The Thirties: An Intimate History of Britain

Men working in insurable occupations and earning less than £250 a year were covered by a contributory National Health Insurance scheme, introduced in 1913, to (barely) tide them over in times of sickness and provide basic medical treatment and medicines from a ‘panel’ doctor. However, by 1936 only around twenty million people, about 40 per cent of the total population of 47.5 million, including six million working women, were covered. They did not include dependent wives (except in the case of maternity benefit) and children. Those earning over £250 a year would have to make their own private sickness insurance arrangements — though they could contribute to the NHI scheme through voluntary payments if they could afford to.

The NHI scheme did not cover dental or ophthalmic treatment, though some of the larger ‘approved societies’ (usually friendly societies or industrial insurance companies, and a few trade unions) which administered the scheme might offer such fringe benefits to attract customers. This meant that for many working-class men and women tooth decay and premature toothlessness were inhibiting and intermittently painful features of life (‘Teeth, teeth, teeth, they are half the trouble [with women’s health],’ wrote a country district nurse in February 1938), while Woolworths offered ‘do it yourself’ eye tests for those unable to afford to consult an ophthalmologist about their need for spectacles.

There were continual complaints that those who received their treatment from the NHI scheme, known as being ‘on the panel’, got inferior treatment. At least 5,000 doctors remained outside the scheme, and those operating within it in suburban or rural areas often derived most of their income from private patients. A GP employing one assistant could easily have 4,000 panel patients (for each of whom he would receive a capitation fee of about 9s.6d), and it was quite usual for a single doctor to be responsible for as many as 2,500 patients, so those in poor areas with a large percentage of their patients ‘on the panel’ were likely to give only cursory consultations.

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 were able to put some of their ideas into practice, such as increasing the allocation of resources to municipal hospitals, improving the conditions and pay of nurses and other medical staff, providing outpatient facilities at most hospitals for the surrounding community and ridding hospitals of any Poor Law connotations, since ‘every possible suggestion of charity, subservience, and general second rateness must be banished’. Instead London’s citizens should regard ‘the municipal hospitals as their own [since they had] every right to use them and expect the best from them’. But although the reform of London’s health provision was of considerable interest to other authorities, even Somerville Hastings, chairman of the LCC Hospital and Medical Services Committee, recognised that it was unlikely to be fully possible ‘within the limits of existing legislation’.

As well as inadequate hospital provision, the range of remedies doctors could provide was still very limited: during their brief consultation patients would be given a handful of pills, which might come in a range of colours but would in fact probably all be aspirins, though bottles of dilute mixtures of powerful drugs such as kaolin and morphine were also dispensed. A Welsh doctor provided his miner patients with a tincture of chloroform and morphine, effectively an addictive drug, for their chronic chest conditions. Many general practitioners had few aids to diagnosis, a stethoscope, thermometer, ear syringe and maybe a speculum being fairly standard, sterilising instruments was a dispensable luxury, and doctors had to pay for laboratory tests themselves — and therefore tended not to take advantage of new techniques and treatments that were being developed during the 1930s. A Welsh doctor who prescribed little but ‘black liquorice’ for his miner patients’ pneumoconiosis was regarded as a cut above other practitioners in the town, since he had a machine that enabled him to take a patient’s blood pressure.

Aware of their limited therapeutic arsenal, doctors essentially bought time by dispensing medicine, hoping that an illness would turn out to be self-limiting and would disappear, while patients appeared to be satisfied if they left the surgery clutching a bottle of medicine (private patients would have their bottle wrapped in white paper and sealed with sealing wax and usually delivered by the doctor’s errand boy on a bicycle after evening surgery) or, less frequently, a box of pills, for which they had paid two or three pence. Aspirin powder for pain relief had been available since the turn of the century, and a tablet form had been patented in 1914, insulin injections to control diabetes had been introduced in the 1920s, followed by kidney dialysis, radium treatment for cancers, skin grafts and blood transfusions. Salvarsan was effective as a cure for syphilis and pernicious anaemia could now be treated with iron injections (rather than raw liver sandwiches, as previously), while the significance of vitamins began to be appreciated, leading to new therapies using vitamins C and D in cases of scurvy and rickets.

However, there were few things in the medicine cupboard in Eileen Whiteing’s home ‘apart from fruit salts, cough mixture, plus iodine for cuts … and we certainly did not include [the commonplace aspirin] in our home remedies, having to endure headaches and other pains until they went away of their own accord … cod liver oil and “Virol” were favourite remedies for winter ailments … and in the case of nerves or depression, a strong iron tonic would be prescribed, with the advice to “pull yourself together”.’

Diphtheria in children, an infection resulting in the throat thickening and the danger of suffocation, was one of the spectres hovering over the inter-war years, with some 50,000 cases every year. Two thousand children died each year from diphtheria and whooping cough until effective vaccines began to be used towards the end of the decade. Eileen Whiteing recalled that when she and her sister caught ‘the dreaded diphtheria … Mother refused to let us go away to hospital, so a trained nurse was engaged at great expense, and, between the two of them, plus the resident maid, we were nursed safely through the long weeks of fever. Disinfected sheets had to be hung over the bedroom doors, all visitors had to wear white coats and face masks, and the whole house had to be fumigated by the local health officers at the end of the isolation period … People were endlessly kind … since illness was quite a serious event then: I remember hearing the news in hushed tones that straw had been spread over the road outside the house of one of my friends while he lay desperately fighting for his life with double pneumonia in order that the noise of passing traffic should not disturb him until what was known as the “crisis” was past’ and the patient’s dangerously high temperature either fell, or he or she died of exhaustion or heart failure, since in the absence of any effective medication, all the doctor could do was visit several times a day, wait and watch.

It was not until 1935–36 that real advances in medical treatment were possible with the manufacture of sulphonamides, anti-bacterial drugs effective for the treatment of a range of serious illnesses including streptococcal and meningococcal infections, the ‘miracle drug’ of those pre-penicillin years.

Tuberculosis was another killer disease that awaited its antidote: in the first decade of the twentieth century it was responsible for one death in every eight, and although that figure was steadily declining by the 1930s, there were still some 30,000 deaths a year from respiratory tuberculosis, and it continued to be seen as a deadly and frightening disease, freighted with social stigma. George Orwell, the most pungent chronicler of the mid-century, who had first contracted TB in 1938, died from its effects in January 1950, aged forty-six. In 1925 the typical tuberculosis dispensary was described by the Chief Medical Officer of the Ministry of Health as ‘an outpatient department, stocked with drugs that are mainly placebos, or an annexe of an office for the compilation of statistics’, and not much had changed a decade later. Although tuberculosis could be managed to an extent, and a diagnosis was no longer an automatic death sentence, there was no effective treatment until BCG (Bacille Calmette-Guérin) vaccine, after fraught years of trials and considerable resistance from the medical profession, started to be used extensively in Britain in the 1950s. Until then treatment consisted either of radical surgery — usually collapsing a lung, an operation performed on the principle of putting the diseased portion of the body to rest so it could combat disease with its own resources — or exposure to fresh air, on much the same principle of encouraging the recuperative power of nature, since there was not much else on offer.

The notion that sunshine and fresh air helped TB sufferers (and sufferers from other medical conditions) had been popular since the late nineteenth century, and those who could afford it might take the Train Bleu to the South of France or head for the bracing air of the Swiss Alps. The first British sanatorium for the open-air treatment of tuberculosis opened in Edinburgh in 1894, and others followed in Glasgow, Renfrewshire and Frimley in Surrey; they soon spread throughout the country, including one funded by the Post Office Workers’ Union in Benenden in Kent. Some were for the well-off (though the rich usually chose Menton or Davos), many were funded by philanthropists (although, despite its romantic, artistic connotations, TB was regarded primarily as a disease of the poor, and did not attract the same level of donations or research funding as, say, cancer, despite the fact that even at the end of the Second World War it accounted for more deaths between fifteen and twenty-four years of age in Britain than any other condition). Ireland had one of the worst death rates from TB in the world, and although it had been falling since the turn of the century, it started to rise again in 1937, in stark contrast with the rest of the United Kingdom and Europe, due mainly to poverty and a lack of specialist services such as x-ray machines, which barely existed outside Dublin. Faced with the helplessness of the medical profession, those afflicted turned to folk remedies, desperately trusting in the efficacy of a daily dose of linseed oil mixed with honey, swallowing raw eggs or paraffin oil, goats’ milk or dandelion-leaf sandwiches, or positioning themselves in the street outside the Belfast gasworks, since fumes from the vats were reputed to clear the lungs.

Since tuberculosis was ‘the principal social disease of our time’ in the view of Britain’s Chief Medical Officer of Health, with implications for the whole community, the government, in conjunction with local authorities, funded a network of sanatoria (sometimes using old Poor Law infirmaries for the purpose) for free treatment, and aftercare to be provided by tuberculosis dispensaries. If possible the sanatoria were in isolated locations, since statistics showed that tuberculosis was more prevalent in urban areas than rural, and TB was regarded with such suspicion that any proposal to build a sanatorium invariably met with stiff local opposition. (Indeed, local authorities could obtain a court order for a person suffering from pulmonary tuberculosis to be forcibly removed from their home, although they rarely did so.) Ideally they were surrounded by pine trees (which were ‘much appreciated for their exhilarating resinous aroma’), recalling Otto Walther’s German sanatorium in Nordach in the Black Forest, ‘an abode for Spartans’ 1,500 feet above sea level and ‘exposed to every wind’, the model for so many dilute British establishments with names such as Nordach-upon-Mendip and Nordach-on-Dee. They were governed by strict rules — visitors one Saturday afternoon a month was not unusual — with a regime regulated by bells which included rest, a great deal of food (though not always of the highest quality), some outdoor exercise whatever the weather, and indoor crafts such as wood whittling, raffia work, crocheting and painting, and absolutely no sharing of cutlery or crockery. Spitting, a not uncommon habit in the 1930s, was forbidden, since sputum was know to be a carrier of the tubercle bacillus.

Belinda Banham, who had trained as a nurse at St Thomas’s Hospital in London, wrote that the treatment provided to tubercular patients in the 1930s by the Royal Sea Bathing Hospital in Margate (founded in 1791 as the Royal Sea Bathing Infirmary for Scrofula)

consisted, for the main part, in exposure to the elements … each ward gave onto two verandahs, one on either side. The verandahs were equipped with shutters which were never to be closed in the day, and at night only with the permission of the night sister. Permission was rarely granted, even when the snow was falling, as it was thought contrary to the patients’ interest. Cloaks were allowed to nurses only in moving to and from the wards. Strength and stamina were essential to survival … It is difficult today to conceive of the patience and heroism of patients occupying those beds. The length of stay was indeterminate and never less than six months. With tuberculosis of the spine … two or three years was common … with patients often immobilised for two years or more … Efforts were made to protect nurses from contracting tuberculosis, mainly by means of an ample diet … nonetheless, several nursing colleagues did acquire the disease and two died in my time there.

When Dr W.A. Murray arrived at Glenafton Sanatorium in Ayrshire in 1934, he found chilblains ‘prevalent among staff and patients’, which was hardly surprising since the wards had no heating and the icy Scottish wind blew in round the ill-fitting windows, raising the linoleum from the floors in waves ‘which made a ward round something like a trip on a roller coaster. Rain also came through the windows to such an extent that a patient with some skill as a cartoonist’ depicted the doctor ‘doing his rounds in thigh boots while a patient sailed a toy boat round his bed!’

Fresh air was also recommended for supposedly susceptible children who might be ‘pre-tubercular’ (though some were actually suffering from malnutrition), and could be removed from their infectious homes during the ‘delicate years of growth’. By 1937 there were ninety-six open-air day schools in England, catering for 11,409 children; a further 3,985 children boarded at open-air residential schools, while those 2,451 children already affected by pulmonary TB might well attend one of the thirty-six sanatorium schools (or one of the further sixty-five schools catering for children suffering from non-pulmonary tuberculosis). Meanwhile, forty of the 221 schools in Glasgow had been constructed on ‘open-air principles’, with open verandahs, sliding doors to the classrooms and plate-glass windows, and two ‘preventoria’ for children who had been exposed to tuberculosis were built. Those children who for whatever reason could not attend such an institution might be shipped out to foster parents in rural areas to get their fresh air that way.

One problem was the reluctance of those who suspected that they had tuberculosis to seek medical advice, since ill-informed prejudice about the disease might well mean that they were shunned ‘like lepers’ by family and friends, lose their job and find it hard to get another even when they were well again, and have difficulty in getting life assurance cover. ‘The world regards the “lunger” as an outcast,’ wrote a sufferer in the Western Mail in November 1938. ‘Filled with an exaggerated dread of any word ending in “osis,” unthinking people recoil from anyone who had “had it” … Every week scores of “lungers” are released from clinics, hospitals and sanatoria … Each patient goes his own way. Yet each one finds himself up against the same problem … He is not wanted; he is avoided; he is feared — and then alack! forgotten … His own relatives are afraid to have him in the house … Jobs are out of reach … Two kinds of suffering have attended me through the battle [to get well in the sanatorium]. One was the distressful horror of the disease itself. The other is the mental agony born of my knowledge that when I emerge from the fight … I am taboo to my fellow countrymen.’ Such considerations sometimes influenced GPs, who were obliged by law to report cases of tuberculosis, which may mean that rates of incidence in the 1930s were actually higher than reported.