I suppose it was inevitable that as the Downton Abbey series slowed after six seasons, more script time would be spent documenting the social changes swirling around the Crawley Family. Inevitably, an inter-generational power struggle story over leadership of the local cottage hospital as it struggled with modernization caught my eye. It isn't every day that you see a hospital merger story featured in popular culture.
What was at stake was the difficult decision of the local cottage hospital on whether to continue as a small independent charitably funded entity or to join forces with the larger government funded hospital, embracing a more distant (literally and figuratively) form of health care for the village as a tradeoff for access to more modern equipment and services. Interestingly, this sub-plot has been seen as a commentary on American health care reform when, oddly enough, it is a reasonably accurate rendition of Britain's own struggles over hospital identity and health care reform in the early 20th century.
The cottage hospital movement arose in the 19th century as an alternative to large impersonal poor farm and work house-derived acute care facilities for the poor and indigent. Small, intimate, and geographically proximate to the community: the cottage hospital movement symbolized an agricultural laborer or working person's acute care alternative to the large county hospital. In Britain, these were known as voluntary hospitals and they comprised a significant percentage of acute care facilities at the turn of the last century. By the early 20th century, we are witnessing the rise of the government hospital in the series as in history as we chart the decline of the landed gentry who funded voluntary hospitals. The rest, as they say, is history.
The interesting thing is that the cottage hospital movement also took hold, on a smaller scale, in some parts of the United States. Though more often called community hospitals in the United States (meaning hospitals that are independent, free-standing of hospital chains, and not part of academic medical centers), small cottage hospitals were not uncommon in rural areas until well into the 20th century. Cottage hospitals, or community hospitals, in the United States struggle with the same issues: the advantages of community based care traded off against the limited resources available to bring the most modern services and innovations to the local level.
Where does it end in Downton Abbey? In the Season Six Finale, we see Lady Grantham masterfully chairing a community town hall meeting where she managed to, simultaneously, re-assure the local populace that no providers would be lost in the transition to government hospital and clinic care while emphasizing the noblesse oblige redolent of the voluntary hospital would also not be lost by any diminishment of Lady Grantham's interest in the soon to be merged-into-one government hospital entity. But it may be the Dowager Countess, her tart tongued mother-in-law deposed from her power on the local hospital board, who saw it most clearly when she noted that government professionals as administrators would soon have little use for Lady Grantham — she was presiding at her own demise.
Now, Lady Grantham is American by birth, possessed of an incurable optimism and a healthy dollop of can-do philosophy. But even she must have sensed the sagacity of Dowager Countess's prediction of her own obsolescence.