As the rightly acclaimed tv series Downton Abbey unspools its final episode some fans have criticized the producers decision to devote so much time to a debate about the future of Downton’s Cottage Hospital. The show makes the issue mostly personal with delightfully snippy exchanges between Violet, Dowager Countess of Grantham who speaks for a way of life that is passing, and her cousin Isobel, widow and daughter of physicians and trained as a nurse during WWI, who is the voice of modernity. But underneath the repartee lies a serious and persistent issue: what should be the relationship of the community to the emerging age of a high tech, highly capitalized and highly specialized medical system?
As Mary Kay Clunies-Ross, Senior Vice President of the Washington State Hospital Association, who has taken a keen interest in the show told me, “They’re asking the right questions. Who will be in charge? Will someone tell me what to do? Will we be able to continue to provide free care?”
The US and British health systems, while dramatically different, have had to grapple with these same questions. And in their exploration they’ve discovered that case can be made for big and for small but the weight of evidence suggests that the optimum medical configuration is when high tech and specialization is in service to responsible and accountable community hospitals.
In 1859, in real life, Albert Napper opened the first cottage hospital in Cranley. As Doctor Irvine Loudon at Oxford University observes, it was “built explicitly as a warm, clean idealized version of the farm labourer’s cottage in order to reassure patients.” A familiar doctor would treat people in a familiar atmosphere. Communities rallied around the concept. Hundreds of cottage hospitals sprang up and over the decades evolved into relatively sophisticated operations, often with state-of-the-art medicine and surgery.
In a very early episode in the series a farmer John Drake was admitted to the hospital with a terminal case of Dropsy. Isobel suggested to a Dr. Clarkson they use a very new technique. He reluctantly agreed and Drake promptly revived. By 1925, the year in which the final season of the tv series is set, voluntary hospitals constituted about 40 percent of all hospitals. They were largely supported by contributions and staffed with volunteers. There were government hospitals as well: The infirmaries that grew out of the much-despised workhouses of the 19th century. But to many people these remained unwelcome venue.