| ||||||||||||||||||||||||||||||||||||||||||||||||||||
© The Society for the Social History of Medicine 2005, all rights reserved
Coasts and Coalfields: The Geographical Distribution of Doctors in England and Wales in the 1930s
University of Bath, Claverton Down, Bath BA2 7AY, UK. E-mail: hssdmp{at}bath.ac.uk
A number of accounts making reference to the geographical distribution of doctors before the introduction of the National Health Service (NHS) rely on scraps of evidence that appear to become more problematic as they are traced back to source, as well as on assertion and anecdote. This article evaluates existing estimates of the geographical distribution of medical staff, and produces data to examine the distribution at local level across England and Wales in the 1930s. On the one hand, the analysis confirms the conventional wisdom that richer, southern areas tended to have more doctors than poorer, northern areas. However, at a local level, it can be shown that arguments emphasizing urban–rural differentials and the influence of medical schools, cannot be upheld. The contribution also emphasizes the fact that it is crucial to examine differences within, as well as between, regions. In short, use of more reliable disaggregated data here produces a more nuanced picture than a number of earlier accounts.
Keywords: doctors; England and Wales; 1930s; interwar period; equality; geographical distribution
1 H. Eckstein, The English Health Service (Cambridge, MA, 1958); C. Webster, Problems of Health Care. The Health Services Since the War (London, 1988); A. Gray, ‘A Mixed Economy of Health Care’, in A. McGuire, P. Fenn, and K. Mayhew (eds), Providing Health Care: The Economics of Alternative Systems of Finance and Delivery (Oxford, 1991), 233–60; M. Powell, Evaluating the National Health Service (Buckingham, 1997).
2 See, for example, R. Pinker, English Hospital Statistics 1861–1938 (London, 1966) and M. Powell, ‘Hospital Provision before the NHS: A Geographical Study of the 1945 Hospital Surveys, Social History of Medicine, 5 (1992), 483–504; idem, ‘Did Politics Matter? Municipal Public Expenditure in the 1930s’, Urban History, 22 (1995), 360–79; M. Gorsky, J. Mohan, and M. Powell, ‘British Voluntary Hospitals, 1871–1938: The Geography of Provision and Utilisation’, Journal of Historical Geography, 25 (1999), 463–82; M. Gorsky, J. Mohan, and M. Powell, ‘The Financial Health of Voluntary Hospitals in Interwar Britain’, Economic History Review, lv (2002), 533–57; J. Mohan, Planning, Markets and Hospitals (London, 2002); A. Levene, M. Powell, and J. Stewart, ‘Patterns of Municipal Health Expenditure in Interwar England and Wales’, Bulletin of the History of Medicine, 78 (2004), 635–69.
3 R. Titmuss, Problems of Social Policy (London, 1950), p. 70.
4 Sir G. Godber, The Health Service: Past, Present and Future (London, 1975), p. 27.
5 Nuffield Provincial Hospitals Trust, The Domesday Book of the Hospital Services (Oxford, 1946), pp. 6–7. For the Hospital Surveys, see Powell, ‘Hospital Surveys’.
6 S. Cherry, Medical Services and the Hospitals in Britain, 1860–1938 (Cambridge, 1996), p. 29. A complete run of figures is given for England and Wales, and Scotland, but only intermittent entries for Britain (including Ireland and overseas).
7 A. Hardy, Health and Medicine in Britain since 1860 (Basingstoke, 2001), p. 17.
8 A. Digby, Making a Medical Living. Doctors and Patients in the English Market for Medicine, 1720–1911 (Cambridge, 1994), pp. 20–3.
9 I. Loudon, Medical Care and the General Practitioner 1750–1850 (Oxford, 1986), pp. 215–8, 260.
10 S. M. Herbert, Britain's Health (Harmondsworth, 1939); H. Levy, National Health Insurance (London, 1944); A. Bradford Hill, ‘The Doctor's Day and Pay’, Journal of the Royal Statistical Society Series A, cxiv (1951), 1–34; B. Abel-Smith, The Hospitals 1800–1948 (London, 1964); R. Stevens, Medical Practice in Modern England (New Haven, 1966); N. Parry and J. Parry, The Rise of the Medical Profession (London, 1976); F. Honigsbaum, The Division in British Medicine (London, 1979); N. Eder, National Health Insurance and the Medical Profession in Britain, 1913–1939 (New York, 1982); N. Whiteside, ‘Private Agencies for Public Purposes: Some New Perspectives on Policy Making in Health Insurance Between the Wars’, Journal of Social Policy, 12 (1983), 165–94; A. Digby and N. Bosanquet, ‘Doctors and Patients in an Era of National Insurance and Private Practice’, Economic History Review, xli (1988), 74–94; N. Whiteside, ‘Regulating Markets: The Real Costs of Poly-Centric Administration under the National Health Insurance Scheme 1912–46’, Public Administration, 75 (1997), 467–85; A. Digby, The Evolution of British General Practice 1850–1948 (Oxford, 1999); Cherry, Medical Services. See also the novel by the doctor/novelist, A. J. Cronin, The Citadel (London, 1983, first published 1937) and his autobiography, Adventures in Two Worlds (London, 1952).
11 M. Powell, ‘A Tale of Two Cities: A Critical Evaluation of the Geographical Provision of Health Care before the NHS’, Public Administration, 70 (1992), 67–80.
12 Political and Economic Planning, Report on the British Health Services (London, 1937); Herbert, Britain's Health; Digby and Bosanquet, ‘Doctors and Patients’. Political and Economic Planning (PEP) was an influential organization representing ‘middle opinion’ in the 1930s. For more details on the National Health Insurance (NHI) scheme, see Levy, National Health Insurance; Eder, National Health Insurance; Whiteside, ‘Private Agencies’; and idem, ‘Regulating Markets’; Digby, Evolution; Cronin, Citadel; and idem, Two Worlds.
13 Levy, National Health Insurance, p. 129.
14 Bradford Hill, ‘Pay and Day’.
16 Herbert, Britain's Health, p. 76.
17 PEP, Medical Care for Citizens (London, 1944), p. 55.
18 Report of the Inter-Departmental Committee on the Remuneration of Consultants and Specialists, P.P. 1948 (Cmnd 7420), Spens Report, xi, 1947–8, p. 18.
19 Stevens, Medical Practice, p. 98. For the difficulties in constructing a list, see F. Honigsbaum, Health, Happiness and Security (London, 1989), chs 10–13.
20 Stevens, Medical Practice, p. 53.
21 M. A. Crowther and M. Dupree, ‘The Invisible General Practitioner: The Careers of Scottish Medical Students in the Late Nineteenth Century’, Bulletin of the History of Medicine, 70 (1996), 388.
23 Herbert, Britain's Health, p. 75.
24 J. Jewkes and S. Jewkes, The Genesis of the British Health Service (Oxford, 1962), Appendix, p. 54.
25 Cherry, Medical Services, p. 29. See below for a discussion of retired doctors.
26 Stevens, Medical Practice, p. 56. The absence of a definitive list is also noted by D. S. Murray, Health For All (London, 1942), Honigsbaum, Division, and Jewkes and Jewkes, Genesis.
27 Honigsbaum, Health, Happiness and Security, p. 51.
28 Murray, Health for All, p. 16.
29 Herbert, Britain's Health, un-numbered footnote, p. 70.
30 Digby and Bosanquet, ‘Doctors and Patients’, p. 75.
32 Nuffield Provincial Hospitals Trust/Ministry of Health (NPHT), Hospital Surveys, Statistical Appendices, 10 volumes (London, 1945–6). See here Powell, ‘Hospital Survey’.
33 Bradford Hill, ‘Doctor's Day and Pay’.
34 For example, the ratio of generalists to specialists varies from about 5:1 in Honigsbaum, Health, Happiness and Security to 6:4 in Stevens, Medical Practice.
35 Abel-Smith, Hospitals, pp. 406–7.
36 S. Leff, The Health of the People (London, 1950), p. 210.
37 This was frequently reported by the teams of war-time hospital surveyors in the full ten-volume set of reports, and noted by both the ‘Domesday Book’ summary of the surveys and in the Annual Report of the Minister of Health: NPHT, Hospital Surveys, 10 volumes, NPHT, Domesday; Minister of Health's Annual Report for 1945–46, P.P. 1946, vii, 1947–8.
38 In addition to the quantitative distribution of GPs, there was also a debate about the quality of general practice before the NHS and in the early years of the new service. See Levy, National Health Insurance; Stevens, Medical Practice; Eder, National Health Insurance; Digby, Evolution; Taylor, Good General Practice; J. Butler, J. Bevan, and R. Taylor, Family Doctors and Public Policy (London, 1973); J. Fry, General Practice and Primary Health Care 1940s-1980s (London, 1988); I. Loudon, J. Horder, and C Webster (eds), General Practice under the NHS 1948–1997 (Oxford, 1998).
39 PEP, Medical Care, p. 6. However, a ‘haphazard’ distribution cannot be ‘determined primarily’ by one factor.
40 Hansard [HC], cols 620–1. March 17 1944, Debate on ‘A National Health Service’. cols 620–1. P.P. 1943–4, HC, 5th Series, vol. 398.
41 See also Jewkes and Jewkes, Genesis.
43 S. Taylor, Good General Practice (London, 1954), pp. 28, 47. Compare the evidence in Digby, Evolution, for the medical school factor.
46 A National Health Service, P.P. 1944 (Cmnd 6502) 1943–4, viii, p. 25; Minister of Health's Annual Report for 1945–6, p. 67; N. Wilson, Municipal Health Services (London, 1946), pp. 166–7; Leff, Health of the People, p. 228; Murray, Health For All, p. 16.
47 Spens Report; and Abel-Smith, Hospitals, pp. 406–7.
48 Calculated from figures in Herbert, Britain's Health, p. 68.
49 Sir H. Eason, R. Veitch Clark, and W. Harper, Hospital Survey: The Hospital Services of the Yorkshire Area (London, 1945), pp. 19–20. Sir H. Lett and A. Quine, Hospital Survey: The Hospital Services of the North-Eastern Area (London, 1946), p. 13. See also Powell, ‘Two Cities’.
50 Medicine Today and Tomorrow, March 1939, pp. 12–13.
51 The Medical Directory is the most likely source since it provides local lists.
52 Titmuss, Problems, p. 71; Eckstein, English Health Service, p. 61.
53 J. R. Hollingsworth, A Political Economy of Medicine (Baltimore, 1988), p. 43.
54 Leff, Health of the People, p. 210.
55 A. Lindsay, Socialized Medicine in England and Wales (Chapel Hill, 1962); V. Walters, Class Inequality and Health Care (Beckenham, 1980).
56 Eckstein, English Health Service, p. 61; Walters, Class Inequality, p. 57; Hollingsworth, Political Economy, p. 43; Butler et al., Family Doctors, p. 7.
57 Eckstein, English Health Service, p. 59; Titmuss, Problems; Hollingsworth, Political Economy, p. 43; Walters, Class Inequality, p. 56; Stevens, Medical Practice.
58 Gorsky et al., ‘British Voluntary Hospitals’.
59 See Herbert, Britain's Health and Digby, Medical Living.
60 Herbert, Britain's Health, pp. 68–9. There were 9,444 doctors in London, 26,093 in the provinces, 6,091 in Scotland, 3,172 in Ireland, and 1,892 in Wales.
61 Leff, Health of the People, p. 211
62 PEP, British Health Services.
63 Eckstein, English Health Service, p. 62; Leff, Health of the People, p. 211; Taylor, Good General Practice, p. 35.
64 Minister of Health's Annual Report, 1945–6, p. 28.
65 B. Cardew, ‘The Family Doctor’, in J. Farndale (ed.), Trends in the NHS (London, 1964).
67 Powell, ‘Hospital Provision before the NHS’.
68 This is confirmed by a 
2 test: 2=36.6, statistically significant at 0.01.
69 Full details may be found in M. Powell, ‘Hospital Provision before the NHS: Territorial Justice or Inverse Care Law?’, Journal of Social Policy, 21 (1992), 145–63.
70 See Gorsky et al., ‘British Voluntary Hospitals’.
71 Butler et al., Family Doctors, suggest that this continued after 1948 in the NHS.