per cent to 59 per cent of their income,7 financed either out of patients’ own pockets, by health insurance through, for example, the middle-class British Provident Association, or from factory savings schemes and Saturday Hospital Funds. These last, into which people paid against future treatment, were run by the hospitals themselves. For the less well-off such schemes often bought out-patient but not in-patient treatment. Lady Almoners controlled means-tested access to beds, and substantial donors were often allocated free beds to distribute to the deserving, so a letter of reference from a JP or a councillor or from the local gentry might have to be begged to ensure admission.8 Increasingly the voluntary hospitals came to rely on charges and on private patients. The price of survival, as Ruldolf Klein has put it, became ‘to an extent the repudiation of the inspiration which had led to their creation in the first place’.9
Despite all these stratagems, flag days, and ‘a begging bowl [always] at the end of the ward; you would not dare to pass that bowl if you visited on those days’,10 by the late 1930s many of the voluntary hospitals, which accounted for about one-third of the beds, were in deep financial trouble. Even the great teaching hospitals endlessly teetered on the edge of bankruptcy. As early as 1930, the House Governor of the Charing Cross Hospital declared that the hospitals could not rely on sweepstakes and competitions for survival and predicted that within ten years they would be nationalised – state-supported and state-controlled.11 In 1932 out of 145 voluntary hospitals in London, 60 failed to balance their books,12 and by 1938 the hospitals were pleading with the Ministry of Health for state grants.13
Geoffrey Rivett, a senior health department civil servant who was a driving force behind the controversial new family doctor’s contract in the 1980s, records in his history of the London hospital system:
It was said that a hospital need never despair so long as it was bankrupt, but the plaintive cry of ‘funds urgently needed and beds closed’ led in the end to the belief that the voluntary system was not only insolvent, but might not be worth saving.14
The Second World War and the Emergency Medical Service did save it, but only for a time. In these hospitals, consultants had honorary, unpaid appointments; they made their income from private patients while treating the less well off free. As a result specialist care was only available in parts of the country wealthy enough to provide sufficient private practice to attract specialists. These more prosperous areas were, needless to say, not necessarily those with the greatest need. Elsewhere, surgery and anaesthetics were carried out by GPs (family doctors) working in the hospitals. What this could mean, even after the founding of the NHS, has been illustrated by Dr Julian Tudor Hart, who recalled that just before specialists replaced GPs at Kettering General Hospital where he worked in 1952, a young woman with acute intestinal obstruction was admitted. At Kettering GPs did the surgery,
helped once a week by a part-time consultant who travelled 100 miles by rail from London.
The family doctor opened the abdomen to find multiple obstructions caused by Crohn’s disease. He excised four or five segments along the seven metres of small intestine, leaving the loose ends to be reconnected. Then his troubles began; which end belonged to which? Never having met this unusual condition before, he had waded into the macaroni without planning his return. In those days emergency surgery was still regarded by patients as a gamble with death. If he had confidently reconnected the tubes as best he could, praying he hadn’t created any collisions, dead ends or inner circles, he would probably have been acclaimed whatever the outcome. Being a man of integrity, he persuaded his GP-anaesthetist colleague to keep the patient unconscious for what turned out to be four hours, with a small coppice of metal clamps splayed out from the incision, telephoned the London consultant, and waited for him to come up by the next train to sort it all out. Remarkably, the patient survived. It was the last anecdote of a closing era of GP surgery; the professionals put an end to all that, and not before time.15
Alongside the voluntaries were the municipal hospitals, many of which had grown up as appendages to the 1834 workhouses: some were still called the ‘Workhouse Infirmary’. Run by local authorities, these were regarded in the main by doctors, nurses and patients alike as grossly inferior to the voluntary hospitals – certainly outside the big cities – and real stigma attached to many. They comprised a mix of old Poor Law institutions, the great mental illness ‘bins’, and the ‘fever’ and ‘TB’ (tuberculosis) hospitals. Most depended on general practitioners to service them. They ranged in quality from the occasionally excellent to the awful. But they had in the decade before the war been supplemented in some cities by a determined expansion of purpose built hospitals. Before 1930 only three local authorities had exercised a right under the 1875 Public Health Act to establish general hospitals. But by 1938, councils in England and Wales provided 75,000 general beds (as opposed to the mental or fever beds they ran) and the London County Council was arguably the biggest hospital authority in the world, rivalling in size the entire voluntary sector. Middlesex developed a hospital service of the highest class, while City hospitals in Birmingham, Bristol, Newcastle, Sheffield and Nottingham set new standards for local authority provision, attracting academics as well as employing specialists and staff doctors. Access to their general hospital beds was means-tested, although on one estimate only about 10 per cent of costs were recovered from patients.16 None the less, the stigma of the old Poor Law hospitals which made up the bulk of local authority provision still left many reluctant to resort to them: ‘There was a certain sense of shame in being taken there,’ patients recorded.17 Patients from just over the border in the next authority would often be refused admission to empty beds, and voluntary hospitals dumped patients who failed to respond to treatment on to the Poor Law infirmary for the chronic sick.18
The two systems thus fought among themselves and against each other. Sir George Godber, who was to become the greatest of the Chief Medical Officers the NHS has seen, helped run the 1937 survey which revealed the appalling physical state of many hospitals and the acute shortage of beds. Run down though they were, he recalled, ‘the physical difficulties imposed by unsatisfactory buildings were less important than the defects in district services resulting from competition, if not overt hostility, between the several hospitals providing them’.19
The local authorities, who numbered several hundred, also ran a range of other health services. These included the school medical service, some home nursing, a small number of health centres, and ante- and post-natal care: most births were midwife-delivered home births, with a doctor only called if complications arose. One mother in 350 died in childbirth.
Family doctor or GP services remained based on Lloyd George’s ‘Ninepence for Fourpence’ National Health Insurance, and 43 per cent of the adult population was covered for a ‘panel’ doctor by 1938.20 Ninety per cent of GPs took at least some part in the scheme. Non-working wives and children, the self-employed, higher income earners and many of the elderly, however, remained excluded. Hospital treatment was not covered, and the Approved Societies which ran the scheme offered wide variations in ‘extra’ cover for dentistry, spectacles (which many people bought for 6d. [2.5P] at Woolworths) and sometimes some hospital care. Schoolchildren and the poor could get free treatment, subject until 1942 to the humiliating ‘family means-test’ in front of the Relieving Officer, and some queued at the ‘casualty’ or ‘dispensing’ departments of the voluntary hospitals seeking treatment for illnesses that ranged from the minor, which really needed only a GP’s attention, to the horrifyingly major.
An Aberdeen woman quoted in Margaret Whitehead’s compilation of pre-NHS memories, recalls getting rheumatic fever on top of scarlet fever when her mother took her to the dispensary because they could not afford a doctor. ‘I took scarlet fever … and I was ill for a few days and my mother took me to the dispensary. We had to walk to the dispensary because it was free there, we couldn’t afford to pull in a doctor. ‘Cos my mother would have had the doctor in the house maybe … well, at least twice a week, ’cos she had eight of us. And you know what it is, there’s always something wrong with one. And it had to be serious before she took in a doctor because she couldn’t afford to pay for it.’21
Some GPs only saw their panel patients at lock-up surgeries, receiving private patients in their homes; others