Hospitals

What was middle class healthcare like before the NHS?

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In the public mind – and that of many historians – healthcare in pre-NHS Britain was a toxic combination of charity, poor law and unaffordable doctors’ bills. This image, recently heavily revised by academics like Martin Gorsky, Nick Hayes and George Gosling, applies, in the main, to the experience of the working class. The fate of the middle class in this system is largely absent and any views we may have are probably shaped by popular culture with its emphasis on Harley Street specialists or sturdy local GPs. But what did happen to the average middle class person if they needed medical treatment, and especially hospital care, in interwar Britain? The hurdles that they faced were often as complex and worrying as those experienced by the bulk of the working class.

Central to the operation of health care between the wars was the premise that the middle classes could – and should – meet their own medical bills. In the nineteenth century when the middle class was smaller and medical practice simpler, this was probably an achievable ambition – although, as Anne Digby has shown, the precarious nature of many medical livings at this time suggests the system was far from efficient. However, as the century progressed this instability moved sharply against the bourgeois patient, and especially those new entrants who flooded into the black-coated sectors of society in the later years of Victoria’s reign.

 

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Long running television series, Dr Finlay’s Casebook shaped understanding of middle class healthcare

A number of factors were at play but most notable was the rising complexity and cost of medical treatments as drugs, tests, operations and technologies such as the x-ray were adopted by the medical profession. The increasing prevalence of these new practices made institutional responses to medical problems more common as the general practitioner no longer had the room or the facilities, or probably the skills, to meet these new expectations. Referral to a specialist or consultant became more and more common while a group of GPs were willing to tackle some of these challenges themselves and began to make use of institutional settings to extend their treatment portfolio.

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A handbill promoting the Liberal Government’s National Insurance Reforms, 1911

But the middle class patient was also being challenged by the shifting nature of health care entitlement. In 1911 Lloyd George introduced National Health Insurance for workers with a membership salary cap that excluded all but the lowest paid white collar workers. In a similar vein the development of hospital contributory schemes and the breaking up of the poor law in 1929, opened up hospital wards to most of the working class at little or no cost – though again entitlement caps barred lower professionals and even shop floor supervisors. Moreover, these salary caps were strictly policed by doctors to ensure those who should pay were not receiving subsidized treatment at the GP’s expense. This was particularly relevant in urban areas where most general and specialist hospitals relied on the medical staff providing their services for free and so physicians did not wish to see potentially fee paying clients on the general wards.

Thus, unlike the average worker, the average middle class person saw an increasing restriction in his or her healthcare options as costs rose and access declined. Moreover, it would seem that the quality of the care available was also diminishing. In the late nineteenth century GPs and consultants had looked to move their more complex cases, especially the surgical ones, out of the domestic surgery and into institutional settings typified by the nursing home and the rural and suburban cottage hospital. In this transition stage these settings proved adequate for medical practices that still relied predominantly on care and personal attention. But they were not designed for the newer high tech medicine being developed in the leading urban hospitals.

 

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The impressive Bristol St Mary’s Private Hospital in the 1930s – most were not of this standard!

With a few exceptions, like St Mary’s in Bristol, these were small, poorly equipped and under staffed establishments where the matron might be the only qualified member of the permanent staff. They could oversee chronic and mental health patients – often found in the smallest, most poorly equipped operations– many provided maternity services while the better were associated with surgeons like Middlesbrough’s Dr Dickie who opened Ardencaple in 1909 in a purpose built block that he extended in the 1920s to include many modern touches, including lifts. The best were centred on London and the big cities with teaching hospitals where world famous surgeons like Lord Moynihan conducted their private practice. Concerns about the quality of many nursing homes increased in the early 1920s prompting a select committee followed by the introduction of registration and light touch inspection to stamp out ‘the grave abuses – hygienic, medical and social – [that] existed or were suspected to exist in relation to the conduct of many establishments known as nursing homes’ [Dr J J Buchan in Public Health, 1929 p.187]

 

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The cottage hospital in Moretonhampstead Devon, opened in 1900

Although the quality of care in the cottage hospitals of rural and suburban England was usually more consistent, much like the nursing homes the premises were often small and cramped – the average had around 20 beds – the facilities frequently basic – many lacked x-ray equipment, access to laboratories or even adequate operating facilities – and the staff could have limited qualifications. In the 1920s patients generally had to pay a minimum fee while those being treated by their own GP were charged fairly standard rates – normally around three guineas per week maintenance plus the doctors fee. Nursing homes varied in price depending on the service and quality. Around 1929 it was suggested that charges in London ranged from eight to sixteen guineas per week for maintenance with the doctor’s fee in addition. However, in certain cases, mostly small homes for senile and chronic patients, fees could be as low as three guineas a week, a figure Medical Officers of Health and nursing home matrons felt was too low. Admittedly some nursing homes were very impressive – like Dickie’s – and in the big cities the skill of the surgeon was matched by the quality of the surroundings – but also by the cost. While Dickie was probably charging around thirty guineas for a standard operation, surgical stars like Moynihan expected hundred guineas for the same procedure, putting considerable pressure on the wallets of the bourgeois client.

 

V0014882 Royal Masonic Hospital, London: aerial perspective of the wh Credit: Wellcome Library, London. Wellcome Images images@wellcome.ac.uk http://wellcomeimages.org Royal Masonic Hospital, London: aerial perspective of the whole scheme. Process print after C.A. Farey, 1933. 1933 By: Cyril Arthur Farey and Burnet, Tait and LornePublished: - Copyrighted work available under Creative Commons Attribution only licence CC BY 4.0 http://creativecommons.org/licenses/by/4.0/

 

 V0014882 Royal Masonic Hospital, London:  By: Cyril Arthur Farey and Burnet, Tait and Lorne 1933.  Credit: Wellcome Library, London.

 

Some improvement was discernible in the healthcare options of the middle class by the later 1930s. In the face of considerable opposition from medical practitioners, some of the contributory schemes were slowly extended to white collar and lower professional groups. In 1938 the Sheffield Penny in the Pound Scheme was embroiled in a long battle with the local BMA over their willingness to let teachers, office staff and police officers join the scheme, a situation eased by the gradual raising of the income threshold for National Insurance that had provided a proxy limit for the contributory schemes. A more widespread development was the creation of provident schemes for middle class workers. Similar in operation and benefits to the contributory schemes, for a payment of between one and two guineas a year they provided free treatment for the contributor and their family either on the general wards or in the growing number of pay wards in voluntary hospitals. They could also be used to meet the costs in cottage hospitals and even in the small number of municipal hospitals charging private rates.

 

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Pay Ward in the new Miners’ Welfare Block at Sheffield General Hospital, 1937

The emergence of the provident societies was linked to the opening of pay wards or blocks in a number of voluntary hospitals. These wards were introduced to address the increasing disparity between the level of affordable hospital treatment available to working and middle class patients. The case was summed up in 1930 by Col. Tetley, Chairman of the Leeds Hospital for Women, when he noted:

We think there is a demand for this sort of accommodation [pay beds], partly because there are a great many people who can’t afford to pay charges for nursing homes and partly because it is often difficult to find, outside a hospital, the facilities for diagnosis and treatment and for immediate medical attendance in the event of an emergency occurring during treatment, which the ordinary hospital patient receives at a voluntary hospital. Many people…now often feel that in times of sickness they themselves cannot obtain the modern facilities for treatment which they are helping to provide for the ordinary hospital patients.

Academic examination of this phenomenon has been minimal but George Gosling has made some attempt to estimate the number of voluntary pay beds. He found that the number of private beds rose from around 4200 in 1933 to 6500 on the eve of the Second World War and 7500 in 1947, just before the NHS came into operation. There were however, significant differences in the regional distribution of these beds with almost 13% of voluntary hospital beds in London available to the middle class by 1938 but outside the capital just 7%. (Gosling, Charity and Change, Fig 5.2 and 5.3, p.251)

As Tetley implied, charges in this type of accommodation were lower than in the traditional nursing home – varying from three guineas for a shared room to nine guineas for a large single. Physician fees were on top of this but most were agreed the service and treatment were superior – not least because most private wings by the end of the 1930s were brand new. But as the figures from Gosling show, the available stock of pay beds did not cover demand from a middle class keen to take full advantage of the services a modern general hospital could offer.

Thus, it would seem that the arrival of the NHS did much to improve the health options of the middle class, especially the less wealthy crippled by large doctors fees for poor service and denied access to the most up to date and efficient hospital treatment. As with education, the new system made a substantial difference to the family budgets of clerks, lower professionals and even middle managers freeing up income for improved housing, more discretionary spending and even the ultimate status symbol of the 1950s, a motor car – and in the process possibly sowing the seeds of an increasingly sedentary, over-indulgent and unhealthy lifestyle!

 

Beauty and the Hospital in History: Call for Papers

International Network for the History of Hospitals
Malta, 6–8 April 2017
Hosted by the Mediterranean Institute at the University of Malta, and the University of Warwick

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Beauty, and its perceived absence or loss, has been a part of hospital experiences, therapies, and
planning throughout history. This conference aims to shed new light onto the history of beauty and
health by exploring the subjective concepts of beauty, ‘normality’, and their opposites within and
around the hospital.
This eleventh INHH conference will consider the relationship between beauty and the hospital in
history through an examination of five key themes: (1) the arts and the hospital; (2) landscape and
environment; (3) restoring beauty; (4) patient and staff experiences; and (5) beauty and the senses.
Below are more details about the themes the conference will address, along with related questions.
These themes and questions are by no means exhaustive, however, and we encourage the submission
of abstracts that discuss other aspects of beauty and the hospital in history in innovative ways.

Key Themes and Questions to be Explored:

1. The Arts and the Hospital:

  • How has the beauty of the arts been perceived to affect encounters within the hospital,
    been promoted by hospital patrons, or been used as a healing therapy in the hospital?

    •  Examples: Music, painting/s, festivities, crafts, creativity, architecture

2. Landscape and Environment:

  • How has the beauty of a landscape or environment — or its absence — shaped the choice
    of location for hospitals, and why?

    • Example: A medieval or colonial leprosy hospital situated in a beautiful landscape
      for its therapeutic value
      o Example: Asylums, isolation hospitals, or prison hospitals intentionally located in
      marginal, inaccessible or ‘ugly’ spaces, both urban and rural, and the consequences
      this was perceived to have on the health of patients
  • How have landscape and environment been adapted to affect hospital therapies and
    conditions?

    • Example: Hospital gardens
  • How did ancient ideas about the influence of environmental conditions upon health
    affect hospital care in the medieval and early modern periods?

3. Restoring Beauty:

  • Who decides what is beautiful or aesthetic, and whether and how that beauty should be
    restored? What strategies have been used in hospitals to restore or enhance that beauty,
    be it physical, mental, or emotional?

    • Example: Cosmetic surgery, prosthetics
    • Example: Psychotherapy to restore the perceived beauty of the mind
  • What happens when beauty or health cannot be fully restored? How have such
    therapies been depicted?

    • Example: Palliative care aimed at lessening suffering or alleviating the effects of
      ‘ugliness’; depictions of such care in before and after photographs, textbooks, and
      publicity material

4. Patient and Staff Experiences:

  • How have patients and staff experienced beauty or ugliness in hospitals? How and why
    has their access to beauty been encouraged or restricted?

    • Example: Hospital gardens for the use of patients only
    • Example: The isolation of patients in ‘ugly’ spaces as punishment
    • Example: The most beautiful spaces in a hospital compound restricted for the
      accommodation of European or white staff and patients
  • How was daily life in the hospital informed by the desire to create a beautiful order
    structuring the resident community?

    • Example: Ordinances and regulations inspired by religious or imperial precepts that
      guided daily life in residential hospitals

5. Beauty and the Senses:

  • How can we understand beauty — or its perceived absence — through the senses of
    smell, touch, sight, taste, and hearing? How has the hospital been a place for the care,
    enhancement, or experience of the beauty of these senses?

    • Example: Disgust surrounding ugly smells in hospitals; strategies to silence or
      shroud unsightly patients and practices
    • Example: The preferential hospitalisation of patients considered damaged in terms
      of their senses, e.g. the predominance of in-patients with a loss of nerve sensation
      in their hands and feet in colonial leprosy settlements

The Advisory Board of the INHH, as organisers of this conference, wish to invite proposals for 20
minute papers which address the conference theme. Potential contributors are asked to bear in mind
that engagement with the theme of beauty and the hospital will be a key criterion in determining
which papers are accepted onto the programme.

Abstracts should be a maximum of 300 words in length, in English and accompanied by a brief self
biography of no more than 200 words. Proposals should be sent to beauty.inhh@gmail.com by
15 May 2016. As with previous INHH conferences, it is intended that an edited volume of the
conference papers will be published. Submissions are particularly encouraged from researchers who
have not previously given a paper at an INHH conference.

Upon provision of full receipts, we hope to be able to support attendance at this conference,
particularly for postgraduates and early career researchers. Speakers will be asked to make use of
alternative sources of funding where these are available.

Any queries may be directed to
beauty.inhh@gmail.com.

European Healthcare before Welfare States

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The ‘Hospital for Businessmen’, Prague

 

The Centre for Health Histories at the University of Huddersfield (formerly the Centre for the History of Public Health and Medicine CHPHM) has been awarded almost £90,000 by the University research Fund for a project designed to enhance the international research and profile of the Centre. The Centre, led by professor Barry Doyle, includes Dr Lindsey Dodd, Dr Rebecca Gill, Dr Rob Ellis, Dr Alex von Lunen, research students Andrew Holroyde and Sarah Taylor and recent appointment as Centre Research Assistant, Dr Steve Taylor.

The project will develop the international elements of the Centre through three inter-linked activities:

1. A research network of UK, European and North American scholars to meet in two focused workshops in 2016 and 2017 to discuss national and transnational themes in healthcare before welfare states.
2. A focused pilot project to collect data on health care systems in Poland, Hungary and Czechoslovakia to build knowledge in an area with little published research in either local languages or English.
3. The appointment of 3 visiting professors on short term placements in Huddersfield to develop projects, co-write for international journals and prepare funding bids.

Work Package 1
A research network of UK, European, North American and Australasian scholars to meet in two focused workshops in 2016 and 2017 to discuss national and transnational themes in healthcare before welfare states.
We propose to hold one workshop on Hospital Provision in Europe and North America, 1880-1950 and a second on Treating Mental Health before the Welfare State.

Work package 2
A focused pilot project to collect data on health care systems in Poland, Hungary and Czechoslovakia.

The aim of this element of the project is to identify a primary source base to explore how hospital provision was established, managed and funded in the successor states of East Central Europe (Poland, Czechoslovakia and Hungary) created in 1918. It will examine these developments from a ground up approach to explore the practical process of building health care provision at a local level. It will seek to locate suitable source material to undertake local case studies of hospital services.

The project will use international comparison across three countries and will open up opportunities to examine healthcare in diverse economic, social and political situations. It will draw on Doyle’s comparative work on Anglo-French hospital services which utilised urban case studies to assess the day-to-day operation of healthcare before welfare states. Healthcare provision in the three nations chosen for this project Poland, Czechoslovakia and Hungary has received limited attention from historians. Much of the English language work has focused on the activities of the Rockefeller Foundation, between 1918-25, while studies of early national health policy have concentrated on links between eugenics and local services. Local studies of provision remain rare.

We will conduct literature reviews, archival scoping and the collection of some pilot data with the help of research assistants with high-level competence in Czech, Polish and Hungarian respectively. After an initial period reviewing literature and identifying appropriate collections, the RAs will spend up to two months in their respective countries exploring archival sources, undertaking initial data collection and meeting with potential collaborators and project partners. The research visit will include a period in the capital identifying national records, print sources and medical journals and some time in a provincial centre scoping local archival material such as hospital records, local authority material, newspapers. In the final two months they will write up reports to include assessment of the scope and quality of archival material, the problems and possibilities offered by the source base and the initial pilot data collected. This material will be presented in a plenary workshop involving ten-fifteen academics interested in interwar health care provision in a European context. There will also be a co-authored article on the findings of the project for submission to a major medical history journal.

We hope the project will make a significant contribution to the history of health care provision by opening up local records in East-Central Europe for researchers and by placing hospital development in these countries in a Europe wide context. In particular, we will view these developments from the ground up examining the practical process of building health care provision at a local level. Integrating East Central Europe into the history of European hospitals will challenge existing paradigms based on the relatively wealthy, urban and politically stable states of western Europe that currently dominate the historiography and offer an opportunity to explore the role of health care in national identity formation.

Work Package 3
The appointment of 3 visiting professors on short-term placements in Huddersfield to develop projects, co-write for international journals and prepare funding bids. Opportunities may exist for reciprocal or complementary visits.

The visiting professors will: work on their own research, supported by colleagues in the Centre for Health Histories; present their research at Huddersfield and other institutions; provide advice and mentoring to staff and students associated with the Centre, especially around applying for non-UK funding, research strategies and environments in Europe and North America, opportunities for collaboration and reciprocal visiting roles; develop joint funding bids with colleagues in the Centre; co-author articles/co-edit books or special issues with Centre staff and students.

We are looking forward to developing this project, mounting the workshops and working with our project partners, including Professor Petr Svobodny of Charles University. It is intended to set up a web presence for the European Healthcare before Welfare States Network, with a blog and to explore both academic and non-academic outputs including information for governments and think tanks across. Europe.

‘Comforting the Sick’: Christmas in the interwar Hospital

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Sheffield, 1925

Nobody wants to be in hospital and especially not at Christmas. In recent years the health service has done what it can to minimise Christmas admissions and to send people home if they possibly can. But that option was often not available to the medical institutions of the interwar period. Many of their patients were chronically sick, especially the children, while even relatively straight-forward conditions normally required a stay of two to three weeks on the wards. In these circumstances the management and medical staff did what they could to make Christmas as pleasant as possible.

Between the wars a hospital Christmas was characterised by four recurring elements: a public appeal for gifts; the decoration of the wards; a round of civic visits; and a staff entertainment for colleagues and patients. As with most elements of hospital life, these activities became more democratic, more professional and more informal as these institutions extended their patient base.

Sheffield newscuttings 949Sheffield, 1934

During the interwar period non-cash contributions remained part of a wide range of voluntary forms of giving that had Christmas at their heart. However, the form of this giving changed over time. At the end of the First World War it was still a largely middle class activity. At Leeds General Infirmary in 1919 around 100 individuals donated fruit, flowers, sweets and chocolate, Christmas puddings, cakes, trees and turkeys, toys and cigarettes, with Mr Bland of Kippax also supplying 20 partridges, 30 pheasants and a forequarter of venison.
However, by the early 1920s donors were being drawn from across society. From 1932 the annual report of the Leeds General Infirmary carried a list of Christmas contributions which by 1937 showed around 250 people giving £350 with an additional £75 coming from collecting boxes in the Infirmary and local department stores. In Middlesbrough the weeks before the holiday saw an annual appeal from the Matron of the North Riding Infirmary for donations of toys, cigarettes or money for patient gifts while in Sheffield the entire community was mobilised in an organised effort to provide presents for over 2000 patients and members of staff.

 

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Women’s Ward, North Riding Infirmary, Middlesbrough, 1925

Here the collection and distribution of Christmas gifts and money was undertaken by the Joint Hospitals’ Council and the distribution of present became the task of the Rotary Club. In addition to Christmas gifts given direct to institutions – such as trees and turkeys – the Hospitals’ Council collected around £350 per annum in cash to fund the purchase of presents. This was supplemented by gifts given by local traders and the parcels were made up by the Rotary Club and the Ladies Auxiliary. In 1924, when a total of over 10,000 gifts in 1516 parcels were handed out, the Christmas parcels for men contained tobacco and pipe or cigarettes, fruit, handkerchief and book; for women, fruit, handkerchief, chocolates, needlecase and book; for children, fruit, chocolates, sweets, book and toy and for the nurses a box of chocolates. In addition, large permanent toys such as rocking horses were sent to the children’s wards. The following year the number of parcels rose to 2,500 and remained at roughly this level for the rest of the period.

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c.1925

In preparation for Christmas, staff set about decorating the wards. In the early part of the 1920s this retained a traditional feel with trees and festive decorations, however, in the 1930s there was a move towards artistic, topical and even exotic themes. In Middlesbrough one year saw a

Japanese garden, with the women patients garbed in Kimonos, was a pleasing contrast to the ‘One Way’ ward of the men, where each bed was marked with a Belisha Beacon and various road signs were introduced.

In Sheffield Royal Hospital in 1938 a ward was ‘transformed into an Eskimo Encampment’ while the Children’s Ward drew inspiration closer to home – the Blackpool promenade as:

From the children’s beds came a merry clamour and the effect was enhanced by roundabouts and a toy elephant that seemed to be thoroughly alive, so comical were its antics.

Inevitably, children’s wards were a particular focus of attention, the one in Sheffield Infirmary in 1934 being influenced by J M Barrie.

Mounted on a pedestal with a pipe to his lips was Peter Pan. Floating gracefully from the ceiling was Wendy, and nearby, also suspended in space, was the fairy Tinker Bell, who lived up to a her name by spontaneously ringing at intervals.

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Sheffield 1934

Most improbable to modern sensibilities was a male ward transformed into ‘the Nicotine Club, [where] gigantic pipes, cigarettes, matches and petrol lighters made the Lord Mayor regret that he has left his tobacco in the car’.

 

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Sheffield, 1938

On Christmas Day itself the wards became a hive of activity as civic dignitaries and local volunteers began a tour of the institutions to well-wish and distribute gifts. In Sheffield, with its four hospitals, the civic circuit could last up to four hours, with the scene in the Royal Hospital in the 1928 typical of the events:

To the delight of both patients and staff, the Lord Mayor and Lady Mayoress (Alderman and Mrs H Bolton) accompanied by the Master and Mistress Cutler (Mr and Mrs T G Sorby) visited the Hospital and were received by the Chairman and Vice- Chairman. Each Ward was visited and the patients were given a message of greeting on Christmas morning. Closely following the Lord Mayor’s party was “Father Christmas” a member of the Rotary Club, who distributed the gifts which were provided by the Joint Hospital Council. The singing of Carols by Miss Ida Bloor, Miss Ena Roberts, Mr Stanley Jepson and Mr Joseph Green during the distribution of the Christmas gifts was a source of much enjoyment to all who spent their Christmas Day in the Hospital.

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Sheffield , 1933

Finally, in the days after Christmas, the staff mounted a show for hospital supporters, other staff and patients when, as the Sheffield Telegraph punningly noted, ‘Staff desserts theatre for theatre’. These events had a long tradition – the one at the Sheffield Royal Infirmary had been underway in some form since the 1890s – but as was noted in 1937 those events were not as ambitious or ‘so carefully rehearsed’! Indeed, this year was the first that sets had been hired while ‘bright costumes and clever lighting lent the production an atmosphere of pageantry as well as pantomime’.

 

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Christmas Panto, Little North Riding Hood,

North Riding Infirmary, Middlesbrough

The Christmas entertainment was an opportunity for the world to turn upside down (a little). The staff dressed up and played different roles – aided by the pantomime form. Invariably it also included the (all male) resident medical staff dressing as women – 1937 saw them as a harem for a ‘dance of the seven veils’ routine while in 1938 they appeared as fairies. The shows, written by the staff, also gave the opportunity for a flurry of in-jokes and to poke fun at each others – even if the journalists reporting didn’t always understand what was gong on!

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Middlesbrough’s Lord Mayor Pulls a Cracker

Middlesbrough General Nurses Home, Christmas 1946

Pictures: Sheffield all from Sheffield Daily Telegraph. Middlesbrough from B. Doyle, A History of Hospitals in Middlesbrough, South Tees Hospital Trust, Middlesbrough, 2002

‘A Piece of Useful Propaganda’: Britain’s First Hospital Film as Fundraiser

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Sheffield Royal Hospital Annual Report, 1931

How the voluntary hospitals of interwar Britain raised the cash to keep them running has been a major issue for historians in recent years. Large-scale surveys and local studies have challenged the traditional image of failing charity and endless, futile tin-rattling on street corners. They have uncovered a world in which charity gave way to payment, though largely at one step removed via membership of a mutual contributory scheme. Yet our (including my) fascination with contributory schemes – insurance or voluntary gift? Source of power or toothless club? Alternative to socialism or short term expedient – has led us to ignore the role of face-to-face fundraising in interwar hospital budgets. Yet this remained an essential element in the income mix, especially for capital projects and for clearing debts racked up in the aftermath of the First World War and the lean years of the economic depression.

In a recent article Nick Hayes and I explored some of the ways hospitals benefitted from and utilised traditional forms of casual income – legacies, endowments, non-cash gifts etc – but also how fundraising was modernized between the wars as new social groups like students, schoolchildren, works’ social committees and even political parties used their collective pennies to match the large gifts of the wealthy. One element of this I found particularly interesting was the harnessing of new techniques and technologies to fundraising, typified by Sheffield Royal Hospital’s Centenary Appeal of 1932.

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Sheffield Royal Hospital Annual Report 1932

The appeal was launched at the end of 1931 as the city of Sheffield reached the pit of the Great Depression and one in three men were out of work. As the later official history noted ‘Realising at the outset that few large contributions could be expected owing to the depressed state of the local industries, the Centenary Committee approached every section of the community with a request that efforts of all descriptions should be started; such as Entertainments, concerts, Dances, Garden Party…’ The range of activities was immense drawing initially on traditional fundraisers like flag days, sales of work, whist drives and hand delivered appeal brochures. Women, in particular, were tasked with these more conventional approaches, often supported by young people in schools and youth organisations and by the unemployed.

But the Committee also embarked on a range of new methods. They applied to the growing range of charitable funds. They approached, directly, the Miners Welfare Fund. They encouraged saving schemes using postage stamps on cards and the assembling of miles of pennies. There was a gymkhana and the equine theme continued with a parade of pit ponies to support the flag day. Furthermore, modern technology was utilised to boost the effort. Electric light signage advertised the appeal while the Sheffield Motor Organisation arranged various events including an Air Pageant. However, the most interesting was the production and distribution of a short film entitled ‘A Day in Hospital’.

 

 

The 3 reel, 16mm film, a copy of which is held in the Wellcome Library and is available to download via their online service, was written and directed by Dr Skinner and shot by Mr Watson, the hospital radiographer. Lasting just over fifteen minutes it ranged across the work of the hospital including scenes that showed nursing staff, domestic activities (like the delivery of the daily bread), the work of the hospital board, preparation and consumption of food, the work of the laundry and a closing shot of a busy telephonist. The elements of the medical work of the hospital were carefully chosen to reflect the modern, up to date and relevant services. As my book on hospitals in Leeds and Sheffield has shown, the 1920s saw a significant growth in outpatient appointments forcing hospitals to improve the facilities and operation of this part of their service and the film proudly showed the progress made in this area. It also gave extensive coverage to the electro-massage and physiotherapy facilities and to the oldest of the outpatient departments – ear, nose and throat. The important role the hospital played in the city’s economy and society was demonstrated by the prominent position given to the orthopaedic department and the accident service, including shots of an ambulance arriving.

The hospital’s own history of the appeal devoted considerable attention to the film which it claimed was ‘unique in as much as it was the first film of the actual work of a hospital to be produced.’ Whether this assertion is true remains open to dispute but it is clear that the novel fundraiser did its part to bring in cash and publicise the work of the institution. It proved itself ‘to be a piece of useful propaganda’ being shown all over the town and surrounding districts – including all the Sunday schools – and even in other towns and cities.

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Tapton Hall, site of the new nurses’ home

Although the appeal failed to meet its headline ambition of raising £100,000 for the objectives shown in the image above, it laid the groundwork for considerable expansion at the hospital in the mid-1930s. The cash collected put a small dent in the substantial overdraft but this proved less important than two significant donations. Local philanthropist Alderman J G Graves gave Tapton Hall and its grounds as a new, more convenient and salubrious nurses’ home. The building was quickly refurbished by the gifts of other leading figures from Sheffield’s industrial and medical establishment, including the newly wealthy Viners. In addition, the Miners’ Welfare were convinced by the need to support the institution and gave £25,000 towards the building of a new seven storey block which included an orthopaedic department, x-ray facilities and a private ward for paying patients of moderate income. In a third instance the convalescent services were extended by a major grant from the Zachary Merton Trust to fund a 48 bed unit adjacent to the Fulwood aftercare facility on the semi-rural western edge of the city.

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The new Miners’ Welfare Block, opened in 1937

On the face of it the Royal Hospital Centenary Appeal – by securing less than half its target – fits the model of declining private charity in the face of economic pressures and state growth. Yet it belies the idea of a stagnant, traditional approach to fundraising with its dependence on the middle class and the collecting tin. Rather, it embraced both new givers and modern technology –especially cinema, the ‘essential social habit of the age’  – to mobilise a more democratic philanthropic movement.

‘A good many people have come to look upon the hospitals as their family doctor’

Health news in the last few months has been dominated by the ‘Crisis in A&E departments’ as hospitals struggle to deal with an apparent flood of patients attempting to access emergency and outpatient services. The dominant cause identified by press, public and hospital authorities is a perceived difficulty accessing general practitioner surgeries which is creating tensions between primary and secondary health care providers. Yet these tensions are far from new – indeed they are as old as publicly accessible hospitals and frequently erupt into the public sphere.

At the root of this tension is resource allocation which, irrespective of the type of health care model operating in Britain, has tended to push the desperate, the complicated or the plain troublesome patient from the GP waiting room to the ever open doors of the hospital.

The outpatient problem became a public scandal in the last quarter of the nineteenth century when London’s voluntary hospitals – publicly accessible, charitable institutions, free to the sick poor and staffed by unpaid surgeons and physicians – noted a sharp rise in attendances in the casualty room and the outpatient waiting halls. General Practitioners and charity organisers cried foul, claiming many of these patients could afford to pay a private practitioner but were ‘abusing’ the voluntary hospitals’ generally lax approach to outpatient treatment. Abuse was conceived of in two ways – denying GPs their fees and taking advantage of the charitable (both donors and doctors) who gave their money and time to the deserving sick poor. Although these remained constant problems up to 1911 and the National Health Insurance Act (NHI), they were increasingly addressed by stricter policing of outpatients, more effective sorting of the casual patient and ultimately by the introduction of almoners.

 

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The Waiting Hall at Leeds Public Dispensary c.1914
Annual Report, Leeds Public Dispensary, 1914-15 in Leeds Local Studies Library

The introduction of National Insurance did not solve the problem of too many people opting for secondary over primary consultation. Indeed there is some, admittedly contradictory, evidence that it may even have forced certainly groups not covered by the state system to use institutions as a place of first, rather than last, resort. It was certainly the case that patients and attendances in both casualty and outpatients (often unhelpfully mixed up categories) grew rapidly in the 1920s, especially in Leeds. This partly reflected a growing confidence in hospitals that fuelled the development of a ‘hospital habit’ among the general public. But changes in the structure of the medical profession also promoted specialist consultation over generalist knowledge. Moreover, some argued, National Insurance didn’t pay enough to keep difficult patients in the GPs surgery. The problem reached a head in Sheffield in mid-1932 when Moses Humberstone, chair of the Sheffield and District Association of Hospital Contributors, launched an attack on the growing number of patients who ‘have come to look upon the hospitals as their family doctor’.

Concerned by the increasing cost to the hospital of outpatient treatment, he blamed three factors for the ever-swelling numbers in the waiting and sorting rooms: a lax attitude among the hospital authorities who were too ready to accept any patient who turned up – especially if they were members of the Contributor scheme; doctors who, at the slightest hint of difficult patients were too ‘ready to tell them that he could do nothing further and they had better go to hospital’; and that ‘people seem to have lost a lot of confidence in their own doctors, and think that if they can be transferred to the hospital all will be well with them’. [Sheffield Daily Telegraph, 9 June 1932] Interestingly, Humberstone mused on the effects of the panel patient system introduced with National Health Insurance, asserting that ‘there does not seem to be the same sympathy between doctor and patient to-day as was the case twenty or thirty years ago, when the club doctor system was in operation.’ Plus ça change?

Family Doctor

Sheffield Daily Telegraph, 9 June 1932

Much as today, tensions simmered between GPs and hospitals. Humberstone accused panel practitioners of not doing the job they were paid for and of treating ‘the hospitals as clearing houses for their own surgeries’. He urged GPs to ensure that if there was no need for a patient to go to hospital ‘even to see a consultant’ the person should be told so. Moreover, he urged practitioners to help ‘educate their patients to use the hospitals only on their advice, or, on the other hand, patients should realize that primarily the hospitals were established for accidents, urgent emergency cases and…not to be run to for every little ailment which requires attention.’

The GPs defended themselves by claiming it was the fault of the NHI for not including specialist consultation as a benefit within the system, though they assured the world they would punish doctors who were found to be passing on cases unnecessarily to the institutions. Attempting a middle way the consultants noted that most GPs were using a proper referral system but in another echo of contemporary concerns, Professor Naish pointed a finger at the patients, admitting ‘there is a certain type of person who really enjoys going to the out-patients’ department of a hospital. After they had been stopped and told there was no need for them to come again, they turned up some time later for some reason or other. (Laughter)’. [Sheffield Independent, 9 June 1932]

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A General View of the Accident centre, 1959

Opening Brochure, South Tees Hospitals NHS Trust

One might think that the NHS would have put a stop to outpatient abuse but this was not the case – though the reasons for it were sometimes a little odd. In 1959 a new Accident and Emergency Department was opened in the Middlesbrough General Hospital. In the first year the unit was over run by thousands of people seeking attention, prompting the Health Authority to commission an investigation by Newcastle University academics. After comparing usage to other units in the region and considering the availability of GP services and the longer term culture of A&E use in a town with a number of dangerous trades, the researchers concluded the improbably large attendances were down to simple inquisitiveness on the part of the local population keen to experience the new service.

Whatever the causes of our contemporary crisis in A&E – lack of access to GPs, insufficient capacity, cuts to frontline hospitals services or a public battles over resource allocation – they have their roots in longer term tensions between primary and secondary health care. But they are also part of a much simpler concern – when people feel unwell they want treatment, and they will go to the place where they think that treatment will be found. In extremes that has always been A&E.