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The Gloucestershire Extension of Medical Services Scheme: An Experiment in the Integration of Health Services in Britain before the NHS

Published online by Cambridge University Press:  16 November 2012

Martin Gorsky
Martin Gorsky
Affiliation:
Centre for History in Public Health, Department of Public Health and Policy, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HY, UK
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One of the animating beliefs of British health service reformers in the first half of the twentieth century was that delivery would improve if greater co-ordination was imposed over disparate providers. The fundamental divisions were between the voluntary, public and private sectors. Voluntary provision predominantly meant acute care hospitals, but also included a range of other therapeutic and clinical services. The public sector delivered general practitioner (GP) services to insured workers through the state national health insurance (NHI) scheme, while the remit of local government covered environmental health, isolation and general hospitals and a wide range of personal services addressing tuberculosis, venereal diseases, mental illness, and maternity and child welfare. Finally, the private sector provided nursing homes and GP attendance at commercial rates. Within each area there were tendencies towards independent rather than co-operative working. Voluntary hospitals often lacked any mechanism for conferring with neighbouring institutions and the competitive logic of fund-raising enforced an individualistic ethic. In the public sector health responsibilities were dispersed across various agencies: local authority health committees, advised by the county or borough Medical Officer of Health (MOH), oversaw sanitation, hospitals and personal health services; education committees were responsible for the School Medical Service (SMS), whose remit was the compulsory medical inspection and treatment of elementary schoolchildren; the Poor Law provided institutional care either in workhouses or separate infirmaries, although after the 1929 Local Government Act the boards of guardians were broken up; their powers were then transferred to the public assistance committees of local authorities, however these remained distinct from health committees. GP services accessed through the state NHI system were overseen by local insurance committees separate from local government. Private practice co-existed with NHI and doctors tended to prioritize fee-paying rather than panel patients.

Type
Articles
Information
Medical History , Volume 50 , Issue 4 , 01 October 2006 , pp. 491 - 512
Copyright
Copyright © The Author(s) 2006. Published by Cambridge University Press

References

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19 C Webster, ‘Conflict and consensus: explaining the British Health Service’, Twentieth Century Br. Hist., 1990, 1 (2): 115–51.

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21 Gloucestershire County Council, Annual report of the Medical Officer of Health, 1936 (hereafter GCC MOH), Gloucester, 1937, p. 40.

22 Dawson Report, op. cit., note 6 above, p. 7.

23 A Newsholme, International studies on the relation between the private and official practice of medicine, 3 vols, London, Allen & Unwin, 1931–1932, vol. 3, ch. 16, p. 282; Newsholme was MOH for Brighton (1888–1908), then Medical Officer to the Local Government Board (1908–19), and was a strong advocate of comprehensive municipal medical services, see J M Eyler, Sir Arthur Newsholme and state medicine, 1885–1935, Cambridge University Press, 1997, p. 214.

24 NA:PRO MH66/90, A C Parsons, ‘Administrative County of Gloucestershire: report on a survey of health services’, p. 97.

25 Ibid., p. 90; D Orr and J Orr, Health insurance with medical care: the British experience, New York, Macmillan, 1938, pp. 140–2. Charles-Edward Amory Winslow was the chair of Yale's Department of Public Health (1915–45); around the time of the visit he was a member of the Committee on the Costs of Medical Care (1927–32), which examined international experience in its consideration of health services reform in the United States, and an expert health assessor (1927–30) of the League of Nations Health Organisation. See A J Viseltear, ‘C.-E. A. Winslow: his era and his contribution to medical care’, inC Rosenberg (ed.), Healing and history: essays for George Rosen, Folkestone, Dawson Science History Publications, 1979, pp. 205–28; I V Hiscock, ‘Charles-Edward Amory Winslow, February 4, 1877–January 8, 1957’, J. Bacteriol., 1957, 73 (3): pp. 295–6.

26 PEP, Report, op. cit., note 3 above, pp. 165, 256, 367–8, quote on p. 398.

27 Fox, op. cit., note 12 above, p. 60.

28 J Middleton Martin, Gloucestershire scheme for the extension of medical services, Gloucester, 1920, pp. 4, 6.

29 Ibid., p. 6.

30 Gloucestershire Archives (hereafter GA), CM/M/16/1 ‘Extension of Medical Services Board of Management Minute Book’ (hereafter GEMSS MB), 25 Oct. 1919, 24 April 1920.

31 ‘Extension of institutional medical services’, Br. med. J., 22 Feb. 1919, i: 218–19, p. 218.

32 J Middleton Martin, ‘The problem of medical services’, Contemp. Rev., 1922: 364–72, on p. 369; Parsons, op. cit., note 24 above, p. 94.

33 Middleton Martin, ibid., p. 371.

34 GA, CJ/M/16/1 GEMSS MB, 14 July 1920; NA:PRO MH/66/ 91 ‘Appendix 6’, pp. 3, 5.

35 GA, CM/M/16/1/ GEMSS MB, 21 June 1919.

36 Middleton Martin, Gloucestershire scheme, op. cit., note 28 above, p. 7.

37 GCC MOH 1924, p. 33.

38 Middleton Martin, ‘The problem of medical services’, op. cit., note 32 above, p. 369; idem, ‘The medical profession and rate-provided hospitals’, Br. med. J., 6 Aug. 1921, ii: 191–2.

39 Middleton Martin, Gloucestershire scheme, op. cit, note 28 above, p. 6; Br. med. J., 1918, ii: 23–6, 56–9; intriguingly Dawson and Middleton Martin both trained at University College London, though Dawson was six years the elder: C Webster, ‘The metamorphosis of Dawson of Penn’, in Dorothy Porter and Roy Porter (eds), Doctors, politics and society: historical essays, Amsterdam, Rodopi, 1993, pp. 212–28.

40 F Watson, Dawson of Penn, London, Chatto and Windus, 1950, pp. 155–6.

41Who was who 1951–60, London, Adam & Charles Black, 1967, p. 227.

42 ‘Correspondence’, Br. med. J., 27 Nov. 1920, ii: 842; 11 Dec. 1920, p. 916; 18 Dec. 1920, p. 952; Honigsbaum, op. cit., note 20 above, pp. 64–133.

43Br. med. J., 6 Aug. 1921, ii: 191–2, on p. 191.

44 GCC MOH, passim.

45 Webster, op. cit., note 39 above, pp. 213–16; Sturdy and Cooter, op. cit., note 15 above, pp. 433–4.

46 Ministry of Pensions, First annual report of the Minister of Pensions to 31st March 1918, London, HMSO, 1919, pp. 4–11, 30–1, 36–7; Second annual report of the Minister of Pensions from 31st March 1918 to 31st May 1919, London, HMSO, 1920, pp. 26–7.

47 Newsholme, op. cit., note 23 above, pp. 311–12.

48 ‘Extension of institutional medical services’, Br. med. J., 22 Feb. 1919, i: 218.

49 Middleton Martin, ‘The problem of medical services’, op. cit., note 32 above, pp. 367–8.

50The Medical Directory 1934, London, J & A Churchill, 1934, p. 975.

51 J Middleton Martin, ‘An analysis of Gloucestershire statistics, 1901–10’, Proceedings of the Royal Society of Medicine, Section of Epidemiology and State Medicine, 1915–16, 9: 1–32; idem, ‘Scarlet fever outbreak at Stroud due to milk’, Public Health, Dec. 1901, 14: 138–42; idem, ‘Schools and infectious disease’, Public Health, July 1902, 14: 608–11; idem, ‘An inquiry into the distribution of certain diseases (cancer, phthisis, and pneumonia) on the western slopes of the Cotteswold Hills’, Public Health, Oct. 1904, 17: 4–31; Eyler, op. cit., note 23 above, pp. 27–41.

52 J Middleton Martin, ‘Tuberculosis—dogmas and doubts of sixty years’, Br. med. J., Feb. 1939, i: 204–9; Parsons, op. cit., note 24 above, pp. 71–3.

53 Middleton Martin, ‘The problem of medical services’, op. cit., note 32 above, p. 372.

54 ‘Obituary’, Lancet, 20 Jan. 1940, i: 149; ‘Obituary’, Br. med. J., 13 Jan. 1940, i: 74.

55 Harris, op. cit., note 3 above, pp. 81–2.

56 J Middleton Martin, ‘Poor law reform and public health’, Br. med. J., 28 Aug. 1926, ii: 376–80, on pp. 378–9; Report of the Royal Commission on the Poor Laws and Relief of Distress (hereafter Majority Report), 5 vols, Cd. 4499, 1909, vol. 1, pp. 371–2, 380–1.

57 Webb and Webb (eds), op. cit., note 5 above, pp. 585–7; though authored by Beatrice Webb, these recommendations were informed by Arthur Newsholme, whose pioneering organizational work as MOH for Brighton must have been familiar to Middleton Martin from his contemporaneous stint in the city, Eyler, op. cit., note 23 above, pp. 165, 195–219; A M McBriar, An Edwardian mixed doubles, the Bosanquets versus the Webbs, Oxford, Clarendon Press, 1987, pp. 231–6, 297–8.

58 Majority Report, pp. 384–8; S Sturdy, ‘Alternative publics: the development of government policy on personal health care, 1905–11’, in S Sturdy (ed.), Medicine, health and the public sphere in Britain, 1600–2000, London, Routledge, 2002, pp. 241–59.

59 Majority Report, pp. 358–9; Middleton Martin, ‘Poor Law reform’, op. cit., note 56 above, pp. 378–9.

60 Middleton Martin, ibid., p. 377.

61 Middleton Martin, ‘The problem of medical services’, op. cit., note 32 above, pp. 364–7; idem, ‘Poor Law reform’, op. cit., note 56 above, pp. 376–8.

62 Middleton Martin, ‘Poor Law reform’, op. cit., note 56 above, p. 380.

63 J Middleton Martin, ‘The medical profession and rate-provided hospitals’, Br. med. J., 6 Aug. 1921, ii: 191–2, on p. 191.

64 Stewart, op. cit., note 20 above; J Harris, Private lives, public spirit: Britain 1870–1914, Oxford University Press, 1993; Harmondsworth, Penguin, 1994, pp. 237–41.

65 GA, CM/M/16/1 GEMSS MB, 20 Dec. 1919, 27 March 1920, 24 April 1920.

66 B Harris, The origins of the British welfare state: society, state and social welfare in England and Wales, 1800–1945, Basingstoke, Palgrave Macmillan, 2004, pp. 180–1.

67 GA, CM/M/16/1 GEMSS MB, 10 Oct. 1921, 1 May 1922; CM/M1/4 ‘Public Health and Housing Committee’, 26 Nov. 1921.

68 GA, CM/M/16/1 GEMSS MB, 21 June 1920, 11 Dec. 1920, 12 March 1921; GCC MOH 1936, Gloucester, 1937, p. 56.

69 GA, CM/M/16/1 GEMSS MB, 26 Nov. 1921, 24 June 1922.

70 GA, CM/M/16/1 GEMSS MB, 13 Oct. 1922.

71Gloucestershire County Council report of the Education Committee for 1922–23 (hereafter GCC EC), p. 32.

72 GA, CM/1 Gloucestershire Education Committee, signed copies of Minutes, May 1921 to March 1923, inclusive, vol. lxv, 25 Nov. 1922.

73 GCC EC, 1921–22, p. 33.

74Gloucestershire County Council, Abstract of accounts, 1921–22, 1922–23 (hereafter GCC Abstract).

75 GA, CJ/M/8/1 GEMSS MB, 21 April 1923; CM/M1/4, ‘Public Health and Housing Committee’, 24 March 1923; CC/MS Gloucestershire County Council, minutes of proceeding, xxxv, 10th April, 1923 to 18th February 1924, 9 July 1923.

76 GA, CJ/M/8/1 GEMSS MB, 21 April, 7 July, 5 Aug. 1923.

77 GCC MOH, 1921, 1930, 1936.

78 Parsons, op. cit., note 24 above, insert after p. 93.

79 NA:PRO MH/66/ 91, ‘Appendix 6’, p. 7.

80 Ibid., p. 9; GCC MOH 1933, p. 28.

81 NA:PRO MH/66/ 91, ‘Appendix 6’, pp. 10–11.

82 Ibid., p. 5; GCC MOH 1933, p. 32.

83 Harris, The health of the schoolchild, op. cit., note 3 above, pp. 110–13.

84U.K. Local Government Financial Statistics, 1935–36.

85 Parsons, op. cit., note 24 above, p. 91.

86 Ibid., p. 96.

87 NA:PRO MH/66/ 91, ‘Appendix 6’, p. 14; GCC MOH 1932, p. 32.

88 NA:PRO MH/66/92, L Harrison, ‘Gloucestershire VD Scheme’, 9 July 1934.

89 NA:PRO MH/66/ 91, ‘Appendix 6’, p. 4.

90 GCC MOH 1932, p. 32; this was a national trend, see Harris, Health of the schoolchild, op. cit., note 3 above, pp. 110–11.

91 GCC MOH 1932, p. 31.

92 GCC MOH 1934, p. 35.

93 GA, CJ/M/8/7 GEMSS MB, 2 Dec. 1929.

94 GCC, Abstract, passim; composition of income was reported only for the years shown; from 1934–5 the GEMSS element was not disaggregated from the total school medical service contribution to public health.

95 H Finer, English local government, London, Methuen, 1946, pp. 464–5.

96City and county of Bristol: epitome and general statistics of the city accounts for the year ended 31st March 1932, Bristol, 1932, pp. 6–7.

97 Finer, op. cit., note 95 above, p. 462; Harris, Health of the schoolchild, op. cit., note 3 above, p. 92.

98 GCC, Abstract, 1918–19.

99 Welshman, op. cit., note 4 above, pp. 135, 176, 181, 258–9.

100 Parsons, op. cit., note 24 above, pp. 5, 8; the comparison was made with Cornwall, Shropshire, Berkshire, West Sussex, Bedford, Dorset, Devon, Somerset, Wiltshire and Hampshire.

101 GCC MOH 1921, p. 41.

102 GA, CM/M/16/1 GEMSS MB, 1 May 1922.

103 GA, CJ/M/8/1 GEMSS MB, 6 Oct. 1923.

104 NA:PRO MH/66/ 91, ‘Appendix 6’, p. 9.

105 GA, CJ/M/8/1GEMSS MB, 8 Sept. 1923; CJ/M/8/8 GEMSS MB, 5 Oct. 1931.

106 GA, CJ/M/8/4 GEMSS MB, 4 Sept., 4 Dec. 1926; CJ/M/8/8 GEMSS MB, 5 Dec. 1932; CJ/M/8/12 GEMSS MB, 7 June 1934, 4 March 1935.

107 GA, CJ/M/8/11 GEMSS MB, 6 Nov. 1933.

108 Parsons, op. cit., note 24 above, p. 91; GCC MOH 1929, p. 31.

109 GCC MOH 1933, p. 27.

110 Ibid., p. 27.

111 Parsons, op. cit., note 24 above, pp.189, 191–2.

112 GCC MOH 1932, p. 30.

113 NA:PRO MH 66/92 ‘Gloucestershire CC Post survey’, ‘Annex to 664/4201/2’, 2 Feb. 1934; ‘Previous history of the services transferred from the Guardians’, n.d. 1936.

114 Ibid., ‘Previous history’; and ‘Post survey’, ‘Gloucestershire County Council’ 2 March 1937, typescript of meeting.

115 Cowan went on to be MOH for Essex County Council, 1949–54, then Chief Medical Officer to the Scottish Department of Health, 1954–64, Who was who, 1971–1980, London, Adam & Charles Black, 1981, p. 177.

116 GA, CJ/M/8/15 GEMSS MB.

117 GA, CJ/M/8/15 GEMSS MB, 3 Jan. 1938.

118 Ibid., 5 July 1937; GA, CJ/M8/17 GEMSS MB, 4 Sept. 1939, 29 April 1940.

119 T Willis, ‘The Bradford Municipal Hospital experiment of 1920: the emergence of the mixed economy in hospital provision in inter-war Britain’, in M Gorsky and S Sheard (eds), Financing medicine: the British experience since 1750, London, Routledge, 2006; Gorsky, op. cit., note 13 above; Pickstone, op. cit., note 13 above, pp. 276–83.

120 Sir A Newsholme, Medicine and the state: the relation between the private and official practice of medicine with special reference to public health, London, 1932, p. 29; for Newsholme, see notes 23 and 57 above.

121 Sturdy (ed.), op. cit., note 58 above, pp. 242–9.

122 ‘Interim report on encroachments on the sphere of private practice by the activities of local authorities’, Br. med. J., Supplement, Nov. 1928, pp. 185–95, esp. paras 16, 17.

123 GA, CJ/M/8/10 GEMSS MB, 7 Nov. 1932.

124 Parsons, op. cit., note 24 above, p. 27.

125 Eyler, op. cit., note 23 above, pp. 324–33; Harris, Health of the schoolchild, op. cit., note 3 above, pp. 98–102.

126Fifteenth annual report of the Ministry of Health, Cmd. 4664, PP 1933–34, XII 265, pp. 45–54.

127 Parsons, op. cit., note 24 above, pp. 127, 189–90, 200.

128 GCC MOH 1929, p. 30.

129 NA:PRO MH 66/90 Minute Sheet, 24 Dec. 1932, H MacEwen to Wrigley.

130 W A Robson, The development of local government, London, Allen & Unwin, 1954, pp. 194–5, cited in Welshman, op. cit., note 4 above, p. 253; Eyler, op. cit., note 23 above, pp. 387–8.