Medical social work was placed in an odd position by the arrival of the NHS in 1948. The profession had gained a high-status foothold in British hospitals by administering the patient payment schemes that rapidly became commonplace in the financially turbulent years following the First World War. The fact that no such role would exist once a health service free at the point of use was established could easily have posed an existential threat. Yet this did not happen, and this is testament to how much the profession and its role in the hospital had changed over its first half-century.
The first medical social worker was appointed at London’s Royal Free Hospital in 1895. Miss Mary Stewart was a case worker for the supremely Victorian Charity Organisation Society, so was used to encouraging both the material and moral improvement of the poor. She was given three duties: to prevent the ‘abuse’ of admission being given to ‘persons able to pay for medical treatment’; to refer the ‘destitute’ to the Poor Law; and to encourage those between the two to join ‘Provident Dispensaries’ whenever financially possible. She was also given the title by which the medical social worker was known officially until 1964: the Lady Almoner. The ‘almoner’ reflected the fact they were administering charity, akin to giving alms, by acting as the gatekeepers of medical charity. The ‘lady’ was to distinguish between between them and other officer holders in some of the oldest charity hospitals, but it served to reinforce the notion of class distinction between the middle-class almoner and the typical working-class patient. It was this model of the almoner, who we might say operated the hospital means test, that was rolled out across the provinces in the 1920s and 1930s.
Elizabeth Gloyne described the introduction of the NHS as she experienced it running the social work department at the Coventry and Warwickshire Hospital:
“Of course all hospital assessment went out because it was a free service, and there you were at the end of June 1948 going round collecting Coventry and Warwickshire Hospital Savings Association vouchers saying, ‘This is a week you pay but you won’t have to pay next week’. And next Monday there was no need to go round, and it was a tremendous jolt to those of us who’d been in hospitals where there was assessment as part of our job. Was the raison d’être of your being there financial? I suppose to the committees, it was. I don’t honestly think to your colleague staff it was. You went up to the ward and said to sister, ‘Well I don’t need to see all these people to get money off them. But on the other hand, you and I are pretty aware that it’s not always money that’s the problem. So shall I go round and see them all? How shall we play this one?’ One sort of learned how to play it a bit. Of course in actual fact there were just as many social problems.”
A focus on social problems was nothing new. It was something that been made easier by the development of public hospital services even before the NHS. For example, during the Second World War there were many patients treated under the Emergency Medical Service who weren’t expected to pay anything, which gave the almoners the opportunity to shift their focus. Indeed, even when running the payment schemes, they weren’t necessarily their top priority. As former almoner Enid Warren recalled years later: “If I’ve got several people outside my door in out-patients with difficult problems, and others are just waiting for me to assess whether they can manage one and sixpence per attendance or not, there is no question in my mind where I’m going to spend the time.” At Addenbrooke’s Hospital in Cambridge, the almoner’s annual report in 1935 which made no mention of payment whatsoever, but explained their purpose as follows:
“Each Department of the Hospital sees the patient from a different angle. In the Almoner’s Office he is no longer the gangrenous appendix, the obstinate arthritis, or the glaucoma that has responded so well to treatment, but an ordinary human being with his background of ordinary human cares and relationships. He is for us the out-of-work trying to balance a budget that can never quite meet the household needs; an Old Age Pensioner without kith or kin; a child whose future still hangs precariously in the balance. Through the Almoner’s Office pass all the types which go to make up the Hospital world, the lonely, the misfits, the discouraged and the difficult–all through sickness or poverty, in need of some help or advice.”
Once the almoners had separated themselves from the task of assessing patient payments, they were eager to keep themselves distanced from anything resembling it. This was tested when, only a few years after the establishment of the National Health Service, various charges were introduced. Under Attlee’s Labour government these began with charges for dentures and spectacles, and the door was opened for Churchill’s subsequent Conservative government to bring in charges for prescriptions and hospital appliances. The almoners were adamant they would not – as some hospital administrators assumed – be collecting these new charges. In February 1952, the council of the Institute of Almoners met and issued a statement declaring what the Ministry of Health would by the summer accept:
THAT ANY ASSESSMENT OR COLLECTION OF CHARGES UNDER THE NATIONAL HEALTH SERVICE IS NOT AN APPROPRIATE DUTY OF ALMONERS’ DEPARTMENTS AND IN NO CIRCUMSTANCES SHOULD ALMONERS (OR THEIR CLERKS) ACCEPT SUCH RESPONSIBILITIES.
In rejecting such tasks, the almoners saw themselves as fighting off a distraction from and a dilution of their real work. At their national association’s annual general meeting shortly after, Miss Hornsby Smith spoke for the profession when she remarked: “I am sure many of you rejoice in the fact that your work is no longer association with the extraction of money and that those other services which you render to the patient and to the National Health Service have assumed their proper place.”
Social Workers Speak Out, Modern Records Centre, University of Warwick – recordings and transcripts of Alan Cohen’s 1980-81 interviews with 26 pioneers of social work, 5 of them former almoners, available online.
Joan Baraclough, Grace Dedman, Hazel Osborn and Phyllis Willmott, 100 Years of Health Related Social Work 1895-1995 (BASW, 1996).
Lynsey Cullen, ‘The First Lady Almoner: The Appointment, Position, and Findings of Miss Mary Stewart at the Royal Free Hospital, 1895-1899’, Journal of the History of Medicine and Allied Sciences, vol. 68, no. 4 (2013), 551-582.
George Campbell Gosling, Payment and Philanthropy in British Healthcare, 1918-48 (Manchester University Press, 2017) – available as an open access free e-book here.