What was middle class healthcare like before the NHS?


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.



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.


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]


Cottage Hospital

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 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


 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!



Pie in the Sky? Paul Nelson’s Design for the Cité Hospitalière de Lille, 1932

The inter war period saw a marked change in the demands placed upon health care providers as public expectations rose and medical science and practice improved. The need for service improvement was felt particularly strongly in the hospital sector where providers sought modern institutions to satisfy the demands of doctors, patients, scientists and medical schools as well as their funders. These trends were especially noticeable in the Anglo-American world, Germany and France with the 1930s seeing some impressive new projects undertaken, notably in Strasbourg and at Columbia University. Moreover, design was increasingly driven by US influences which promoted the idea of building up to increase efficiency, light and space.



 Conditions in the old hospitals of Lille c.1950.

 It was in this climate that the City of Lille embarked upon its ambitious plans for a major hospital complex. From 1925 the city council had been under the leadership of the socialist mayor, Roger Salengro (1890-1936) whose vision included both improved living and working conditions and the need for a city worthy of its citizens. In 1929 he pushed through a plan of ‘grand works’ to ‘edify’ Lille, especially improving the ‘salubrity’ and health of the city by the transformation of the city sewers, water supply and hospital provision. The planned Cité Hospitalière would replace the existing out-dated buildings with an entirely new complex unifying all of the services of Les Hospice de Lille (the hospital administration), together with a new model maternity unit, an anti-cancer centre, a tuberculosis sanatorium and a medical school. Condemned by the right-wing press as an indication of ‘socialist megalomania’ and as overly ambitious in the prevailing economic climate, the project almost collapsed when the plans for the complex were unveiled in December 1932.


 Hôpital St Sauver, lille in the 1920s


Designed by Paul Nelson, an American born but Paris resident architect and ‘following modern conceptions’, it took the current thinking on hospital design to a new level. Nelson’s idea was to build high, with two central blocks each of twenty-five floors, prompting a sceptical press to note that:

This method of construction offers, say the specialists, a number of advantages for the running of hospitals.

It allows saving to be made in general expenses and a rationalisation in both therapeutics and medical teaching.


A press representation of Nelson’s plan 

Undoubtedly, such modernist ideas were spreading in France, with the new Beaujon hospital under construction at Clichy – to a design by the French architects Walter and Martine – adopting many innovative principles. But Nelson’s plan was even more physically and aesthetically radical. Of ‘très vastes’ proportions covering over 40 hectares, one tower would be the Hospice, erected in the form of a cross, the other a ‘block hospital’ in the shape of an open book containing all of the medical services and the faculty of medicine. There would, in addition, be an eight storey private hospital with maternity and surgical facilities; a 200 bed convalescent home; a school of nursing; various scientific and administrative buildings and a leisure centre with swimming pool.



The proposal prompted a flood of hostile comment from the local press who focused on the appearance and cost of the project to support a sustained anti-American and anti-socialist attack. Sympathetic commentators noted that, as an American Nelson could ‘not do otherwise than envisage a sky-scraper (gratte-ciel)’ while harsher critics contended his design was ‘totally without aesthetic qualities’ and indeed ‘was perfectly ugly’. Moreover, the right wing papers attacked the payment of 250,000 francs to ‘l’architecte americain’ for the model and it was claimed the likely cost of executing his grand design would be between 250 and 400 million francs (up to £20m). Indeed the government – who had promised to meet some of the cost – had to step in to cap the price at a maximum 200 million FF.


Nelson’s controversial model unveiled in December 1932

By early January 1933 the virulently anti-socialist Depeche had rallied opposition from the Federation of Architects of the Nord, who penned an open letter to protest against the choice of a foreign architect. Depeche was right behind the profession attacking both the appointment of a foreigner but also ‘the quality of the product: artistic horror, crazy idea’ and concluding that it would end in a ‘shell of grandeur’ accompanied by ‘an astronomical bill’.

There had undoubtedly been a lack of transparency in the way Nelson had been commissioned to produce his treatment for the complex and faced with both media and state opposition to the project Lille city council abandoned his plan and launched a competition amongst French professionals. Although the Nelson project was now presented as an opening shot which ‘had for its object, above all, the giving of general ideas’ this was a significant climb down for Salengro as the decision on the final shape of the Cité Hospitalière would now rest with a more conservative jury made up of professionals, state officials and doyens of university departments. Yet the proposal they chose, though not as radical as that of Nelson, was still a significant design. The competition winner, also by Walter and Martine, extended some of the principles of their work at Beaujon to create a work recognised as pioneering both in its structure and in the ambition it showed to unify hospital services on a single site.


The Cité Hospitalière de Lille as it looked when it opened in 1953

So why did the Nelson hospital of the future fail? It failed, in the main, because it gave too many targets for the right to aim at. Certainly Lille needed improved hospital services, but these could have been provided by a more modest scheme, focused on a combination of extensions at existing institutions and some new building on green field sites. The failure to take this route in the cash strapped 1930s, and fuelled by the suspicion the socialist authority wanted a grand project not an economical extension, allowed the conservative press to castigate the plans of Salengro as socialist megalomania.

More important, however, was the issue of national interest. Papers like Croix du Nord were quick to pour scorn on Lille’s ambition to compete with Strasbourg or cities in Germany and America by building a grandiose ‘foreign’ gratte-ciel. But this was nothing to their hostility to the appointment of an American as the chief architect, Depeche claiming they learned of Nelson’s contract from an American newspaper when ‘for a construction of such importance, it would seem to us that there should have been a competition and with a preference given to a French architect’ not least because the project would be financed entirely by municipal and state funds. In the increasingly nationalist and protectionist world of the early 1930s it was easy to claim that the appointment of Nelson was unpatriotic and his ideas at odds with the cultural and aesthetic values of the French. Yet ultimately Lille did create a radical and monumental hospital complex which merged French taste with American ideas.

This piece is based on records held in the Archives départmentales du Nord and Lille Archives Municipales.