At the University of Huddersfield, Professor Barry Doyle has been examining debates that took place within the local labours movement in three English cities before the founding of the NHS in 1948. State intervention in any aspect of our lives is an emotive topic, pitting notions of welfare state, nanny state and individual autonomy against each other. Not surprisingly the issue of whether or not to have a National Health Service (NHS) was hotly contested - between and within political parties - prior to its foundation in 1948.
The NHS was the cornerstone of the new welfare state, which was introduced by Labour's first ever majority government from 1945 to give every British citizen lifelong protection against unemployment and ill-health. It therefore seems reasonable to assume that support for a government-run health service was unanimous within both the national Labour Party and the wider labour movement generally. Certainly, that tends to be the view of historians.
The reality, as Professor Barry Doyle at the University of Huddersfield has been discovering, is rather more complex. He has been exploring labour attitudes to hospital provision in the interwar years in three English cities: Leeds, Middlesbrough and Sheffield. With a Wellcome Trust Research Leave Award, he will be writing up his findings in a book to be published by Pickering and Chatto.
His research suggests that while the national Labour Party in Parliament may have been as one on the matter of state hospital provision, within the wider labour movement (the unions, local councils and cooperatives) opinion was far more divided.
Before the NHS, people with low incomes went to hospitals provided by charities or by the government. The latter were either Poor Law hospitals or municipal institutions run by local councils. The wealthier classes tended to eschew the government hospital wards and instead paid for care in private nursing homes, or (later on) in private hospital wings.
From the 1870s onwards, another form of hospital provision sprang up, with its roots in the mutualist tradition, which flourished in some industrial towns from the middle of the 19th century. Often, with the encouragement of their employers, unions and liberal-minded politicians of the day, workers formed cooperatives, friendly societies and other mutual organisations to protect themselves and their families in case of high food prices, illness, unemployment or death.
Workers also began to pay into hospital contributory schemes, such as Workpeople's Hospital Fund in Leeds and the later 'Penny in the Pound' scheme in Sheffield. By paying a penny out of every pound of their wages into the scheme, as its name suggests, they could guarantee medical care in the hospital supported by the scheme for themselves and their families. Many of these voluntary-sector hospitals, such as Leeds General Infirmary, are the big-name teaching hospitals of today.
"We have a tendency to think of hospitals before the NHS as either being charities, run by people like you have on 'Casualty 1909'," says Professor Doyle, "or Poor Law hospitals where you were poorly treated and kept in terrible conditions. Either way you're being made to grovel, or you're being made to grovel. Whereas in fact, people were showing an awful lot of control, particularly in the north of England, over making provision for themselves. Right up until the 1940s, where you find radical liberals talking about the 'right' of people to have these things for themselves. They're not going to be run by the state, or given by charity; they're going to do it for themselves."
A cartoon from ‘Punch’ about Poor Law “kindness”, 1864. Credit: Wellcome Library He believes membership of these schemes often led to a degree of involvement in the welfare of the hospital that went beyond mere membership of an insurance scheme. "People from the schemes helped run the hospitals. They were on the hospital boards and helped raise money for the hospital." In the 1930s he says around 50 000 people went every year to the annual Leeds Gala, where they could watch or take part in running events and hot-air balloon rides, and visit stalls and sideshows. "One of the main reasons people went was to raise money for the hospital. So there's a close relationship between being part of the community, and being part of the voluntary scheme, and supporting the hospital. It united the three points of the triangle: patient, scheme and hospital."
Professor Doyle has been investigating whether, in light of the success of these voluntary hospitals, there was resistance to their appropriation by a state-owned NHS within the wider labour movement: the trade unions, local Labour councillors, mutualist cooperatives - as well as more traditional voluntarists from the Liberal and Conservative parties.
Location, location, location
His research, drawing on case studies of Middlesbrough, Leeds and Sheffield, reveals that in each of these three cities the nature of that wider movement was strongly influenced by the specific social and demographic structures of the local economy. This in turn impacted on attitudes within the labour movement to a state-run hospital system.
Middlesbrough and Sheffield had similar local economies: both were dominated by heavy industries associated with metal-making and had small middle classes of relatively recent vintage.
As a result they had a powerful labour movement centred on the trade unions, whose dominant concerns were practical issues linked to industrial relations and working and living conditions. The unions were generally sympathetic to voluntary hospitals, which provided acute emergency services for a male workforce vulnerable to industrial accidents, and were extensively represented on the hospital boards. In both cities the unions worked with the councils to develop joint schemes allowing reciprocal patient exchange between the voluntary and municipal hospitals.
The politics of the local councils differed. In Middlesbrough Labour was weak and the Liberals had influence, while in Sheffield Labour dominated from the middle of the 1920s. But in both cases, the strength of the unions diminished ideological conflict in the councils. At one with their local unions, the Labour councillors' predominant concern was to ensure there were adequate hospital services, rather than to play politics with those services.
Hence in Middlesbrough there was very little agitation by the local Labour Party for a municipal hospital system. In Sheffield, it is even possible that despite Labour's strength on the council, the party may not have wanted a municipal system at all. The reason for this was the excellent relationship and high degree of consensus between the two hospital sectors: the municipality and the organisers of the voluntary city-wide 'Penny in the Pound' scheme.
Moses Humberstone, the secretary of the Sheffield Trades and Labour Council (the local unions federation) and Labour Lord Mayor, was a leading advocate for Sheffield's voluntary scheme. He lauded it as "a great humanitarian effort" because it linked the mutualist, industrial and political wings of the labour movement. As a result, says Professor Doyle, by the end of the 1930s Sheffield had one of the most efficient, complex and democratic hospital systems in England, almost seamlessly integrating hospital services, finances and expertise.
The picture in Leeds provides a striking contrast. Textiles rather than metals constituted its traditional industry. Unlike Middlesbrough and Sheffield, it also had a highly developed commercial sector including a financial services sector and a ready-made clothing sector employing mainly women workers. Reflecting the economy and workforce, hospital provision was geared more towards illness and maternity care than towards acute injury and trauma.
The city had an old, well-established middle class with its roots in the textile era as well as a flourishing new business and professional middle class. Members of this educated middle class were consistently involved in politics and voluntary associations throughout the period.
Here ideology flourished, while the trade unions were much weaker. The council vacillated between Labour and Conservative control, with both parties acting more ideologically. Party politics, especially over hospital provision, were far more contested.
The voluntary hospital scheme in Leeds was defended in the 1930s by local Conservative politician Sir George Martin (who was chairman of the council Health Committee and of the voluntary Public Dispensary). "He was deeply interested in ideas of self-support and used his position to shape hospital services in line with his ideological view - which was to support the voluntary system and weaken the municipal service," says Professor Doyle. "He warned against allowing the 'leaden hand of state' to control the hospital system."
The position adopted by the Leeds Labour Party seems therefore to have been more in line with the national party than it was in either Sheffield or Middlesbrough. Party members viewed the voluntary sector with contempt and, as early as the 1920 municipal elections, Labour candidates were campaigning actively for a unified state-owned hospital system, claiming an "Efficient Municipal Hospital Service for All is Labour's Aim". As a result, joint working and the development of a hospital system were considerably more contested than in either Sheffield and Middlesbrough.
"There wasn't one equal, universal system out of which the NHS was formed," says Professor Doyle. "The labour movement at a local level wasn't united in its approach to hospital provision." Instead, decisions about hospital provision were shaped locally by individual politicians, socioeconomic structures and, in some cases, sharp ideological differences both between left and right, and within the labour movement. "Those local factors had a definite effect. On attitudes to a state-run system - and on the kinds of hospital services that developed."