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This article brings to the attention of the journal's readers an online database of British and Irish hospital statistics, which was launched in 2010.1 The data it holds cover the period 1890 to 1946 and relate to voluntary hospitals; in other words those hospitals maintained neither by the for-profit sector nor by public bodies. These institutions were characterised by their independent status and by their reliance on philanthropy and other principally private sources of funding. Their governance was handled by committees of lay people serving in a volunteer capacity and they were staffed to a significant extent by physicians and surgeons working in honorary and unpaid posts.2 Prior to the launch of the National Health Service in 1948, many of the hospitals in England, Scotland, Ireland and Wales lay in the voluntary sector, including the major centres of general acute medicine, notably hospitals with medical schools, along with special hospitals providing care for particular groups of diseases, and the cottage hospitals which flourished in small towns and rural areas.3 It is material on these which the database now makes available to the research community. The rationale for collecting and presenting these data lies in the increased scholarly interest in the modern history of the hospital. Of course, the voluntary hospitals are only one part of this story. They contained (in England and Wales) about 26 per cent of general medical beds in the 1890s, rising to 33 per cent by 1938; at which point the remaining 20 per cent were within the Poor Law workhouses and infirmaries, which provided long-term care in sickness and old age, and 47 per cent in local government, including isolation, long-stay and general hospitals.4 They were also lesser players in psychiatric care, with the major asylums administered by local government. However, it was in the voluntary hospitals that cutting-edge acute medicine was practised and where most medical education was located. Recent years have seen substantial new studies of hospitals in both the voluntary and municipal sectors, and of cross-sectoral efforts to integrate the two.5 There are several different constituencies for this work: medical historians for whom institutional health services were the sites in which scientific knowledge and practice was fostered; urban historians tracking the growth and proliferation of major civic institutions, whose governance and financing were central aspects of local political authority; historians of social policy interested in the nature and performance of the mixed economy of health and social care which preceded the welfare reforms of the mid-century; and political scientists interrogating the dynamics of civil society organisations. Behind much of this, perhaps, lies the assumption that attention to a history characterised by localism and other models of democratic engagement is relevant to the challenges of health system stewardship today.6 Two major research questions initially inspired the creation of a database of surviving statistics of British and Irish voluntary hospitals. First, how did patterns of voluntary hospital provision and utilisation differ by area, and how did these change over time? Second, how did the distribution of charitable financing vary by place, and what were the trends in income and expenditure? Funded by the Leverhulme Trust, the original project was based at the University of Portsmouth, where an ORACLE database was constructed between 1996 and 1999.7 A series of publications providing a spatial and temporal analysis of the voluntary hospitals between the 1890s and 1940s arose from this, of which more detail is given below. The final phase of the project in 2008–9 was sponsored by the Wellcome Trust, and involved the preparation of the database for web access, and linkage to the Hospitals Record Database of the National Archives and Wellcome Trust.8 The aim was not only to make our material publicly available but also to facilitate researcher access to details of archival holdings through this linkage exercise.9 What does the database contain? Statistical material was drawn from two main sources: Burdett's Hospitals and Charities: The Year Book of Philanthropy and Hospital Annual, published between 1892 and 1930; and its successor, The Hospitals Yearbook, produced by the Central Bureau of Hospital Information and ‘issued under the auspices of the Joint Council of the Order of St John and the British Red Cross Society and the British Hospitals Association’.10 Henry Burdett, who initiated the yearbooks, was a philanthropist and champion of the voluntary hospital movement. His aim was to produce an almanac of medical charities, both for benevolent donors and for the trustees and administrators of hospitals seeking information about the organisation and costs of similar institutions. After Burdett's death, there were some gaps between 1921 and 1928, before continuous records resumed again with The Hospitals Yearbook. To fill these gaps we drew on volumes 3 to 9 of the Order of St John's Annual Report on the Voluntary Hospitals in Great Britain (excluding London) and the King Edward's Hospital Fund for London, Statistical Summary. Despite some omissions (due to underreporting, especially by smaller institutions), these yearbooks contain a uniform and systematic record of finance, beds, patients and staff in about 1,300 individual institutions. Finally, for a small number of the large, older hospitals we were able to add data from an early survey undertaken in 1863 by Bristowe and Holmes.11 The records in Burdett's Hospitals and Charities varied in their level of detail of individual hospitals. Every institution had a main listing with basic description of location, foundation date, governors, staff, beds, patients and total income and expenditure. However, it was only for the larger hospitals, particularly those with medical schools, and the major general and special hospitals that more detailed statistical tables were provided. These were divided into three categories: beds and patients; income sources; and different heads of expenditure. Tabulation in the Hospitals Yearbook followed a slightly different format, with fewer attributes of the smaller hospitals recorded, including numbers of beds, patients, total income and expenditure. More fulsome records of the larger hospitals were again compiled, covering provision, utilisation and a detailed disaggregation of categories of income and expenditure. The quality of the printed text was such that we were unable to scan data from the early yearbooks and had to enter the statistics manually. Time constraints prevented capture of every year, so we took the census years (i.e. 1891, 1901 and so on) to facilitate analysis utilising other socio-economic data, such as the calculation of bed to population ratios. We also took the midpoints between census years (i.e. 1896, 1906 and so on), then added data from some intervening years for the larger hospitals whose experience was tabulated. The quality of the later Hospitals Yearbook was better and allowed us to use optical character recognition software to scan the text.12 We therefore obtained a full series of data for the 1930s up till 1942; after this point systematic recording faltered under wartime conditions and gaps in the sequence became more numerous. In addition to the annual variables mentioned already, the database contains some basic information about each hospital, such as name, address and foundation date, as well as the county and town in which it was located. The spatial units recorded were the administrative counties and the county boroughs (burghs in Scotland) that were current in local government organisation between the 1890s and 1940s (as distinct from present day administrative areas). We endeavoured to produce accurate co-ordinates for each hospital's location, and these have been used for the website's mapping function. Several different strategies were followed to locate these grid references: for surviving hospitals we converted their current postcodes to grid references; some from the London region are available in Mayhew's doctoral work; others were obtained directly by John Mohan from old Ordnance Survey maps held in the British Library map collection.13 For a small number of years we also recorded the type of hospital, differentiating general medicine from specialties, and the terms of admission, which might include the use of the subscriber letter, means-tested user fees, or simply free entry. The core of the database is the annual statistics, which users can access in different ways. Hospitals may be located through a name search, or by navigating an interactive map, or through drop down menus of counties and county boroughs. Once at an individual hospital's page, the website contains a simple graphing mechanism to allow immediate visualisation of trends in a limited number of key variables. For more detailed analysis, content may be downloaded to an Excel spreadsheet, either at the level of the individual hospital, or for all hospitals within a particular county or major city. With respect to provision and utilisation data it includes at a minimum the numbers of beds, new in- and out-patients, and for the larger hospitals, average bed occupancy and length of stay, and comparative costs of in- and out-patients. For a small number of years we have also recorded numbers of staff, comprising medical staff, medical residents, nurses and nurse probationers. The categories of income vary somewhat over time, and between the different yearbook formats, with London hospitals particularly anomalous in the later series. Broadly though, information is available for the larger hospitals on different forms of philanthropy (subscriptions, donations, legacies, church collections), on mass contribution (Saturday and Sunday funds, workers' schemes), invested capital, public subventions, user fees, and earnings from services. As to expenditure in the larger institutions, the major categories included are salaries, provisions, building maintenance, surgical and dispensing costs, pensions, management, and rents and rates. As noted above, the original project generated various research articles which may be of interest to users. In essence, our findings on spatial distribution illustrated the markedly variable levels of provision and utilisation across regions and countries, and related these to the uneven geography of voluntary financing.14 Our temporal analysis of funding trends broadly confirmed earlier pessimistic accounts of the difficulties faced by interwar hospitals as expenditure demands rose and traditional charity stagnated.15 However, aligning our data with statistics on the growth of municipal hospitals suggested that public provision was beginning to reduce disparities in access.16 Finally, the dataset helpfully undergirded qualitative research into aspects of health service administration; we argued inter alia that evidence for successful cross-sectoral integration was rather patchy and that despite advancing user empowerment the grip of bureaucrats and medical professionals remained strong.17 To the extent that any of this work yields policy implications, its tenor has been to caution against amnesia about, or ignorance of, the weaknesses of the hospital system before the NHS. This seems valuable in a policy arena in which the virtues of localism, the capacities of third sector providers, and the impact of public involvement are frequently mooted as prescriptions. Others, of course, will wish to offer different readings, and we hope that the availability of this database will further encourage them to do so.
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