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Response to Review of The Politics of Hospital Provision in Early Twentieth-Century Britain

First I would like to thank Martin for a very thorough and considered review of my book which engages with the ideas and content in a vigorous and fair way. I am also pleased to see the way he has adopted the spirit of Reviews in History to place works in their wider context and open up potential debate. The review raises three general issues which are worthy of consideration: the limits of a single volume; methodological approaches; and context, especially international context.

In putting the book together I obviously had to make a number of decisions about what to put in and what to leave out. Indeed when I finished the book I wrote a blog about the decisions I had to make, such as my decision to exclude other case studies. Certainly a holistic approach that incorporated mental health provision and primary care would make an even stronger contribution – though I suspect the fact that I am not aware of a study which has achieved this suggests it is a very tall order. Maybe an avenue for future research. In the mean time I hope the work of Huddersfield doctoral student Alice Brumby on mental health provision in early 20th-century West Yorkshire will fill some of the gaps as might my recent paper on non-acute care in municipal hospitals given to Sean Lucey’s workshop in Belfast.

The core of Martin’s critique of my book is methodological. My interest is, and always has been, in how urban systems operate – how and why power and decision-making are distributed in the city – the core unit of British public policy until 1948. Such an approach may not produce easily testable models but it provides the building blocks for a nuanced understanding of similarity and difference across a small but complex nation. What drove me to write this book was a desire to understand the impact of specific local factors – economic, social and political – shaping hospital provision in these cities. Such an approach has been very effectively developed by a generation of British urban historians (among whom I would count Martin Gorsky) who have used the local to test existing ideas, challenge orthodoxy and develop new themes. In this case, I aim to show that services were (much as they are today) shaped by local needs: by economic structures; gender; party politics; and associational cultures. By viewing local differences in this light, rather than as a deviation from a norm, we can understand more effectively how and why services developed in Britain and across the world in this period.

Thus it looks like the division between optimists and pessimists is one of method – as John Pickstone noted back in the 1980s – though ultimately it may be one which is damaging to our understanding of hospital provision in the first half of the 20th century. By looking at everything through the prism of the NHS we are failing to see health care systems in their contemporary contexts. In particular, by always measuring them against the gold standard of some imagined NHS we overlook how far provision had travelled in the 20 years after 1918 and how much potential it had to continue to grow.

This takes us to the third key issue raised in the review, context, and in particular international context. I agree entirely with Martin that we need to place developments in England in an international context, as he is doing with the UK and the US and I am doing with England and France.(1a) What my comparison has highlighted is how unusual the NHS was as a response to what were, essentially, a very similar set of problems. Indeed, despite its rather messy administrative structure, the English hospital system was probably the biggest, most highly developed and open of any system in the world in 1938. Yet the government abandoned most of the financial and administrative structures that had underpinned impressive interwar growth in both capacity and turnover. This was not the case in France where pre-war developments were built on, as politicians and policy makers found nothing wrong with a system which was neither universal nor free at the point of delivery. Similar models were adopted in the Netherlands and West Germany where contributory schemes, not taxation, formed the core funding method. I suspect that international comparison will not help us explain the turn to universal, tax funded, free at the point of delivery health services in Britain – it will just make it look more anomalous. Moreover, I would encourage more comparison within the UK as is being done by Virginia Crossman and Sean Lucey (2a) to highlight how the different nations operated in diverse political and religious contexts as well as a variety of geographical, linguistic and cultural environments.

Much as I would like to think this is the last word on inter-war hospital systems, I really don’t think it is. As Martin notes there is scope for a wide range of further case studies, especially looking at the south of England (suburbs and seaside), Scotland and even reviewing the situation in London but also for a work which does attempt to resolve the methodological clash between macro and micro approaches. I also agree that a focus on the 1940s is long overdue – but this should be for its own sake and not geared towards understanding the establishment of the NHS.

Thanks again to Martin for the robust and stimulating review. I suspect we will continue the debate in the years to come.


  1. See my forthcoming article: ‘Healthcare before welfare states: hospitals in early twentieth century England and France’, Canadian Bulletin of Medical History (Forthcoming, 2015); M. Gorsky, ‘Hospitals, finance and health system reform in Britain and the United States, c.1910–1950: historical revisionism and cross-national comparison’, Journal of Health Politics, Policy and Law, 37 (2012), 365–404.Back to (1a)
  2. Healthcare in Ireland and Britain 1850–1970: voluntary, regional and comparative perspectives, ed. Virginia Crossman and Sean Lucey (London, 2015).Back to (2a)