Shaping Hospital Services before the NHS

New wing 1938Architect’s impression of the New Brotherton Wing before completion

This month sees the publication of The Politics of Hospital Provision in Early Twentieth Century Britain by CHPHM Director, Professor Barry Doyle. The latest volume in the Pickering and Chatto published series Studies for the Society for the Social History of Medicine, the book is the central outcome of two Wellcome Trust grants awarded to explore the factors shaping institutional health service delivery in Leeds and Sheffield in the period 1918-48.

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Building on his research on Middlesbrough, Doyle argues that class, gender and local economic structures and cultures were central elements in shaping hospital provision in the first half of the twentieth century. In particular, he suggests that the differences of emphasis in interwar health care delivery noted by contemporaries and historians were not necessarily the outcome of luck (whether a benefactor was willing to endow an institution), chaotic competition (especially among voluntary and municipal providers) or penury due to the depression but owed much to the specific needs of their localities. Thus, it is argued, in Sheffield – where masculine heavy industrial production dominated the labour market, trade unions were strong, corporate economic structures were developing, the middle class was small and economic and political roles for women were limited – hospital services remained focused on addressing the health concerns of adult males. Conversely, in Leeds – where employment opportunities for women were extensive, male economic conditions were constrained by the small scale nature of many works, unions were weak, the middle class was large and important roles existed for women in politics and associational culture – the city created extensive hospital services for women. In particular, Doyle notes the development of sophisticated ‘new’ orthopaedic services in Sheffield supported by funds from employers and the Miners’ Welfare while Leeds could boast extensive institutional maternity provision which saw over fifty per cent of all babies born in hospital by the Second World War.

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Rooms in the Miners’ Welfare block at Sheffield Royal Hospital, 1937

Thus the first part of the book is concerned with the development and provision of the hospitals and specialist services of Leeds and Sheffield across both the voluntary and municipal sectors. The second part goes on to explore the politics of that provision, especially the origin and extent of funding, the party based debates about public versus voluntary services and the extent, nature and progress of co-operation and collaboration between providers in the thirty years before the NHS. As local economic and social structures helped shape services so they also fed into funding patterns for the voluntary sector and expenditure priorities for the municipalities.

In Sheffield, where corporate industrial structures based on well paid, unionized men in large scale enterprises were coming to predominate, a mass contributory scheme pioneering the penny in the pound method of payment, was created by the Sheffield Hospital Council with almost universal backing from employers, unions and workers. Although, in providing 80% of ordinary income the scheme seemed to squeeze out traditional voluntary contributions – subscriptions, donations, fundraisers – closer examination has shown that employers now contributed much more through their top up to the Penny in the Pound fund than they had as individuals, while the structures of the Hospital Council could be used to mobilise support from all classes for extraordinary giving as with the Million Pound Appeal of 1938. In Leeds, on the other hand, a diverse economic and social structure produced a complex funding profile. Workers’ contributions were present in the form of the Leeds Workpeople’s Hospital Fund but these constituted less than half of income while traditional forms such as donations underpinned a growing range of patient payments – either indirectly through contributory schemes in other areas, or directly on the private wards of the Brotherton Wing. Moreover, the wide and deep middle class could still be relied upon to engage with major appeals as evidenced by the £250,000 raised in the mid 1930s by conventional fundraising.

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How the Sheffield Penny in the Pound Scheme divided up its cash, 1924

The nature of funding (as well as broader structures) was significant in determining the politics and leadership of the hospital sector. In Sheffield the scale of labour movement involvement in the Penny in the Pound scheme and on the council (Labour held control from 1926) meant workers interests were important and hostility to the voluntary system was kept in check until the later 1930s. In Leeds, however, the socialist influence on the Labour party and the strength of women in local politics and associational culture, saw a much more vocal debate about hospital ownership and yet a more by-partisan approach to the running of both sectors. In particular, women held positions of authority in general and specialist hospitals and a predominant role in the Council’s health and hospital committee structures and almost all of the seats on the Maternity and Child Welfare Committee. This role for women, which contrasted strongly with the situation in Sheffield, may help to account for the significant investment in services for women in the city, especially in the area of maternity provision.

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Leeds Maternity Hospital (almost) All Female Board, 1913

These political lines also seem to have had a bearing on the extent of co-operaton and competition within and between the voluntary and municipal sectors. The book challenges the traditional view that hospital providers were jealous of each other and reluctant to work together to create modern hospital systems across their towns. In particular, it shows the highly developed nature of relations between the voluntary hospitals of Sheffield – which led to the merging of the two general hospitals in the later 1930s – as well as charting the close interactions within the local state service which saw the council funding a maternity unit at the Poor Law Institution in 1927. These collaborative responses underpinned the quick and notable partnership agreement signed between the voluntary and municipal sides in 1930 which saw agreements on new services at the City General, some exchange of patients paid for by the council and the division of the city into three sectors for casualty clearance. However, a swing to the left within the Labour administration and anger amongst municipal health managers at the voluntary sector’s decision to build a new super hospital without consulting the City Corporation, led to a breakdown in relations and the growth of competition in the years before the Second World War.

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The Distribution of Hospitals, Sheffield, 1938

Although the extensive co-operation in Sheffield is well known, Leeds has not been seen as an area of co-operation, in part because it did not have a joint committee on hospital services until 1936. However, by looking at relations between participants, especially consultants, medical superintendents and hospital administrators, Doyle is able to demonstrate a tradition of collaboration between voluntary and state providers in the city. Indeed, from the later 1920s voluntary hospital honoraries were making regular – often bi-weekly – visits to the wards of St James’ Hospital where a growing number were in control of beds while patients were being exchanged between the various institutions of both sides as the admissions room at the Leeds General Infirmary became a city wide clearing house. These practical arrangements were aided by the movement of administrators and politicians between the two sectors, especially the figure of Sir George Martin who was chairman of both the council Health Committee and the voluntary Leeds Public Dispensary. Such links could even extend beyond the city boundaries to the development of regional services. Both cities operated regional Radium Centres to provide specialist cancer treatment for around a million people in their respective catchment areas, while Leeds joint hospital committee quickly incorporated representation from the adjoining West Riding County Council to discuss county wide service development. Leeds General Infirmary even took over the running of the small general hospital in the adjoining mining town of Normanton – a move which may have become more common in the aftermath of the Second World War had the NHS not intervened.

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Sir George Martin, Chairman Leeds Health Committee and the Leeds Public Dispensary

The Politics of Hospital Provision in Early Twentieth Century Britain therefore provides important insights into the development of provincial hospital services in this crucial pre-NHS era. It complements surveys of other major cities such as those of the late John Pickstone on Manchester and Jonathan Reinarz on Birmingham but by contrasting two diverse communities and focusing on the interaction of voluntary and municipal sectors it opens up new ways of approaching the history of urban health care. In particular, its emphasis on the important of class, gender and the local economy in the shaping of services allows us to escape from the belief in ‘some ideal distribution of facilities’ and appreciate that very often local provision reflected perceived, and real, local need.

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To read the introduction click on the title above. For Barry Doyle’s thoughts on the process of writing the book see his article on the University of Huddersfield’s Historians@Work blog.

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