections were raised, the RHB repeatedly voted to discuss the matter of the KMVH without the press present, later sharing only concise statements. This ‘scheming’ and ‘secretive’ approach was condemned by the KMVH’s doctors and their supporters for lacking transparency and impeding accountability.154

To address concerns over the RHB’s actions, multiple calls for a public inquiry were made. As justified by MP Boyd-Carpenter: ‘one of the major reasons why local opinion felt that an injustice had been done was that no opportunity had yet been given for local opinion to express itself directly to those responsible’.155 In March 1950, Boyd-Carpenter called for an inquiry into the RHB’s dismissal of members of the Kingston Group HMC.156 In November 1950, the BMA called for an inquiry into the RHB’s proposals to convert the KMVH157—a call subsequently repeated by the KMVH’s doctors158 and the MPs for Kingston and Wimbledon on several occasions each.159

These appeals were rejected by the Minister of Health and Labour MPs who believed agreeing to an inquiry would set a precedent meaning no RHB could make any decision without ‘looking over their shoulders to see whether what they were doing met with the approval of the Minister’.160 According to one Labour MP, agreeing to an appeal would lead to the ‘breakdown of the service’.161 Both Bevan and his successor as Minister of Health Marquand repeatedly refused calls for inquiry: Bevan proclaimed the House of Commons was the ultimate ‘court of inquiry’162 and Marquand similarly maintained that through discussion in the House of Commons, there had already been ‘ample inquiry’.163

The narrative campaigners created of the RHB refusing to hear public opinion is rather misconstrued. Not only was the future of the KMVH debated several times in the House of Commons, but the hospital’s doctors and their political supporters also had separate deputations with the RHB164 and the Minister of Health,165 and were invited to offer alternative proposals to the RHB.166 Following a meeting between the RHB, HMC and two of KMVH’s doctors in December 1949, the HMC was invited to submit alternative plans for providing the gynaecological and maternity beds needed in the Group.167 A sub-committee was established, which included the two KMVH doctors who had been present at the meeting. The sub-committee’s recommendation of building a £25,000 extension to the general hospital168 was rejected by the RHB as too costly.169 In March 1951, several of the KMVH’s doctors and Boyd-Carpenter also had a deputation with then Minister of Health Marquand. Although the final decision was not what the KMVH’s doctors and their supporters wanted to hear, their voices had certainly been heard.

When Marquand upheld the RHB’s decision to convert the KMVH, and declined for the final time to hold a public inquiry, the KMVH’s medical staff and house committee issued the following response: ‘Our attitude remains what it has always been. We know we are right – in the interests of our patients and the wider interest of the public, as against a blind and bigoted new bureaucracy – and we maintain our stand until ejected.’170 The KMVH’s doctors subsequently held a meeting—records of which have not been kept—to determine their next action. It was after this meeting, and the closure of the KMVH, that the plans for establishing the New Victoria were announced.

The New Victoria Hospital: Reinstating Local Control

To restore the perceived loss of voice in and control over their local hospital provision, the former KMVH doctors and Kingston and Malden residents who supported their cause subscribed to and backed the establishment of the New Victoria. Amidst a context of concern for state control and in an affluent, predominantly middle-class county dominated by Conservative politics, voluntarism—in the form of a new voluntary hospital—was portrayed as a vehicle for local democracy, an escape from ‘the paternal embrace’ of the NHS.171 The New Victoria’s founders tried to restore a sense of local control by implementing pre-NHS methods of patient participation and accountability. At no point did the KMVH’s doctors advocate specifically the benefits of voluntarism, or describe efforts to address pre-NHS limitations of voluntary hospitals. Their goal was to restore local patient and public control, not advance voluntary action.

The establishment of the New Victoria was heralded as a victory for democracy. Outside of and independent from the apparent ‘bureaucratic’ confines of the ‘dictatorial’ RHB, the New Victoria liaised openly with the local community from the onset, sharing information transparently. Whereas the RHB had held meetings about the Hospital ‘in secret’, the Foundation held AGMs at which ‘[a]ny member of the public who is interested in the New Victoria Hospital is welcome to attend’.172 These meetings were often attended by the Mayors of Malden and Kingston.173 Whilst the RHB had withheld key decisions from the public and press, Kingston and Malden residents were regularly updated on the progress of the new hospital through the publication of The New Victoria: A Quarterly Magazine of News, Views and Events of The Kingston & Malden Victoria Medical Foundation and Annual Reports stating income and expenditure, patient statistics and governance details (e.g. staff and committee members). These were both shared for free with local residents who were encouraged to share their copies with others.174

Local voice was also included in the foundation and running of the New Victoria. Mirroring how the original KMVH had been run prior to the NHS, the New Victoria was managed by an elected Board of Management and Board of Governors. Any individual or organisation who donated 50 guineas or more in a single year was offered a ‘Life Governorship’ of the Hospital. At least 17 Local Area Committees were established, each of which had an elected Chair and collectively had over 800 members.175 These Committees primarily fundraised for the new hospital but were also represented on the Boards of Management and Governors, giving them ‘a voice in the effective running of the hospital’.176 Though one can question how representative these Boards and Committees were of the 50,000 residents of Kingston and Malden, the New Victoria’s supporters evidently believed they were more representative than the 15 members of the RHB-appointed HMC they had previously dealt with. Dr Lake expressed his hope that such endeavours at the New Victoria ‘might even initiate administrative reforms that would make a healthier Health Service everywhere’.177

Establishing the New Victoria was presented as restoring the local community’s and doctors’ sense of ownership of ‘their’ hospital. Through the conversion of the KMVH, the hospital’s former doctors, along with Kingston and Malden residents, had lost a local resource over which they had perceived a sense of ownership and autonomy.178 Throughout the dispute, patients, doctors and local residents had referred to the KMVH as ‘their’ hospital,179 condemning ‘the destruction of the hospital built by and for local people’.180 Before the NHS, the very idea to build the hospital had been proposed by the community, and it was built and sustained over 50 years through their contributions—financial and otherwise.181 This sense of local ownership was not replaced by the offer and conversion of the Surbiton Annexe—the move was criticised by Boyd-Carpenter as ‘a transmigration of souls’182 and an effort aimed ‘utterly to destroy the identity of the Victoria Hospital’.183 The feeling of ownership was however restored through the establishment of the New Victoria which, upon its opening, was described as the ‘Town’s own hospital’.184 This is an interesting contrast against the early promotion of the NHS in 1948 as ‘Your National Health Service’.185

Such comparisons of ‘our hospital’ against ‘our NHS’ illuminate the different conceptions of ‘public’ conveyed throughout this case. The KMVH/New Victoria doctors and their Conservative supporters prioritised a ‘local public’ comprised of Kingston and Malden residents, predominantly those who were their patients. Thus, despite multiple deputations between doctors, politicians and policymakers during the KMVH dispute, they persisted ‘public’ voice had still not been heard, and, therefore, local residents were afforded channels of representation in the New Victoria. Labour prioritised a ‘national public’, represented through government and served by a national system.

This portrayal of the New Victoria as a democratic haven resonated with the medical conservativism of the FFM. In his analysis of the FFM, Seaton demonstrated the Fellowship’s medical, economic and ideological opposition towards nationalised medicine. The FFM saw the NHS as ‘an economically dangerous bureaucratic machine that crushed medical independence and risked pushing the country towards dictatorship’.186 The FFM hence embraced the KMVH dispute as a poster boy for their anti-NHS cause, portraying it as evidence against the ‘evils’ of bureaucracy and state control:

The health of the nation was controlled by a bureaucracy … . [T]he Minister of Health was a dictator, under whom the service was controlled downwards. Such a system destroyed the freedom of the individual and disregarded the collective wishes of the people.187

However, the KMVH’s doctors’ own views of the NHS—and of the FFM’s opposition to it—are decidedly more complex.

Before the KMVH was closed for conversion, none of its doctors aligned themselves publicly with anti-NHS views. The defence of the KMVH was a defence of GPs in hospitals, driven by the professional interests of the KMVH’s own doctors. When the KMVH’s Dr Tom Morgan spoke at the FFM’s annual general meeting (AGM) in 1950, his speech focussed on the interests of the General Practitioner—thus resonating with the medical concerns of the FFM—but did not raise any economic or ideological opposition to the NHS. Privately, some of the KMVH’s doctors may have supported the FFM’s ideological stance: when Skentelbery was elected the FFM’s first lay member in 1950, his wife (also a doctor) was already a regular member.188 However, publicly at this time, the KMVH’s doctors continued to insist that their efforts aligned with the values of the NHS. This suggests, that whilst they welcomed the FFM’s support, they largely—and certainly not publicly—did not share the FFM’s ideological opposition.

After the KMVH was closed for conversion, this view seems to have transitioned and connections with the FFM strengthened. The FFM hosted an ‘in memoriam’ event the day the KMVH was closed for conversion, attended by the KMVH’s doctors.189 Dr Lake subsequently adopted similar language to the FFM when campaigning for the New Victoria, describing the NHS as a ‘machine’ that regarded patients as ‘units’ rather than people.190 The FFM founder—Lord Horder—volunteered as an honorary consulting physician of the New Victoria Hospital,191 and then FFM Chair Dr Hale-White was invited to speak at the Victoria Foundation’s AGM in 1961, indicating at least some resonance with the doctors’ own opinions. Speaking at the AGM, Dr Hale-White celebrated the New Victoria as a ‘bulwark of freedom against state monopoly’ which ‘shines as an example of enterprise across a flat and uninteresting sea of control’.192

Yet, in contrast to the FFM’s unwavering opposition to the NHS, the New Victoria was still not portrayed by its doctors or fundraising committees as against the NHS in principle. In a promotional leaflet for the New Victoria, the Foundation explicitly stated as such:

Is the new Hospital in any sense in opposition to the National Health Service? Emphatically NO. The exact opposite is the case. The NEW Victoria Hospital will supplement and help (by providing additional accommodation and facilities) the services provided by the State.193 [all emphasis in original]

Whilst this statement was likely an effort to gain non-partisan support and funds for their campaign, it directly conflicts with the FFM’s opposition to the NHS. Whereas the FFM argued that private practice was needed to avoid ‘State monopoly of medicine’,194 the New Victoria’s staff presented themselves as supporting the state system.

After 1958: Barriers to Voluntarism?

The Foundation’s initial funding proposals for the New Victoria were to raise £40–50,000 in donations and subscriptions to fund the Hospital’s first 2 years. Thereafter, the income from two private beds was expected to cover most of the projected £13,000 annual running costs of the hospital, allowing minimum reliance on voluntary contributions.195 Not only did initial funds raised fall short of their target, and take years longer than hoped, but running costs also soon exceeded these expectations and sufficient financial support was often challenging to attain.

After the appeal launched in 1951, the Foundation solicited support from The King’s Fund. However, these appeals were repeatedly rejected as the Fund’s Management Committee believed ‘that the hospital wanted a grant not so much for the money as for the prestige that would be conferred if the Fund implied approval’.196 It was not until the RHB expressed a will to ‘bury the hatchet’,197 that the King’s Fund were willing to support the New Victoria.198 The King’s Fund contributed £1,000 in 1960 to various maintenance and infrastructure costs,199 and a further £4,000 in 1962 covering most of the costs of the Hospital’s new operating theatre.200 In 1960, the New Victoria was described as ‘trying to get contractual relations with the Board’,201 although there are no records from the RHB indicating these efforts were successful.

By 1966 the hospital had an annual shortfall of £4,000,202 and in 1973 an appeal was launched for £200,000 to build ‘a 16-bed private wing to help with the financial support of the rest of the hospital’s resources’.203 This gradual trajectory towards private medicine reflects fundraising challenges experienced by voluntary hospitals before 1948 which had led to their reliance on patient fees and contributory schemes. The pre-1948 healthcare model adopted by the New Victoria struggled in the post-1948 context. Voluntarism had not wholly been eliminated under the NHS—nor had that been Labour’s aim—but the main forms of voluntary action in the health sector did shift significantly. Labour opposed Victorian, paternalistic charity, the type which had founded and endowed hospitals prior to 1948. However, they supported mutualistic voluntary efforts.204 Though NHS hospitals could still receive donated funds,205 most voluntary actions in the health sector shifted away from financial contributions and towards acts of service.206 Critics of the KMVH’s doctors similarly criticised the New Victoria’s establishment as a ‘retrograde step’207 in healthcare: ‘though private money may be forthcoming for isolated endeavours of this sort, it will never again be found for a comprehensive hospital service’.208

Conclusions

The New Victoria’s founding is far more than an example of anti-NHS sentiment. Beginning as a defence of GP independence, the ensuing debates reflected pre-1948 tensions between the middle and working classes and between Conservative and Labour ideologies. They also highlight the persisting demand for patient input in healthcare.

Before 1948, middle-class people were more likely to support voluntary hospitals, oppose state interference, and, after 1948, to complain about the NHS.209 The campaign to establish the New Victoria appealed to these middle-class preferences, and, like the KMVH before it, mostly served and was supported by middle-class patients and locals. Ultimately, it therefore faced the same financial difficulties that the KMVH and voluntary hospitals had faced prior to 1948: after the initial excitement around the campaign had died down, voluntary contributions were not sufficiently forthcoming to sustain the hospital. Without a contributory scheme or core funding from the state, New Victoria had to expand private provision as a means of survival.

The New Victoria case additionally reflects Conservative-Labour differences during the 1950s in terms of attitudes towards nationalisation, voluntarism and conceptions of ‘the public’. The Conservatives’ prioritised individual freedom and responsibility, supporting the independence of medical practitioners and local patient voices against state control; Labour prioritised centralised control with accountability through government, and an efficient healthcare system for the national population. Conservative politicians thus backed the KMVH’s doctors; Labour backed the RHB.

The founding of the New Victoria also demonstrates that concerns for patient participation in healthcare did not simply disappear in 1948, only to later re-emerge in the patient consumerism movement of the 1960s. Rather, the debates over democracy which predated the establishment of the NHS210 permeated the founding of the service and were accentuated during the debate over the future of the KMVH. Some even used the language of consumerism in the 1950s,211 and expressed hope their actions would initiate channels of patient and public participation in the NHS itself.212 Whilst the KMVH’s doctors were unique in setting up a voluntary hospital to address their concerns, they were not alone in their objections: calls for improved representation of HMCs continued for several years across the NHS.213 It appears demand for patient participation in the NHS is as old as the NHS itself.