In industrial areas the doctor’s surgery would often be housed in a shop where the window would be painted halfway up to ensure some degree of privacy. Patients would queue outside (even when it was raining) until it was their turn to see the doctor. Doctors were not salaried (nor were hospital consultants), so they relied on fees and/or insurance payments, the latter of which were invariably lower, so in general poorer areas, where there were few if any fee-paying patients, were served by either less able or more altruistic doctors. In more prosperous middle-class areas, doctors would usually see their patients in the front room of their own homes. The fee-paying patient would have an appointment and be shown in at the front door by the doctor’s wife (or maybe a maid, if finances and status permitted), whereas panel patients would enter by the surgery door, and sit and wait until the doctor was ready to see them. The surgery would smell of phenol, since most GPs were expected to perform operations such as removing appendixes and tonsils, hysterectomies, hernia repairs and suchlike, although increasingly these took place in the local cottage hospitals found in suburbs, smaller towns and rural areas, which by 1935 provided around 10,000 beds. Or patients might request a home visit (more readily agreed to for private patients), when all the technology available would be the instruments the doctor could carry in his (or very occasionally her) Gladstone bag.
Eileen Whiteing remembered that if influenza or tonsillitis were suspected in her comfortable Surrey home, ‘Dr Cressy would be sent for and he usually prescribed the dreaded “slops” which meant that we were only to be given such things as steamed fish, poached eggs, beef tea, milk puddings and so on, until he called again in a day or so.’ Doctors’ fees varied depending on the area and sometimes on the patient’s ability to pay. A doctor attending poorer families would usually require to be paid cash at the time of a consultation or visit (as earlier ‘sixpenny doctors’ had) rather than sending in a bill. If an operation were needed, the surgeon’s and anaesthetist’s fees would have to be found, plus nursing home fees.
Having a baby for a middle-class woman often meant a private nursing home, whereas for most working-class women it would be a home confinement, possibly but by no means necessarily with the help of a midwife who delivered babies as the sort of community service that ‘wise women’ had provided for other women down the ages, often at low cost and sometimes with inadequate standards of medical knowledge or hygiene, as a ‘Report on Maternal Mortality in Wales’ showed. It was not until 1936 that the Midwives Act obliged local authorities to provide trained midwives, and it was not until 1946 that the number of hospital births exceeded those at home.
So the uninsured, the unemployed who had exhausted their sickness benefit entitlement and whose names were removed from doctors’ lists as ‘ceased to be insured” (although doctors were no longer paid to treat such people, ‘If they were well known to us, we felt morally under an obligation to attend to their wants when asked to’), the dependents of those covered by the NHI and the poor and old, would have to spatchcock together medical care as they did other social services. In the first instance they were likely go to the local chemist for a bottle of patent medicine (almost £30 million a year was spent on patent medicines during the 1930s, and it was not until the 1939 Cancer Act that the advertising of cancer ‘cures’ bought over the counter was banned), and only if that was ineffective would they seek medical advice. They might be able consult a doctor who participated in the Public Medical Services, or be treated by those employed by enlightened local authorities such as Glasgow, Oxford or Mansfield in Nottinghamshire. Most local authorities, though, provided only those services they were statutorily obliged to, mainly concerned with infant and maternity care, or mental and infectious diseases. People might join a doctor’s ‘club’ and pay a small amount each week, or go to the outpatients’ department of a public hospital.
Married women were particularly disadvantaged if they could not afford to pay for their medical care. They were not covered by the NHI scheme, and were considered a poor risk by insurance companies since the mass of burdensome ‘dull diseases’ contingent on their biology would be likely to prove expensive — a burden the Chief Medical Officer of Health, Sir George Newman, admitted privately he was reluctant to enquire into too deeply, since it was ‘a wandering fire to which there are no bounds’ that would create demands way beyond the resources of the Ministry of Health. There were few women general practitioners, since most preferred to work directly with women and children in clinics, and many women were reluctant to take their troubles to a male doctor, so they struggled on with varicose veins, anaemia, prolapsed wombs, phlebitis, haemorrhoids, rheumatism, arthritis, chronic backache, undernourishment and exhaustion without ever seeking medical advice. Death in childbirth remained at much the same level –4.1 per thousand — in 1935 as it had been in 1900, and in the depressed areas of South Wales and Scotland it was 6 per thousand. Better antenatal care as well as improved living conditions might have helped, but the primary cause of death in childbirth was medical, and it was not until the mid-1930s that puerperal fever, which presented the gravest danger, became treatable with sulphonamide drugs.
Hospitalisation was not covered by health insurance, and the choice was between voluntary hospitals, which had originally been endowed by the rich for the care of the poor, and which included some of the most famous London teaching hospitals, and local authority hospitals, many of which had been former Poor Law institutions. The voluntary hospitals were permanently strapped for cash by the 1930s, and were dependent on bequests, fund-raising events such as concerts and fêtes, flag days and patients’ fees. Those on low incomes might have been paying a few pence a week which would give them the right to treatment should they need it (or if they were lucky their employer might have made a block provision for employees in this way), or they might be charged whatever the hospital almoner assessed they could afford. But the days of such hospitals were numbered: it was clear that voluntary contributions were no longer sufficient to keep them going, despite the fact that private patients’ fees, mostly paid through insurance schemes, covered almost half such hospitals’ costs), and by the end of the decade more hospital accommodation was provided by local authorities than by the voluntary sector.
The financial difficulties of the voluntary hospitals and the fact that they were not planned on a national scale according to the needs of the community, gave an opportunity to a group of medical practitioners who had a larger vision for health. The Socialist Medical Association (SMA) had been founded in 1930 with the support of, among others, the first Minister of Health, Christopher Addison, the journalist and propagandist for science Ritchie Calder and medical scientists and practitioners such as Somerville Hastings, a surgeon at the Middlesex Hospital in London and a Labour MP, Charles Brook, a London GP, David Stark Murray, a Scottish pathologist, and Richard Doll, who in the 1950s would prove the link between smoking and lung cancer. The SMA looked to the creation of a socialised medical system which would both streamline the chaotic health provision of the 1930s and ultimately make health care ‘free to all rich and poor’. Furthermore, it wanted to end what it regarded as the ‘lonely isolation’ of the GP by creating salaried posts and locating them in a series of health centres based on municipal hospitals that integrated all aspects of medical care — owing something to the Peckham, Finsbury and Bermondsey models.
Although this blueprint for socialised medicine appears to prefigure the creation of the NHS in 1948, it was at local level — particularly in London — that the SMA came nearest to implementing its ideas in the 1930s. ‘Municipal socialism’ increasingly seemed to be a plausible strategy for undermining the National Government, and during the 1934 London County Council (LCC) elections the SMA produced a health manifesto claiming that the capital’s ill health was due to poverty, bad sanitation and inadequate medical care and treatment (due to lack of resources), for which ‘the anarchy of capitalism’, reflected in uncoordinated health care provision, was to blame. Seeing health as ‘every bit as important as education’, SMA members were appointed to a range of LCC committees when Labour won control, and