Research
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Books: Research
Even before arriving at the LSE, a significant proportion of Titmuss’s work was concerned with health. He had researched population health, was interested in eugenics, and had contributed to the origins of social medicine. Much of what he argued was shaped by the idea that ill health might have socioeconomic, or even psychological, causes. Consequently, treatment or, preferably, prevention should involve dealing with the individual’s environment as much as their body. In terms of how this might be realised, Problems of Social Policy had drawn attention to the supposed shortcomings of existing provision, and called for large-scale social reconstruction once the war was over. To some extent this materialised perhaps most successfully in the shape of the NHS, whose creation, as we noted in Chapter 1, Titmuss was later to describe as ‘one of the most unsordid and civilised actions in the history of health and welfare policy’. This chapter examines Titmuss’s analysis of health and healthcare in the first decade or so of the new service. Although an enthusiastic supporter of the NHS, and proponent of the idea that it constituted good value for money, Titmuss was not unaware of its shortcomings. It is important to recognise, too, that the post-war era saw not only organisational changes in healthcare. Startling advances in drug therapies and surgical techniques seemed to further advance the phenomenon of ‘scientific medicine’. Reviewing a clutch of books on social medicine in 1954, Titmuss noted that the ‘new accent’ on the social content of medical theory and practice was, in part, a response to ‘the scientific revolution’ which had been sweeping through medicine since the discovery, in 1935, of sulphonamides, the first class of drugs to effectively tackle certain pathogenic bacteria.
Throughout the 1960s Titmuss engaged in an acrimonious dispute with the Institute of Economic Affairs over the market’s role in healthcare provision. More positively, this ultimately resulted in one of his most significant works, and last major book published in his lifetime, The Gift Relationship. Here, as well as dealing with the mechanics of the acquisition and use of blood for medical purposes, Titmuss sought to articulate, as advertised on the cover of the first edition, his ‘social philosophy’. For Titmuss, the contrast between the British and American methods of securing blood was marked. The former rested on voluntary donations, and for proponents of altruism in welfare this situation was truly exemplary. Donors gave their time freely, donated their blood at no charge, and could not know who might receive their donation – an instance of the kindness of strangers. Voluntary workers, too, were an important part of a system which existed within a necessary framework of universal healthcare provision. In America, blood was often sold by impoverished donors to for-profit blood banks, arguably laying blood supplies open to contamination, and to potential shortages. The British system was thus both morally superior and more efficient. As we saw in Chapter 24, The Gift Relationship had an impact on American opinion and policy, something returned to below when considering the book’s reception. In spring 1963, Titmuss’s ‘Ethics and Economics of Medical Care’ appeared in the first edition of the journal Medical Care. Titmuss was involved in this publication’s creation, a member of its editorial board, and had participated in its inaugural press conference, agreeing to say ‘a few words from the “social” point of view.
Titmuss, despite his ever mounting commitments, was generous with his time, and this applied to other academics, both junior and well established. This chapter examines his support for American scholars working on British subjects. This could take the form of, for example, advice on sources, supplying suitable contacts, reading manuscripts, or facilitating a collaborative project. A number of the individuals involved were visitors to the LSE and, on occasion, Titmuss’s home, and all went on to, or were already pursuing, distinguished academic careers in the US. While Titmuss undoubtedly gave his support for unselfish reasons, nonetheless the establishment of further contacts in American academia can only have added to his transatlantic networks. It is not suggested that the individuals discussed below were the only American scholars Titmuss aided. Rather, each illustrates the generosity of Titmuss’s collegial approach to academic life, and the perception of him as an authority on social welfare. It is the case, too, that these Titmuss-inspired, or aided, works can be viewed as commentaries on American social policy, something with which Titmuss himself was intimately engaged, and the subject of the next chapter. Equally, some of Titmuss’s comments further illuminate his perceptions of contemporary British society. We have already encountered our first recipient of Titmuss’s support, Hugh Heclo, later Professor of Government at Harvard University, who had worked for Titmuss during the latter’s membership of the Finer Committee. Titmuss had been instrumental in Heclo’s appointment, and was clearly keen to promote the young American’s career.
Richard Morris Titmuss was born in October 1907, and died in April 1973. His life thus embraced a period central to British social welfare history. At the time of his birth the reforming Liberal governments of 1906–14 were enacting measures such as old age pensions. In his inaugural lecture at the London School of Economics (LSE) in 1950, Titmuss acknowledged ‘the great surge forward in legislation for collective help’ in the decade preceding the First World War. That conflict was followed by the uncertainties of the inter-war era, the consequences of which informed Titmuss’s early work, and political activities. By the late 1930s, now married to social worker Kathleen (Kay) Caston Miller, he had produced his first published volume, Poverty and Population, which opened with the striking statement that there could be ‘no subject of more fundamental importance to any nation than the physical and mental well-being of its people’. Titmuss was, at this point, an active member of the Liberal Party. His research, again mostly on population and population health, continued into the Second World War. But his most significant wartime activity came with his engagement to contribute to the series of official histories of the war on the Home Front. Titmuss’s volume, Problems of Social Policy, was published in 1950, contributed to a life-changing advance in his career, and continues to influence how we perceive wartime Britain. The war also engendered much discussion about post-war social reconstruction, of which Titmuss was a committed advocate, leading him to shift his political allegiance to the Labour Party.
The 1960s saw student unrest across Western Europe and North America, and the LSE was one of the main British participants by way of what came to be called ‘The Troubles’. Titmuss did not approve. In April 1969 his old friend Margaret Gowing, now at the University of Kent, hoped that ‘things aren’t as bad as they sound for you but I fear they probably are. It must be hard with departments and friends on different sides etc: presumably a complete civil war. I am sorry’. Titmuss replied that at ‘the moment most of us here are living from hour to hour – it really is hell’. The following month it was announced that David Donnison was leaving, as The Times put it, the ‘embattled LSE’, to take up another post. Donnison admitted to ‘feeling like the proverbial rat leaving the sinking ship’. But the School had not become ‘a more attractive place to work recently’, and he only wished that he ‘was leaving when morale was higher’. What was it that reduced Titmuss, and Donnison, to such despair? Titmuss was justly famed for taking considerable care of his students at a time when this was not necessarily the norm in British higher education. While he could be disparaging about their middle class backgrounds, on a personal level he was kind, attentive, and supportive, and devoted to education in all forms. During his final illness, although in considerable pain, he went out of his way to maintain his teaching commitments as best as he could.
When Labour returned to power in 1964, hopes were high for welfare reform. These were increased when, in 1966, Labour was re-elected with an improved majority. But the economy proved troublesome, with, for example, unemployment on the rise. The circumstances for radical social policy innovation were not, therefore, necessarily favourable. However, many advocates of reform, including some close to Titmuss, became increasingly frustrated with the government. This resulted in, notably, the creation of the Child Poverty Action Group in 1965, a body which was to become a thorn in the government’s side and, increasingly, critical of Titmuss. This chapter discusses Titmuss’s response to this situation, how he continued to refine his ‘philosophy’ of welfare, and how all this affected his relationship with his colleagues. For example, on the issue of welfare ‘rights’ he was to engage in a ‘fierce’ debate with David Donnison. More formally, Titmuss became a member of the Supplementary Benefits Commission, retaining this position until his death. In autumn 1966, Crossman gave the last in a series of Fabian Society lectures. Among the earlier speakers had been Abel-Smith and Townsend who, he recorded, had launched ‘a tremendous attack on the Government for its failure to abolish poverty’. He had delivered a ‘really rambunctious reply’ to a packed audience. Pointing out the difficulties the administration faced, Crossman questioned how, given it had only been in office for two years, more could have been done, especially in difficult economic circumstances. Titmuss, Abel-Smith, and Townsend had been sitting immediately in front of him.
By the time of his LSE appointment, Titmuss’s reputation as a social scientist, historian, commentator on social affairs, and advisor to official bodies was well established. His work on population continued to resonate and led, for example, to an invitation to lecture on the subject at the University of Nottingham in late 1949. This suggests, too, that his findings were favourably viewed in at least some academic circles, a point further borne out by his ability to gain research grants, and to undertake work for bodies such as the MRC. Problems of Social Policy had finally been published in March 1950, and was well received. A further review, in The Times, was likewise upbeat. The anonymous reviewer (conceivably François Lafitte, employed at the paper since 1943, and its social policy expert) praised Titmuss’s ‘lucid account’ of the development of government policy suggesting, in a sentiment of which the author would have approved, that the ‘war was, in fact, the forcing house of the contemporary welfare State’. Such positive notices in the run-up to his appointment can only have helped Titmuss’s cause. Titmuss also had a strong media presence, in both published and broadcast formats. He was by this point an experienced public speaker to a range of audiences. And, importantly, Titmuss was now extremely well connected. He knew, and had the backing of, the LSE director, Carr-Saunders, as well as the influential support of colleagues such as Keith Hancock. In the very small world of British social science, this counted for a lot. In a curious incident which nonetheless flags up some of Titmuss’s key concerns, in spring 1948 he wrote to David Weitzman, barrister and Labour MP, who had been imprisoned for illegally supplying cosmetics, the production of which had been scaled down in wartime.
Titmuss actively engaged with certain developing countries, partly motivated by his support for racial equality. He also acted as an advisor to overseas academic institutions. So, for example, in 1963 he sought leave to act as external examiner for a new diploma course in Social Administration at Makerere University College in Uganda. This, he told Sydney Caine, was being developed to meet ‘East African needs’. Where possible, such initiatives should be supported, not least because of the LSE’s own interests in ‘undergraduate and graduate courses in Social Administration and Community Development for students from overseas’. More broadly, the School had long been involved with the development of the social sciences in what were, initially, British colonies. Sheard, meanwhile, points to the significant number of African politicians who took their experiences at the LSE back to their own countries. In this chapter we examine Titmuss’s engagement with Mauritius, Tanganyika (Tanzania), and Israel. In the case of the first two, Titmuss was commissioned by their governments to suggest ways forward for their welfare systems. Although Titmuss was the lead figure, it would appear that nearly all the heavy lifting, in terms of writing and research, was done by Abel-Smith and, in the case of Mauritius, Tony Lynes. In part, this resulted from Titmuss’s indifferent health, although his willingness to delegate to a significant degree likewise needs to be taken into account. Israel was different. There Titmuss was involved more through talks and lectures, and the establishment of what were to be important professional and personal relationships. This involvement has, though, been little commented upon.
Titmuss was concerned, from the 1930s onwards, about the psychological effects of modernity. This informed his approach to social medicine, given its aspiration to see patients and their families in their total contexts, and not just as clinical entities. In turn, this suggested there was more to individual, and social, wellbeing than simply the provision of medical services. Consequently, Titmuss was a critical supporter of community care which, although not a new idea, had nonetheless expanded in scope with the advent of the ‘welfare state’. Although community care can take a number of forms, here we are especially concerned with its relationship to mental health, an area with which Titmuss directly engaged. He was also a critic of what he saw as the overweening ambitions of ‘welfare professionals’, including medical doctors. The training of the latter, he argued, paid too little attention to the patient as a psychological and social being. Social workers, too, could behave in an overbearing way, but Titmuss was keen to defend their role as ‘front line’ workers in the ‘welfare state’, and to see their numbers expanded. This chapter examines Titmuss’s approach, in the 1960s, to mental health, community care, and medical education. These activities should be seen in the context of both his critique of ‘The Affluent Society’, and his contribution to the debates over the future of local authority social services, discussed in Chapter 19. In his input to Labour’s Working Party on the NHS in the late 1950s, Titmuss had, as we have seen, raised concerns about proposed changes in mental healthcare, non-medical staffing in health and welfare settings, and the need for an enquiry into medical education.
In 1969 Titmuss entered into discussions about his retirement date. He, like others in his age bracket, was originally due to retire at 65 (that is, in 1972), but this was extended by the LSE to 67. In May 1969, when all this was being formalised, he told Walter Adams that, in previous discussions, he had thought it ‘most unlikely that I shall want to stay on a full-time basis to the age of 67. However, in looking at the regulations it would seem to be best at the present time to accept reappointment for the full term of five years’. It is clear that Titmuss had wanted to at least begin to wind down full-time employment, while the School wanted him to stay on in some capacity. Adams had consulted Abel-Smith about this, with the latter responding that he had ‘no doubt at all that we would very much want Professor Titmuss to continue until the age of 67 if he would be willing to do so’. It was not to be. Titmuss died of lung cancer in spring 1973. A sickly child, his health remained problematic throughout his life, outdoor activities such as hiking (especially in the 1930s, and 1940s) notwithstanding. Recurring tuberculosis in the late 1950s and early 1960s was problematic, as was a bout of dysentery contracted in Mauritius in 1960. As has been suggested, Titmuss’s demanding work schedule may have adversely affected his physical wellbeing. What was unquestionably a contributory factor in his relatively early death was that he, like Kay, had been a tobacco smoker throughout his adult life (one of Oakley’s memories of childhood is the smell of cigarettes pervading the family home).