Wednesday, 30 April 2014

Medical Appliances and the Decline of the Welfare State: Lessons from the Past

It was with a weary sense of familiarity that I read the recent news from South Warwickshire concerning proposals to introduce charges for medical appliances such as crutches, walking sticks and neck braces. Sue Lear, presenting to twenty elected patient representatives on behalf of the GP-led Clincal Commissioning Group, asked 
Would it be reasonable to ask people to contribute to the cost of orthotics, aids and appliances? If so, which items and how could we agree this? If so, what criteria should be applied, eg low-cost items below a specified threshold?
While the “tentative” cost-saving suggestion brought widespread criticism from sources as diverse as the general secretary of the TUC, the chief executive of Disability Rights UK, and the British Medical Association, I cannot help but see it as merely another stage in the undermining of the ideals of the welfare state and its consequent accelerating dismantling. It of course raises practical as well as ethical questions. How will the new system decide who ‘deserves’ free appliances, and how will those not deemed worthy raise the necessary cash? Are we not already seeing these issues with the hated ATOS healthcare scheme, or the depressingly rapid rise of charitable Food Banks? Medical appliances, of course, have not always been provided by the state; looking at how these problems were 'solved' in the past may provide a hint of what could, unfortunately, happen in the future.

The Manchester Surgical Aid Society (MSAS) provides a neat case study. Formed in 1897 to provide the poor and working classes with medical appliances, its funds were raised through a combination of middle-class philanthropic subscription and recipient contribution. The MSAS epitomised what Gareth Stedman Jones has termed ‘the deformation of the gift’, a process of charitable giving symbolising individual sacrifice and superiority on the behalf of the donator, and a consequent moral obligation on the behalf of the receiver. As an expression of the liberal individualist politics that permeated definitions of citizenship in the nineteenth century, helping the worker to overcome a physically dehabilitating illness encouraged a return to work, an avoidance of debt, and accordingly a cementing of ‘good citizenship.’ Concurrently, it was a manifestation of the benefactors own moral responsibility and claim to being a good citizen. In the welfare politics of the nineteenth century, in other words, there was rarely such a thing as a free crutch.

As the purpose and power of both local and national governments increased, beginning especially with the Liberal social reforms in the Edwardian years, welfare organisations were increasingly supported with money from the public purse. For the MSAS this support was vital since, in the 1920s, its committee had begun to complain of a budget deficiency caused by high prices, increased unemployment, and a supposedly receding ‘spirit of giving’. Despite financial difficulties its services remained vital to local people, with no public provision of medical appliances in the city. Claimants to the Society grew; in its infancy in 1899 it helped 117 cases, by 1914 this figure had grown to 499, and in 1934 it hit a peak of 702. While the MSAS helped the majority of applicants to its funds, some claims were rejected, middle-class philanthropy implying not only moral obligation, but also a separation of the deserving and non-deserving.

In the 1940s the tides of change began to swell, and the public provision of healthcare increased. Though the recent work of historians like James McKay and Matthew Hilton is certainly correct in highlighting the longevity and vitality of voluntary associations in the ‘mixed economy of welfare’, some organisations undeniably found their services redundant. By 1945 the number of applications to the MSAS had dwindled to 315, due mostly to the supply of appliances for schoolchildren by the Manchester Education Committee under the provisions of the 1944 Education Act. In 1947 the Society celebrated its half-century, but recognised that, with the National Health Service Act of 1946, its future was ‘rather an unknown quantity’. After the act became operational in July 1948, the Society received only five applications, making it ‘quite plain that practically all needs are now met from public funds.’ This being so, the Society disbanded, declaring ‘another instance of private enterprise in the voluntary field blazing a trail, and handing over to the State when the work has proved its worth.’ 

The rise and fall of the MSAS tells a common story of the shifts in the political culture of citizenship and welfare in the nineteenth and twentieth centuries. In terms of the welfare state and the new social democracy, the provision of (at least some) free medical appliances was a universal social and legal right bestowed due to the individual’s membership in the nation-state. As Stedman Jones argued, the moral and social results of ‘the gift’ had depended on a personal relationship between the giver and receiver; de-personalised, it lost its elements of voluntary sacrifice, prestige, subordination, and obligation. While the MSAS helped many, though not all, of applicants, it did so, a cynic may argue, with an ulterior motive of social control. With the potential decline of the NHS, is this really a position to which we want to return? 

Tom Hulme

* Thanks to the New History Lab, a wonderful organisation that I was privileged enough to be a part of while undertaking a doctorate at the University of Leicester, for letting me use their blog. I more frequently blog at and tweet at *