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In the debates over the politics of National Health Service foundation, there has been little investigation of the attitudes of the inter-war labour movement to a state-run hospital system. In particular, there has been limited assessment of views outside parliament in provincial Labour parties and trade unions. Drawing on a case study of Middlesbrough, Leeds and Sheffield, this article examines the politics of hospital provision prior to the National Health Service (NHS). It focuses on the involvement of the labour movement in hospital provision within localities and on the extent to which the dominant form of labour politics—labourist or socialist—shaped hospital policy. It suggests that, in the heavy industrial towns of Middlesbrough and Sheffield, close involvement with voluntary hospitals through workers contributory schemes dampened the enthusiasm for a state system. However, such a policy was heavily promoted by socialists in more economically diverse Leeds.
The history of inter-war hospital provision has been transformed in recent years by a group of historians concerned to provide a more nuanced analysis of the period based on wide and deep research. At a national level there have been major surveys of the voluntary sector and of municipal provision.1 These have built upon and supported a range of important regional and local studies that have done much to correct the traditional pessimistic accounts of the period.2 However, much of this work is based on national sources—such as the Ministry of Health records—supported by case study approaches providing largely illustrative or paradigmatic evidence of local experience. Moreover, it has paid limited attention to the politics of hospital provision, tending to follow Powell's assumption that at the local level, party and ideology were relatively unimportant in determining the form of hospital provision, although politics could shape policy in other areas.3 In particular, there has been little discussion of how the labour movement on the ground approached the issue of hospital management, funding and control. John Stewart's work on the Socialist Medical Association has been very influential in updating the view that the Labour party and the wider labour movement were committed to a state-run hospital service delivered by the municipalities.4 This image has been reinforced by Willis's study of Sheffield and evidence presented by Gorsky et al. that, despite labour movement involvement in contributory scheme administration and management, these were regarded as necessary evils until municipalisation was possible, rather than as a viable alternative promoting mutualist democratic ownership.5
Thus there are few alternatives to the view that the Labour party and the wider movement were as one on the issue of a state service except that of Ray Earwicker. Although usually cited as an authoritative source on labour unity, he notes early in his thesis that, by 1923, as the voluntary sector recovered from the financial crisis created by the First World War, the party and the unions were divided in their approach to hospital finance and management. Given the unions' commitment to extending National Health Insurance to include hospital benefits, they were often sympathetic to voluntary hospitals, supporting contributory schemes as the best way to ensure access for members to the best care.6 This raises the broad question: how united was the labour movement on the issues of hospital provision, finance and control? And what local factors may have influenced support for alternative models to municipal provision, especially the mutualist contributory scheme? For whilst party and ideology may not have been the main or key determinant of policy formation in the inter-war period, Levene, Powell and Stewart have pointed to the importance of ‘the attitudes and preferences of the council, including the personalities of individual officers and personnel,' whilst elsewhere Taylor, Powell and Stewart have argued that ‘we need a more sophisticated understanding and analysis of roles taken by council representatives and officials’ in the local and national dynamics of hospital provision.7
This article will explore these issues through a study of labour movement involvement in the provision of hospitals in three Yorkshire towns—Middlesbrough, Leeds and Sheffield—between the two world wars (1919–1938). It will place particular emphasis on the economic and social structure of the places being examined, especially the impact of the dominant industry on demography, health, risk and labour politics. The case study approach has been utilised to provide an opportunity to undertake a detailed analysis of the kinds of social and political factors forming hospital politics emphasised by Levene, Powell, Stewart and Taylor in their macro-studies of county borough provision between the wars. It will complement the recent case studies of Cherry, Willis, Gorsky and Reinarz.8 The particular towns have been chosen as they represent three different experiences for the Labour Party between the wars: Sheffield where Labour dominated the Council from the middle of the 1920s; Leeds which vacillated between Labour and Conservative control; and Middlesbrough where Labour representation was low, power resting with a Liberal-dominated coalition. It is divided into four main sections. The first will provide an overview of the economy and society of Middlesbrough, Leeds and Sheffield. This will be followed by an account of the provision and management of hospitals across the three towns and an assessment of labour politics in the respective municipalities. The main section will consist of an analysis of hospital policy and the part played by the labour movement and finally a brief examination of the ways in which a hospital system emerged in the three towns. It will argue that the labour movement at a local level was not united in its approach to hospital provision and that both labour markets and the dominant orientation of labour politics shaped the response to the voluntary and municipal provision.
This article will compare three towns and cities in the historic county of Yorkshire: Middlesbrough, a new industrial town on the northern edge of the North Riding of the county; Leeds, an industrial and commercial centre in the heart of the West Riding; and Sheffield, a heavy industrial city on the southern edge of the West Riding, close to the Derbyshire border. Both Leeds and Sheffield had played a part in the early stage of the industrial revolution, the population of Leeds reaching a quarter of a million and Sheffield 160,000 by the 1851 census. Over the next 50 years, the population of both cities more than doubled, peaking in the inter-war period at over half a million. Middlesbrough, though not on the same scale, was probably the only industrial boom town of nineteenth-century England, growing from a population of a few hundred in 1831 to almost 100,000 by 1901. However, depression and limited boundaries meant the town could not develop much beyond this figure, peaking in 1951 with 147,000 denizens.9
All three towns owed their growth, wealth and position in the demographic and economic hierarchy to the industrial revolution. Middlesbrough and the adjoining Cleveland area was Britain's premier iron-producing region, especially in the third quarter of the nineteenth century. However, Middlesbrough found the transition to steel-making difficult, becoming a producer of semi-finished iron and steel for use in engineering, fine steel-making and heavy construction goods. This structure relied largely on manpower. In 1907, Lady Florence Bell noted that the manufacture of iron was ‘all done by human hands, and not by machinery’.10 Moreover, the industry's reliance on imports and exports made it particularly vulnerable to the vagaries of the trade cycle and even more to cyclical depression and unemployment between the wars.11 Sheffield, on the other hand, was the world leader in fine and specialised steels, in edged products from cutlery to swords and, from the later nineteenth century, in the mass production of armaments and munitions. As with Middlesbrough, these were highly masculine occupations where wages were good but risks were high. Though proving less vulnerable than Teesside to the down-turn of the inter-war period, the city did experience mass unemployment and considerable rationalisation and refocusing.12 The economic structure and function of Leeds was very different to that found in Sheffield or Middlesbrough. Leeds had been a pioneer textile town of the early industrial revolution, but over the nineteenth century the focus of the city changed as manufacture gave way to the commercial organisation of the industry and new sectors began to emerge, especially an engineering industry and an increasingly sophisticated ready-made clothing sector. Both textiles and clothing (and to a lesser extent, footwear manufacture) were industries with significant numbers of female workers—and commensurately low levels of pay—with only the engineering sector really offering a range of remunerative masculine jobs for male workers.13
Moreover, neither Sheffield nor Middlesbrough were particularly important as either commercial or administrative centres, acting mainly as sub-regional centres serving overwhelmingly rural and heavy industrial hinterlands. They did have retail sectors but there was no particular growth in areas like banking, insurance, commerce or public administration. As a result of this, and the fact that the management of industry was highly concentrated—especially in the case of Middlesbrough—the middle class in both towns was small, with the withdrawal of leading figures from residence in the town a key characteristic of bourgeois development. Sheffield's middle class did grow to some extent with the development of the armaments sector and the mass production of steel, but it remained small relative to the population.14 Leeds, however, had a very different experience. It had an old, well-established middle class based on the textile era, a highly developed commercial sector, an emergent white collar workforce and a sophisticated retail centre serving the densely populated West Riding of Yorkshire.15 Middle-class engagement was strong, with both the old elite and new business and professional citizens consistently involved in politics and voluntary associations throughout the early twentieth century. These differences had a significant impact on the development of hospital services in the respective centres and ultimately on the attitude of local Labour parties to how these should be run.
Indeed, politics played a significant part in how hospital services developed over the inter-war period. As is well known, this period saw the rise of the Labour party at both Westminster and in the boroughs and particularly in Yorkshire where the party gained control of seven of the twelve county boroughs by 1929.16 In Sheffield, pre-First World War labour politics had been characterised by levels of division rarely seen in industrial cities. There was a very strong tradition of Lib-Lab politics, with leading trade unionists from the traditional light steel trades maintaining strong relations with the Liberal party and working within liberalism to achieve labour representation. With the growth of the heavy steel sector, which employed large numbers of semi-skilled and unskilled migrants, more militant unionists emerged who challenged the established Lib-Lab position. They failed to capture the Trades Federation or to develop a united front in relation to labour representation, leading to the formation of a second trades' council in 1908. However, during the war the increasing power of the heavy sector and the growth of industrial militancy on the shop floor saw the two bodies reunite in 1920, the Lib-Lab group retaining some power within the new body. This new organisation saw rapid success and in 1926 the Labour party took control of the council, holding it until the war with the exception of 1932.17 In Leeds, labour politics were characterised by the early development of a socialist movement in the city associated initially with the Socialist League and then the Independent Labour Party (ILP). By 1903, the Trades Council had agreed to support a predominantly socialist Labour Representation Committee which had experienced considerable municipal success by 1913. In the post-war period, Labour quickly emerged as the main challenger to a very strong Conservative party, the socialists building on their long pedigree to gain control of the council between 1928 and 1930 and again from 1933 to 1936.18 However, despite its strength in Leeds and Sheffield, the party was quite weak in Middlesbrough. As in Sheffield, its early development was slowed by a strong Lib-Lab tradition and the dominance of middle-class socialists in the ILP. Although successful in parliamentary elections, the party never held more than one-third of the seats on the council in the inter-war period.19
The nature of the wider labour movement was shaped by the social and demographic structures of the local economy. Both Middlesbrough and Sheffield were dominated by the masculine industries associated with metal-making which were generally well paid but dangerous, with a high incidence of accidents at work and evidence of occupational long-term illness. Thus, in 1907, Lady Bell observed that in the Middlesbrough iron industry the men suffered from:
rheumatism, from asthma, from pneumonia (often of a dangerous and virulent kind), from feverish attacks, from blood-poisoning in one form or another caused by some scratch on the surface of the skin when handling hot iron, from affections of the eyes due to exposure to dust, to glare, and to noxious vapours. Consumption is also frequent.20
Given the extreme and dangerous conditions, workers in both towns promoted a strong mutualist structure of trade unions, friendly societies, hospital contribution schemes and cooperatives to help smooth the frequent and unpredictable disruption to earnings caused by cyclical unemployment and occupational hazards.21 Moreover, the strength of the unions and the needs of employers to maintain productivity meant that industrial relations were generally good from the 1870s onwards with the exception of a brief period of unrest and militancy during and immediately after the First World War.22 The situation in Leeds was far more complex. By the early twentieth century, the dominant industries in the city were clothing and footwear employing mainly women workers along with a strong engineering sector. As a result the unions were generally weak—divided on ethnic lines and suffering significant defeats at the beginning of the twentieth century which saw the local labour movement switch to a broadly political approach.23 Thus, Middlesbrough and Sheffield were dominated by labourist political movements—where the dominant concerns were practical issues linked to industrial relations and living conditions rather than ideology—whilst in Leeds the focus was on a socialist approach. Furthermore, hospital provision and policy in the three towns was largely shaped by these social, economic and political structures, with the extent to which both access and hospital management were democratised, owing much to the needs and shape of the local working population.
Between the wars, English hospital provision was divided amongst three providers. The voluntary sector provided the majority of general beds (although these were limited to predominantly curable and surgical cases) along with a range of specialist institutions. The medical provision of the poor law provided largely chronic nursing care, plus growing maternity coverage and in some areas general medical services up to 1929. The third service was that delivered by local councils which was initially focused on infectious diseases and mental health but after 1929 took over the commitments of the poor law.24 This tripartite arrangement was reflected in hospital services in the towns under consideration (Table 1). In Middlesbrough, there were two voluntary general hospitals dating from the 1860s and a general practitioner-staffed institution, which together provided just over 400 beds by the 1930s. The 280-bed Poor Law Infirmary, Holgate, was appropriated as a general hospital by the council in 1930. It joined a municipal maternity hospital which opened in 1919 and grew steadily to 60 beds; a large infectious diseases institution which serviced the wider sub-region and further tuberculosis and infectious disease provision. The latter included Poole Hospital, a TB sanatorium opened in the early 1930s, then rebuilt as a joint venture with various neighbouring boroughs.25
Hospital beds in Sheffield were more diverse, ranged across two voluntary general hospitals, a children's hospital and the Jessop Hospital for Women. Municipal provision initially included TB treatment and an infectious diseases unit but in 1930 the council acquired the various institutions of the Board of Guardians, creating a large general hospital in the city centre, a smaller mixed institution taking chronic sick, maternity and TB patients and a Public Assistance Institution for the nursing of the chronically ill and aged infirm. By 1938, the city could boast 1,000 voluntary beds, almost 1,500 in the two appropriated municipal institutions, 300 for infectious diseases, 250 sanatorium and 140 surgical TB beds and almost 800 beds purely for the chronically ill—a total of 4,000.26 In Leeds, although the number of beds and proportion of voluntary to municipal provision was similar, the number and type of institution was quite different. Voluntary provision in the city was dominated by the large Leeds General Infirmary (LGI) supported by small institutions for particular social groups, highly developed services for women and a rare chronic sick hospital, a total of 900 beds (extending to 1,000 in 1940 with the opening of the Brotherton wing of the LGI). Prior to 1929, Leeds had four poor law institutions, whilst the city had developed a number of hospitals for infectious diseases and a TB sanatorium. After a protracted political battle, three of the poor law infirmaries were appropriated in 1934 providing the city with the substantial St James Hospital with acute, medical, chronic, maternity and mental health beds whilst St George's and St Mary's provided largely chronic nursing.27
In part, the differences of voluntary provision were a result of the diverse ways in which such hospitals were funded. Although all were ‘voluntary’, few were traditional charitable institutions relying predominantly on subscriptions, donations and bequests. Rather, each hospital benefited more or less from workers' contributions organised in one of three ways. In Middlesbrough, over 60 per cent of income at both North Ormesby Hospital and the North Riding Infirmary was derived from works based collection schemes which facilitated extensive representation on both the House Committees and increasingly the management committees of these two institutions.28 In Sheffield, workers' support came through a city-wide contributory scheme. This was an early ‘penny in the pound’ scheme, established in 1920 following a severe post-war financial crisis, and was set up at the behest of the medical staff and the management of the main voluntary hospitals.29 Its success was based on the fact that it quickly received the support of the labour movement, business leaders—who proved more generous than those involved in similar schemes across the country—and the university as well as the hospitals. It managed to bring together an extensive list of stakeholders and had amassed 220,000 members by the mid-1930s with workers securing significant representation on the Contributors Council, a number of seats on the Joint Hospitals Council (which coordinated hospital provision) and some places on the boards of individual hospitals—although in this case their power was very limited.30 The situation in Leeds was substantially different. Here the one dominant voluntary hospital was controlled by the city's traditional elite, as were the smaller institutions. There was a large contributory scheme, the Leeds Workpeople's Hospital Fund, with some representation on the Board of Governors of each voluntary hospital and a very limited role in their management.31 Yet despite a highly politicised atmosphere in hospital politics, close links between the voluntary hospitals, the city council and the contributory funds did emerge in various ways by the later 1930s.32
Thus, in Middlesbrough there was close involvement by the labour movement in supporting, financing and managing the voluntary hospital sector based on long association through works' contribution schemes.33 These provided extensive representation in the management structures of the two main voluntary hospitals—North Riding Infirmary (NRI) and North Ormesby Hospital (NOH)—representatives of works' contributory committees dominating the membership and leadership of the House Committees in particular. Moreover, there was strong workers' representation on the governing Council of NRI whilst contributor representatives gained increasing representation on the Council of NOH including leading labour activists such as C. R. Stephenson, President of Middlesbrough Trades Council.34 This representation was reward for the huge financial contribution the works' schemes made to the voluntary hospitals of the town, which at its peak in the early 1930s amounted to around 70 per cent of annual income.
The labour movement's involvement in running Middlesbrough's hospitals and their understanding of the role of these institutions was starkly revealed during the prolonged crisis at the North Riding Infirmary over the period 1929–33. In a series of scandals which touched on the role of the consulting and resident medical staff, the nurses, hospital management and patient rights, labour movement activists highlighted the belief that the NRI was already owned by the people. Thomas McKenna, Secretary of the Blast Furnaceman's Union, observed that:
we as members of the community financially and otherwise interested in the Infirmary, which is a public institution, assert our right to know how it is managed and the right to know the merits of the service rendered to patients.35
Yet despite these critiques of the management, there were few calls for change before the very end of the 1930s. Labour activists rarely commented on hospitals nor did they demand municipalisation. Indeed, comments about the voluntary hospitals were usually complimentary with only occasional alternative views expressed, such as the socialist Mrs Coates Hanson's call for a civic service in the early 1920s.36 However, by the late 1930s a sense of mounting unease saw some criticism from the general public such as ‘A Working Man Subscriber’ who commented that:
the voluntary hospital system is being forcibly questioned just now and that unless they bring their efficiency up to the standard of the municipal hospitals they will be superseded. … We as working men don't want to lose the voluntary hospital system but. … Either the voluntary system meets all our needs or it makes way for the municipal system.37
Whether such views were widespread is unclear, although the available evidence points to extensive local support from within and outwith the labour movement for the voluntary hospitals of the town.
Arguably, Sheffield had the most developed and democratic hospital management and funding system in England. This system was based on a wide-ranging Joint Hospital Committee to manage service delivery and strategy for the city and an area-wide contributory scheme utilising the ‘penny in the pound’ collection principle.38 This outcome had not looked likely prior to 1914, when the city's hospitals faced financial crisis as subscriptions fell and costs rose. Attempts to improve the proportion of income raised from the workers via the Saturday and Sunday Funds faltered whilst the left wing Trades' Council condemned contributory schemes in favour of municipalisation.39 This situation was exacerbated by the impact of the First World War which left the voluntary hospitals in debt and unable to meet patient demand. To address this crisis, the Sheffield ‘Penny in the Pound Scheme’ was developed over a three-year period, beginning in 1919 when the management committees of the voluntary hospital boards formed a Joint Consultative and Advisory Hospitals Council. It reported in 1920, proposing that ‘if a penny in the pound of wages earned or two shillings per quarter was appropriated to the hospitals and institute, £40,000 a year might be raised’.40 However, the Sheffield Trades and Labour Council (STLC) was initially cautious about how to respond to the crisis in the voluntary hospitals, stating that:
whilst declaring in favour of municipalisation of all Hospitals and Infirmeries, [sic] recognises the present unsatisfactory financial position of the Hospitals and Infirmeries of the district, and expresses itself in favour of the workmen of Sheffield contributing the sum of 1 1/2d per week each to these Institutions, provided direct labour representation on the Board of Management is accorded.41
At first the STLC was hostile to the ‘penny in the pound’ scheme but gradually they became more sympathetic, although they continued to express concern about the under-representation of labour on the Joint Hospitals Council. As a result, in mid-November 1920 they once again rejected the scheme unless employers matched employee contributions from profits.42 But following a meeting with the Joint Hospitals Committee, a plan for employer contributions and additional labour representation was thrashed out and by March of 1921, STLC were supporting the full launch of the scheme, although they remained unhappy with the level of representation on the Joint Hospitals Committee for ‘labour’.43 From this point they threw themselves entirely behind the scheme, especially as the scale of public support became apparent even from within the labour movement.
At the forefront of working-class acceptance of the new approach to the voluntary hospitals was Moses Humberstone, secretary of STLC, Labour Alderman, Lord Mayor in 1927 and President of the Sheffield and District Association of Hospital Contributors, 1922–39, who declared himself ‘in love with the movement’.44 He had been a leading advocate of the penny in the pound scheme in 1920, symbolising the joining-up of the mutualist, industrial and political wings in support of the Sheffield scheme. Yet he remained a passionate advocate of contributory schemes over municipal control and was critical of simple insurance solutions, claiming Sheffield was not an insurance scheme ‘and I hope that it never will be. I trust we shall all of us look upon this as a great humanitarian effort, and, come what will, those who are “down and out” shall be assured of treatment.’45
Thus, despite Labour's municipal strength there was little direct hostility to the voluntary system. Indeed, when the Royal Hospital launched a Centenary Appeal in June 1932, STLC agreed, along with the leaders of the two main parties, to support a house-to-house canvass for donations and to help address letters.46 Admittedly by 1939, as the STLC moved sharply to the left, criticism of the scheme was beginning to appear. A city councillor wrote an article on municipalisation of the hospitals and the STLC mounted campaigns for greater representation on individual hospital boards and against the election of the new Bishop to the chairmanship of the Joint Hospital Council.47 As in Middlesbrough, the labour movement also campaigned for fair wage clauses in contracts and by the end of the period they were supporting hospital workers in their campaigns for trade union recognition and better conditions.48 But these growing industrial issues did not markedly undermine enduring support for the penny in the pound scheme and its continuing maintenance of the voluntary system. Thus it is apparent that in Middlesbrough and Sheffield, with their heavy industrial structure, high levels of accidents, well organised male work force and strong mutualist traditions, the contributor-based hospital system was popular, democratic and generally effective, only meeting criticism in the late 1930s when the costs and conditions of labour in the hospitals came firmly on to the agenda against a backdrop of broader inflationary pressures.
The situation in Leeds hospital politics was very different. In general, party politics were far more contested in the city with both Labour and the Conservatives acting more ideologically, especially over hospital politics.49 In addition, the main voluntary hospital, the Leeds General Infirmary, was a more traditional hospital, ruled by a closed board of management dominated by the old city elite whilst the development of a municipal service was considerably more contested.50 In part, this was influenced by the leading figure in medical politics, Alderman Sir George Martin, chair of the Health Committee when the Tories were in power, member of the Council of LGI and leading light in Leeds Joint Hospitals Advisory Committee. Martin utilised his position to shape hospital services in line with his ideological view—which was to support the voluntary system and weaken the municipal service. According to Alderman Brett (Labour chair of the Health Committee), Martin had always been the ‘most vigorous’ opponent of hospital appropriation.51 His role suggests that hospital provision was not a simple administrative decision, as argued by Powell, but could be very strongly influenced by ideology and politics.52
Labour party health politics were equally ideological, with Leeds Labour activists attacking the voluntary hospital system from the early 1920s. Their paper, the Leeds Weekly Citizen, carried numerous articles by national figures such as Somerville Hastings as well as local activists, on the failure of the voluntary system and the righteousness of municipal control.53 Thus, it reported the statement by a consultant neurologist, Dr Morgan, at the SDF Conference in London that ‘Shrieking appeals for voluntary assistance had realised inadequate sums and always would do so … ’ and reprinted an article from the Railway Review published in 1928 which noted that ‘we are compelled to pay taxes for the army and navy as a defence against a possible or probable enemy, but against disease and accidents, enemies that are always attacking us, we depend for half our defence on voluntary subscriptions and some of us glory in the method’.54
Local criticism, far from abating as in Sheffield, grew in intensity. As early as the 1920 municipal elections, Labour candidates were calling for municipal hospitals.55 Whilst in a debate on municipal support for the work of the Leeds General Infirmary in 1924, Labour Councillor Arnott:
supported the proposal [to grant £10,000 to the LGI] as an instalment in the right direction, but regretted it was only for a year. He challenged Sir Chas. Wilson's statement that voluntary hospitals were better than municipal hospitals … they could soon have municipalised hospitals. Labour was perfectly sound in that direction and believed the present voluntary system was unable to cope with present day public demands.56
When a similar grant was proposed four years later, another Labour member, Councillor Armstrong, supported the subvention reluctantly, noting that ‘some of us feel that the institutions which are so essential to the welfare of the people should not be subjected to charity. He did not wish to belittle charity but looked forward to the time when the municipalities and government would see to it that all such institutions were maintained from public funds.’57
The position adopted by the Leeds Labour party seemed more in line with the national party than either Sheffield or Middlesbrough and had much in common with the attitude of socialists in adjoining Bradford.58 Thus, it presented favourably Arthur Greenwood's early comments as Minister of Health which hinted at a unified system and his recognition of the important part working-class organisation and finance was playing in maintaining the voluntary system:
I should like it to be felt that in any great scheme which envisages the ensuring and improving of the health of our people, the public health services on the one hand and the voluntary hospitals, which have largely been built up from the contributions of working people should all be brought into one great scheme which will give us the best possible benefits.59
Recourse to such views intensified during the 1930s. One activist, commenting on the maternity hospital, stated ‘we shall have taken a giant step forwards towards social democracy when we are able to own and control nationally and locally, all similar hospitals; wherein science and medical skill and nursing can give both mother and child the best possible chance to start life on its journey.’60 Overall, Leeds labour viewed the voluntary sector with contempt and looked forward to its extinction, a position equally apparent in its operational policy.
Indeed, it is apparent that politics—both inter- and intra-party—played a greater part in the development of local hospital systems than historians have so far recognised. Such politics could be either positive, drawing on generally consensual relations between left and right or the domination of a particular group, or they could be negative, with ideology intervening to restrict development. In Middlesbrough, relations between the voluntary and state sector were generally positive for most of the inter-war period. The town's Poor Law Infirmary was appropriated without controversy in 1930 and most of the building was turned over to a general hospital which had been developing since 1915.61 However, despite the obligation for the voluntary and municipal sectors to work together to rationalise and modernise the system, little was achieved before 1936. In part this was because the management of the voluntary sector (especially North Ormesby) acted in a rather high-handed and uncooperative fashion whilst, on the municipal side, the Medical Officer of Health (MOH) Charles Dingle was influenced by the 1922 Dawson Report, promoting a centralised clearing clinic for hospital patients under his control. However, within his own provision he did not compete with the voluntary sector whom he acknowledged should act as the general hospitals for the district.62 Dingle's retirement in 1936 prompted closer working within the voluntary sector and between the voluntary and state sector. Serious attempts at joint working were prompted by labour dissatisfaction that voluntary hospital contributors had to pay if they were forced to use the municipal hospital either in an emergency or if their preferred voluntary was full.63 The late 1930s saw the gradual emergence of a town-wide system once a joint scheme was set up which allowed reciprocal patient exchange between NRI, NOH, Stockton and Thornaby General and Middlesbrough Municipal General Hospital. Further moves forward occurred in the early 1940s—when some positive exchange of patients began—though still largely on the basis of separate development rather than either competition or cooperation.64
Yet overall hospital politics were eschewed by the Middlesbrough labour movement—both industrial and political. Labour activists took a back seat in the development of the town system after their success in securing the joint board—upon which ironically they were then denied a seat. Labour councillors played a part in the house committee of the municipal hospital and advocated minor changes but did not campaign for a major overhaul of the site.65 The labour movement also backed the proposed amalgamation of the two voluntary hospitals in 1938, but again did not push for the change.
In Sheffield, the relations between the two sectors appeared excellent, especially after Labour took control of the council and municipal policy from 1926 onwards.66 The appropriation of two of the city's Poor Law infirmaries took place in 1930 without any problems, although, as in Middlesbrough, the expansion of general services at the City General appears to have been limited.67 In 1935, the vast majority of the 850 beds were reserved for ‘medical’ cases, with only 99 surgical beds and significant provision for children and maternity cases. Ten years later, the Hospital Survey asserted that the City ‘has taken … an increasingly important part in the acute hospital work’ whilst acknowledging that the ‘service differs in certain respects from that in the voluntary hospitals of the town’. In particular, it took most of the city's pneumonia cases, whilst the developing specialties were in areas like dermatology and obstetrics, not generally undertaken by the voluntary hospitals.68 As in Middlesbrough, the municipality made some improvement in areas like maternity services and tuberculosis treatment as well as developing a casualty unit just prior to the Second World War.69 Furthermore, as early as 1930, the STLC were involved in lobbying for the exemption of penny in the pound scheme members from charges in the City General, leading to the setting up of a joint arrangement between the scheme and the municipal hospitals. Thus, in 1935, Humberstone could boast to the annual conference of the British Hospital Contributors' Association meeting in Sheffield that a joint scheme between the voluntary institutions and the municipal authorities had been running for over four years and that ‘there is no jealousy between the voluntary hospitals and the Municipal Authorities’.70 Indeed, it would seem that Sheffield had developed an exemplary system by the mid-1930s which linked up services, finances and expertise in a complex and efficient network.
In the case of Leeds, the contrast is, once again, marked. Relations between the two sectors were not very close before the late 1930s, typified by the bungled attempt to appropriate the municipal hospitals in 1930. When in power in the late 1920s, the Labour administration prepared plans to appropriate three of the city's poor law institutions, receiving Ministry of Health and main Council approval in the course of 1930.71 However, following a boundary extension and major redistribution of wards, Labour was trounced in the November municipal ‘general election’, delivering a huge majority to the resurgent Conservatives.72 The new administration acted quickly to reverse a number of the Labour party's policies, including the hospital appropriation.73 On their return to power in 1934, Labour dusted off the 1930 scheme and pushed it through with the support of the MOH.74 Moreover, unlike the situation in Middlesbrough and Sheffield, they adopted an aggressive attitude to the development of St James's in particular, which quickly began to take on a large acute caseload. Labour campaigned actively on their hospital policy, claiming an ‘Efficient Municipal Hospital Service for All is Labour's Aim’ and proposing to extend facilities in a number of areas.75 Labour lost power in 1936, but the Tories continued with a policy of developing relations between the voluntary and municipal sector. In October 1936, the Health Committee met with representatives of each of the voluntary hospitals to form a Joint Hospitals Advisory Committee which appears to have been dominated by the agenda and ambitions of the voluntary sector and was chaired by Sir George Martin, chair of the municipal Health Committee and the Public Dispensary.76 Whilst the LGI seems to have benefited most from the emerging system in the city, the municipal sector did continue to improve, with St James in particular developing a wider range of services.77
The funding of the voluntary sector was also highly contested. Labour were hostile to the continual subventions voted by the council in support of LGI, whilst its representatives, even in non-political roles, emphasised the need for a socialised service. Thus, speaking at the AGM of the Leeds General Infirmary in 1928, the Labour Lord Mayor, Alderman D. B. Foster, observed that:
I think the time is opportune for agreeing that, while we will continue the voluntary method in connection with our hospitals, we will nevertheless be willing to accept some public help. … We want to give the voluntary system every chance to succeed, but this everlasting debt is intolerable. … Something should be done to put our charities in a more satisfactory financial position.78
Labour also took a different attitude to joint financial arrangements between the Workpeople's Fund and the LGI. Whilst trades councils in both Middlesbrough and Sheffield supported and indeed campaigned for reciprocal arrangements between the voluntary and municipal sectors, in Leeds proposals in 1931 for an arrangement with the Workspeople's Hospital Fund under which contributors would be admitted to St James or St Mary's for a payment of 25 shillings from the fund raised criticisms. Labour's Councillor O'Donnell, although not opposed to the plan, pointed out the dangers of allowing too easy transference from the General Hospital ‘whereby St James might be regarded as a sort of lying-in hospital for the infirmary’.79 Overall, joint working and the development of a system was considerably more contested than it was in Sheffield and even in Middlesbrough, with both voluntarists and municipalists wary of the other side.
This discussion raises questions about how united local labour movements were on the municipal route to hospital services. In Middlesbrough, there was little agitation for a municipal system, with most workers seemingly content with the works' schemes. In Sheffield, it is conceivable that they actively did not want a municipal system, although more work needs to be done on this to be certain. In Leeds, conversely, local activists closely followed and probably helped shape the party line of opposition to the voluntary sector and its replacement by a municipal alternative. But what explains these differences in labour movement hospital policy? First would seem to be the need for readily accessible and adequate emergency services, with the pattern in Middlesbrough and Sheffield similar to other heavy industrial areas.80 The needs in Leeds were rather different, with more illness and less trauma resulting from the industrial structure. Second would seem to be the depth and form of the middle class, both Middlesbrough and Sheffield having small middle classes of relatively recent vintage resulting in a limited tradition of voluntarism in these towns. This combined with mixed experiences of fund-raising for voluntary hospitals prior to the First World War, with Sheffield especially struggling to develop an effective model of worker contributions. In Leeds, however, there was a highly developed middle class and commensurate associational culture, even in the 1830s.81 Thirdly, the economic structures of Middlesbrough and Sheffield saw heavy industry produce strong mutualist structures and a powerful labourist labour movement concerned primarily with masculine work-based issues. Unions were strong whilst labour parties were relatively weak and their concern was to ensure the existence of adequate services, not to play politics with services. Leeds, on the other hand, had a significantly more socialist Labour party which developed separately from the labourist tradition and came to dominate the party in the years prior to the First World War. Clearly, in Leeds hospitals were a highly political issue—occupying a central position in municipal campaigning rarely seen elsewhere. In Middlesbrough and Sheffield, however the strong labourist traditions diminished ideological conflict, leading to enduring working-class support for the voluntary sector. This case study tends to support the findings of Levene, Taylor, Powell and Stewart that under the headline views of national policy and national politics, local decision-making was shaped by a wide range of factors including individual politicians and officers, socio-economic structures and, in some cases, sharp ideological differences both between left and right and within the labour movement.
I would like to thank the researchers who have worked with me on this project: Robina Weeds who collected much of the material on Middlesbrough hospitals, Dr Charlie McGuire who completed research on Middlesbrough and Leeds Labour, and Dr Alan Gaukroger who has undertaken some additional work on Leeds and the research on Sheffield. Thanks also to my colleague Keith Laybourn and to the two referees for helpful suggestions and advice.
This work was supported by a grant from the Wellcome Trust, History of Medicine Grants Panel (Grant number 079543).
2Gorsky in Wardley (ed.) 2000 and Gorsky 2004; Mohan 2002; Cherry 1992; Welshman 2000; Doyle 2007: Abel-Smith 1964; Webster 1988. The essays in Gorsky and Sheard (eds) 2006 cover municipal and voluntary hospitals and include a number of case studies.
10Bell 1907, p. 39.
16See table ‘Labour Performance in 1929 Municipal Elections in 12 Yorkshire County Boroughs’ in Davies and Morley in Worley (ed.) 2005, p. 127.
20Bell 1907, p. 91.
24Cherry in Gorsky and Sheard (eds) 2006.
26Parsons, Clayton Fryers and Godber 1945, pp. 18–23 and 128–31.
27Eason et al. 1945, pp. 31–4 and 102–5.
28Annual Report of the North Riding Infirmary (hereafter NRI) various years; Annual Reports of the Cottage Hospital, North Ormesby Hospital (hereafter NOH) various years; Doyle in Borsay and Shapely (eds) 2007.
30For discussion of labour movement hostility, see Gorsky, Mohan with Willis 2006, pp. 51 and 115–16; British Hospitals Contributory Schemes Association (hereafter BHCSA) 1935, pp. 16–17; Sheffield Hospitals Council Annual Report 1924, pp. 2–4 and 1938, pp. 2–5.
31Leeds Workpeople's Hospital Fund (hereafter LWHF), Annual Report 1918, pp. 2–3.
32Leeds Joint Hospitals Advisory Committee (hereafter LJHAC), Annual Report 1936–7.
35North East Daily Gazette (hereafter NEDG), 4 March 1930.
36NEDG, 1 February 1923.
37NEDG, 27 October 1937.
39Cherry in Gorsky and Sheard (eds) 2006, pp. 65–7.
41Sheffield City Archives (hereafter SCA), LD1637, Sheffield Trades and Labour Council (hereafter STLC), Minutes of the Delegates Meeting, 25 June 1918.
42SCA STLC, LD1638, Minutes of Executive Committee, 10 August 1920, 27 September 1920, 16 November 1920.
43SCA STLC, LD1638, Minutes of Executive Committee, 19 January 1921, 22 March 1921.
44Gorsky, Mohan with Willis 2006, p. 102.
45BHCSA 1935, p. 24.
46SCA STLC, LD1645 Minutes of Executive Committee, 21 June 1932.
47SCA STLC, LD1654 Minutes of Executive Committee, 4 April 1939, 4 July 1939, 19 March 1940.
48SCA STLC, LD1654 Minutes of Executive Committee, 4 April 1939, 28 July 1939; Doyle in Borsay and Shapely (eds) 2007, p. 219.
50Leeds General Infirmary (hereafter LGI) Annual Report 1919, p. 8; 1931, p. 25; 1940, p. 45.
51Leeds Weekly Citizen, 29 October 1937.
53See, for example, Leeds Weekly Citizen, 27 January 1928, 28 February 1930. Middlesbrough did not produce a regular Labour newspaper but received extensive and broadly sympathetic coverage from the Gazette. In Sheffield, the Trades' Council paper, Sheffield Forward, gave little coverage to hospital politics although it regularly carried advertisements for the Penny in the Pound Scheme.
54Leeds Weekly Citizen, 11 August 1922, 16 March 1928.
55Leeds Weekly Citizen, 29 October 1920.
56Leeds Weekly Citizen, 3 October 1924.
57Leeds Weekly Citizen, 6 July 1928.
58Willis in Gorsky and Sheard (eds) 2006.
59Leeds Weekly Citizen, 28 June 1929.
60Leeds Weekly Citizen, 4 November 1934.
61Doyle 2002, ch. 2.
62Doyle 2007: ‘Report of Conference between the Middlesbrough Voluntary Hospitals Joint Consultative Committee and the Sanitary Committee, to which the whole of the members of the Middlesbrough Corporation were invited. Held on Thursday 18th December 1930’. Teesside Archives (hereafter TA) H/NOR 1/14; ‘Relations between Voluntary and Municipal Hospitals’ Special Reports of Medical Officer of Health, 1933–45,TA CB/M/H 14, 1933.
63NEDG, 15 September 1936; TA H/NOR 1/15, ‘Report of conference held between the representatives of the North Ormesby Hospital, North Riding Infirmary and the Hospitals Committee of the Middlesbrough Town Council’, 19 November 1936; TA CB/M/C2/233, Hospitals Committee, 14 June 1938; TA H/NOR 1/16, Middlesbrough Hospitals Advisory Joint Committee (hereafter HAJC), 26 July 1938.
65Middlesbrough Council Hospital Committee, 19 September 1934; 16 January 1935, TA CB/M/H 13.
67Sheffield Labour Party 1932, p. 18.
69Parsons et al. 1945, p. 19.
70BHCSA 1935, p. 46.
71Minutes, Meeting Leeds City Council, 30 July 1930.
72Leeds Mercury, 3 November 1930, p. 5.
73Leeds Mercury, 5 February 1931, p. 5.
75Leeds Weekly Citizen, 21 October 1938, p. 9.
76‘Members of the Health Committee Meeting with Representatives of the Voluntary Hospitals to Discuss Co-ordination of Hospital Services, 19 October 1936’, Typescript of Minutes, Leeds Central Library.
77Eason et al. 1945, p. 33.
78LGI Annual Report 1928, p. 21.
79Leeds Weekly Citizen, 3 July 1931.
80For South Wales, for example, see Thompson in Borsay (ed.) 2003.
Sheffield City Archives, Sheffield, UK