The Politics of Hospital Provision in Early Twentieth-Century Britain by Barry M. Doyle (review)

Barry Doyle has been a keen participant in the debate on interwar health services in England (not Britain) that has now been running for more than thirty years. Fellow historians, notably Steven Cherry, Alysa Levene, Martin Gorsky, John Mohan, John Pickstone, Martin Powell, and John Stewart, have continued to exploit Charles Webster’s lodestone thesis: that a lack of local planning and integration of services (private and state-funded) led to a chaotic and highly inefficient situation that in part explains the creation of the National Health Service (NHS) in 1948.¹ Research strategies have varied, focusing on either municipal or voluntary hospitals, studies of individual towns, or analyses of geographical variations. Doyle suggests there is room for another study, this time comparative, of two cities (Leeds and Sheffield), to show that the size and format of interwar hospital services were a product of local social, economic, and political structures. This is a variation on Pickstone’s study of Manchester and its region² (which also covers a longer time period): it is quite a challenge to say something new.

After a brief historiographical justification, the book charts the economic, social, and political histories of the two cities. Sheffield was characterized by heavy industry that favored a male, unionized workforce; although there was a strong Labour presence, the city council supported the expansion of voluntary hospitals and contributory funding schemes. Leeds had a more complex and diverse economy that employed large numbers of women; the city council, usually Conservative controlled, was keen to develop municipal hospitals and maternity services. Although the balance among voluntary, Poor Law, and municipal hospital services in each city changed during the interwar period, Doyle’s structural analysis suggests that it was impossible for them to move far from these initial determinants.

The strongest parts of Doyle’s study focus on the development of specialist services (maternity, cancer, casualty, orthopedics), the balance between competition and cooperation, the role of university medical faculties, and the impact on women’s and children’s health. There is some excellent material here that demonstrates the managerial responsiveness to new challenges in both the municipal and voluntary sectors, and especially the importance of individuals and networks in shaping services, which Doyle finds is deeper-seated and less formal than Webster suggested. The pictures that emerge in both cities are predictable: only cooperate where there will be a benefit; try to pass on undesirable patients (chronic sick, elderly) to other hospitals; protect your assets (from out-of-town or nonpaying patients). There are some weaknesses: the chapter on finance fails to build on the now extensive analysis of voluntary and municipal hospital income and expenditure patterns, and the statistics for Leeds and Sheffield are not put into comparative formats (per thousand population, or per hundred hospital beds would have been helpful). The politics chapter would also have benefitted from some wider contextualization on the political economy of interwar Britain.

Do these interactions among municipal, Poor Law, and voluntary hospitals constitute evidence of viable pre-NHS “systems” as Doyle suggests? Throughout the book there are occasional glimpses of a bigger issue—“space”—in the sense that health services are usually planned for a defined geographical area. The absence of maps is perhaps indicative of Doyle’s attitude to this factor, although he does briefly outline increasing demand for “regional” services. While Leeds is at the center of the old county district of West Riding in Yorkshire (but next to Bradford, an equally large city), Sheffield is located on the perimeter, but serves as “the big town” for its Derbyshire neighbors. It is difficult to analyze the development and viability of city hospital “systems” in isolation from their regions. This analysis of Leeds and Sheffield (not Britain as the title misleadingly suggests) has highlighted the diversity, trajectories, and different speeds...