Historians of the pre-NHS hospital system have addressed a number of themes in recent years: the scale and speed of development of both voluntary and municipal hospitals; the rise of specialist services; the central part played by finance in hindering or promoting change; the role of politics; and the extent of collaboration and co-operation within and between the sectors at an urban and regional level. This book has been concerned with exploring each of these themes in two localities, providing a comparison of developments within Leeds and Sheffield and placing those trends within their wider national context. The two cities examined here provide important perspectives; by focusing on regional centres with medical schools, we have been able to assess change in the most highly developed part of the contemporary hospital system. Historians have often dismissed such places as atypical with their experiences having little to tell us about small towns, rural areas or places struggling with limited resources and the effects of depression. Yet, as Pickstone observed in relation to his study of the north-west:

Between the end of the First World War and the mid-1940s hospital provision became an increasingly politicized field of social policy. National debates were prompted by the financial crisis of the early 1920s, the introduction of the 1929 Local Government Act and the series of reports and surveys produced in the later 1930s which laid the basis for national state involvement. Central to these discussions were considerations of who should finance and who should control public hospital services and while general issues of state subsidy arose, it was the relationship between the voluntary hospitals and the local state which occupied the key area of debate. In analysing these debates historians have usually looked to national sources and the positions adopted by leading pressure groups such as the BMA or the British Hospital Association, especially in the period from 1937. There has been a tendency to emphasize Labour hostility to the voluntary system and support for a state-run service under the control of the municipality as espoused in The Labour Movement and the Hospital Crisis (1922). Those on the right, along with the medical elite, are less clearly drawn but are seen to provide consistent support to the voluntary sector coupled to a fear of municipal control. The Ministry of Health attempted to maintain a neutral line in these disputes but seems to have become increasingly hostile to the voluntary sector and their supporters in the contributors' associations.

During the nineteenth century England acquired the hospital infrastructure which would form the institutional basis of the NHS. By 1861 there were around 65,000 hospital beds in England and Wales and this figure more than trebled to almost 200,000 by the outbreak of the First World War. Although growth slowed considerably between the wars, the stock of hospital beds had passed a quarter of a million by 1938 – a fourfold increase on the mid-Victorian period. Development was most rapid in major urban centres like Leeds and Sheffield which saw the emergence of general and specialist institutions shaped by both the generic health-care demands common to city regions of an advanced industrial nation and the specific needs of the place influenced by socio-economic structures and political considerations. In particular, Leeds developed a single acute centre with extensive associated provision for women while Sheffield saw a more fragmented acute and specialist service with strong local authority institutions all focused on addressing the health needs of adult male labour.

Prior to 1929 hospitals were created by three separate agencies reflecting separate responsibilities and income sources. Acute care for the sick poor was provided by voluntary institutions which were maintained by subscriptions, donations, legacies and other non-public funds and staffed mainly by unpaid medical practitioners and professional nurses.

By 1929, hospital providers in Leeds and Sheffield had assembled the buildings, the doctors and specialties, the finance and the political structures to deliver a modern hospital service to their cities. However, this process took place without any overarching control, with each hospital or authority free to inaugurate any service they wished or could afford (with some limits on the guardians and the municipality). As we have seen, finance and political will would place limits on development but the existence of a service or specialty in one institution did not preclude it being taken up by another hospital. As a result duplication was common and its potential to multiply was embedded in the 1929 Local Government Act which had encouraged the municipal authorities to take on the delivery of general hospital provision. Yet it is evident that a free-for-all was avoided and the 1930s and 1940s saw the development of integrated services in Leeds and Sheffield. This process saw the large number of independent institutions in the voluntary, poor law and municipal sectors begin to collaborate, merge and reorientate to create increasingly efficient and democratic regional services. The form this co-operation took and the speed and scale were shaped by local economic, social and political cultures and structures responding to internal imperatives and external stimulus from government, national bodies and major crises like the two world wars and the economic depression.

As hospital patients diversified in the first half of the twentieth century, so too did the institutions and staff who treated them. New techniques and knowledge, medical markets and the desire to order and manage patients all influenced the emergence of hospital specialization and by the arrival of the NHS the population at large increasingly identified the hospital as a centre of specialist treatment. Moreover, as the population became healthier and wealthier their expectations of hospitals changed. They began to see them as places where modern medicine would cure or at least repair them while their financial contributions gave them a sense of entitlement to the best, most advance care. These new demands from a more affluent and democratic society produced variable responses, reflecting the effects of the economy and the relationships and hierarchies within the different hospital structures. They also added a new element to the stimulus to special services – local need. Rather than the diversity of specialist provision reflecting the failings of a system which had arisen without the benefits of rational planning, difference may have emerged from priorities shaped by specific economic and social structures and the ensuing political priorities. This chapter will consider the development of specialist services, especially those emerging between the wars, such as mental health outpatient services, and will then address two case studies which illuminate the influence of local economic, social and political factors in the shaping of orthopaedic and maternity services.

In the period between the end of the First World War and the inauguration of the NHS the demands on hospitals grew significantly: inpatient and outpatient numbers soared necessitating increased accommodation; new drugs and technologies were developed; and more, better trained and better remunerated staff were required. To meet these financial commitments voluntary hospitals had to diversify the source and increase the volume of their income at a time when social and economic changes were weakening traditional philanthropic giving. Provincial voluntary hospital income – after an initial crisis between 1918 and 1923 – did largely keep pace with expenditure, increasing by about 65 per cent between 1920 and 1938. Moreover, most historians accept that they were not on the verge of collapse by the later 1930s as argued by Titmuss, with many adapting to the increased demand for services. Certainly the inability of traditional voluntary sources of finance – subscriptions, donations, collections – to meet growing demand meant payment, either direct or indirect, was vital to the survival of the voluntary system but how this was achieved and its long-term impact remain the subjects of considerable debate. It has been argued that while mass worker prepayment schemes were essential to the economic viability and vitality of these institutions, this was at the expense of any philanthropic claims they may have made. Others see workers contributions as retaining implicit and explicit voluntary elements bolstered by the hospitals' insistence that prepayment did not ensure treatment.

General histories of hospital services in the first half of the twentieth century often highlight the variability in provision between towns, pointing to the serendipitous and illogical foundations of voluntary hospitals and the restrictions imposed by finance and political preference on local authorities. Yet this, as Pickstone has noted, under-estimates the fact that local need shaped by economic, social and political structures was often the vital component in determining hospital services in the fifty years before the NHS. Admittedly, a number of studies have demonstrated the importance of local financial resources and political cultures on the form services took but these rarely consider how socio-economic structures may have created specific needs resulting in unique patterns of provision. Thus, to understand fully the influences on hospital services, finance and management regimes in Leeds and Sheffield, it is necessary to explore their changing urban ecology. In particular, we need to explore how the fate of both the individual hospitals and the broader citywide provision were determined by longer-term developments in economic specialization, class structure, the role of gender in the workforce and the scale and nature of trade unionism along with shorter-term factors such as the impact of unemployment and the outcome of municipal elections.

At the beginning of December 1946 the Sheffield Hospital Contributors' Association met for its one hundredth quarterly meeting. The association invited a number of local dignitaries to the meeting and also the Minster of Health, Aneurin Bevan, MP. Mr Bevan was, unfortunately, unable to attend but wrote urging the contributors to welcome, not fear, the new service. For:

In these few lines Bevan encapsulated many of the perceived characteristics of the pre-National Health Service (NHS) hospital system – financial anxiety, individualism and a chaotic lack of organization. Yet he also had to recognize some of its strengths – independence, voluntary effort and a sense of commitment and ownership.

The provision of a modern and extensive hospital infrastructure, as seen in Leeds and Sheffield in the first half of the twentieth century, was intimately intertwined with the growth and transformation of the patient population. Between the wars the general public acquired what one Leeds politician described as the ‘hospital habit’, with inpatient numbers increasing by about 35 per cent at the voluntary general hospitals, by around 300 per cent at the specialist hospitals and by at least 100 per cent in the municipal general institutions. By the outbreak of the Second World War the cities' hospitals were treating around 58,000 inpatients – an overall increase of 65 per cent. Added to this impressive expansion was a growth of 50 per cent in the number of outpatients to 120,000 while casualties doubled to 80,000 and, most remarkable, outpatient and casualty attendances quadrupled to almost one million visits. Put another way, these combined figures were equivalent to one-fifth of the population of both cities receiving hospital treatment annually by 1938.

Inpatient and outpatient numbers rose across the country in this period but the speed and shape of this growth in Leeds and Sheffield was determined to some extent by economic, social and political factors specific to the cities. Although there are clear signs that health care was becoming more democratic, this was not as yet a universal system and access to treatment was determined by a complex set of criteria.