Journal of Historical Geography, 18, 3 (1992) 307-316

The geography of English hospital provision in the 1930s: the historical geography of heterodoxy

Martin Powell

This paper examines the geography of English hospital provision in the decade prior to the introduction of the National Health Service (NHS). Orthodox opinion with respect to both geographical equality and equity of provision is critically examined. These claims are then analysed using empirical data from a national survey of hospital provision in 1938. It is found that while provision of voluntary hospitals was geographically inequitable, this was compensated for to some extent by more equitable provision by municipal hospitals. Two main conclusions follow. First, it appears that the degree of geographical equality and equity of provision was not as bad as orthodoxy would have us believe. Second, the reason for this heterodoxical view seems to be that previous writers have ignored the political geography of the 1930s and the consequent differential effort of local authorities to provide for their populations.

It has recently been argued that the geographical dimension of the historical development of welfare services has been neglected. For example, the abstract of a recent conference has claimed that historical analyses of welfare systems have tended to neglect the significance of local initiatives in creating modern welfare systems and that the place-specific nature of welfare before 1945 needs to be emphasized. [‘I Similarly, Leet*l considers it necessary to “establish a case for a geography as well as for a history of the making of the welfare state”. In a way this concern is misplaced for it is clear that few, if any, writers believe that a “top-down” perspective of central government policy directives131 has much value in the study of welfare provision. Many writers from a range of discipline recognise that social conditions and the provision of welfare services were not, and are not, geographically uniform throughout the country. For example, geographical inequality of both health care provision and health status is addressed in a number of standard texts of social administration/health policy,[41 as well as in geographical texts. ~1 Moreover, it is recognized that, to some extent, current geographical inequalities are a reflection of the historical pattern of provisio@] and the standard history of welfare texts note the importance of local variations in provision.t71 In fact, as Leet81 argues, the inter-war years, in many ways, represented the zenith of municipal welfare in Britain with a large degree of local autonomy leading to a wide variation in provision between local authorities. Indeed, one of the main reasons for a National Health Service (NHS) was the recognition of a large degree of geographical inequality in

03057488/92/030307 + 10 $03.00/O 307 0 1992 Academic Press Limited

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provision.t91 Thus, the “case for geography” has been established for many years. However, an emphasis on the geography of welfare is valid if it directs attention to the problematic nature of many contributions to the topic. At the risk of oversimplication, it may be claimed that the historical geography of welfare literature may be divided into a series of case studies of particular regions, localities and individual institutionstlOl on the one hand and brief and oversimpli- fied assertions without evidence at the national level on the other hand. Although the case for geography is accepted in such studies, empirical data illuminating that geography is often lacking. Where present, data is often problematic. For example, Eyles[“l presents a table showing the provision of hospital beds for “London” and the “provinces” which implies uniformity of provision both outside and within London. This dichotomy at such a crude spatial scale gives little useful information. On the other hand, Thanen21 shows that in Manchester a “panel doctor” might have more than a thousand patients, while in Gloucestershire less than seven hundred. Unfortunately, such scraps isolated from their broader context are almost meaningless. In order to place any significance on such data, it is necessary to know at the very least the national average, and ideally to have information on the other 140 or so local authorities in order to place such information in a national “league table”. In other words, there is the problem of how “typical” are isolated case studies. There has been little “middle range” work which attempts to link the national and the local studies and allow a contextualization for local case studies. As Preston n31 puts it, we need to know something about how each community fits into the national urban system. This paper is concerned not with examining individual case studies, but rather with a critical evaluation of the “assertions without evidence” and “assertions with poor evidence” with respect to the geographical distribution of hospital provision before the NHS. This is done by focusing on the general lack of evidence supporting the assertions and by drawing attention to the problematic nature of some arguments. Then, the assertions are compared with empirical evidence on the geographical distribu- tion of hospitals. This data is taken from a well respected, but under-utilized, source, the Ministry of Health/Nuffield Provincial Hospitals Trust Hospital Surveys published in 1945-46. li41 It is concluded that the orthodox views on the geographical distribution of hospitals before the NHS, namely the assertions of spatial inequality and inequity, may need to be revised, hence “the historical geography of heterodoxy”.

Orthodoxy examined: inequality and hospital provision

Many writers have claimed that the provision of hospital services before the NHS was geographically unequal. Webster writes that one of the primary features of hospital services before the NHS was uneveness of provision.t’51 Of course, all health care systems are unequally distributed in geographical space, and so more meaningful issues are the degree of inequality, which areas are disadvantaged and perhaps most important, the question of whether inequalities are also inequities.[i61

It is convenient to separate the assertions of unequal levels of geographical provision into three main themes. First, it is sometimes claimed that the south of the country was better served than the north. ~‘1 Two points may be made about such claims. First, neither writer provides evidence to back up these assertions.

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Second, even if valid, the claims would not be particularly meaningful. This is because regions are large spatial units and regional averages clearly hide a large degree of intra-regional variation.

The second specific theme within the general argument of uneveness is the assertion that rural areas were poorly served as compared with the urban areas.u81 Again, no evidence is produced to back up this assertion. It does, however, sound eminently plausible. Hospitals, like other public and commer- cial services, tend to be located in urban as opposed to rural areas. This is because towns are more likely to have a large enough population to support these facilities and because urban locations tend to be more accessible for many rural as well as urban dwellers. The issue, then, is more one of accessibility than location per se: it does not matter much if rural areas have less provision than urban areas if rural dwellers can travel easily to the town for the relevant service. The difficulty faced by remote rural areas is probably a more valid point: for example, a report by Hospital Almoners[lgl mentions cases of a journey of many hours for an appointment which lasted a few minutes. The final theme of uneveness concerns the availability of specialist medical staff. WhiteheadlzO1 claims that as a result of their honorary status at voluntary hospitals and the necessity to subsidize this side of their work from private practice, consultants tended to congregate in the prosperous districts in and around London and in the parts of the country where they could make a good living. Neither the densely populated, but poor, mining and industrial areas of the country nor the sparsely populated agricultural areas could provide a thriving living for con- sultants. Titmuss makes a point similar to that of Whitehead. On the basis of the Hospital Surveys, he claims that:

before the war some counties were without a single gynaecologist; the Eastern counties had no thoracic surgeons, dermatologists and paediatricians and only two hospitals with psychiatrists on their staff.t*‘l

However, according to Hollingsworth: many counties had no gynaecologists, thoracic surgeons, dermatologists, paediatricians or psychiatrists (Titmuss, 1940).[**1

This illustrates a number of points. First, the significant differences between the quotations show the dangers of writers examining secondary accounts without reference to the original. Second, Titmuss is careful to refer to the (rural) counties rather than the (urban) county boroughs and it can be shown that provision was generally less in the counties (see below). Third, Titmuss refers to what were generally accepted as the “more restricted” rather than the “fairly common” specialties such as general surgery, obstetrics and Ear, Nose and Throat (ENT). [23] In particular, thoracic surgery was often considered as a regional specialty. [241 Thus the above observation has similar value to a hypothetical modern obseriation that District General Hospitals do not have a regional speciality such as neuro-surgery.

Orthodoxy examined: inequity and hospital provision

Some writers have claimed that the pre-NHS distribution of hospitals was not only geographically uneven, but also inequitable. In other words, it is claimed that the areas with the greatest levels of need for health care and/or the poorest areas had the worst levels of hospital provision. Aneurin Bevan, with no

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apparent supporting evidence, claimed that the best hospital facilities were available where they were least needed. [*Y More recently, Webster has asserted, “health standards precisely mirrored diversities within the health services.“[26l In other words, the correlation between health status and health care was perfectly positive. Sometimes, claims of inequity are made for one of the two main sectors of hospital provision. The famous and often quoted phrase of Abel-Smith states:

the pattern of [voluntary] provision depended on the donations of the living and the legacies of the dead, rather than on any ascertained need for hospital services.Iz71

In other words, philanthropy led to greater provision in the richer areas. On the other hand, similar claims are made with respect to municipal provision. Chalmers claims that, “poor local authorities could not afford to provide the same services as wealthier ones”.l28l Similarly, Whitehead writes:

In the local authority sector, . . the amount of money available for developing services was dependent on local rates, and again the prosperous areas could and did provide much more extensive services than the bulk of the country .l29J

Finally, Webster argues: There was a great contrast between better developed services in more prosperous areas like Greater London, and conditions in smaller authorities or the depressed regions. The areas of greatest need were least able to sustain effective health and social services.[w

None of these assertions appear to be supported by any evidence. This is hardly surprising. We have seen above that there is a dearth of data on the geography of hospital provision before the NHS. However, evidence of spatial inequity requires information not only on provision, but also on need for health care and this is almost entirely lacking. The only case where need and provision data are juxtaposed is for tuberculosis. Bryderf3’l reproduces a Table showing that county councils and county boroughs with more tuberculosis deaths have fewer beds for every 100 TB deaths. Bryder concludes that:

the poorest areas, most in need of facilities for dealing with a disease generally acknowledged to be associated with poverty, could least afford them.‘”

However, the Table lists 12 areas (5 county boroughs and 7 county councils) with high tuberculosis death rates but low levels of provision and 12 areas (5 county boroughs and 7 county councils) with low tuberculosis death rates but high provision. However, no information is given on the other 121 major local government units. The reader is expected to infer that these areas are represent- ative of the total pattern, but it may be possible to select areas with high need and high provision and vice versa. In short, are the data representative or carefully selected to prove a point?

Orthodoxy questiod the evidence of the Hospital ‘Fmst ~Surveys

It is now proposed to examine the conventional wisdom in the light of empirical data taken from the Ministry of Health/Nuffield Provincial Hospital Trust Surveys. In order to collect data to aid planning for the proposed post-war health service, a national survey of all hospitals in England and Wales (excluding “mental hospitals” and “mental deficiency institutions”) was initiated by the Minister of Health in 1941. The country was divided into ten regions, each with its own team of surveyors. These surveyors included some of the leading doctors and administrators of the day. [331 The teams visited almost every hospital in

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England and Wales, and their work resulted in “the first [full] survey of British hospitals since 1863 . ” [341 Indeed, the summary volume is termed “the Domesday Book of the Hospital Services”.t35]

The ten regional surveys and the summary volume have been highly praised by many subsequent writers in the field. For example, according to Eckstein,f3’jl the hospital surveys “constitute perhaps the most remarkable factual and critical reports on medical facilities ever published in any country. Not a bed escaped the researchers’ attention. The surveys are an invaluable aid to research”. Webstert3q claims that the surveys gave the health departments their first precise insight into the state of the nation’s acute and chronic hospitals. A number of other writers have relied heavily on this sourcet3*] and as Godber[391 points out, the reports provided the basis for the early work of the regional hospital board appointed in 1947. Indeed, Rivett t401 claims that the London survey remained an essential tool for hospital planners until the publication of the Hospital Plan in 1962.

However, while the textual comments of the surveyors of this “invaluable aid to research” have received much attention, the quantitative data in the statistical appendices has largely been neglected. Information down to the individual hospital level on the number of beds by type (for example, acute, chronic), the number of staff and on activity (for example, the number of in-patients and operations) is presented for 1938. Provision data has been divided by population estimates for 1938 taken from the Registrar General’s Report to achieve per capita levels of provision. While the use of such estimated figures is not totally satisfactory, they are the best available for that year (bearing in mind that there was no Census in 1941). Thus, data on beds and staff has been rescued from the relative obscurity of the statistical appendices to evaluate the conventional wisdom of hospital provision before the NHS. The first point to examine is the assertion of a north-south divide.

It is the case that some northern regions were poorly supplied with hospital beds. For example, the North-Eastern region had 5.45 beds per thousand population and the Yorkshire region had 5.51. However, the North-Western region was second only to the London region with 6.70 beds per thousand, while the Berkshire, Buckinghamshire and Oxfordshire region had the lowest per capita provision of hospital beds in England with 5.36. Moreover, there were large intra-regional variations in provision. For example, in Yorkshire per capita bed provision varied from 11.11 in Halifax to 3.17 in the East Riding, while for the London region, the maximum-minimum range was found in the neighbouring authorities of West Ham with 13.55 and East Ham with 2.68. So, there was no north/south dichotomy at the regional level and at the local authority level there were many well provided areas in the north and poorly provided areas in the south.

The second theme of urban areas being better provided than rural areas appears to be perfectly valid, but unexceptionable. As today, hospitals tended to be located in the urban rather than rural areas. Data calculated from the Hospital Surveys show that the London County Council area had a total of 12.32 beds per thousand population, while the corresponding figures were 8.00 for the County Boroughs and 4.73 for the County Councils. However, as today, rural dwellers travelled to the town for hospital treatment. For example, Ipswich residents accounted for only some 48% of the inpatients at the town’s voluntary hospital in 1938, while the figures were 36% for Northampton and 22% for

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Chester. Movement across administrative boundaries into municipal hospitals was much more limited, but still not uncommon. For example, 805 residents of St. Helens were in-patients in Liverpool’s municipal hospitals, as were 1669 Lancashire residents. So, the fact that the county council areas tended to have less hospital provision within their boundaries did not necessarily mean that their residents did not have access to hospital provision.

The final theme of unevenness concerns the availability of specialist medical staff. It is generally claimed that affluent areas had the most staff. Two points may be made. First, while this may be valid in general terms (see below, p. 313) there were exceptions to this. For example some reasonably prosperous areas around London could boast few consultant staff in their hositals: for example, Buckinghamshire with 13 staff per million population compares badly with the worst provided area in the North-Eastern region, Gateshead, with 17. Second, the difference between provision within an area and access to a service should be mentioned again. To some extent, the above figures are irrelevant as the Hospital Surveyors argued that teams of consultants should be formed at the major centres. So, many Buckinghamshire residents travelled to London for hospital treatment where there were 324 staff per million, just as many Gateshead residents travelled to Newcastle with its 223 staff per million. Thus, instead of examining the number of consultants in all areas, it may be more meaningful to ask whether patients had access to towns with large hospitals and an adequate team of specialists. To answer Whitehead’s point, many of the “densely populated, but poor, mining and industrial areas” may have had access to specialist staff depending on their proximity to a major centre. For example, as the surveyors for the North-Western region pointed out, if an area was near Manchester or Liverpool, “it can get all the service that it needs from these towns without dificulty”.[421

The focus now changes from inequality to inequity which means examining the geographical relationship between need for and provision of hospital services. In order to examine this relationship, a range of needs data was assembled. The date of these indices was as near to 1938 as possible in order to match the provision data described above. The indices can be divided into those which act as a proxy for poverty which is often said to be positively correlated with need for health care and those which measure mortality rates. The unemployment rate and the number of persons per room were taken from the 193 1 Census. The crude death rate, adjusted death rate and infant mortality rate were taken from the 1938 Registrar General’s Report. The rateable value per head, a proxy measure for local wealth, was extracted from the Local Taxation Returns.l43] An “official” view of need, the need element of the block grant formula for distributing central resources to local authorities, was taken from a 1937 Report. Finally, an index of “social conditions” calculated for the county boroughs via principal components analysis was utilized.[441 This index includes such measures as unemployment, the receipt of domiciliary poor relief, over- crowding, social class IV and V and the product of a penny rate.

These needs indices are correlated with provision indices: bed provision per capita separated into type (for example, acute, chronic) and divided into sector (voluntary, municipal), and staffing per capita divided by sector. For all available local authority areas, 88 of the 184 correlations suggest that high need areas tended to have higher levels of provision. In other words, according to the crude measure of examining the direction only of correlation coefficients, the

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system appeared to be neither equitable nor inequitable. However, to some extent, these correlations may be spurious since they may show little more than that the urban County Boroughs tended to have both high levels of need and provision. In a sense, “like” is being compared with “unlike” and it was decided to examine the County Councils and County Boroughs separately. Table 1 shows the correlations between need and provision for the larger and more important system of provision, the County Boroughs.t4’l

Voluntary and municipal beds are each divided into the categories of acute, maternity and tuberculosis which add to the fourth category, total beds. When voluntary and municipal beds are summed to give total beds, two extra categories are introduced, namely chronic and infectious disease. These were overwhelmingly concentrated in the municipal sector. However, they are counted as “total” rather than “municipal” in this table to enable easier comparison between the correlations for voluntary and municipal beds. The staffing figures are composed of the categories of medical, nursing and qualified technical staff. Each category is then correlated with each of the eight needs indices: for example, 4 categories of voluntary beds multiplied by 8 needs indices equal 32 correlations for voluntary beds. The table then shows how many of these correlations suggest an equitable distribution of resources: one in which areas with high needs tend to have high provision. This is defined as a positive correlation between provision and the need indices (except for a negative correlation between provision and rateable value per head). The number of correlations suggesting equity are then examined to see if they reach statistical significance at 0.05 and 0.01, with the number of correlations suggesting inequity being subjected to a similar process.

TABLE 1 Degree of spatial equity for the County Boroughs 1938

Number suggesting equity Number suggesting inequity Number of Correlations Total SigS% Sigl% Total SigS% Sigl%

Voluntary beds 32 3 - - 29 24 17 Municipal beds 32 31 17 12 1 - - Total beds 48 26 1 - 22 - - Voluntary staff 24 1 - - 23 20 18 Municipal staff 24 22 9 2 2 Total staff 24 1 - - 23 9 5

It may be seen that voluntary beds were inequitably distributed, but municipal beds were equitably distributed. When the two sectors were added to give the total number of beds per capita, provision favours neither high nor low need areas, with only one correlation reaching statistical significance at 0.05. Sim- ilarly, voluntary staff were negatively and strongly correlated with need but municipal staff were positively and weakly correlated with need. Thus, while the provision of municipal beds was sufficient to compensate for the inequitable distribution of voluntary beds, the provision of municipal staff reduced but could not eradicate the inequitable distribution of voluntary staff. It appears,

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then, that only the claim of Abel-Smith, t46] that voluntary provision favoured the richer and less needy areas and the claims that there were more staff in the richer and less needy areas are supported by the evidence. At first sight, it seems counter-intuitive that the poor and needy areas appear to have more municipal provision than the more wealthy areas. t471 However, this may be explained in a number of ways. First, local authorities were not totally reliant on their rate revenue. Since 1929 they had received a mildly redistributive block grant.t48] Second, even if greater rateable capacity gave the richer local authorities the ability to spend, they did not necessarily translate this ability into actual expenditure. Ceteris paribus, the richer authorities could afford to spend more, but “other things” are rarely equal. The term “Poplarism” reminds us that the propensity to spend is not always in line with financial capacity. Hicks and Hicks[49] distinguish between the “spenders” and the “stinters”: towns which have a similar level of resources available to them but differ in their expenditure on public services. For example, Barnsley and Smethwick have similar re- sources; but Barnsley is termed a “spender” while Smethwick is termed a “stinter”. Thus, resources are clearly not the only influence on expenditure. Indeed “in the case of hospitals a propensity to spend seems to be a more potent influence than an excess of wealth in making for large expenditure”.t5’] This differential propensity to spend may be linked to a number of possible explanations: local politics, the influence of official such as the Medical Officer of Health, municipal pride and the perceived adequacy of the local voluntary hospitals. The “explanation” of local spending is at a fairly rudimentary level for more recent timest5’1 and even less advanced for periods such as the 1930s.tSZ1 However, one crude and tentative analysis using the categories of Hicks and Hicks finds that 13% of the “stinters” were controlled by the Labour party at some time during the 1930s compared to 71% of the “spenders”.t5’]

So, then, as today, local authorities with greater financial capacity were not necessarily those who translated this potential into actual spending. In particu- lar, it appears that previous writers have tended to ignore the importance of the political geography of the 1930s and the consequent differential effort of local authorities to provide for their populations.t54]

Conclusion The conventional wisdom of the geographical distribution of hospital provi-

sion before the NHS appears to be flawed. It is undermined by lack of supporting data and problematic arguments. This analysis has shown that the north was not uniformly more poorly p;ovided as compared with the south and that residents of poorly provided areas did not necessarily lack access to hospital beds and specialist medical staff. The assertion of the inequitable nature of voluntary provision is supported, but that of the inequitable nature of municipal provision does not appear to be valid. Indeed, the equitable distribution of municipal provision reduces the overall inequity of the distribution of staff and eradicates inequity for the distribution of hospital beds.

Of course, this exploratory analysis suffers from a number of problems. First, provision is measured in purely quantitative terms, and it may be the case that the needier areas had less well equipped hospitals and poorer quality staff. Second, the number of hospital beds, to some extent, reflects the constraints of past provision: in particular, much of the municipal sector’s stock was inherited

ENGLISH HOSPITAL PROVISION 315

from the Poor Law Guardians after the 1929 Local Government Act. However this does not invalidate the above argument on influences on spending. It merely transfers it to apply to the previous agency of provision, the Guardians as hospital provision under the Poor Law varied greatly in quantity and quality.[5s] It may be the case that areas of low numbers of beds and staff were spending heavily in order to increase provision. However, at least in terms of the number of hospital beds and staff, in the period just before the introduction of the NHS[“l it appears that geographical inequality and inequity was not as bad as orthodoxy would have us believe.

School of Health and Human Sciences, Hatjield Polytechnic, College Lane, Hatjield AL10 9AB, UK

Notes [l] “Community, Locality and Welfare: the History of the Welfare State from Below”, one day

conference, Queen Mary and Westfield College, London, 4 April 1990 [2] R. Lee, Uneven Zenith: towards a geography of the high period of municipal medicine in

England and Wales Journal of Historical Geography 14 (1988) 260-280 [3] The “top down” perspective is often associated with the Webb’s writing on Poor Law history:

see for example A. Kidd, Historians or Polemicists? How the Webbs wrote their history of the English Poor Laws Economic History Review XL (1987) 409

[4] J. Allsop, Health policy and the National Health Service (London 1984) 92-99; C. Ham, Health policy in Britain (Basingstoke 1985) 166-173; P. Townsend, P. Phillimore and A. Beattie, Health and deprivation (London 1988)

[5] J. Eyles, The geography of the national health (London 1987); S. Curtis, The geography of public welfare provision (London 1989)

[6] N. Mays and G. Bevan, Resource allocation in the health service (London 1987) Ch. 2; R. Klein, The politics of the National Health Service (London 1983)

[7] P. Thane, The foundations of the welfare state (London 1982); D. Fraser, The evolution of the British werfare state (Basingstoke 1984). For the NHS in particular, see C. Webster, The health services since the war (London 1988); Klein, op. cit. fn. 6

[8] Lee, op. cit. fn. 2, 263 [9] J. Pater, The making of ihe National Health Service (London 1981) 108; Klein, op. cit. fn. 6,

18-19; Webster, op. cit. fn. 7, 83 [lo] For example, J. Pickstone, Medicine and industrial society (Manchester 1985); G. Rivett, The

development of the London hospital system 1823-1982 (London 1986) [l l] Eyles, op. cit. fn. 5, 156 [12] Thane, op. cit. [13] B. Preston, Rich town, poor town: the distribution of rate-borne spending levels in the

Edwardian city system Transaction of the Institute of British Geographers 10 (1985) 77-94; see also S. Ward, The geography of interwar Britain (London 1982); M. Powell, How adequate was hospital provision before the NHS? An examination of the 1945 South Wales Hospital Survey Local Population Studies (forthcoming); ibid, Hospital provision before the NHS: an analysis of the 1945 Hospital Survey (1991) Hatfield Polytechnic, mimeo

[14] Ministry of Health/Ntield Provincial Hospitals Trust, Hospital Surveys (10 volumes) (London 1945-6). It should be noted that data refers to the year 1938

[15] Webster, op. cit. fn. 7, 12 [16] J. LeGrand, The strategy of equality (London 1982); M. O’Higgins, Egalitarians, equalities

and welfare evaluation Journal of Social Policy 16 (1987) 1-18 [17] Pater, op. cit. fn. 9, 19; Webster, op. cit. fn. 7, 13 [18] Thane, op. cit. fn. 7, 192; Pater, op. cit. fn. 9, 20; Webster, op. cit. fn. 7, 13 [19] PRO MH 77/18 Report by Hospital Almoners’ Association (1943) [20] M. Whitehead. National Health success (London 1988) 20-21

316 M. POWELL

[21] R. Titmuss, Problems of social policy (London 1950) 71, fn. [22] J. R. Hollingsworth, A political economy of medicine: Great Britain and the United States

(Baltimore 1986) 200 [23] MOH/NPHT op. cit. fn. 5 passim [24] Ibid, passim [25] Quoted in M. Buxton and R. Klein, Allocating health resources (London 1978) 1 [26] Webster, op. cit. fn. 9, 14 (my emphasis) [27] B. Abel-Smith The Hospitals 1800-1948 (London 1964) 405 [28] F. Chalmers, Labour and the Birth of the NHS Health Service Journal (Supplement) (1988) 4 [29] Whitehead op. cit. fn. 13, 21 [30] Webster op. cit. fn. 9, 8 [31] L. Bryder, Below the Magic Mountain: a social history of tuberculosis in twentieth century

Britain (Oxford 1988) 83 [32] Ibid, 82 [33] Sir G. Godber, The domesday book of British Hospitals Bulletin, Society for the Social

History of Medicine 32 (1983) 5 [34] Ibid, 13 [35] Nuffield Provincial Hospitals Trust, The Hospital Surveys: the domesday book of the hospital

services (Oxford 1946) [36] H. Eckstein, The English health service (Cambridge, Mass. 1958) 3435 [37] Webster, op. cit. fn. 7, 32 [38] S. Leff, Thehealth ofthepeople (London 1950); Rivett, op. cit. fn. 10; Pickstone, op. cit. fn. 10;

Titmuss, op. cit. fn. 21 [39] Sir G. Godber, Origins and early development British Medical Journal 297 (1988) 38 [40] Rivett, op. cit. fn. 10, 255 [41] MOH/NPHT, op. cit. fn. 14, passim [42] E. Rock Carling and T. S. McIntosh, Hospital Survey: the hospital services of the North-

Western areas (London 1945) 14, my emphasis [43] A number of other writers use rateable value per head as a proxy for local wealth. See, for

example, a review in L. J. Sharpe and K. Newton, Does politics matter? (Oxford 1984) and also Preston, op. cit. fn. 13

[44] The last two sources are Report on the Result of Znvestigation under Section 110, Local Government Act 1929 (London 1937). For more details, see, for example, H. Finer, EngIish Local Government (London 1945, 2nd edn.) 476 seq; E. J. Buckatzsch. An index of social conditions in the County Boroughs in 1931. Bulletin of the Institute of Statistics 8 (1946) 364- 74

[45] For more details, including the correlations for the County Councils, see M. Powell, Territorial justice or inverse care law? Journal of Social Policy (forthcoming)

[46] Abel-Smith, op. cit. fn. 26, 405 [47] This is in marked contrast to spending in the Edwardian city system as shown by Preston, op.

cit. fn. 13, where the correlation between “wealth” and “spending” was + 0.86 [48] See, for example, Finer op. cit. fn. 32. [49] J. R. and U. K. Hicks Standards of local expenditure (Cambridge 1943) [SO] Ibid., 38 [51] K. Hoggart, Geography, political control and local government policy outputs Progress in

Human Geography 10 (1986) I-23; Sharpe and Newton, op. cit. fn. 43 [52] While attempts have been made to statistically “explain” outputs using regressions models in

recent years, “explanation” for the 1930s remains largely non-statistical. See, for example, N. Wilson, Public health services (London 1938); Hicks and Hicks, op. cit. fn. 49; Ward, op. cit. fn. 13

[53] Powell, op. cit. fn. 45 [54] but see Lee, op. cit. fn. 2; Ward, op. cit. fn. 13; Hicks and Hicks, op. cit. fn. 49 [55] M. A. Crowther, The workhouse system 1834-1929 (London 1983) ch. 7; Abel-Smith, op. cit.

fn. 27, chs. 13, 14, 22, 23; Rivet& op. cit. fn. 10; Pickstone, op. cit. fn. 10 [56] The “Emergency Medical Service” to deal with wartime hospital needs was formed in 1939,

while the NHS was formed in 1948. See, for example, Abel-Smith, op. cit. fn. 27; Titmuss, op. cit. fn. 21; Webster, op. cit. fn. 7; Pater op. cit. fn. 9; Klein, op. cit. fn. 6