From Segregation to Integration in the English Hospital System: 1914-45

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Author: Professor Barry Doyle (University of Huddersfield)

 

In the years before the creation of the National Health Service (NHS) the hospitals of England were divided between two providers – acute and specialist voluntary institutions treating a range of mostly curable conditions and a much larger number of municipally controlled establishments providing isolation for infectious diseases or with roots in the nineteenth century poor law. On the eve of the Great War these providers drew their patients from distinct socio-economic groupings with patients segregated between paupers and the respectable sick poor, men and women, adults and children, the acute and the chronic, the dangerous and the safe, the old and the young, the curable and the incurable.

Architect’s Impression of the Completed King Edward VII Extension, Leeds, 1917 (Edward VII Memorial Appeal leaflet, West Yorkshire Archives, Leeds 2295/299)

Architect’s Impression of the Completed King Edward VII Extension, Leeds, 1917
(Edward VII Memorial Appeal leaflet, West Yorkshire Archives, Leeds 2295/299)

Further distinctions emerged with the finance and management of institutions and from the way the medical staff were appointed. Voluntary hospitals drew their income from subscriptions, gifts, donations and legacies from local elites supplemented by some democratic community and workplace fundraising. Their management reflected this – small boards dominated by the subscriber elite – while their patients often secured admission through an element of patronage. The medical staff, in keeping with this charitable profile, gave their services for free acquiring status and private patients from their honorary positions.

Public hospitals were left to deal with the social groups and conditions excluded by the gatekeeping practices of the voluntary establishments. Local authorities were obliged to protect their communities from the infectious and the mentally ill. The sick wards and infirmaries of the workhouse took care of the rest. The fact that these services were paid for by local taxation limited their development as did the belief that the conditions and people dealt with were socially, physically or morally suspect or dangerous. Moreover, management roles carried less status and power while the salaried nature of the small number of medical staff meant they were viewed with suspicion. As a result the two systems rarely cooperated, both sides resisting efforts to integrate in the interests of either efficiency or the patients.

New Operating Theatre, St James’ Hospital, 1940 (Brochure for the Opening of the Extensions at St James’ Hospital, Leeds, West Yorkshire Archives 2295/390)

New Operating Theatre, St James’ Hospital, 1940
(Brochure for the Opening of the Extensions at St James’ Hospital, Leeds, West Yorkshire Archives 2295/390)

Yet over the following thirty years the segregation by class, age, gender and condition associated with the pre-war system began to break down in the face of a democratization of the funding base, changing political conditions, increasing pressure on beds and the transfer of power from traditional elites to the medical staff. A major financial crisis immediately after the First World War led many voluntary hospitals to either set charges or attempt to secure a contribution from patients. In some parts of the country, especially heavy industrial areas (but also London) pre-payment mutual schemes were established ensuring free treatment for members when admitted. This move coincided with the collapse of the subscriber recommendation system of admission and its replacement by medical criteria with access to a bed mainly decided on medical need rather than elite patronage.

‘How the Penny in the £ Fund is Spent’ (Sheffield Hospitals’ Council, Third Annual Report, 1924)

‘How the Penny in the £ Fund is Spent’
(Sheffield Hospitals’ Council, Third Annual Report, 1924)

The democratization of funding and the ascendancy of medical criteria for admission put huge pressure on the resources of the voluntary hospitals leading to over-crowded wards and ever lengthening waiting lists especially for minor or mundane conditions. Yet at the same time most workhouse medical provision was under-utilized. At the end of the 1920s, the government abolished boards of guardians and transferred their responsibilities to councils. As a result some local authorities developed their poor law infirmaries as general hospitals admitting non-pauper patients at a small charge. Many urban poor law infirmaries were re-branded as municipal general hospitals and began to expand their services to include extensive maternity provision, the appointment of consultants, the undertaking of minor surgical procedures and the development of some specialties. This move has sometimes been seen as a competitive challenge to the voluntary hospitals if not an outright act of aggression. Yet in most cases this was not the case and indeed the emergence of the municipal general hospital permitted the incorporation of an increasing number of patients into an integrated local hospital system which distributed cases by medical need rather than perceived financial or social status.

 

Although historians have questioned the extent to which collaboration followed the abolition of the poor law, in the case of Leeds and Sheffield there is evidence of joint working driven by local contributory schemes, patient demand, political will and medical professionals. In both cities, around 5,000 patients were being treated in municipal hospitals at the expense of the mutual schemes by the end of the 1930s. Despite initial concerns that members would not want to be admitted to the supposedly inferior municipal general, the sick showed little discrimination, preferring treatment – often by the same doctors – to waiting for a voluntary hospital bed. This seems to have been the case particularly amongst women, seeking treatment for minor ailments or wanting to have their babies in hospital.

 

But integration was also being promoted by the doctors. In Leeds consultants were being appointed to the poor law infirmary before it was taken over by the council while from the mid-1920s the medical superintendent was increasing the number of operations undertaken. More significantly, the superintendent was working closely with the admissions ward of the Leeds General Infirmary to sort and allocate patients and from 1936 this became policy across the city. Similar arrangements were made for maternity cases after 1936 – with the voluntary hospital taking first time mothers and complicated cases while the municipal hospitals admitted ‘ordinary’ births. In Sheffield arrangements in 1930 saw a specific number of cases transferred to the municipal hospitals at the expense of the council while it was agreed that additional maternity beds and a casualty unit would be built by the local authority and the city divided into three zones for the allocation of accidents and emergencies. Integration was most widely canvassed in the case of those conditions requiring acute surgical or specialist therapies and long term care, especially cancer treatment by radium which was moving towards collaboration by 1945.

An artist’s impression of the Graves Radium Institute, Sheffield, c.1945  T.W. Barnard, Memoir on the Origin and Progress of the Trust, (pp Sheffield 1964)

An artist’s impression of the Graves Radium Institute, Sheffield, c.1945
T.W. Barnard, Memoir on the Origin and Progress of the Trust, (pp Sheffield 1964)

Thus, even before the NHS came into being in 1948 it is apparent that, in urban areas at least, much of the segregation which had characterised the pre-Great War hospital system had given way to a more integrated approach. Relatively few patients found their way into particular institutions because of who they were and the majority were admitted first and foremost on medical grounds, usually meeting their obligation to contribute directly or indirectly to their care.

For more on changing hospital provision in Leeds and Sheffield see Barry Doyle, The Politics of Hospital Provision in Early Twentieth Century Britain, is available from Pickering and Chatto.

Integration, Segregation and the Early Modern Plague Hospital

This is the first of a ‘mini-series’ of papers on integration and segregation, leading up to the next INHH Conference on the same theme in Dubrovnik April 2015.  It is intended that these short papers will help to stimulate debate and discussion before the conference, and to spark a wider interest in hospital history. If you would like to submit your own mini-paper to be published on this site, please get in contact!

 

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Dr Jane Stevens Crawshaw (Oxford Brookes): ‘Integration, Segregation and the Early Modern Plague Hospital’.

 

Of all of the things patients might have expected to receive within an early modern plague hospital, news probably did not come high up the list.  Few institutions have been more strongly associated with segregation; many early modern writers (and modern historians) stress the social breakdown that ensued during plague epidemics in early modern Europe and have characterised plague hospitals as sites within which infection spread quickly and the sick were abandoned to their fate.

Plague Hospital

This account of the death of Doge Nicolò da Ponte in 1585 and subsequent election of Pasquale Cicogna was written on the wall of the large warehouse (the tezon grande) on the island of the lazaretto nuovo.  When the warehouse was built in 1561 it was one of the largest buildings in Venice and its purpose was to accommodate vast quantities of merchandise on the island which housed one of Venice’s two plague hospitals.

The graffiti reminds the historians of the significance of channels of commerce and communication in relation to the history of the plague hospitals.  These hospitals played a vital role in the Republic’s networks of maritime trade, public health and charitable care.  Surviving sources illustrate that Venetian Health Officers attempted to balance both integration and segregation in their administration of these hospitals in order to bring about an improvement in health across a number of different spheres, principally both medical and economic.   As a result, links between patients and their communities were not severed.  Although underplayed in literary sources, this element of the hospitals’ history is visible in archival sources as well as surviving building structures.  This example of early modern graffiti, therefore, has much to say to historians today.

St Thomas’ Hospital, London

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Credit: Dazeley.

St Thomas’s is one of London’s great medieval hospitals, and evolved out of the hospital of the Priory of St Mary Overie, now Southwark Cathedral. In 1215 a new hospital was established as separate from St Mary with the Prior and canons of  St Mary, and it continued to be a religious foundation until the reign of Henry VIII when it was closed in 1540 during the dissolution of the monasteries. It was reopened in the reign of Edward VI  in 1552 on the same site in Southwark and remains a working London hospital today, though it moved from it’s original Southwark site to Lambeth in the 1860s.

In the very late 17th century, during a period of growth and renovation, St Thomas’s Hospital’s governors made the decision to demolish the old church of St Thomas, due to it being in a poor state and suffering some subsidence, and to build a new church on the same site. The Old Operating Theatre Museum is situated in the roof spaces of that new church, which was built between 1700 and 1703. Extensive references to the monthly process of the rebuild, including details of the fate of the materials from the old church, the fittings for the new interior and the debates about the timber to be used in the roof, can be found in the minutes of the court of Governors and shorter summaries of the process in Benjamin Golding’s Historical Account of St Thomas’s Hospital (1819). The build was directed by master mason and governor Thomas Cartwright.

Counter Credit Dazeley

Credit: Dazeley.

The church was a parish church, with a very small local parish, but it was also part of the complex of the hospital,  and it seems probable that from the time of it’s completion in around 1703, the apothecary of the hospital used the dark dry roof spaces where the museum is now found as a storage garret for the herbs used to make the medicines of the hospital. When the spaces were rediscovered in the late fifties, poppy heads were discovered scattered on the floor. Preserved with varnish in the 50s, some of these are still on display in the museum today.

Table Credit Dazeley

Credit: Dazeley.

In the early 1820s, half of the roof space over the church was converted into a new operating theatre for the use of the surgeons and their medical students. In the previous arrangement, operations on female patients had been taking part in a space at the end of the adjoining ward block. This situation was not suitable for the other patients, nor was it adequate to contain the growing audience made up of the medical pupils of the United Borough Hospital schools of Guy’s and St Thomas’s. The space created in the roof of the church provided the room to accommodate the audience and to perform the operations in, and the light the surgeons needed, from the large skylight in the roof.

Capital surgery was carried out in theatre for roughly 40 years, between 1821 and 1862. The space witnessed the advent of anaesthesia in the 1840s but not the development of antiseptic surgery.

St Thomas’s Hospital left it’s ancient home in Southwark in 1862 and began the move to it’s current home on the banks of the Thames in Lambeth. The theatre lay undisturbed for around 100 years before it was rediscovered in the late 1950s by the distinguished heart surgeon Lord Brock, and a period of restoration was undertaken. The museum, with a basic collection and it’s first simple displays, opened to visitors in 1962.

Today, the Old Operating Theatre Museum and Herb Garret, accessed from a spiral staircase in the bell tower of St Thomas’s Church, has 40,000 visitors a year. Today, the growing displays feature a large selection of surgical instruments, herbs, pill making equipment and pharmaceutical glass and pathology specimens and the museum has a lively events and education programme. The museum is devoted to telling the story of St Thomas’s Hospital, the church and the medical use of the roof spaces, and the development of materia medica and pharmacy, anatomy and surgery, and medical education over the 160 year period in which the spaces were in use by St Thomas’s.

Julie Mathias, The Old Operating Theatre Museum and Herb Garret, London