Introduction

Since its inception NHS hospital management has been subject to the ‘bedpan doctrine’. Although no-one seems certain exactly when, Aneurin Bevan, the founder of the NHS, is often credited with saying that ‘If a bedpan is dropped on a hospital floor in Tredegar, I want the noise to reverberate in the corridors of the Palace of Westminster’. Essentially, the government is ultimately responsible for how NHS hospitals are managed or mismanaged. However, there are practical limits upon how far central government can actually anticipate or prevent politically awkward developments and events in NHS hospitals. The tension has existed for 75 years since but as we shall see some health policies exacerbate it. This chapter uses the bedpan doctrine as a framework for examining how the governmental balance between central control and local managerial discretion (see Chapter 1) has played out in NHS hospitals, especially since the 2008 financial crash, a watershed in UK economic development (Cribb and Johnson, 2018), including that of NHS hospitals.

What doctrine implies

Central control

A doctrine which attributes to government the ultimate responsibility for the state of NHS services appears to legitimate extensive government involvement in controlling NHS hospitals, an implication which ambitious or reforming policy-makers might welcome. However, the doctrine also implies that governments are also responsible for how NHS hospitals respond to adverse circumstances or events. In the last 75 years that has happened on a grand scale in three ways. One was, and is, the demographic shift. The proportion of UK population aged over 65 has slowly risen, from 16.0 per cent in 2001–02 to 18.6 per cent in 2019–20 (Office for National Statistics, 2022) with the well-known consequences of increasing demand on NHS hospitals, in particular ‘winter pressures’. Rising socio-economic inequality has similar consequences (Kivimäki et al, 2020). Another was the 2008–10 financial crash which was followed by a fiscal policy reversal from expansion to austerity. COVID was the third. Additionally, more transient problems have also recurred, including safety scandals, waiting times and strikes. Even when a government is guiltless in creating such problems, the bedpan doctrine still holds it responsible for making NHS hospitals implement a remedy, and culpable should they appear to fail. The bedpan doctrine may also motivate governments to conceal or massage information that might make them seem culpable.

In this chapter we deal with the preservation and transmission of Greek and Latin letters in Late Antiquity. We begin with the problematic of letter-collections, in which a large number of letters has come down to us, before addressing the transmission of letters in translations, many of which were made in order to save their authors from damnatio memoriae. Missing letters then occupy us, whether their absence is documented or can be read between the lines or whether they were never written at all. In this section we discuss the problematic correspondence between Augustine and Jerome, a cause célèbre in late-antique epistolographical studies and an example of what could go wrong in correspondences of the time, before addressing the question of forgeries, tampering of documents transmitted from author to recipient, and pieces that have some down to us with erroneous attributions.

In this chapter we consider the differences and similarities between Classical and Christian approaches to epistolarity in Late Antiquity, and the extent to which we can speak of the ‘Christianisation’ of the letter-form in that period. We provide a consideration of the materials and mechanics of letter-writing in Antiquity, including materials, length of letters, dictation, scribes, autograph, and signature. After an assessment of the ‘pagan-Christian divide’, we take cognisance of the tropes of the letter and how Christianity made its mark in this regard. Subsequently we discuss literary vs papyrological letters. Finally we look at the various modes of address used by pagans and Christians in their letters.

Did a Christianisation of gifts accompany Christian letter-writing? It is certain that gifts of books became particularly important for cultivating Christian unity in the doctrinal sphere. Food, saints’ relics and church plate were also prized by recipients. While the fourth and fifth centuries saw an explosion of epistolarity, by 500 CE letter exchange had begun to dwindle, or at least fewer examples from then have survived. With regard to future directions we note that the study of letter-writing in the Jewish diaspora is very much needed. In addition more work remains to be done on the process of collecting letters, whether secular or Christian, in the late Classical period and in Late Antiquity. This is particularly true of papyrological sources, and the letters and collections of the sixth century deserve more scholarly attention.

In this chapter we deal with letter types and their uses, discussing the popularity of new letter forms in early Christianity. These forms are then divided into groups: episcopal letters, conciliar letters, those written by monastic bishops and by the bishops of Rome. Monastic letters and those of spiritual direction are also considered, together with imperial letters to or from the imperial family and other royal houses.

Here we convey the variety and complexity of late-antique Greek and Latin correspondences, tracing their antecedents from Classical times, their indebtedness to the apostle Paul, and subsequently to the post-apostolic writers. In the course of this overview we consider the considerable influence which Adolf Deissmann wielded in the first quarter of the twentieth century, and subsequently, on the question of what exactly a letter is. Now we are more cautious about writing and speaking about ‘letters’ and the ‘letter-genre’. Our next step in this chapter was to attempt a taxonomy of the more than 9,000 literary letters from Christian Late Antiquity, beginning with the category of dissenting voices.

The importance of the early Christian letter can only be understood in the context of information exchange in the early Christian church. The information exchange networks that characterised first-century Jewish letter-writers were spatially very limited when compared with the expanded remit of letter-writing Christian leaders. This chapter deals with the networks of communication reflected in the late-antique Christian letter, a period when there was a significant increase in long-distance travel as elites established communication networks that went beyond single provinces. One of the greatest innovations of the Christian letter was that it could be addressed to people whom one did not already know. Previously, elite correspondence was carried out with known people who were absent, and thus letters provide our best look at how such people communicated.

In this chapter we turn to the question how letters were delivered to their destinations and beyond. We consider the difference between public and private letters and their bearers, and what impact this may have had on early Christian correspondences. Modes of transport and various possible itineraries affected the progress of the letter from the writing to the delivery stage, in all of this the bearer being of paramount importance, which requires us to investigate as far as possible the identity of the couriers, and how they were chosen. The important place occupied by the verbal report of the bearers is addressed, together with the considerable problems and hazards which they faced in their missions, some of which were occasioned by brigands, delay or haste. We consider the hospitality offered to these travellers and the friendship which either existed or could ensue between them and the recipients of letters. Finally, we look briefly at the circulation and forwarding of letters.