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.


bristol st mary's

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 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!



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.


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.


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.


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.


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.


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.


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.


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.