Mutualism and Health Care: British Hospital Contributory Schemes in the Twentieth Century (review)

In this volume, Martin Gorsky, John Mohan, and Tim Willis set out to explain the paradox of why, despite their popularity in interwar Britain, hospital contributory schemes were largely absent from the National Health Service. Taking their cue from the literature on voluntarism, the role of voluntary organizations in civil society, and the economics of health insurance, their aims are, first, to extend and develop their work on the historical development of contributory schemes; second, to relate these to debates about ways of organizing welfare services; and third, to place this history in the context of current and future developments in the welfare state.

The authors show how hospital contributory schemes emerged through workplace subscription and hospital collecting funds so that by the 1920s and 1930s, working-class contribution had become an essential element of the hospital system. In chapter 3, then, they chart mass contributions and hospital finance, the heterogeneous nature of schemes, and the growth of membership and income, and also assess the aggregate impact of schemes on hospital finances. Mass contributions both introduced new incentive schemes and structures and also raised expectations and demand for hospital treatment (p. 64). In chapter 4, the authors trace the geography of hospital contributory schemes in interwar Britain; they look at the variability of membership, discuss imbalances in the distribution of contributors, and assess the role of schemes in the integration of hospital services. Localism was a source of strength but also an obstacle to progress, and the schemes never gained comprehensive coverage (p. 87).

The authors move on in chapter 5 to hospital contributions and civil society, exploring the mechanisms for popular participation, how active contributors were, the ethos of contributory schemes, and the notions of social citizenship held by trade unions and the Labour Party. It has many attractive illustrations. In the next chapter, Gorsky, Mohan, and Willis move on to contributory schemes, working-class governors, and the local control of hospital policy. They ask whether contributory participation affected decision making and signaled a genuine shift in the control of institutions (p. 124). In chapter 7, they look at the state and hospital contribution in the period 1941–46, when contributory schemes folded and the remainder transformed themselves into nonprofit insurance associations. With the coming of the National Health Service, the schemes tended to follow events rather than preempt them; there was no systematic appeal to public opinion and no clear and constant position in Parliament (p. 171). The schemes retained strong local and urban identities but had limited success in expanding to areas where coverage was low (pp. 202–5). There was confusion about the identity and status of the schemes; by the 1970s, their ethos was under threat, and it is difficult to see them as a revival of mutualism. Thus the authors argue that, through the history of the contributory schemes, one can see both the attractions and limitations of this form of funding and the arguments for voluntary provision, but also the difficulties. Arguably, the challenge for the future is how to combine the strengths of public funding with the democratic and participatory ideals of the schemes (p. 233).

Generally, this is an authoritative and well-written history of hospital contributory schemes in Britain, based on very detailed study of a wide range of primary sources, notably case studies of individual hospitals. Inevitably, there are some weaknesses. Some chapters have been written by Gorsky, some by Mohan, and some jointly; their styles are rather different. Moreover, while authoritative, the treatment is at times rather dry for the general reader; there are sections where nearly every sentence has a footnote, and some parts are very detailed. Nevertheless overall, this is an impressive history, offering a convincing analysis of the contributory schemes themselves and wider insights into voluntarism and civic society.