This paper provides a comprehensive analysis of the pattern of hospital utilization (rather than provision) in England prior to the establishment of the NHS, showing the extent to which the probability of obtaining hospital treatment was a function of residence. Access to hospital care depended on the vigour of voluntarism and the political priorities of local governments. The pattern of voluntary hospital utilization is shown to have been markedly unequal, but the effect of municipal provision was to reduce disparities in access to services. The paper demonstrates variations in hospital utilization and discusses contemporary assessments of the situation. This work contributes to debates about the efficacy of non-profit forms of welfare delivery; it provides a novel British study to complement American work in this field. It also raises questions about the contemporary vogue for partnerships in health care delivery between the public and private sectors, arguing that such proposals rest on an optimistic view of history.