On the eve of the NHS, the British healthcare system was possibly the best in the world. In terms of the proportion of the public who received free treatment, the location of modern hospitals and the effectiveness of new treatments, Britain was well ahead of most other countries.
Before 1900, healthcare was mainly provided by charities, poor law (local welfare committees that operated the workhouses) and an unregulated private sector. However, building on 19th-century developments of mental health and fever hospitals, between 1900 to 1948 it moved to a highly effective mixed economy of mutual payment schemes, local authority services and not-for-profit providers, with little place for commercial medicine.
In 1900 few working-class people paid for their own medical treatments, with charity and the poor law the main routes to treatment for the poorest. Others, including many in the emerging lower middle class, struggled to afford treatment, relying on hospital casualty departments, kind doctors or folk remedies. But the National Insurance Act of 1911 changed that. It provided access to general practitioners (GPs) for manual labourers and lower paid non-manual workers earning under a certain income, together with tuberculosis care. Changes to that income limit meant that by 1936 half the adult population was included, and by 1938 19,060 doctors were included in the National Insurance “panel”.
But this system had significant weaknesses. Fees for GPs were increasing for the middle class and wealthy who were outside the system, leading Thomas Horder, an eminent physician, to complain that his private patients were coming to him armed with the results of diagnostic tests carried out elsewhere to save them money. Wives and children of National Insurance members were excluded, as was hospital treatment, meaning many had to pay further fees, or rely on older workers’ friendly society insurance schemes, free clinics for mothers and children, and visiting pharmacists for advice.
Yet some GPs created new types of practices, such as the Pioneer Health Centre, which opened its doors in Peckham, south-east London, in 1926. Funded by weekly subscriptions, it was established with the belief that health and medicine should not be divided between medical services and the promotion of a more general healthy lifestyle. In addition to doctors surgeries, it housed a swimming pool, dance floor, nursery and cafeteria.
Big changes also occurred in hospital services. In 1900, acute and general treatment was provided by voluntary hospitals paid for by upper and middle-class philanthropists and staffed by doctors who treated patients for free. Infectious diseases, such as typhoid and diphtheria, were the responsibility of local councils, while the chronic and infirm had to rely on the workhouse. There was a small group of nursing homes where doctors treated their private patients for a fee. The donors and the ratepayers largely decided who could receive treatment and where, often on social rather than medical grounds.
The hospital habit
But this changed after World War I as the population “acquired the hospital habit”. Although hospital treatment was not covered by National Insurance, access was made possible by working-class contributory schemes that collected around three pence a week from workers to secure members free hospital treatment.
By 1939 about 20m people were covered by these schemes, the biggest being found in London, Liverpool and Sheffield. They ensured that most people would gain admittance to a bed on medical need alone. They were also an important focus for community activity, with members holding social events and engaging in an annual Easter collection of eggs. The one in Yorkshire delivered around half a million eggs a year to the county’s hospitals.
At the same time state hospitals were changing. In 1929 the poor law was abolished and a growing number of workhouse infirmaries became general hospitals. In Leeds the huge infirmary became St James’s Hospital and developed extensive medical specialities, including plastic surgery. But they also remained the places of last resort for the chronic and infirm, leading politicians in Sheffield to attack selfish young couples for causing “bed-blocking” by refusing to look after their aged parents at home.
The main beneficiaries of hospital expansion between the wars were women and children. Most infectious disease patients were children, and as the threat of typhus and smallpox declined these hospitals switched to general child medicine. Maternity wards were the fastest growing specialist service, with the public hospitals converting old poor-law blocks for the needs of expectant mothers. Voluntary hospitals like the Jessop in Sheffield expanded their services, introducing scientific laboratories to help tackle rising maternal deaths.
Voluntary first aid networks
The work of doctors and hospitals was underpinned by a vast reservoir of active first aiders. Building on the work of the British Red Cross and Order of St John Voluntary Aid Detachments of the Great War, the interwar period saw the growth of a voluntary first aid network, providing a range of first response services. They were responsible for most of England’s ambulance services, and established roadside first aid posts, blood donation services and training for young people.
At big events like the British Empire Exhibition at Wembley in the summer of 1925, the two organisations collaborated, caring for over 16,000 people suffering from accidents or illness. In addition to this medical work, by 1939 they had trained over 100,000 people to deal with gas attacks expected in the event of a war.
By 1948 well over half the population could access GP and hospital services free at the point of use. Certainly big gaps remained, some filled by voluntary bodies such as the British Red Cross.
Women and children had limited access to GP surgeries but growing hospital services provided for them. The middle class were largely excluded and had to rely on increasingly expensive private doctors and their sub-standard nursing homes.
This exclusion, particularly from hospital treatment, probably explains why there was less opposition to the NHS than might have been expected, despite its radical restructuring of a broadly successful healthcare system. The middle class had little to lose and much to gain from a reform that reduced their direct costs and improved their access to the best facilities.
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