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Private complaints and public health

Epilogue 201
*** Richard Titmuss’s contribution to the sociology of health and illness
Raymond Illsley

General bibliography 209

Bibliography of work by Richard Titmuss 225

Richard Titmuss: further reading 231

Index 233

IV
 Sources of extracts

Prologue: The experience of being a patient

Originally published as a Postscript to the posthumous collection
of lectures, Social policy: An introduction (1974), edited by
Brian Abel-Smith and Kay Titmuss

Part 1: Social medicine and social inequality

one Infant mortality
From Poverty and population (1938)
two The social disease of juvenile rheumatism
Originally published with J.N. Morris as ‘The epidemiology
of juvenile rheumatism’, The Lancet (18 July 1942, pp 59-73)
three Health and social change: the example of rheumatic
heart disease
Originally published with J.N. Morris as ‘The recent history of
rheumatic heart disease’, The Medical Officer (26 August 1944)
four War and disease
Originally published as ‘Camp followers of war’, The Listener
(7 October 1943)

Part 2: The National Health Service

one Towards a national hospital service
Originally published as ‘Preparations: the emergency medical
service’, in Problems of social policy (1950, Chapter V)
two The policy background
Lecture given as ‘Trends in social policy: health’ at the London
School of Economics and Political Science (1958); first published
in M. Ginsberg (ed) Law and opinion in England in the twentieth
century (1959) and later in Commitment to welfare (1968)
three The structure of the NHS in England
Lecture at the Law School, Yale University, USA (April 1957);
originally published as ‘The National Health Service in England:
some aspects of structure’, in Essays on ‘The welfare state’ (1958)
four The NHS and general practice
Originally published as ‘The National Health Service in England:
some facts about general practice’, in Essays on ‘The welfare state’
(1958)
five The ethics and economics of medical care
Originally published in Medical Care (January-March 1963);
later in Commitment to welfare (1968)

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Private complaints and public health

Part 3: The sociology of health care

one Medical behaviour, science and the NHS
Originally published as ‘The National Health Service in England:
science and the sociology of medical care’, in Essays on ‘The welfare
state’ (1958)
two The hospital and its patients
Lecture at the Jubilee Conference of the Institute of Hospital
Administrators (London, May 1952); originally published in
The hospital (1952) and later in Essays on ‘The welfare state’ (1958)
three ‘Therapeutic’ drugs
Paper given at a conference ‘Drugs in our society’, Johns Hopkins
University, Baltimore, USA (November 1963); originally published
in P. Talalay (ed) Drugs in our society (1964) and later as
‘Sociological and ethnic [sic] aspects of therapeutics’, in
Commitment to welfare (1968)
four Planning for ageing
Lecture at the Twelfth National Conference on the Care of the
Elderly, Torquay (April 1964); originally published in Planning for
ageing (National Council of Social Services, 1964) and later in
Commitment to welfare (1968)

Part 4: Health, values and social policy

one Choice and the welfare state
Lecture to the Fabian Society (November 1966), published in
Fabian Tract 370 (1967) and in The philosophy of welfare (1987)
two The gift of blood
Papers published as ‘Why give to strangers?’ (The Lancet, 16 January
1971, pp 123-5) and ‘The blood donor’ (Proceedings of the Royal
Society of Edinburgh (B), 71 (Supplement) 6,1971/2)
three Medical ethics and social change in developing societies
From The Lancet (4 August 1962, pp 209-12)
four Health and the welfare state
Lecture at the Hebrew University, Jerusalem (August 1964), revised
as ‘Goals of today’s welfare state’, published in J. Kahl (ed)
Comparative perspectives on stratification (1968)

VI
 Notes on editors and
contributors
Editors
Ann Oakley is Professor of Sociology and Social Policy, and Director
of the Social Science Research Unit at the University of London
Institute of Education. She has researched and written widely in the
fields of gender, health, methodology and evidence-informed public
policy, and currently directs a large programme of health and education
research. Ann is Richard Titmuss’s daughter and literary executor.

Jonathan Barker directs Far-sight Research, an independent research

organisation which explores the views and priorities of service
consumers, focusing especially on older people and other minority
groups. He directed the Age Concern Research Unit from 1979 to
1986 and headed New York’s Accessibility House from 1986 to 1991.

Contributors
John Ashton, Visiting Professor at universities in Liverpool and
Manchester, is Regional Director and Regional Medical Officer of
Public Health for the North West of England. He has always believed
that Richard Titmuss’s insights should inform public health policy
and health service organisation. He co-edited, with Ann Oakley, a
new edition of Titmuss’s The gift relationship in 1997.

Janet Askham is Professor of Gerontology at King’s College, London,

and Research Director at the Picker Institute Europe. She is Scientific
Adviser to the Department of Health Policy Research Programme
on Older People and has published widely in the field of the sociology
of ageing.

Raymond Illsley was formerly Director of the Medical Research

Council’s Medical Sociology Unit and Professor of Medical Sociology
in Aberdeen. He has worked on problems of social class and health
in Britain since 1951 and was for many years consultant to WHO on
health and equity and on health systems research.

Julian Le Grand is the Richard Titmuss Professor of Social Policy

at the London School of Economics. He has published extensively
in the fields of economics, philosophy and social policy, and has been

VII
Private complaints and public health

a senior policy adviser at No 10 Downing Street, and a consultant to

HM Treasury, the Department of Health, the World Bank, the World
Health Organisation, the OECD and the European Commission.

Michael Wadsworth is Director of the Medical Research Council’s

National Survey of Health and Development, and Professor of Social
and Health Life Course Research in the Department of Epidemiology
and Public Health at University College, London. His particular
interest is in longitudinal and life history studies.

VIII
 Introduction

Ann Oakley and Jonathan Barker

Private complaints and public health offers an accessible compendium

of the writings on health of one of the 20th century’s foremost social
policy thinkers: Richard Morris Titmuss. A self-made social theorist,
Titmuss was Professor of Social Administration at the London School
of Economics (LSE) from 1950 until his premature death in 1973.
He wrote widely on subjects across the health, welfare and social
service complex. His early work pioneered the subject of social
medicine and examined the roles of environmental factors and unequal
access to health services in explaining widespread patterns of social
inequality. Later, his work on health focused more particularly on
the origins, development and success of the National Health Service
(NHS) in the UK as a model of public health care and welfare service
provision. Richard Titmuss
Much of Titmuss’s work is out of print. This volume follows an
earlier one, Welfare and wellbeing, edited by Pete Alcock, Howard
Glennerster, Ann Oakley and Adrian Sinfield, published by The Policy
Press in 2001. The earlier volume collected together some of Titmuss’s
main writings on social policy. Private complaints and public health
performs the same service for his work on health care. Sections of
the book bring together his writings on social medicine; the
development and organisation of the NHS; the sociology of health
care; health, values and social policy; and explanations of the concept
of altruism, which Titmuss saw exemplified in the UK’s system of
voluntary blood donation and which symbolised for him a key
difference between public health provision and private market-based
approaches to health care. Most of Titmuss’s work on health care is
less well known today than his later work, which focused more
narrowly on welfare and social policy, but it was in the early work
that he developed many of his key themes and ideas.
The title of the book is suggested by a sentence from one of
Titmuss’s early papers on the NHS (reproduced here in Part 3, Chapter
One, page 128). In this, he remarks that the advent of the NHS
converted private complaints into public ones, making it possible for
both doctors and patients to benefit from scientific and technological
advances in medicine. An absolutely key theme in Titmuss’s approach
to the study of health is the tension between science as the basis of

1
Private complaints and public health

what today is called ‘evidence-based medicine’ and the therapeutic

importance of less easily quantifiable aspects of health care, such as
people’s capacities to care for one another, to exhibit altruism and to
form solidary relationships.
We have had three aims in putting these writings together into
one collection. The first, noted above, is to make Titmuss’s less
accessible writings on health available again. Both as a writer on
social policy and as a critical analyst of health issues, his work is still
widely read and much in demand. Moreover, as several commentators
in this volume note, recent developments in health and social policy
in the UK and elsewhere give his work a heightened relevance today.
Although Titmuss’s work is dated in some respects (the last of it was
written over 30 years ago), the themes with which it deals are of
huge contemporary relevance. These include the benefits and dis-
benefits of private and public health care systems; the purposes and
values of social policy; the role of ‘evidence’ in policy decisions; the
relationships between ‘experts’ and ‘consumers’; the causes and
treatment of social inequalities; the ‘problem’ (in terms of cost and
human tenderness) of technological advance in medicine; the
promotion of the health of particular vulnerable groups, including
older people; and both personal and social meanings of the term
‘health’. Our second aim, linked to the first, is thus to highlight
some of the ways in which Titmuss’s thinking can enhance current
debates about how modern societies can best provide for the health
of all their citizens. People outside the UK remain fascinated by the
NHS as a health system offering universal coverage. There are fierce
debates about the extent to which the NHS is an efficient way of
reducing those morbidities and mortalities which are ‘amenable’ to
health care, and whether greater investment in the NHS results in
greater efficiency (Nolte and McKee, 2003; Smith, 2003).
Our third aim in gathering together the writings in Private complaints
and public health has been more serendipitous. Although Titmuss wrote
and otherwise disseminated his work widely, he did not put together
any sustained, integrative account of his distinctive theoretical and
policy perspectives. This is true for his work on welfare – a point
noted in Welfare and wellbeing – as well as for his work on health,
highlighted in this volume by Raymond Illsley in the ‘Epilogue’.
One can reflect on the reasons for this absence. The pressures of
teaching and administration attached to Titmuss’s post at the LSE are
obvious causes. From the earlier pre-LSE period, there survive various
proposals for, and drafts of, books on social medicine. There were
also more conceptual social medicine projects that never saw the
light of day. These were conceived jointly with Jerry Morris, with
whom Titmuss worked at the Medical Research Council-funded
Social Medicine Research Unit in the late 1940s. The most ambitious
is probably the proposal for a book called The people’s health, which

2
 Introduction

was intended to “examine the health of the people of Britain in the

context of the Society which to so great an extent determines it”.
There are notes in the archives for seven chapters, including a
concluding chapter which would cover “Social medicine in
reconstruction and social medicine in politics, in sociology, in medical
education”.
Titmuss’s work in social medicine and health inequalities was, in
many ways, a visionary project. It also played a particular role in his
intellectual career. Richard Titmuss started out as an “autodidactic,
degree-less insurance clerk” (Jefferys, 1997, p 125), working for a
large London-based insurance company after having left school at
14 with no formal educational qualifications. It was the experience
of his insurance work that schooled him in the mysteries and
importance of vital statistics, and that opened the door to a world of
‘social statistics’ capable of yielding an understanding of systematic
differences between the life chances of different social groups. Titmuss
stayed in insurance until 1942, working on his statistical and social
projects in his spare time, and beginning to publish and become
known in academic circles. A connection with the British Eugenics
Society helped him on his way to academic recognition, at the same
time as providing the Society with a much-needed environmental
focus to counter the unfortunate biological determinism of the war
years (Oakley, 1991). In 1942, he was recruited to write a volume of
the official war history, Problems of social policy (see Part 2, Chapter
One). Widely acclaimed as an intellectual tour de force, the book
secured him the Chair in Social Administration at the LSE, which he
held from 1950 until his death in 1973. In 1948, he moved from a
position in the Cabinet Office to take a job as Deputy Director of
the newly formed Social Medicine Research Unit. Its Director was
Jerry Morris, a medically trained epidemiologist, who remained a
close friend and colleague throughout Titmuss’s life. Jerry Morris,
still active at the age of 93 (Watts, 2000), was enthusiastic about
contributing to this volume but regretfully had to decline at the last
minute on the grounds of having too much to do!
During his years at the LSE, Titmuss reorganised the teaching of
social work, established social administration as a scientific discipline
and acquired an international reputation as a champion of a social
policy based on moral and ethical positions, and as the ‘ideologue’ of
the British welfare state. He also chaired many important committees,
acted as an advisor to gover nment (both nationally and
internationally), and published a long list of academic papers and
seven books. Two of these (Essays on ‘The welfare state’, 1958, and
Commitment to welfare, 1968) were collections of lectures and essays.
A number were practical assignments. The most important of these
was The cost of the National Health Service in England and Wales (1956),
written with Brian Abel-Smith, which argued that the real cost-

3
Private complaints and public health

effectiveness of the NHS was obscured by the misleading way in

which official accounts presented the statistics (see Part 2, Chapter
Three). Another of the practical projects was Social policies and
population growth in Mauritius (1961), with Brian Abel-Smith, assisted
by Tony Lynes (see Part 4, Chapter Three). The other post-1950
books reflected Titmuss’s interest in income and class inequalities
(Income distribution and social change, 1962), and altruism in social and
health policy (The gift relationship, 1970); see Part 4, Chapter Two.
During this period, inequalities in health and health care became in
many ways subsidiary to his main interest in social service provision.
However, the importance of health care, equally and freely available
at the time of need, remained the best exemplar of an altruistic social
policy, and it was a theme to which he returned in his last book on
blood donation.

*****
The format of Private complaints and public health follows that of its
earlier companion volume, Welfare and wellbeing. Extracts from Titmuss’s
work are presented in thematic parts, with each part preceded by a
commissioned commentary. Although these commentaries differ in
style, with varying degrees of attention to polemics and evidence,
they all reflect on the significance of Titmuss’s work, and make explicit
links between the themes in it and issues of concern in the field of
health policy since Titmuss wrote, and as these issues have emerged
today. This volume also has a ‘Prologue’ and an ‘Epilogue’, with
slightly different functions. The ‘Prologue’ is a personal account by
Richard Titmuss of his own experiences of NHS treatment as a cancer
patient. It was written shortly before his death from lung cancer in
1973, and was first published in the posthumous collection of lectures,
Social policy: An introduction (1974), edited by Brian Abel-Smith and
Kay Titmuss. It is a brief and moving defence of the principle, key to
the NHS, of equal access to ‘free’ treatment on the basis of need. To
21st-centur y readers, it also highlights some of Titmuss’s
disappointment at ways the NHS incompletely lived up to his dream
of respect for patients and high quality heath care for all. The author
of the ‘Epilogue’ is Raymond Illsley, formerly Director of the Medical
Research Council’s Medical Society Unit in Aberdeen. Illsley worked
in the field of social medicine for many years, including with colleagues
of Titmuss in Aberdeen who, in the late 1940s and 1950s, were looking
at environmental influences on the health of women and children.
In his contribution, Illsley reflects on the historical and contemporary
significance of Titmuss’s work, concluding that there has been a
remarkable degree of consistency in the central themes of the sociology
of health and illness over the 60 or so years in which it can be
considered to have had some status as a distinct topic.
Part 1 reproduces some of Titmuss’s classic early work on social

4
 Introduction

aspects of health and disease. The commentary by Michael Wadsworth

highlights the ways in which this work drove forward in new ways,
both conceptually and methodologically, the project of social medicine.
The first extract is from Titmuss’s first published book, Poverty and
population (1938). This lays out a case for regarding large regional
differences in health as a consequence of different social environments.
As noted above, much of Titmuss’s work on social factors and health
was done in collaboration with Jerry Morris at the Social Medicine
Research Unit. Their use of vital statistics to study the relationship
between disease and the social environment was pioneering work at
the time, and an early example of British social medicine, which
paved the way for the later development of the sociology of health
and illness. In the 1940s and 1950s, social medicine was a radical
discipline, the ‘social’ side of public health. It was then viewed with
suspicion by many clinicians and leaders of the medical profession,
both for questioning their focus on the individual patient at the
expense of a wider public good, and for its perceived ideological bias
in favour of public care and policies. These included the
encouragement to move GPs to health centres – then seen as an
erosion of their independence, now more often regarded as enhancing
their prestige and capabilities.
What social medicine provided was a methodology for
substantiating the claims of the public health doctors that personal
health depends on a healthy environment. Its protagonists in the UK
were an eclectic mix of social reformers and/or analysts from different
backgrounds who shared an interest in the role of government, the
professions and the public in shaping and regulating effective and
appropriate services and policies to promote health (Jefferys, 1997).
The main strategy of social medicine was establishing statistical links
between life hazards, poor environments and poor health. This
required careful work in an era when few reliable official statistics
were collected and before computers could process large quantities
of data and deliver results in a few seconds. Thus, most of Titmuss’s
and Morris’s calculations were done on now yellowing foolscap paper,
by hand.
The result was a clear message behind the social class and
geographical differences in life chances: poverty kills. Two papers
from the Titmuss–Morris collaboration are reproduced here (Part 1,
Chapters Two and Three). The paper on juvenile rheumatism plots
the social geography of the disease, showing the highest incidence in
the rural districts of economically depressed areas. Juvenile rheumatism
was the most common serious children’s disease at the time; when
Jerry Morris started out as a young doctor, hospital wards were full
of children with rheumatic heart disease (Watts, 2000). Titmuss and
Morris’s approach to the “little worked goldmines” (p 35) of the
statistics of this disease was to see it as a case study of the relationship

5
Private complaints and public health

between ill-health and unemployment during the 1920s and 1930s.

The chapter makes the case for links between poverty and health by
arguing for a dynamic relationship between social conditions and health
indices: health changes as a response to changing economic
circumstances. This emphasis on the dynamic nature of the
relationship between social factors and health was a critical element
in the way social medicine was conceived at the time – at its heart,
the subject was the study of the interplay between the health of
social groups and social and economic change.
The last chapter in Part 1 discusses the importance of civilian health
and disease in times of war. War brings additional exposure to the
battle against disease that goes on all the time. But during times of
war, civilian and military resistance and the efficient planning of
services and allocation of resources are especially crucial, and tend to
be more centrally controlled.
Part 2 reproduces some of Titmuss’s most important work on the
origins, principles and organisation of the NHS in the UK as “a
unique experiment in social engineering” (Klein, 1995, p vii). The
belief that health services should be provided by the state was a key
part of the early social medicine endeavour, both in the UK and
elsewhere in Europe (Murphy and Egger, 2002). Significantly,Titmuss
himself in these writings refers to ‘the Service’ or ‘the Health Service’,
rather than to ‘the NHS’, although his references have been edited to
adopt the modern usage of ‘NHS’. Titmuss’s own interest in ‘state
medicine’ was driven both by his early work on social medicine, and
by his research on the development of social policy during the Second
World War, when the foundations were laid for a national health
service and for parallel changes in social welfare, education and housing
policy. These changes can be attributed to several factors: the
involvement of the Labour Party in the coalition government; a
perceived need to encourage morale through the promise of a clearly
different (fairer and more appreciative, if not more egalitarian) society
for troops and bombarded civilians to look forward to; the experience
of participation (especially by women) in a shared struggle and in
the workforce; and the involvement of people like Titmuss in collecting
(and, crucially, disseminating) social data and in exploring the
implications of these for the nation’s health and wellbeing. In
examining the conditions of health and illness and the provision of
health services during wartime, Titmuss uncovered the soil that gave
rise to the flower of the NHS.
The first chapter in Part 2 is from the last part of Problems of social
policy (1950), in which he summarises the implications for the post-
war development of health services of the government’s commitment
to providing emergency hospital treatment for all during wartime.
Chapters Two and Three in Part 2 link the establishment of the
NHS with other policy developments in the field of national insurance

6
 Introduction

and social security, address the question as to why state intervention

in the field of medical care made greater advances earlier in England
than in any other country in the western world, and consider the
impact of the NHS on the experience of health care. Titmuss was
very conscious of an international audience here; much of his writing
on the NHS was addressed to American audiences, which he felt
were often blinded by fears of ‘socialised medicine’ to the real benefits
a non-marketised system of health care could offer. A two-month
stay in the USA in 1962 had convinced him that the Americans’
misconceptions about the NHS were endemic and widespread
(Titmuss, 1963a). From his wartime work, he must have been
conscious that this was the most significant element in Roosevelt’s
New Deal dream never to have been implemented at what was,
perhaps, the only stage in American history when such a social contract
could have been negotiated, encountering perhaps only the kind of
surmountable opposition met by Bevan and a determined post-war
British government. The single most important effect of the National
Health Service Act of 1946 was to abolish the financial barrier between
doctor and patient. Crucial to the Titmuss vision was the view of
medical care as a ‘social service’. Twinned with this – an equal
consequence of the social determination of health – was the need for
initiatives to prevent ill-health at a social, not simply a personal, level.
In Part 2, Chapter Four, Titmuss examines the impact of the NHS
on the standard of medical care provided in general practice. However,
he notes, ‘family doctors’ had to adjust, not only to the NHS, but also
to the challenge of a more scientific medicine, the changing balance
of physical and mental ill-health, and rising ‘consumer’ expectations.
These parallel developments threatened the traditional basis of
authority in general practice; they required doctors to base their
treatment on reliable evidence, rather than on individual judgement,
and they also propelled them in the direction of treating patients as
equal partners in the therapeutic encounter. With hindsight, it must
be recognised that these factors also had the potential to trigger
increased expense, and they raised new questions about choice and
priorities. However, Chapter Five in Part 2 introduces us to another
essential Titmuss principle: the inapplicability of neo-classical
economic theory to the demand for, and supply of, health care. Here
we encounter the Institute of Economic Affairs, a right-wing think-
tank, with which Titmuss had a long-running dispute; this helped to
sharpen his focus and arguments. It was a battleground that proved
particularly fertile for the development of his later ideas about altruism
and the example of blood donation (Fontaine, 2002).
Economic issues are at the heart of today’s debates about the NHS
in the UK. New Labour is committed to a ‘mixed economy’ of
health care in which the profit motive is rapidly becoming an uneasy
bedfellow of the principle of public service. The Private Finance

7
Private complaints and public health

Initiative, the public purchasing of supplementary care from private

sources and, especially, the establishment of ‘foundation hospitals’,
reintroduces a potential for conflict between equity and the workings
of markets. Everyone in the corridors of power, says John Ashton in
his commentary to Part 2, should read Titmuss on the ethics and
economics of medical care, and for his wide-ranging insights into
the overt and covert benefits conferred by the NHS on personal and
public health.
Part 3 of the book looks more closely at the provision and use of
health care from an emerging sociological perspective. It focuses on
health care both as institution and as relationship – as a complex of
needs and services, and demand and supply, in which both the carers
and the cared for respond to particular sets of social factors. Chapter
One takes up the themes of the social and psychological factors
underlying the ‘demand’ for health care, and the impact of
technological development – the growth of ‘scientific medicine’.
Titmuss expresses the central challenge as the need for medicine to
become both more scientific and more social – goals that are not
necessarily opposed, but which may be seen as so by some stakeholders.
Chapter Two moves the case on to an ethnographic level, recording
a critical failure of much health care (however funded) as in a famous
phrase,‘discourtesies of silence’. When doctors do not talk to patients
and patients are not listened to by doctors, we can see how silence
operates: as a device to maintain authority (and define and control
demand). The sociological study of patients is neglected, argues
Titmuss, anticipating much of the subsequent sociology of health
and illness which has expanded just this theme and explained, often
with Titmuss’s predisposition to improvement in the patient’s interest,
the relationships between providers, patients and the hierarchies of
power existing in professions and large organisations, such as hospitals
and the NHS.
Titmuss contributed a paper with the title ‘Sociological and ethnic
aspects of therapeutics’ to a conference on ‘Drugs in Our Society’
held in the USA in 1963; this forms the basis of Chapter Three in
Part 3. (Since ‘ethnic’ seems a curious word to use in the title we
have assumed a typographical error and substituted the word ‘ethical’.)
The chapter looks at the impact of the ‘therapeutic revolution’ (more
and more drugs for more and more diseases) on the costs of health
care, and the relationship between providers and users of health care.
An increasingly important group of health care users, even when
Titmuss wrote, was older people. In Part 3, Chapter Four, Titmuss
considers what kinds of care are needed and used by older people,
and the implications of this for the health and welfare complex as a
whole. Consequences of ‘successful’ health provision, both through
healthier lifestyles and enhanced care, include greater longevity and
a shift in demand for care from younger people (and even young old

8
 Introduction

people) to those who existed only in tiny numbers in the 1940s and
1950s, namely a burgeoning population of people aged 75 and over.
This has raised unforeseen issues relating to the social engagement of
(and pensions for) active retired people, and also posed challenges
relating to the nature and funding of care for large numbers of the
very old, whose ‘welfare state expectations’ are liable to combine
with chronic disabilities and a particular concentration of health care
demands in the last year or so of life (Barker, 1993).
Titmuss’s thinking about health, like all his thinking about social
policy, was influenced by a vision of what public services can achieve
in a democratic society. An underlying moral agenda relating to
equality and collectivism led him to take a particularly broad view of
the role of health services. This is the focus of Part 4, the book’s final
section. Julian Le Grand, currently Richard Titmuss Professor at the
LSE, reflects in his commentary to this part on the danger of Titmuss’s
position being oversimplified. Nonetheless, Titmuss emerges (then
and now) as an opponent of market mechanisms in the health care
sector on grounds both of morals and efficiency. Significantly, those
academics, such as Le Grand, who take a more sympathetic view of
the contribution a ‘free’ market can make to the provision of health
care, continue to find in Titmuss’s writings a viable and complementary
philosophy that demands attention, not least for its moral and public
appeal.
Chapter One in Part 4 discusses theories of private social policy
and consumer choice within the context of economic growth and
increasing social and economic inequalities. It critically examines
some of the assumptions commonly made about the operation of
the market and shows how market forces are unlikely to deliver either
an adequate or comprehensive response to social need, or an
enlargement of consumer choice – a point often argued by the
economists. Chapter Three is rather different. It reflects Titmuss’s
interest in the historical development of medical care systems and
the problems of population and poverty in ‘underdeveloped’ countries.
It is a brief account of an ambitious consultancy project in Mauritius;
Titmuss, along with his colleague Brian Abel-Smith, advised the
Mauritian government on social security and health and welfare
services in the face of a rapidly increasing population. The two men
arrived in Mauritius at the request of the Mauritian government in
1960 in the aftermath of two catastrophic cyclones that had damaged
half the houses and most of the sugar crop; they found an island beset
by multiple social and economic problems. Perversely, their solutions,
which rested on the voluntary restriction of family size through
targeted welfare policies, were rejected by the government, but the
goals of the Titmuss ‘programme’ were achieved anyway (Salo, 1982).
Titmuss’s last book, The gift relationship, is in many ways his best
known and most influential work. Part 4, Chapter Two summarises

9
Private complaints and public health

its main themes, using the text of two papers:‘Why give to strangers?’,
published in the medical journal, The Lancet, in 1971, and ‘The blood
donor’, a paper given at a conference in 1972, in which Titmuss
reflects on the work that went into The gift relationship (Titmuss, 1970).
An edited and updated edition of this book was published in 1997
(Oakley and Ashton, 1997). The argument is one about how altruism
and social policy can work together in modern societies in ways that
are much more likely than market forces to promote people’s health.
This thesis has had considerable staying power, despite the fact that
Titmuss may have been inaccurate in some of his diagnoses of the ills
of the US health care system (Starr, 1998).
At the same time, the embourgoisement of British society since
the 1950s, combined with better access to information, has raised
new questions about the relative nature of health. Knowing more,
patients ask more of their doctors and complain more if things do
not meet their standards. They also have more sources of information,
including advice that can help them choose healthier lifestyles, if
they can afford them. Similarly, changing expectations – for example,
of privacy or of hotel services in hospital, as well as of new images of
‘perfect’ health and bodies – have imposed unexpected burdens on
an NHS offering free and equal care to all at the point of delivery.
One wonders where Titmuss might today consider an appropriate
border between public and private provision (that is, when to ask a
patient to pay or when to submit to market forces). Communal
wards, for example, might have fitted a pattern of living compatible
with wartime conditions, but modern holiday hotels and private cars
have given rise to expectations about personal space that can make
anything other than a private hospital room with bath seem intrusive.
Should state care include satellite TV access in hospital or some elective
cosmetic procedures at a time when, in England (but not Scotland),
the NHS does not currently provide or pay for ‘social care’ for patients
with Alzheimer’s who have to live in, and pay for, private nursing
home places following the arbitrary abandonment by the NHS of
this category of seriously ill person? This causes outrage to people
forced to sell their homes to finance their care and met with disapproval
from the Royal Commission on Long Term Care (Sutherland
Commission,1999), but it is justified by a New Labour government
as an essential cap on ‘uncontainable’ public spending.
The final chapter is an argument about the interdependence of
economic and social growth, and a plea for the ethics of equality to
be considered as just as important as productivity in the conventional
economic sense. Medical care is seen in the broader public policy
context as a key ‘redistributive’ service along with education, housing
and income maintenance. Titmuss’s interest in health is accommodated
as a central plank of his welfare project, and we are reminded of his
unique contribution to social policy, which was to combine the

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