Hospitals in Mid-Twentieth Century Britain and France
The past twenty years has seen a significant growth in studies of the British hospital system,
especially in the first half of the twentieth century. This work has paid particular attention to
issues of financial viability, entitlement and control, and the geographical inequalities of
provision. In general, it has tended to focus on acute services, especially in the voluntary
sector, as opposed to the less fashionable long term care of older people; provision in bigger
cities and the regions with the greatest concentrations of population and hospitals rather
than rural or sparsely populated areas; and on Britain in isolation from the comparable
changes and challenges occurring in Europe and the United States. Much of this work has
been shaped by a presumption –as set out by contemporary health reforms - that there was
both a need and a strong popular demand for change by the early 1940s.
This panel will address some of these absences by bringing together three papers exploring
the health of hospitals in Britain and France from the end of the First World War through to
the end of the Second World War. It will draw on both national survey and local case study
approaches; urban and rural settings; British and French systems to examine financing in a
period of acute crisis; the failure of long term and geriatric services, especially in rural areas;
and levels of satisfaction with, and demands for change in, the British system by the Second
World War. The papers will provide new perspectives which will challenge existing
understanding by viewing the inter war British system from the point of view of older people
in the countryside, the general public, especially former patients and in the light of activities
in France.
Papers:
Barry Doyle, University of Huddersfield, b.m.doyle@hud.ac.uk
‘The Hospital Crisis in Post-war Britain and France: Leeds and Lille, 1918-28’
Martin Gorsky, London School of Hygiene and Tropical Medicine, martin.gorsky@lshtm.ac.uk
‘The legacy of the Poor Law: long-stay hospitals and older people in the West of England,
1929-1950’
Nick Hayes, Nottingham Trent University, nick.hayes@ntu.ac.uk
‘Did we really want a National Health Service? Popular Opinion and Patients’ Views on
Existing Voluntary Hospital Provision’
The Hospital Crisis in Post-war Britain and France: Leeds and Lille, 1918-28
Barry Doyle, University of Huddersfield
Recent research has paid particular attention to the way voluntary hospitals in provincial
England attempted to meet the challenge of a significant financial crisis in the decade
following the end of the First World War. Drawing on a range of aggregated statistics and a
number of important case studies historians have shown how a significant gap in operational
income in 1920 had been largely filled ten years later, allowing the voluntary system to
survive and recover without recurring state support. Historians of hospitals in France,
though drawing attention to a similar crisis, have done little to investigate either the causes
or the local effects of this situation.
This paper will address the way in which hospital managers in the English city of Leeds and
the French town of Lille, places with a very similar economic and social make, experienced
and responded to the crisis. Concentrating on the Leeds General Infirmary, Leeds Public
Dispensary and Leeds Maternity on the one hand and the more complex Hospices de Lille,
an administrative body which managed the two general and six chronic hospitals in the city,
it will consider the causes of the crisis – which included falling subscriptions and donations,
severe inflation, under investment during the war and problems in the local economy, all
exacerbated in the case of Lille by four years of occupation by the invading German army
and considerable war damage. Faced with these problems hospitals in Leeds switched to
increased reliance on direct patient payment and indirect support from the successful
mutualist collection scheme, the Leeds Workpeople’s Hospital Fund as well as a continuing
contribution from traditional sources. The French city made little attempt to charge patients
directly or recover costs from non-pauper patients. The Hospices de Lille benefitted from a
notable growth in the number of patients covered by compulsory state support but this,
along with long term disputes over the price charged for treatment, responsibility for
renovating the investment housing stock and recompense for war damages led to tense
relation with the City Council. Moreover, the Hospices became increasingly reliant on the
council to cover their recurrent deficits yet without the municipality gaining any real
managerial control.
Overall, these case studies will demonstrate different ways in which urban communities in
England and France met the crisis in their hospital systems, the English opting for
independence from state control via a switch to direct and indirect payment whilst the
French saw increasing involvement by the municipality in funding but at the expense of a
series of conflicts which left the council with responsibility but without power.
The legacy of the Poor Law: long-stay hospitals and older people in the West of England,
1929-1950.
Martin Gorsky, LSHTM
Context: Older people have been leading beneficiaries of the health systems developed in
twentieth century welfare states. However, studies of the British NHS suggest that hospitals
providing non-acute care for older citizens on low incomes persistently suffered from underresourcing and neglect. Explanations for this emphasize two factors, both rooted in history.
First, the tendency of states to privilege productivist over humanitarian concerns in social
resource allocation, thus disadvantaging groups considered economically marginal. Second,
the preference of medical professionals for general acute medicine, deemed to be of greater
scientific importance, and hence status, than ‘geriatrics’. In some ways however, this
neglect is surprising because the mid-century saw two reforms which promised to improve
public institutional care for poor and vulnerable adults, the 1929 Local Government Act,
which famously ‘broke-up’ the Poor Law, and the 1946/7 NHS Acts. How do we explain this?
Aims and methods: The concern of this paper is to discover whether policy towards long-stay
hospitals for older people in the 1930s and 1940s had indeed left this sector in a weak
position at the start of the NHS, and if so why. The approach is a regional case-study, based
on three cities and two largely rural counties in the West of England (Bristol, Bath,
Gloucester, Gloucestershire, Somerset). The methodology is partly quantitative, tracing
expenditure choices through local taxation data, and analysing patients through admission
statistics, and partly qualitative, drawing on administrative records and the medical press.
Results: The region’s 34 long-stay hospitals are introduced, all of which originated as Poor
Law workhouses or infirmaries. A transition from mixed institution to populations
dominated by the aged ‘infirm’ and sick is demonstrated and the difficult material
inheritance explored. The impact of the shift from Poor Law to municipal/county control is
documented, and it is argued that while two of the urban examples illustrate the successes
of hospital ‘appropriation’ and public/voluntary sector integration, these were a minority.
Time-series analysis of real expenditure trends comparing ‘public health’ with ‘public
assistance’ (the budget which covered most older long-stay patients) reveals that while the
former grew, the latter flatlined. This reflected local and national government priorities,
shaped, it is argued, both by medical preferences and by lingering Poor Law prejudices.
Qualitative evidence confirms that the result was under-investment, poor staffing and
deteriorating fabric. The start of the NHS promised new medical and policy initiatives,
though this was dependent on a funding injection which was slow to materialise.
Meanwhile the location of the long-stay hospitals within mixed hospital management
groups, the impediments imposed by the tripartite structure of the NHS, and the dominant
role of acute medicine in committees all militated against investment and integrated
planning as the new service began.
Did we really want a NHS? Popular Opinion and Patients’ Views on Existing Voluntary
Hospital Provision.
Nick Hayes, Nottingham Trent University
Charles Webster, in making the case for radical reform, listed amongst other key factors, the
‘overwhelming public pressure’ for a nationalised, universal hospital system, fuelled by a
popular discontent with the charitable foundation of much of existing provision.
Contemporary reformers were also quick to point to high levels of existing dissatisfaction.
Political and Economic Planning played on ‘the long waiting lists ... which cause misery and
worry to many persons waiting for operations or other treatment’, while the Socialist
Medical Association drew attention to the ‘cold as charity’, ‘unsympathetic and inhuman
atmosphere that pervades the public wards of hospitals’, and the ‘long waits in crowded,
unhygienic halls’ in ‘gloomy and depressing’ hospital building.
Yet we know surprising little about what patients actually thought about the existing
hospital system, and the treatments and care they received in them. This makes
commenting authoritatively on the popular demand for a nationalised hospital service
problematic. Indeed historians recently have laid great stress on the level of general
ignorance about the welfare reforms being proposed. Within this there was only limited
fundamental discontent with existing provision – despite the attempts by New Jerusalemists
to suggest otherwise. For most people there were simply other more pressing priorities.
This paper evaluates, using 1940s survey material, TNA data and other oral
evidence, the views of ‘ordinary’ people, and not those of the doctors, politicians or civil
servants that so dominate the official record. It surveys attitudes to the hospitals
themselves, to medical charitable giving, and to the impact this had on opinions on
voluntary hospitals. It looks also at popular understanding of contributory schemes, and
compares, too, levels of satisfaction, complaints and grumbles about hospital treatment
before and after the founding of the new nationalised service. It is readily accepted that
certain categories of existing medical provision were both substandard and/or unpopular. In
a majority of cases, however, satisfaction levels with existing hospital provision were high,
and compared favourably with recorded after 1948.
Popular opinion on voluntary hospitals divided the nation, just as it did the political
parties and medical profession. Yet the data reveals that more favoured voluntary hospitals
than opposed them. Dissatisfaction lay much more with general practitioner than hospital
provision, where the power of the voluntary hospital and its associated networks to inspire
civil loyalty and a deep-rooted local support was acknowledged by critics and supporters
alike. That disquiet which existed was less evident amongst ex-patients than the population
as a whole, and noticeably weaker in certain social groupings than others. Most instead
wanted a rationalised system of payment to cover both general practitioner and hospital
services for the whole family, although not one supported by rates or taxation. The paper
concluded, therefore, that any popular demand for radical reform was significantly lower
than was stated at the time, or than has been recorded subsequently.