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The Development of Municipal General Hospitals in English County Boroughs in the 1930s

Published online by Cambridge University Press:  26 July 2012

Alysa Levene ,
Martin Powell  and
John Stewart
Alysa Levene
Affiliation:
Department of History, Oxford Brookes University, Oxford OX3 0BP, UK
Martin Powell
Affiliation:
Department of Applied Social Science, University of Stirling, Stirling FK9 4LA, UK
John Stewart
Affiliation:
Department of History, Oxford Brookes University, Oxford OX3 0BP, UK
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When thinking of spurs to hospital development in the first half of the last century, it would be easy to assume that the greatest watershed was provided by the 1946 National Health Service Act. In this article, however, we focus on an earlier and often overlooked piece of legislation, which had a perhaps equally significant impact on the development of hospitals in England and Wales. This was the 1929 Local Government Act, which changed both the ownership and the focus of many of the largest hospitals in the country. As Robert Pinker has observed, the act “radically altered the percentage distribution of hospital beds in the public sector”. Such observations notwithstanding, municipal medicine in the 1930s has not received the historical attention it deserves, an omission which this article seeks in part to remedy. The terms of the act in respect of hospital development were permissive, and the extent to which local authorities acted had a great effect on the way in which their municipal hospital services developed, and hence the beds and facilities available at the time of the nationalization of the health services. The reaction of local authorities to the act, however, depended partly on their own choices, and partly on constraints over which they had less control.

Type
Articles
Information
Medical History , Volume 50 , Issue 1 , 01 January 2006 , pp. 3 - 28
Copyright
Copyright © The Author(s) 2006. Published by Cambridge University Press

References

1 Robert Pinker, English hospital statistics, 1861–1938, London, Heinemann, 1996, pp. 78–9. For a discussion of the historiography of interwar municipal medicine, see Alysa Levene, Martin Powell, and John Stewart, ‘Patterns of municipal health expenditure in interwar England and Wales’, Bull. Hist. Med., 2004, 78: 635–69.

2 Historians who have noted the unevenness of health care in the period include Charles Webster, The health services since the war: volume 1, Problems of health care: the National Health Service before 1957, London, HMSO, 1988, pp. 1, 20; W M Frazer, A history of English public health, 1834–1939, London, Ballière, Tindall and Cox, 1950, p. 299; Roger Lee, ‘Uneven zenith: towards a geography of the high period of municipal medicine in England and Wales’, J Hist. Geogr., 1988, 14 (3): 260–80, p. 260; Norman Wilson, Municipal health services, London, Allen & Unwin, 1946, pp. 165, 168–70; John Mohan, Planning, markets and hospitals, London and New York, Routledge, 2002, p. 24; George Godber, ‘The Domesday Book of British hospitals’, Bull. Soc. soc. Hist. Med., 1983, 32: 4–13.

3 Steven Cherry, Medical services and the hospitals in Britain, 1860–1939, Cambridge University Press, 1996, p. 48, states that towards the end of the nineteenth century one-third of entrants to Poor Law infirmaries were non-paupers.

4 Ministry of Health survey report correspondence, Eastbourne, National Archives, Kew (hereafter NA), MH66/596.

5 Webster, op. cit., note 2 above, p. 5; Brian Abel-Smith, The hospitals, London, Heinemann, 1964, pp. 50–1, although he states that conditions did improve in the twentieth century, resulting in greater demand (pp. 201–3); Pinker, op. cit., note 1 above, p. 68.

6Local government financial statistics, 1936, London, HMSO, 1936. Two of these boroughs (Kingston-upon-Hull and Blackpool) spent only a nominal amount per head on general hospitals. Evidence from the Ministry's surveys suggests that they did not in fact appropriate an institution, and were perhaps making payments to a neighbouring borough for user rights.

7 Martin Powell, ‘An expanding service: municipal acute medicine in the 1930s’, Twentieth Century British History, 1997, 8 (3): 334–57, p. 348.

8 Pinker, op. cit., note 1 above, pp. 49–50. These figures include the municipal and voluntary sectors, and represent a slight decline in the proportion provided by the public sector towards the end of the interwar period.

9 Powell, op. cit., note 7 above, pp. 337–40.

10 Ministry of Health general circular on the Local Government Act 1929, NA, MH55/6.

11 Minister of Health annual report, 1933–4, p. 34.

12 Dorothy Porter, Health, civilization and the state: a history of public health from ancient to modern times, London, Routledge, 1999, p. 214; William A Robson, The development of local government, 3rd ed., London, Allen & Unwin, 1954, p. 85.

13 See Powell, op. cit., note 7 above, for a developed argument on unrealistic judgements of the outcomes of the Local Government Act.

14 Stephen V Ward, The geography of interwar Britain: the state and uneven development, London, Routledge, 1988, p. 157.

15Local government financial statistics, 1930, London, HMSO, 1930.

16 For London's hospital services and the 1929 Local Government Act, see John Stewart, ‘“For a healthy London”: the Socialist Medical Association and the London County Council in the 1930s’, Med. Hist., 1997, 42: 417–36; and Gwendoline M Ayers, England's first state hospitals and the Metropolitan Asylums Board, 1867–1930, London, Wellcome Institute of the History of Medicine, 1971.

17 This lack of rigorous quantification of change over time has been noted by Powell, op. cit., note 7 above, p. 336.

18 Local government financial statistics, 1922/3 to 1936/7 (providing information on expenditure, population and rateable values); Burdett's Hospitals and Charities Yearbook, 1929, London, Faber and Gwyer, 1929.

19 This point is noted for the north-west by John V Pickstone, Medicine and industrial society, Manchester University Press, 1985, pp. 260–2.

20 Stoke, Birmingham, Coventry, Huddersfield, Hull, and Wigan all planned new hospitals in this period. Newcastle, South Shields, and Sunderland made plans to build or expand which were halted by the outbreak of war. Powell, op. cit., note 7 above, p. 343.

21 Ministry of Health survey report, Darlington, NA MH66/571.

22 Ministry of Health survey report, Hastings, NA MH66/665.

23 Aneurin Bevan, Hansard, House of Commons, 422, 30 April 1946, cols 48–9.

24 Ministry of Health survey report, Grimsby, NA MH66/645.

25 Ministry of Health survey report, Lincoln, NA MH66/718.

26 Minister of Health annual report, 1930–1, pp. 51–2.

27 Ministry of Health survey report, Hastings, NA MH66/665. The Hastings and East Sussex councils had evolved a scheme whereby the sick from both councils were to be accommodated in the Hastings institution, which could then be appropriated. The scheme was shelved by 1934, however, and not resurrected.

28 Martin Powell, ‘The geography of English hospital provision in the 1930s: the historical geography of heterodoxy’, J. Hist. Geogr., 1992, 18 (3): 307–16, pp. 309–10. Those supporting the assertion that poor boroughs were less able to afford good health care (at least prior to the changed grant system of 1929) include Webster, op. cit., note 2 above, pp. 294–337; J R Hicks and U R Hicks, Standards of local expenditure: a problem of the inequality of incomes, National Institute of Economic and Social Research Occasional Papers, 3, Cambridge University Press, 1943; Brian T Preston, ‘Rich town, poor town: the distribution of rate-borne spending levels in the Edwardian city system’, Trans. Inst. Br. Geographers, 1985, New Series, 10: 77–94.

29Ministry of Health/Nuffield Provincial Hospitals Trust hospital survey, London, 1945–6.

30 Ministry of Health survey reports, Barnsley, NA MH66/421, Bolton, NA MH66/459; re-survey correspondence, Burton, NA MH66/507; survey correspondence, Eastbourne, NA MH66/596.

31 Ministry of Health survey reports, Gloucester, NA MH66/625 and Blackpool, NA MH66/454. The Blackpool council did point out that as a resort town much of their commercial income was concentrated in three months of the year. This may have led to a cautious attitude towards finance, although they were by no means the only borough in this position.

32 Ministry of Health re-survey correspondence, Burton-upon-Trent, NA, MH66/507.

33 Financial position of local authorities, Indebtedness of Local Authorities Committee (1922), NA HLG52/1343; Stephen V Ward, ‘Implementation versus planmaking: the example of List Q and the depressed areas 1922–39’, Planning Perspectives, 1986, 1: 3–26.

34 Financial position of local authorities, NA HLG52/1344-5.

35 Ministry of Health survey report and correspondence, Gateshead, NA MH66/619 and 622.

36 Ministry of Health survey report, South Shields, NA, MH66/890.

37 Frazer, op. cit., note 2 above, p. 392.

38 Ministry of Health survey report, Doncaster, NA, MH66/584.

39 Ministry of Health survey report correspondence, Gloucester, NA, MH66/628.

40 Ministry of Health survey reports, Canterbury, Carlisle and Dewsbury, NA, MH66/519, 524 and 580.

41 Aneurin Bevan, Hansard, House of Commons, 422, 30 April 1946, cols 48–9.

42 James E Alt, ‘Some social and political correlates of county borough expenditures’, Br. J. pol. Sci., 1971, 1: 49–62; David N King, ‘Why do local authority rate poundages differ?’, Public Administration, 1973, 51: 165–73; L J Sharpe and K Newton, Does politics matter? The determinants of public policy, Oxford, Clarendon Press, 1984, pp. 14, 178; Tore Hansen, ‘Transforming needs into expenditure decisions’, in Kenneth Newton and Frances Pinter (eds), Urban political economy, London, Frances Pinter, 1981, pp. 27–47, on p. 41; Martin Powell, ‘Did politics matter? Municipal public health expenditure in the 1930s', Urban Hist., 1995, 22: 360–79.

43 On the Socialist Medical Association and the London Labour Party on hospital policy, see Stewart, op. cit., note 16 above, although it is also the case that the early pace in appropriation was set by the Municipal Reform Party.

44 Powell, op. cit., note 28 above, p. 314, has noted the influence of wider factors such as local politics and personnel on expenditure decisions.

45 Ministry of Health survey report, Leeds, NA, MH66/709.

46 Ministry of Health survey report correspondence, Norwich, NA, MH66/784A.

47 J P Bradbury, ‘The 1929 Local Government Act: the formulation and implementation of Poor Law (health care) and Exchequer grants reform for England and Wales (outside London)’, PhD thesis, University of Bristol, 1991, pp. 302–4.

48 Ministry of Health survey report, Bournemouth, NA MH66/473.

49 Data on political composition are taken from The Times annual municipal election reports in early November each year. All three boroughs have missing data for part of the period, but the Conservative influence is strong where data were reported. In Burton, this was especially true from 1928 onwards, when the Conservatives took an outright majority, although they had been the largest single party prior to this. John K Walton notes the tendency for politics in resort boroughs to be based on “internecine struggles between interest-groups”, reflected here in the comments for Yarmouth and Bournemouth: The British seaside: holidays and resorts in the twentieth century, Manchester University Press, 2000, p. 69.

50 Ministry of Health survey report and correspondence, Barrow and Bolton, NA MH66/422 and 463.

51 Ministry of Health survey report, West Hartlepool, NA MH66/988.

52 Ministry of Health survey report correspondence, West Hartlepool, NA, MH66/991. Labour held a steady 15 per cent of seats up to 1934, when its representation began to rise, taking a majority in 1937 (The Times municipal election reports).

53 Ministry of Health survey report correspondence and re-survey report, West Hartlepool, NA, MH66/991 and 993. This lack of action was despite the hope expressed by the council in 1936 that the election of a Labour majority would bring appropriation; one of the few instances where political colour was cited as affecting outcomes. In this case, it ultimately seems not to have had an effect.

54 Ministry of Health survey report, Bradford, NA, MH66/477. Labour held an average of 40 per cent of council seats in Bradford throughout the period (The Times municipal election reports).

55 The Ministry of Health/Nuffield surveys of 1945–6 also noted the progressive stance of Leeds and Bradford in the health field. Powell, op. cit., note 7 above, p. 345, also cites examples of boroughs which had well-developed hospitals in 1929.

56 Ministry of Health survey report, Croydon, NA, MH66/564.

57 Ministry of Health survey report, Kingston- upon-Hull, NA, MH66/685.

58 Wilson, op. cit., note 2 above, pp. 170–1. Webster, op. cit., note 2 above, p. 8, notes the role of the MOH in setting the standards of municipal health care generally. Jane Lewis, What price community medicine? The philosophy, practice, and politics of public health since 1919, Brighton, Wheatsheaf, 1986, also highlights the increased profile of MOsH.

59 Ministry of Health survey report, Bristol, NA, MH66/487; Pickstone, op. cit., note 19 above, p. 259.

60 Ministry of Health survey report, Barnsley, NA, MH66/419.

61 Ministry of Health survey report, Doncaster, NA, MH66/584.

62 J M Mackintosh, Trends of opinion about the public health, 1901–51, London, Oxford University Press, 1953, p. 132, wrote that “it is difficult to overestimate the enthusiasm with which the new Public Assistance Committees set about their task of transforming the old institutions and reclassifying their inmates”. This picture is not borne out by the Ministry surveys, although they of course had an interest in removing the hospitals from the PACs in favour of the PHCs.

63 Ministry of Health survey reports, Blackburn and Oxford, NA, MH66/450 and 805.

64 Ministry of Health survey reports, West Hartlepool and Stockport, NA, MH66/988 and 898.

65 Minister of Health annual report, 1932–3, p. 35.

66 Ministry of Health survey report, Barrow- in-Furness, NA, MH66/422.

67 Ministry of Health survey report, Blackburn, NA, MH66/450.

68 Ministry of Health survey report, Gloucester, NA, MH66/625.

69 Ministry of Health survey reports, Derby and Oxford, NA, MH66/577 and 805.

70 Daniel Fox, Health policies, health politics: the British and American experience, 1911–1965, Princeton University Press, 1986, pp. 58–9.

71 Minister of Health annual report, 1933–4, p. 57.

72 For example, in Carlisle, Bournemouth, Gloucester, Ipswich and Wigan, municipal hospital provision was not developed into general and acute work, as this was adequately provided by the voluntary sector. Ministry of Health survey reports, NA, MH66/524, 473, 625, 693 and 1003.

73 Powell, op. cit., note 28 above, p. 309; Martin Gorsky, John Mohan and Martin Powell, ‘British voluntary hospitals, 1871–1938: the geography of provision and utilization’, J. Hist. Geogr., 1999, 25: 463–82, pp. 464, 468–9, 474; Abel-Smith, op. cit., note 5 above, pp. 405–7.

74 Abel-Smith, op. cit., note 5 above, pp. 380–1.

75 Ministry of Health survey report, Chester, NA, MH66/537.

76 Ministry of Health survey report, Barnsley, NA, MH66/419. Appropriation took place four years later.

77 Ministry of Health re-survey report, Great Yarmouth, NA, MH66/642.

78Ministry of Health/Nuffield Provincial Hospitals Trust hospital survey, London, 1945–6. Report for the eastern area, statistical tables.

79 Ibid., report for the Yorkshire region. The surveyors went on to note that in Leeds there was a successful example of co-operation between sectors, with the Leeds Joint Hospitals Advisory Committee.

80 Bradbury, op. cit., note 47 above, pp. 302–4.

81 See Pickstone, op. cit., note 19 above, passim, on the existence of sub-regional hierarchies in the Manchester region.

82 An example is the Poole Joint Sanatorium for TB patients, which was subscribed to by the county boroughs of Darlington, Gateshead, Middlesbrough, South Shields, Sunderland and West Hartlepool.

83 Information on the geographical origins of patients collected by the 1945–6 Ministry of Health/Nuffield Provincial Hospitals Trust hospital survey bears this out. While generally over 90 per cent of patients at the municipal hospitals were from the borough, sometimes half of those attending the voluntary hospitals were from outside. In Sunderland, for example, 43.4 per cent of inpatients at the voluntary hospitals were from the borough, compared with 98.9 per cent at the municipal medical institutions. Even in Preston, where the catchment area for the municipal hospitals appears to have been wider, 56.3 per cent of the voluntary hospital's inpatients were from the borough, compared with 76.7 per cent at the municipal hospital. Ministry of Health/ Nuffield Provincial Hospitals Trust hospital survey, London, 1945–6, statistical information for the north-eastern and north-western areas.

84 Ibid., north-west, p. 58.

85 Ibid., West Midlands, p. 27.

86 Ibid., north-west, p. 64; Ministry of Health survey report, Bootle and South Shields, NA, MH66/466 and 890.

87 Mohan, op. cit., note 2 above, pp. 28–30.

88 Ministry of Health survey report, Birmingham, NA, MH66/442.

89 Ministry of Health survey report, West Bromwich, NA, MH66/977.

90 Ministry of Health survey report, Gloucester, NA, MH66/625.

91 Fox, op. cit., note 70 above, pp. 29–30.

92 The factors involved in calculating the block grant apportionment consisted of rateable value, proportion of the population under five, and the level of unemployment. Norman Chester, Central and local government, London, Macmillan, 1951, pp. 125–8, 288–307; J M Drummond, The finance of local government, London, Allen & Unwin, 1962, pp. 101–10.

93 The hospitals owned by the Metropolitan Asylums Board (MAB) facilitated such specialization of institutions once appropriated. The number and generally good quality of the MAB institutions meant that the London County Council (LCC) was able to appropriate them rapidly, and create a hierarchy of functions. Ayers, op. cit., note 16 above, pp. 240–1. It was an advantage noted by contemporary health officials in London also. See Stewart, op. cit., note 16 above, p. 426.

94 Powell, op. cit., note 28 above, p. 314, idem, ‘Hospital provision before the NHS: territorial justice or inverse care law?’, J. soc. Policy, 1992, 21: 145–63, p. 159.

95 Ten miles was chosen to avoid any suggestion of the large cities of Manchester and Liverpool impacting on each other. It is worth considering that neighbouring county councils may have played a part also, but they are beyond the scope of the current study.

96 The models were all binary logistic ones, treating appropriation as the dummy “yes/no” dependent variable. Since population was the only significant variable (making appropriation more likely), several models were run, in order to probe its effect more closely. The variable was treated variously as continuous and categorical, and the variable denoting ownership of more than one institution was also included in both of these forms in different models. All the models were able to explain at least 40 per cent of the variation in the dependent variable, almost all of which was provided by the population variable. In all cases, population size, whether treated continuously or categorically, was significant at a 95 per cent level or higher. In all cases, ownership of more than one institution was the next most significant variable, although it never attained statistical significance.

97 Powell, op. cit., note 7 above, p. 345.

98 Ibid., pp. 344–5.

99 Godber, op. cit, note 2 above, p. 8.

100 According to Marguerite Dupreée, both the character of the local élite, and the legacy of charitable institutions from an earlier age had a large impact on local social services; see idem, ‘The provision of social services’, in Martin Daunton (ed.), The Cambridge urban history of Britain, vol. 3: 1840–1950, Cambridge University Press, 2000, pp. 351–94, on p. 355.