Watching Downton Abbey with an Historian: In Sickness and in Health -The Toast

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Home: The Toast

Season 6, Episode 2

Let’s talk about this hospital subplot. Across the internet it’s been dismissed as inscrutable and interminable, but The Toast is made of sterner stuff. And at a moment when the funding of the National Health Service in Britain is under constant debate, and junior doctors are demonstrating in the streets and talking about strike action, it’s worth taking Downton’s invitation to think about the history of paying for medical care.

First things first, let’s sort out what the Violet and Isobel are arguing about here. The Downton Cottage Hospital was built on land donated from the Downton estate by Lord Grantham’s father (and Violet’s husband). It is governed by a board of local worthies: Lord and Lady Grantham, Dr. Clarkson, Isobel Crawley, and, in the role of president, Violet, the Dowager Countess. The Royal Yorkshire Hospital has proposed a merger, on the grounds that this would streamline fund-raising and give access to more up-to-date treatment for Downton’s patients. Violet and Dr. Clarkson are strongly opposed to the merger, preferring to keep Downton Cottage Hospital strictly under local control, while Isobel favors it, believing it will help save lives. She is joined in this opinion by her erstwhile suitor, Lord Merton, a hospital donor who has been invited to head the new Board of Charitable Donors should the merger occur. Cora seems to be convinced by the arguments for the merger as well, while her husband prefers not to take sides in a fight that threatens to pit his mother against his wife.


This is, as characters are fond of mentioning, 1925, which places us in the transitional period between the National Health Insurance Act of 1911 and the creation of the National Health Service in 1948. Both the Downton Cottage Hospital and the Royal Yorkshire are voluntary hospitals, as were about 40% of hospitals in England and Wales at this time. These institutions had roots stretching back to twelfth-century infirmaries at monasteries, which treated the poor as well as residents. By 1925, they were charitable institutions that relied on donations as well as patient payment to meet their costs. Their patients, generally, were men and women who were not able to afford private care.

Isobel’s title of “almoner” suggests that she might have been in charge not only of seeking donations for the hospital, but also of ensuring its patients were sufficiently poor to merit admission. Voluntary hospitals spanned a wide range of institutions, from small hospitals run by general practitioners such as Dr. Clarkson to large teaching hospitals with consultants from many specialties. While cottage hospitals could be popular, especially since they were accessible to local visitors, they were not necessarily so: Anna’s anxious, instinctive “I wouldn’t go to hospital?” is a testimony not only to fear of hospitals in general, but to her lack of confidence in her local hospital in particular.

The other major category of hospital in England at this time was the public hospital, which grew out of workhouse infirmaries and special infectious diseases hospitals set up by local governments. Given their origins and their reputation for being gloomy places lacking in amenities, it is not surprising that, for many people in the 1920s, public hospitals still carried a taint of the workhouse with them.


Private care, meanwhile, was costly. In Downton Abbey, it is embodied in the Harley Street specialist whom Lady Mary takes Anna to see for her recurrent miscarriages. Isobel bitterly remarks that if a member of the Crawley family so much as cuts a finger, they head to London—but this, of course, isn’t true (and would be a dire reflection on Dr. Clarkson if it were). For a cut finger, they would be likely to consult Dr. Clarkson, but at his private surgery and for a substantial fee, rather than under the auspices of the hospital. Doctors like Clarkson would have made their livings primarily from their private practices, often offering their services to hospitals for free in exchange for prestige and reputation.

During the 19th century, the high cost of medical treatment, even in voluntary or public hospitals, meant that ordinary people often went without medical care or faced financial ruin if they were so sick that they had no choice but to seek a doctor. The National Health Insurance program, which was passed in 1911 and came into force in 1913, was meant to alleviate this threat. It marked, too, the entrance of the state into general practice medicine. This program was based on the system of mutual associations or friendly societies which had, from the late eighteenth century, banded together to pool resources to provide medical treatment for members when they fell ill.

The NHI program covered about half of the adult population. In 1925, workers between the ages of 16 and 70 earning less than £250 per year were covered. They received a cash benefit from the society with which they were registered and the right to receive general medical treatment at no cost from certain practitioners, known as “panel doctors.” For the working classes, the scheme was a great step forward; the family breadwinner or breadwinners were insured against illness, and overall health improved as more people were able to take advantage of access to medical care.

Voluntary hospitals in the 1920s thus found themselves caught between rising demand (as more insured patients sought medical care) and falling charitable donations, often resulting in overcrowding and perfunctory treatment. One doctor recalled that at one voluntary hospital’s out-patient evening sessions in the 1920s, “the first few patients would be examined with the utmost interest and thoroughness, and then the porter would come in to say that there were a hundred others who must be seen that evening.” But even though it was common practice to spend as little as three minutes with each patient, voluntary hospitals struggled to cope with rising costs of both commodities and wages as well as the need to keep up with new, complex equipment for diagnosis and treatment. As Lord Merton put it: “How old is our X-ray machine? Does Clarkson really know how to use it? What advanced surgery do we offer? None.”

Recognizing the problem, the postwar government cast about for solutions. In 1920, the Dawson Report, produced by a Ministry of Health council led by Sir Bertrand Dawson, proposed linking hospitals into one, rationalized system. As the report put it, in terms that would have horrified Violet had she read it: “The insufficiency of organisation has become more apparent with the growth of knowledge, and with the increasing conviction that the best means of maintaining health and curing disease should be made available to all citizens.” Voluntary hospitals that agreed to join this new system would be rewarded with government grants-in-aid. But the plan was another victim of the cost-cutting measures known as the “Geddes Axe.” A new committee on voluntary hospitals, the Cave Committee, was formed in 1921; it agreed that these institutions were worth saving but rejected the idea that the government should fund them directly.

The solution, then, would have to come locally. One possibility was for voluntary hospitals to merge with municipal hospitals. In Bradford, an industrial city about thirty miles south of Downton’s village of Ripon, the City Council took over the running of hospital services in 1920 — but this was seen as a bold move that raised fears of “municipal socialism.” Conservative hospital benefactors like Violet reacted strongly against the idea that any government should take a role in controlling hospitals; as Sir George Martin of Leeds said in 1930, “It would be a very bad day for whose who required the help and beneficent care which a hospital could give when such institutions were regulated and controlled by the municipality.” Instead, what really saved voluntary hospitals in the 1920s and 1930s was the development of contributory schemes whereby patients (or potential patients) raised money in exchange for access to treatment. Sheffield and Leeds, two other industrial Yorkshire cities, opted for this model of funding, which raised cash from subscriptions of various kinds, galas, and other events targeted at ordinary people rather than grand patrons.

Voluntary hospitals weathered the financial crises of the interwar years through a combination of reorganization and finding new sources of revenue. But the British hospital system remained in desperate need of an overhaul. In February 1939, 71% of those surveyed told the British Institute of Public Opinion that they would prefer a state-financed hospital system rather than one that relied on charity fund-raising. When World War II broke out that September, the medical system was rapidly reorganized on a war footing, and the National Health Service was created in 1948. The days when hospital management rested on the whims of wealthy benefactors seemed to be over.

Austerity policies in modern Britain have hit the NHS hard. In November, the current Conservative government called for £22 billion to be saved through greater efficiency in the NHS. Junior doctors are currently threatening strike action over a contract that, in the British Medical Association’s words, “represents an existential danger to the NHS as an institution.” The world of the Downton Cottage Hospital seems to loom again.

As Dr. Mark Porter, the Chair of the British Medical Association’s hospital consultants committee, put it in 2011: “Very deliberately the government wishes to turn back the clock to the 1930s and 1940s, when there were private, charitable and co-operative providers. But that system failed to provide comprehensive and universal service for the citizens of this country. That’s why health was nationalised.” Far from being a “dreary” subplot, the battle over the Downton Cottage Hospital might be the most relevant aspect of Downton Abbey this season.


Anne Digby, “The economic and medical significance of the British National Health Insurance Act, 1911,” Financing Medicine: The British experience since 1750, ed. Martin Gorsky and Sally Sheard (London: Routledge, 2006)

Barry M. Doyle, “The Economics, Culture, and Politics of Hospital Contributory Schemes: The Case of Inter-war Leeds,” Labour History Review vol. 77 no. 3 (2012)

Sharon Schildein Grimes, The British National Health Service: State Intervention in the Medical Marketplace, 1911-1948 (New York & London: Garland Publishing, 1991)

Nick Hayes, “Did We Really Want a National Health Service? Hospitals, Patients and Public Opinions before 1948,” English Historical Review Vol. 127 No. 526 (2012)

Sally Sheard, “Reluctant providers? The politics and ideology of municipal hospital finance 1870-1914,” Financing Medicine: The British experience since 1750, ed. Martin Gorsky and Sally Sheard (London: Routledge, 2006)

Tim Willis, “The Bradford Municipal Hospital experiment of 1920: the emergence of the mixed economy in hospital provision in inter-war Britain,” Financing Medicine: The British experience since 1750, ed. Martin Gorsky and Sally Sheard (London: Routledge, 2006)

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