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4
Middle-class medicine
It is well known that Englishmen are in the main opposed to any and
every new system with which they are not familiar. Probably to this inu-
ence is due the fact, that, with a few exceptions, pay wards are as unknown
in this country as the pay hospitals themselves.1
Sir Henry Burde, founder of the King’s Fund, 1879
ere was only one area of the pre-NHS hospital system which genu-
inely saw private healthcare operating on a commercial basis. is was
the parallel provision made for middle-class patients, the likes of
‘George’ from Your Very Good Health, in the British hospital of the early
twentieth century. Since admission of middle-class patients was com-
monly seen as a threat to the charitable character of the institution, as
will be examined in the next chapter, it became the established practice
to have income limits for admission to the ordinary wards. In Bristol
these rose from roughly £250 per year in the 1920s to over £400 in the
1940s, roughly in line with the threshold for income tax.2 ose above
this level would have been termed ‘middle-class’ by the Ministry of
Labour and hospital authorities alike, and commonly excluded from
accessing hospital services through the mechanisms described in the
previous chapter.3 It was only by charging higher rates to this separate
class of patient that the hospitals stood any chance of turning a prot.
is new category of patient would be accommodated not in the usual
dormitory-style wards, but in a separate one- or occasionally two-bed
room, domestic in style. ese private wards would be physically sepa-
rate, sometimes in entirely separate buildings. Charges for such rooms
were not voluntary contributions towards the cost of maintenance, but
rather compulsory fees set at a rate to cover at least the full cost of treat-
ment. Consequently, where patients in the general wards might pay up
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Middle-class medicine 121
to one guinea per week, patients in these private wards could pay up to
ten guineas per week. In addition to which they would have to negotiate
with the doctor a fee for his services.4
Paying the very highest rates was rare, according to condential brief-
ing papers produced for parliamentarians by the King’s Fund, lobbying
in support of more voluntary hospital services for private patients. Sur-
veying the provision on oer in London in the mid-1930s, the King’s
Fund categorised the dierent rates charged as ing for patients of
‘limited means’ (up to three guineas per week), ‘moderate means’
(between four and seven) and the ‘well-to-do’ (eight to ten). e vast
majority (73 per cent) they classed as being for the middle group, with
only 1 per cent for the highest.5 More reliable evidence has been pro-
duced from assessments based on the rateable value of given addresses
in Middlesbrough hospitals, suggesting the ‘class and wealth’ of inpa-
tients changed lile with the arrival of private patients.6
e emergence of private provisions might be seen as a logical devel-
opment, given the elite reputation of the larger voluntary hospitals and
the common view of the alternative – poor law inrmaries – as institu-
tions of last resort.7 Indeed, this was the view of Charles Rosenberg in
identifying a ‘private patient revolution’ in American hospitals at the
turn of the twentieth century.8 However, as Paul Bridgen has argued,
based on King’s Fund evidence for London, the British voluntary hos-
pitals ultimately failed to become the provider of hospital services for
the middle classes. He suggests that, despite the eorts of the King’s
Fund, a ‘voluntary hospital insuciency’ in middle-class provision le
the middle classes with ‘lile to lose’ from the nationalisation of the
hospitals in the NHS.9 Taking a wider view of the paerns of provision,
it is clear that the relocation of middle-class patients requiring institu-
tional care, from the nursing home to the hospital, was only partially
achieved over the early twentieth century. e crude nancial sense of
redirecting the eorts of the hospitals towards these private patients
was rejected in favour of a continued focus on treating the sick poor of
the working classes.
Five key conclusions can be drawn regarding the paerns of provi-
sion across Britain. First, that middle-class provision remained mar-
ginal in the voluntary hospitals up until nationalisation, despite some
gradual growth over the early twentieth century. In line with Bridgen,
this runs counter to assumptions of a fundamental shi towards a
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122 Payment and philanthropy in British healthcare, 1918–48
consumer-insurance system.10 Second, that such provision was more
heavily focused in the general hospitals than specialist institutions.
ird, that it was more oen to be found in smaller hospitals than larger
ones. Fourth, entirely private hospitals were very rare. Instead, private
patients were usually a small minority in the institution; while separate
wards, sometimes in separate buildings, meant they were unlikely to
receive treatment alongside the working classes. Finally, provision was
largely provided around a few major cities, and when considered pro-
portionately to the local population, provision appears predominantly
to be a characteristic of the southern voluntary hospital sector.
As a wealthy southern city and regional medical centre, we might
well expect Bristol to be a hub of private hospital provision.11 In fact, it
was quite the opposite. e number of private beds in Bristol hospitals
was signicantly below the national average and they were atypically
concentrated in specialist institutions. To understand this we must see
Bristol in its regional context, especially alongside the neighbouring
city of Bath. e specialist services of Bristol’s hospitals, particularly in
maternity care, contributed to a dual hub split between the two cities,
jointly providing hospital services to the region’s middle classes. is
variation in locality, size and type of hospital both explains the aytpical-
ity of Bristol and nuances the ‘insuciency’ of private provision identi-
ed by Bridgen.12
The scale of private provision
Britain: the national picture
In assessing the scale of private hospital provision before the NHS, we
nd a problematic lack of comprehensive or reliable data, with confu-
sion common over the term ‘pay bed’. It is a somewhat misleading
phrase as it was increasingly the norm through the early twentieth
century for most patients to pay something. erefore all beds might
be classied as pay beds.13 is problem seems to eect both of the main
contemporary national sources we have for hospital statistics: the Hos-
pital Year-Books (which succeeded Burde’s Charities in the early 1930s
as a compilation of annual hospital information) and the reports of
the wartime regional hospital surveys conducted by the Ministry of
Health and the Nueld Provincial Hospitals Trust. In both there were
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Middle-class medicine 123
confusions in recording the number of private beds for various institu-
tions, sometimes listing all beds as pay beds. In Bristol, for example, this
was seen in the cases of the Bristol Maternity Hospital, the Walker
Dunbar Hospital for Women and Children, and the maternity Grove
House Home.14
To avoid such confusions, we might turn to metropolitan bodies
such as the King’s Fund; although information from an organisation
with its own policy agenda will always need to be seen in that light. e
earliest available gures on the scale of private provision in the volun-
tary hospital sector come from a King’s Fund comparison of the number
of pay beds in 100 London hospitals in 1913 and 1933, provided con-
dentially for parliamentarians promoting simplifying the process for
allowing private patients in hospitals where there were problems with
the wording of their charitable trust deeds. For 1913 they record 393
pay beds and 3,225 ordinary beds (a lile over 10 per cent of the total).
For 1933 it was 1,389 to 4,050 (slightly over 25 per cent).15 ere can
be lile doubt, however, that those 100 hospitals were highly unrepre-
sentative and presumably chosen in order to present a distorted picture
in which private provision for the middle classes was both a signicant
and rapidly growing part of hospital work in the capital. If over a quarter
of beds had been private across London’s 159 voluntary hospitals this
would have totalled over 4,000; rather more than the 1,573 listed in the
1933 Hospitals Year-Book. is fuller source gives the proportion of
voluntary hospital beds for private patients in the capital a lile below
9 per cent.16 Given that the King’s Fund brieng papers claimed the rate
was higher than this in 1913, before twenty years of expansion, the
choice of which 100 hospitals to record – unnamed and with no criteria
given for their selection – appears lile more than an exclusion of those
institutions not sharing their enthusiasm for the admission of private
patients. e King’s Fund itself can hardly have been under the impres-
sion that the capital’s hospitals all ed this paern, when they had
found from a questionnaire in 1927 that forty-one were making no
private provision whatsoever.
Despite all these gaps and uncertainties with various information
sources, some general trends are identiable. From 1933 the Hospitals
Year-Books show a trend of growth. In absolute terms, as can be
seen from gure 4.1, the number of private beds in voluntary hospitals
across Britain increased by four-hs in the een years before the
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124 Payment and philanthropy in British healthcare, 1918–48
introduction of the NHS. e rate of this growth, however, was much
greater in the 1930s than the 1940s. Between 1933 and 1938 it increased
by two-thirds, while by less than one-tenth between 1938 and 1947. A
modest growth was returned aer a temporary wartime slowdown,
when private wards were among those reallocated under the Emer-
gency Medical Service. is growth in private beds was slightly ahead
of the growth in voluntary hospital beds in general, as shown in gure
4.2. Here there was also a clear trend of growth between 1933 and 1938,
from 6 per cent in the early 1930s to around 8.5 per cent. Despite a
small increase in the overall number of private beds during the war, they
Figure 4.1 Number of private beds in Britain, 1933–47
0
1000
2000
3000
4000
5000
6000
7000
8000
9000
1933 1935 1938 1943/44 1947
Scotland
Provinces
London
Figure 4.2 Private beds as a percentage of all voluntary hospital beds in
Britain, 1933–47
0
2
4
6
8
10
12
14
1933 1935 1938 1943/44 1947
London Provinces Scotland Britain
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Middle-class medicine 125
declined as a focus of the hospitals’ work, falling back to almost early
1930s levels. Across the country the balance was restored thereaer, so
the situation in the provinces on the eve of war was very similar to that
on the eve of the NHS. is was not the case for the heavily bombed
and evacuated capital. Although private provision was still most promi-
nent in London’s voluntary hospitals, late 1930s levels were not restored
aer the war either as a proportion of beds or in absolute terms.
What is harder to put a gure on is the number of private beds for
middle-class patients in public hospitals. As previously discussed, the
assumption that all voluntary hospital beds were private has been
unhelpful. e assumption that the larger and more numerous public
hospitals made no private provision has been even more unhelpful.
Most directories and surveys appear to have thought this gure not
worth recording, although the wartime survey of the North West region
is a rare exception (discussed further below). If we treat the North West
of England’s private 0.27 per cent of public hospital beds as representa-
tive, we can come to a very rough projected estimate for the whole of
Britain; somewhere under 4,000 private beds out of the 144,000 total
in all British public hospitals. Taking this combined with the voluntary
hospital gures, we can estimate that only around 3 or 4 per cent of all
hospital beds before the NHS were those for the middle-class h of
the population. While this gure should be taken only as a rough esti-
mate, it does demonstrate clearly that provision for the middle classes
was very much a fringe aspect of the pre-NHS hospitals’ work.
e scale of private provision in Bristol
Bristol did not t this paern. Only slightly more than 2 per cent of
voluntary hospital beds in the city were private in 1933.17 In fact, the
rst private beds were not established in Bristol until 1926. Four years
earlier, the Bristol Royal Inrmary’s House Commiee had prevented
the introduction of private wards by accepting the opening of a new
maternity ward only on the understanding that it would be exclusively
for ‘such patients as can pay no more than the full cost of their mainte-
nance’.18 Of those rst private wards in Bristol, there were three double
wards (two-bed rooms) charged at £5 5s 0d per week, which the King’s
Fund would have categorised as aimed at patients of ‘moderate means’.
Meanwhile, there were a further thirteen single wards (one-bed rooms)
with charges of £8 8s 0d per week, which even a decade later and in
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126 Payment and philanthropy in British healthcare, 1918–48
London would be classed as a level of payment appropriate for the
‘well-to-do’ patient.19 is was signicantly higher than the rates sug-
gested by the Honorary Medical Stas, which at dierent times was a
at rate of ve guineas per week, three-to-four guineas per week, and
£3 3s 0d for double wards and £4 4s 0d for single wards.20 e implica-
tion of the higher rates put into practice is that, although limited, this
earliest private hospital provision in Bristol was amongst the elite.
From this limited but elite provision in the late 1920s, the 1930s saw
an increase in the number of private beds in Bristol. Although provision
at the Bristol Royal Inrmary was reduced in the early 1930s from the
initial nineteen beds to een, other hospitals introduced private wards,
as can be seen from gure 4.3. ese included four (rising to six) beds
at the Bristol Royal Hospital for Sick Women and Children, with
charges of £3 13s 6d. e Cossham Memorial Hospital had three
(reduced to two) and the Bristol Maternity Hospital for a short time
had four, all charged at £4 4s 0d. e six private beds at the Bristol
Homeopathic Hospital were charged at £7 7s 0d per week. e Bristol
General Hospital introduced three private beds at the same time as
Figure 4.3 Growth in number of private beds in Bristol voluntary hospitals,
1933–47
Note: General hospitals in solid, specialist hospitals paerned.
0
10
20
30
40
50
60
70
80
90
100
1933 1935 1938 1943/4 1947
Bristol Eye Hospital
Mount Hope Maternity Home
Walker Dunbar Hospital
Bristol Maternity Hospital
Bristol Children's Hospital
Bristol Homeopathic Hospital
Cossham Memorial Hospital
Bristol General Hospital
Bristol Royal Infirmary
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Middle-class medicine 127
amalgamating with the Bristol Royal Inrmary, producing a combined
eighteen beds, while the Bristol Eye Hospital opened a further twelve
in the late 1930s. At the close of the decade, in 1939, a new private ward
of een beds was opened at the Mount Hope Maternity Home, as the
hospital’s coverage was extended to married mothers. ese gures
reveal a near doubling of private hospital provision in Bristol over the
second half of the 1930s.21
A similar system to that of the voluntary hospitals was in operation
at Bristol’s pre-NHS public hospitals – in particular, Southmead Hos-
pital. A Ministry of Health survey of the city’s health services in the
early 1930s commented on its ten ‘single wards’ for ‘paying patients’ at
a charge of £3 3s 0d per week.22 ere is lile evidence of how private
provision developed from this point, although we know one former
patient was wrien to in 1941 by the city’s Medical Ocer of Health
informing her ‘that the Assessment Sub-Commiee, with their author-
ity passed a Resolution requiring you to contribute the sum of £17 2s
0d in respect of Maintenance of Self’ for a period of thirty-eight days
as an inpatient.23 is shows a municipal hospital operating a private
system based on a distinction between a set charge for maintenance and
a separately negotiated medical fee, just as in the voluntary hospitals.24
A notable dierence in payment between the two, however, was the rate
of payment. is was signicantly lower at Southmead, suggesting the
city’s municipal general hospital was not catering for its wealthiest citi-
zens.25 Another dierence is who requested payment. As private wards
were introduced in the voluntary hospitals it became an important
point for the medical stas that they should not directly be involved in
collecting funds.26 It would appear that the city’s long-serving Medical
Ocer of Health, Dr R.H. Parry, either had no such qualms or was
convinced to set them aside. Although this might not have been stand-
ard procedure, it does suggest the provision of private hospital services
was rmly embedded in the city’s municipal health culture.
We might assume, given the fact that Southmead had been taken
over in 1930 by the Corporation, that the introduction of this system
was part of the new municipal arrangement. However, a conference
organised shortly before by the Medical Ocer of Health, which
brought together representatives of the city’s hospitals heard that,
although Southmead ‘was designed for the pauper sick’, the poor law
guardians had ‘found it necessary to throw open their doors to patients
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128 Payment and philanthropy in British healthcare, 1918–48
of all classes’.27 Of Southmead’s 3,000 patients in 1929, ‘roughly one half
were not pauper patients’ they heard, suggesting the patient base was
increasingly similar to that of the voluntary hospitals even before
municipalisation. Moreover, they were told that this change would
‘remove the stigma of pauperism’ from the hospital.28 e Council’s
policy for admission at Southmead was explained in remarkably famil-
iar terms: ‘the sick poor would have rst claim upon the accommoda-
tion at Southmead, but any citizen would have the right to apply for a
bed at the Hospital, subject to the condition of paying all or part of the
cost, if able.’ e 1929 Local Government Act reinforced this system,
making it ‘the duty of the Corporation under the Act to recover the cost
of treatment from all patients who are able to pay’.29
e fact that these patients were accommodated in the ten ‘single
wards’ is hard to square with their aim ‘to ensure that those persons
who will receive from the Council by reason of their poor circum-
stances assistance in the form of hospital treatment shall do so in the
same hospitals and under the same conditions as the rest of the citi-
zens’.30 At Southmead the Corporation, as the Board of Guardians
before them, were aiming to provide a general hospital service with
essentially the same payment system as the voluntary hospitals.
Locating private provision
Beyond the voluntary-municipal mix, there are three dimensions to the
paern of provision we should consider. e rst of these is the insti-
tutional location of private beds according to the size of the hospital,
which sheds light on how segregated or integrated private patients were
as well as on how much private provision characterised and directed
the work of the voluntary hospitals. Understanding the type of hospital
(i.e. general or specialist) can help us gain some understanding of what
kinds of medical treatment were being provided to middle-class
patients. e third is the geographical spread of provision, revealing the
extent to which middle-class treatment in the voluntary hospitals was
a reality across the country.
Size of hospital
e key question here is whether provision for the middle classes was
primarily located in those larger institutions, the mainstay of medical
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Middle-class medicine 129
treatment for the acute sick in the area, or in those smaller ones focused
on serving a certain group or service, or indeed whether provision
might be spread across the two. Figure 4.4 shows the prominence of
private wards in small hospitals (with fewer than 100 beds), medium-
sized hospitals (with 100–199 beds), and large hospitals. Consistently
we see private beds accounting for by far the largest proportion of all
beds in small hospitals, and the smallest proportions in large hospitals.
Although Bristol had very few private beds in medium-sized hospitals,
it was in line with the national picture in having a majority in small
hospitals. A rather dierent situation was evident in Glasgow, with two-
thirds of its private beds found in large voluntary hospitals, and a further
10 per cent in a 185-bed institution.31 However, the largest with private
beds in the rest of Scotland was the Queen Mary Nursing Home, a
hospital of y-ve beds in Edinburgh. We might assume those large
proportions of beds for private patients in small hospitals added up to
lile, with the smaller proportions in the biggest hospitals being the
most signicant to look at. In fact, as gure 4.5 shows, the opposite is
true. In the early 1930s there were more private beds in small hospitals
than in medium and large ones combined. Even as the proportion of
private beds found in large hospitals increased, and that in medium and
Figure 4.4 Private beds as a percentage of total provision in voluntary
hospitals of dierent size in Britain, 1933–47
0
2
4
6
8
10
12
14
1933 1935 1938 1943/44 1947
Large Medium Small Overall
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130 Payment and philanthropy in British healthcare, 1918–48
small ones decreased, over the next decade there were still more private
beds in small than large hospitals.
While the faster expansion of private wards in large hospitals in the
1940s did narrow the gap to less than 4 per cent, it is clear that middle-
class patients were readily opting for treatment in smaller institutions.
Evidently they did not share the view of Lord Moran, President of the
Royal College of Physicians, who described hospitals with fewer than
100 beds as ‘much too small to full the functions of a rst-class hospi-
tal’.32 Health Minister Aneurin Bevan expressed a similar opinion during
the passage of the National Health Service Bill in 1946:
ere is a tendency in some quarters to defend the very small hospital
on the ground of its localism and intimacy, and for other rather impon-
derable reasons of that sort, but everybody knows today that if a hospital
is to be ecient it must provide a number of specialised services.
Although I am not myself a devotee of bigness for bigness sake, I would
rather be kept alive in the ecient if cold altruism of a large hospital than
expire in a gush of warm sympathy in a small one.33
Figure 4.5 Proportion of all private beds in dierent size voluntary
hospitals in Britain, 1933–47
0
10
20
30
40
50
60
70
80
90
100
(%)
1933 1935 1938 1943/44 1947
Large Medium Small
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Middle-class medicine 131
e larger share of private beds found in small hospitals might be
explained by a great number of entirely private hospitals specialising in
treating middle-class patients, if it were not for the fact that such institu-
tions were exceedingly rare. ere were of course a huge number of
private nursing homes providing care for the sick; but only nine such
institutions with resident medical ocers existed in 1933.34 By 1938
their number had doubled, though remained very limited at only eight-
een in all of England (see table 4.1). In Scotland there were a further
four. ese were a hospital for women in Glasgow of sixty-seven beds
and another of forty in Edinburgh, as well as an eight-bed hospital in
Wick and a four-bed maternity home in Berwickshire. Eight of the
eighteen in England were general hospitals, including London’s Royal
Masonic Hospital in Ravenscourt Park, by some way the largest with
Table 4.1 Entirely private hospitals in England, 1938
Hospital Type Area Beds
Royal Masonic, Ravenscourt Park General London 200
Forbes Fraser Private Hospital General Bath 74
e Fielding Johnson General Leicester 43
Queen Victoria Nursing Institution General Wolverhampton 42
Bromhead Nursing and Maternity
Home
General Lincoln 34
St Mary’s Convalescent Home Special Somerset 34
Leazes House Sanatorium,
Wolsingham (TB)
Special Durham 33
e John Faire, Leicester General Leicester 30
St Saviours for Ladies of Limited
Means (Women & Children)
General London 21
Rosehill Private Sanatorium, Penzance Special Cornwall 20
Ellerslie House Special Noingham 18
Burton-on-Trent Nursing Institution
and Maternity Home
Special Burton-on-Trent 15
Merthyr Guest Memorial Hospital General Somerset 12
Duchess of Connaught Memorial,
Bagshot (maternity)
Special Surrey 7
Sources: e Hospitals Year-Books (London, 1933–47); Ministry of Health,
Regional Hospital Services Survey Reports (London, 1945).
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132 Payment and philanthropy in British healthcare, 1918–48
200 beds and no other having more than seventy-ve. Combined,
entirely private hospitals provided only 583 beds across England in
1938. is was a rather small 9.2 per cent of all 6,341 private beds and
a measly 0.7 per cent of all 83,158 voluntary hospital beds at the time.
While their number increased further to twenty-two before the intro-
duction of the NHS, the private hospital remained in our period very
much a rarity.35
On the basis of these gures, any notion that the voluntary hospitals
were essentially private hospitals can be refuted outright. Sir Henry
Charles Burde, founder of the King’s Fund, had long been amongst
those calling for the introduction of a series of ‘Home Hospitals’. In
1879 he laid out his proposals for ‘a sort of sick lodging-house’ for the
middle classes, ‘where they can, for a reasonable payment, secure all
that their case requires, and that their means will allow’. is was to be
‘the pay hospital par excellence’.36 Plans in 1842 for ‘a hospital for the
middle classes in London’ had failed ‘through lack of support’, and it
was not until 1880 that the Home Hospital Association established
such an institution in the capital. Unlike in Burde’s proposals, however,
Keir Waddington has described the new institution as one where ‘e
pay principle was implicit and the association endeavoured to promote
the contributory system’.37 By the interwar years there was a small
number of entirely private hospitals, more of the kind envisaged by
Burde. A leading example, until it was taken over by municipal author-
ities in the 1930s, was St Chad’s Hospital for paying patients in Edgbas-
ton, Birmingham. Its 1923 report states that they received deputations
from various cities considering seing up some equivalent, including
London, Glasgow, Manchester, Sheeld and Bristol.38 Clearly they did
not decide to follow suit. e Honorary Secretary of the Bristol and
District Divisional Hospitals Council, John Dodd, made a similar visit
twenty years later, ‘in view of the urgent need for this kind of accom-
modation in Bristol’. However, rather than visiting an entirely private
hospital, he went ‘to survey the private ward accommodation’ of the
Bradford Royal Inrmary.39
e overwhelming majority of private beds were to be found in
ordinary hospitals in wards of one or a very small number of beds. Far
more common than an entirely private hospital, was devoting a separate
oor or wing of the hospital building to middle-class patients, as with
the Baker Memorial Wing of St George’s Hospital in London or the
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Middle-class medicine 133
100-bed Canniesburn annexe of the Glasgow Royal Inrmary.40 ese
private wards very rarely became the main business of the hospital, with
private beds at half or more of the total in only ve cases in the mid-
1930s. Combined, entirely private hospitals and those with a majority
of beds for private patients reached their peak of 3.1 per cent of all
voluntary hospitals by the establishment of the NHS.41 Hence, even
aer decades of growth in private provision, heavily subsidised work-
ing-class patients were the majority in 96.9 per cent of voluntary
hospitals.
We can see this paern in Bristol, where there were no private hos-
pitals. Instead, middle-class patients were typically found in one- or
two-bed private wards. As can be seen from table 4.2, there were only
two hospitals in Bristol where private beds were more than 10 per cent
of the total, and none as high as 15 per cent. is means the trend dis-
cussed above, for treating predominantly working-class patients, was
strongly reected locally. Moreover, an overwhelming majority of all
private beds in the city, thirty-ve of y-one, were located in small
hospitals.42 is may have made it harder to provide the respectability
Table 4.2 General and private beds in all voluntary hospitals
in Bristol, 1938
Hospital General Private
Bristol Royal Inrmary 410 15 3.5%
Bristol General Hospital 266 3 1.2%
Bristol Children’s Hospital 103 6 5.5%
Cossham Memorial Hospital 98 2 2.0%
Bristol Eye Hospital 72 12 14.3%
Queen Victoria Jubilee Convalescent Home 80 0 0.0%
St Monica’s Home of Rest 80 0 0.0%
Bristol Homeopathic Hospital 73 6 8.6%
Bristol Maternity Hospital 32 4 11.1%
Walker Dunbar Hospital 29 3 9.4%
Total 1,243 51 3.9%
Sources: e Hospitals Year-Book for 1938 (London, 1938) and V. Cope, W.
Gill, A. Griths and G. Kelly, Hospital Survey: e Hospital Services of the
South-Western Area (London, 1945).
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134 Payment and philanthropy in British healthcare, 1918–48
aorded by physically separating the two types of ward, ensuring mid-
dle-class and working-class patients had no need to brush up against
each other.
Type of hospital
is concentration of Bristol’s private beds in smaller hospitals is more
understandable when bearing in mind that, bucking the national trend
(see table 4.3), over two-thirds were in specialist institutions.43 Although
in the late nineteenth century private payment was far more common
in specialist institutions, by 1938, aer an expansion of private provi-
sion, four-hs of private beds were to be found in general hospitals.44
Yet in Bristol’s three voluntary general hospitals combined there were
only twenty private beds out of a 794-bed total (2.5 per cent).45 is
contrasts with the 100-bed private wards found at both the Manchester
Royal Inrmary (13.5 per cent of the 740 beds) and the Glasgow
Royal Inrmary (12.6 per cent of 794).46 As table 4.2 shows, nearly
one-quarter of the private beds in the city’s voluntary hospitals were
those at the Bristol Eye Hospital, where twelve beds was 14.3 per cent
of the institutional total. What continued to grow in the 1940s was
maternity provision, including the een-bed private ward opened at
the Salvation Army’s Mount Hope Maternity Home in 1939 and an
expansion to twenty-ve private beds at the Walker Dunbar Hospital
(see gure 4.4). Meanwhile, the Homeopathic Hospital was able to
boast of doubling the number of births in its private wards from eight
in 1936 to sixteen the following year.47 Similarly, the private wards at
the city’s general hospitals may well have been used for the connement
of expectant mothers. It is clear that maternity was the driving force
behind the limited private provision made by Bristol’s voluntary
hospitals.
is was a notable change in the decades that followed the city’s rst
private provision at the Bristol Royal Inrmary in 1926, when mental
and maternity cases were the two categories excluded.48 However, this
was a time of change for the status of hospital births in general, as they
grew from under a quarter of all births in the 1920s to a majority in the
1940s.49 roughout the interwar years, however, it was the starting
point for debate that hospital services ‘should be available only for those
mothers whom it was felt unwise to deliver at home, whether for
medical or social reasons, and for teaching purposes’.50 Yet some areas
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Middle-class medicine 135
Table 4.3 Private beds in local, regional and national voluntary hospitals by type and size of hospital in 1938
Bristol South West England
General Private General Private General Private
General 774 20 2.5% 4,716 514 9.8% 51,208 4,918 8.8%
Special 469 31 6.2% 1,550 95 5.8% 24,768 1,192 4.6%
200+676 18 2.6% 1,596 64 3.9% 29,092 2,227 7.1%
100–199 201 8 3.8% 1,429 43 2.9% 22,431 1,440 6.0%
−99 366 35 6.4% 3,241 502 13.4% 24,453 2,443 9.1%
Total 1,243 51 3.9% 6,266 609 8.9% 75,976 6,110 7.4%
Sources: e Hospitals Year-Book for 1938 (London, 1938); V. Cope, W. Gill, A. Griths and G. Kelly, Hospital Survey:
e Hospital Services of the South-Western Area (London, 1945).
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136 Payment and philanthropy in British healthcare, 1918–48
saw institutional birth become the new norm, such as Leeds where
hospitals accounted for the majority of births by 1938, and for nearly
two-thirds by 1946.51 at private provision catered more extensively
for these increasingly common hospital births than for other types of
patients might be simply a result of greater demand, which was certainly
increasing at this time. e explanation for this increased demand in
the historical and sociological literature has gradually shied towards
seeing this as women’s choice rather than the result of coercion on the
part of medical men.52 One factor that may well have made it possible
to take up a preference for a hospital birth was the maternity benet
provisions of the National Insurance scheme. Subject to complex insti-
tutional arrangements, this covered up to thirty shillings for the con-
nement but nothing towards any fees for medical treatment.53 As few
women were covered by National Insurance or contributory scheme
members in their own right, exemption from nding the money was
aorded by virtue of her husband’s employment. Moreover, while the
numbers covered by National Insurance increased between the wars, so
too did the rates of payment expected, which were oen notably higher
than the rate of the benet. Meanwhile, the place of women within the
contributory scheme movement is striking by its absence, with ordi-
nary maternity cases usually excluded from coverage. e deeply awed
rationale given in Oxford for exclusion was that ‘only a comparatively
small number of people could qualify to receive the benet, so that the
spread of the cost over the whole body of contributors would be ineq-
uitable’.54 Furthermore, the usual income-assessed barriers to ordinary
wards were accompanied for maternity patients by moral ones, with
separate wards typically in the maternity hospitals for married and
unmarried mothers. Overall the case of maternity suggests the balance
between medical, nancial and social duties was dierent for female
patients. e social was not restricted to class, but encompassed a far
more varied and complex set of moral dimensions.55
Unfortunately we have no more detailed gures on the gender mix
of private patients in Bristol hospitals. However, we do know that at
Addenbrooke’s Hospital in Cambridge, where the proportion of private
beds was a lile above the national average at 8.5 per cent in the mid-
1930s, 55.3 per cent of private patients were women, 36.5 per cent were
men and 8.2 per cent were children.56 It does therefore appear that
private provision was geared largely towards women, driven by though
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Middle-class medicine 137
not limited to maternity care. While this maternity provision was not
limited to specialist hospitals, it did much to ensure that Bristol bucked
the wider general-specialist trend. e concentration of private beds in
general hospitals was not only seen at the national level but also across
Bristol’s South West region, where around three-quarters of private
beds were in general hospitals. is was not simply a consequence of
general hospitals being larger, as private beds accounted for a greater
share of all beds in general hospitals than in specialist ones. In Bristol,
however, private beds were concentrated in and accounted for the great-
est proportion of the total in small specialist hospitals (see table 4.3).
is unusual situation can only be understood by considering Bristol’s
position as a hub of hospital provision within its region; and it is to
regionalism and its complexities that we now turn.
Regional paerns
e minimal private hospital provision in Bristol complicates Daniel
Fox’s account of ‘hierarchical regionalism’, which has proved surpris-
ingly resilient despite erce criticism from Charles Webster on the
grounds that it was a more accurate description of interwar policy than
practice.57 In most respects the city was a classic example of the regional
centre for research, medical education and specialist services, around
which the region’s healthcare was said to be organised. is position as
a clinical centre for the South West was long-established by the time it
was recognised in the new regional structure of the NHS, with the
Bristol Regional Hospital Board covering the entire region; not only
including nearby Gloucestershire, Somerset and Wiltshire, but also
reaching south to Dorset, Devon and Cornwall. Private hospital serv-
ices, however, are notable by their absence. ere is a clear contrast
between the local and national pictures, but only by comparing the city
to other regional centres and by examining the paerns of regional
provision across the country can we be sure whether it was Bristol or
private provision which bucked the trend. In adopting this regional
view, the available data leads us to focus on voluntary hospitals and on
the situation in England.
London served as a regional and national hub for medical services
of all kinds, and those for private patients were far from an exception.
As seen in gure 4.1, the capital was home to around one-third of all
private beds in Britain and roughly one-quarter in the 1940s, when
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138 Payment and philanthropy in British healthcare, 1918–48
expansion in the provinces was accompanied by the signicant disrup-
tions of war. e regional surveys recorded London’s South East region
having four times more private beds than its nearest rival in 1938, with
3,268 to the 760 in Manchester and Liverpool’s North West region.58
e fact these two regions had the most private beds was in part a result
of them being the most populous (see table 4.4). Indeed, there is a dif-
culty, for example, in comparing what was termed the ‘London Area’
(here renamed the ‘South East’), which covered many populous areas
near the south coast, with the largely rural ‘Eastern Area’ immediately
to its north, which had a population more than eleven times smaller.59
It is more useful, therefore, to look at the number of beds in relation to
the region’s population.
is makes a radical dierence to the North West, where concen-
trated private provision was matched by a concentrated population. In
fact, the region had a lower than average 0.117 private beds per 1,000,
despite having the second largest number in absolute terms. e reverse
is true for Bristol’s less populous South West region, where 609 private
beds were roughly twice as many per head at 0.230 per 1,000. is
was almost identical to the South East’s 0.231, both of which were sig-
nicantly greater than the nearby Oxford region’s 0.189. ese three
southern regions stand out as having the greatest private provision pro-
portionate to population, while the lowest were to be found in Shef-
eld’s East Midlands region, the Yorkshire region which included
Leeds, and the North East, each with less than one bed per ten thou-
sand. is division between north (including the Midlands and East
Anglia) and south appears clear and striking. e overall English rate
of private provision was 0.157 private beds per thousand population,
and while the three southern regions were above this, the rest were
below it.
Scotland both replicates this north–south divide and ts within it.
e voluntary hospitals in the South-Eastern region of Scotland,
centred on Edinburgh, had a higher proportion of private beds than
those in the South-Eastern region of England, centred on London (10.5
per cent to 9.4).60 Despite a few large private wards in Glasgow hospi-
tals, the rate was far lower across the rest of Scotland: 6.1 per cent in
the Western Region, 4.4 in the Northern Region and zero in the North-
Eastern Region, although a sixty-bed private ward was under considera-
tion for the Aberdeen Royal Inrmary. Scotland’s overall 5.3 per cent
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Middle-class medicine 139
Table 4.4 Private beds in voluntary hospitals per population by English
region, 1938
Population General
beds
Private
beds
Private
(%)
Private
beds per
1,000
South East 14,160,044 31,356 3,268 9.4 0.231
South West 2,645,980 6,266 609 8.9 0.230
Berks, Bucks & Oxon 867,140 1,753 164 8.6 0.189
Eastern Area 1,249,270 3,206 173 5.1 0.139
North West 6,480,270 11,025 760 6.4 0.117
West Midlands 4,252,920 7,411 446 5.7 0.105
North East 2,533,982 3,832 241 5.9 0.095
Yorkshire Area 2,835,065 4,773 232 4.6 0.082
East Midlands 3,965,898 6,354 217 3.3 0.055
England 38,990,569 75,976 6,110 7.4 0.157
Sources: e Hospitals Year-Book for 1938 (London, 1938); John B. Hunter,
R. Veitch Clark and Ernest Hart, Hospital Survey: e Hospital Services of the
West Midlands Area (London, 1945); L.G. Parsons, S. Clayton Freyers and
G.E. Godber, Hospital Survey: e Hospital Services of the Sheeld and East
Midlands Area (London, 1945); V. Zachary Cope, W.J. Gill, Arthur Griths
and G.C. Kelly, Hospital Survey: e Hospital Services of the South-Western
Area (London, 1945); Ernest Rock Carling and T.S. McIntosh, Hospital
Survey: e Hospital Services of the North-Western Area (London, 1945);
William G. Savage, Claude Frankau and Basil Gibson, Hospital Survey: e
Hospital Services of the Eastern Area (London, 1945); A.M.H. Gray and A.
Topping, Hospital Survey: e Hospital Services of London and the Surrounding
Area (London, 1945); Herbert Eason, R. Veitch Clark and W.H. Harper,
Hospital Survey: e Hospital Services of the Yorkshire Area (London, 1945);
E.C. Beevers, G.E. Gask and R.H. Parry, Hospital Survey: e Hospital
Services of Berkshire, Buckinghamshire and Oxfordshire (London, 1945); Hugh
Le and Albert Edward Quine, Hospital Survey: e Hospital Services of the
North-Eastern Area (London, 1945).
of voluntary hospital beds for private patients is therefore signicantly
lower than that for England.61
Beneath this broad brush stroke there were also local oddities, such
as the fact that 8.9 per cent of all voluntary hospital beds in Bradford
were for private patients while there were none at all in York.62 No less
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140 Payment and philanthropy in British healthcare, 1918–48
odd was Bristol, a wealthy southern city and a clinical centre for its
region but with very few middle-class private beds. As table 4.5 shows,
Bristol had fewer private beds per head than anywhere else in the
region. Instead the regional hub of middle-class hospital provision
appears to have been to its south in the county of Somerset and espe-
cially in the city of Bath. Despite a population one-sixth the size of
Bristol’s (68,300 to 415,500 in 1938) and less than half the total number
of voluntary hospital beds (680 to 1,294), Bath had more than twice as
many private beds (125 to 51). is was not only a dierence between
two cities but also points to a clear split in this north part of the South
West region, as the situation in each was echoed in their surrounding
rural areas. Across the county of Somerset (including Bath) private
beds accounted for 15.1 per cent of all voluntary hospital beds. Across
Gloucestershire (including Bristol), it was only 5.4 per cent.
Across England private beds accounted for a smaller proportion of
all beds in specialist voluntary hospitals than in general ones (4.6 per
cent to 8.8 per cent), but the picture was typically dierent in areas
serving as a regional centre. In some cases the gap was notably reduced,
such as London (10.1 to 12.2). In others, such as Birmingham, it was
Table 4.5 Private beds in voluntary hospitals per population in the South
West areas, 1938
Population General
beds
Private
beds
Private
(%)
Private
beds per
1,000
Bath 68,300 555 125 18.4 1.959
Somerset 404,600 797 116 12.7 0.287
Cornwall 308,297 443 65 12.8 0.211
Devon & Exeter 529,860 1,249 100 7.4 0.189
Wiltshire 305,900 781 55 6.6 0.180
Gloucestershire 400,120 774 64 7.6 0.160
Plymouth 211,800 424 33 7.2 0.156
Bristol 415,500 1,243 51 3.9 0.122
South West 2,644,377 6,266 609 8.9 0.230
Sources: e Hospitals Year-Book for 1938 (London, 1938); V. Cope, W. Gill,
A. Griths and G. Kelly, Hospital Survey: e Hospital Services of the
South-Western Area (London, 1945).
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Middle-class medicine 141
reversed (8.3 to 7.7). In Bristol this was even more pronounced (6.2 to
only 2.5). Although the former is lower than in either London or Bir-
mingham, it was still signicantly higher than the national average. Bristol
was not home to a major hub in specialist hospital provision for private
patients, instead it was one of a number of centres spread across the region
– principally between the cities of Bristol and Bath – with notably lile
overlap. Beyond Bristol there were only eight private beds in hospitals for
women and children in 1938, seven in Plymouth and one in Wiltshire.63
ere were fourteen private beds in ophthalmic hospitals in the region,
twelve of them in Bristol and another two in Bath. e only six private
beds in homeopathic hospitals were in Bristol and the only twenty private
beds in an ENT hospital were in Bath.64 As such, the regional picture of
specialist hospital service provision for the middle classes is not one of a
single regional centre for provision, but rather one of a cluster spread
across two counties, within which Bristol played a major role.
Possible explanations
When the wartime survey sought to explain the low level of private
provision in Scotland’s eastern region, covering an area including
Dundee to the north of Edinburgh, the report explained:
e proportion of middle-class and wealthy population in Dundee is
relatively small, and the total amount of private practice available for
physicians and surgeons of consultant status correspondingly limited.
Consultant practice in the rest of the region has mostly been divided
between Dundee on the one hand, and Edinburgh or Glasgow on the
other, the laer being easy of access.65
e same cannot be said of the wealthy (if unequal) city of Bristol
with its large middle-class population. ree possible explanations
for the extremely low level of private provision at its voluntary hos-
pitals will therefore be considered. e rst of these is simply a lack
of demand for medical aention amongst the middle classes. e
second is that what demand there was might have been met elsewhere
– either in a non-hospital seing or at the municipal hospitals. e
last is that, while the middle classes were receiving treatment in volun-
tary hospitals, they were prepared to travel to do so elsewhere. Given
the ‘dual hub’ in specialist regional private provision between Bristol
and Bath, it will be suggested that in this case the last of the three
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142 Payment and philanthropy in British healthcare, 1918–48
should be seen as the primary explanation for the startlingly low level
of middle-class provision made by the city’s voluntary hospitals.
Lack of demand
e simplest explanation for limited provision would be limited
demand. In the case of private provision, the reason might be assumed
to lie in a lower rate of illness amongst the middle-class population. is
may go some way to explaining the overall rate of provision, though not
obviously the divergence between the American hospitals’ refocusing
on private provision and the continued focus in British hospitals on the
treatment of the working classes. Neither would it explain why Bristol
should be a city with a large middle-class population, but with far fewer
hospital beds for their treatment than seen elsewhere around the
country and even its own region. Consequently, for any lack of demand
to serve as an explanation, it would need to be in some way specic to
the city itself.
We can look to the city’s hospital contributory schemes for some
gauge of interest in middle-class provision. In addition to their main
business of oering a form of mutual aid designed to ensure an appro-
priate nancial contribution was made on behalf of working-class
patients, in some cases they branched out and established supplemen-
tary middle-class schemes. Across the hospital contributory schemes
and the medical faculty of the hospitals in Bristol, we see a common
assumption that there was a middle-class demand for securing access
to private treatment. e founders of Bristol’s two major hospital con-
tributory schemes were acutely aware of the need for such a service.
When the Bristol Medical Institutions Contributory Scheme (BMICS)
was established in 1927 and then the Bristol Hospitals Fund in 1939,
both immediately gave the maer consideration.66 In 1929, a sub-
commiee of the Bristol Royal Inrmary’s faculty was set up to con-
sider the suggestion of a hospital insurance scheme for the middle
classes, dened as those with incomes of over £300 per year. ey
envisaged that such a scheme would require annual payment into a
central fund, entitling admission if taken ill and covering payments for
both maintenance charges and fees for treatment.67 is reversed the
faculty’s previous stance that the admission of this class of patient
‘should be determined by the almoner on the individual merits of each
case, & not on the basis of subscribing to any contributory scheme’.68
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Middle-class medicine 143
e following year the BMICS established their ‘Section II’ scheme
‘to assist those who normally, owing to income limits, are not eligible
for treatment in the public wards of the Voluntary Medical Institutions’.
is would cover the member or a dependant if they ‘should have to
become a patient in a private ward of a hospital or a nursing home’.69 In
return for an annual contribution of one guinea per annum (or two for
the inclusion of a dependant), the contributor would be entitled to
‘grants-in-aid’ of up to ten guineas per year for hospital expenses.70 Over
the early 1940s the Bristol Hospitals Fund would establish both an
Intermediate Contributory Scheme and a Provident Fund, both oer-
ing access to private services for those earning dierent amounts over
the general ward income limits. ese middle-class schemes excluded
certain categories of patient, such as the chronic sick and maternity
cases, maintaining a focus on treating breadwinners and returning to
them to work.71
As far as membership of the Bristol Hospitals Fund’s middle-class
Welfare Fund suggests, there was an interest in medical insurance for
this section of the city’s population. e middle-class section of the
BHF’s membership had grown to over 40 per cent by the introduction
of the NHS, meaning a presence here twice that of the city’s population
at large.72 is over-representation can be partially explained by the
numerous other contributory schemes in Bristol without middle-class
options. We might further be tempted to look to ideas of civic duty to
explain middle-class membership alongside the schemes’ fundraising
eorts, as identied by Frank Prochaska in London and Nick Hayes in
Noingham.73 However, these middle-class sections of contributory
schemes in Bristol appear to be so heavily framed as insurance that such
an explanation does not seem ing. eir popularity suggests there
was a demand for institutional treatment in times of sickness, of the
kind covered, from the city’s middle classes.
Alternative sites of treatment
Our second possible explanation is that medical aention may have
been sought by the middle classes beyond the hospital seing. is may
mean home treatment by general practitioners, and for those not signed
up to a contributory scheme there would have been a clear nancial
incentive to avoid hospital treatment. While £3 would be a modest
charge for a private bed in a voluntary hospital (with medical or surgical
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144 Payment and philanthropy in British healthcare, 1918–48
fees expected in addition), the typical charge for a doctor’s home visit
in the 1930s would range between one-sixth and one-twelh of that
amount.74
It appears the introduction of the National Insurance panel system
in 1911 and its interwar expansion, when it came to cover the majority
of the adult male population, did lile to diminish private practice.
Although Lloyd George’s ‘ambulance wagon’ speech had vividly painted
a picture of the neglected working-class need for medical aention, in
1926 the BMA estimated that general practitioners made more visits to
private than panel patients.75 We might assume demand for hospital
treatment, at least in the leading voluntary hospitals, would be gener-
ated by their reputation as elite and pioneering institutions. While
George Bernard Shaw had commented in 1911 that ‘the rank and le of
doctors are no more scientic than their tailors’, by 1926 the Bristol
Royal Inrmary, for example, was engaging in work of ‘immense impor-
tance’ treating ‘supposedly incurable’ cancer cases.76 Yet, with the excep-
tion of maternity cases, middle-class patients in Bristol appear to have
received treatment in the hospitals only relatively rarely. e explana-
tion perhaps rests in the fact that the city’s general practitioners were
well-placed to cater for the middle classes beyond the hospital. We can
see this from the geographical concentration of their premises in its
wealthier suburbs to the west and north, such as Clion, Redland and
Westbury-on-Trym.77 is was the opposite of the small town North
American situation where Charles Rosenberg found ‘the intractable
reality of longer distances underlining the hospital’s appeal’, as well as
supposed clinical benets, prompting practitioners to encourage hos-
pital treatment to their patients.78 e location of dozens of surgeries
within each of the city’s wealthiest areas may have acted as a buer
against such a change in Bristol.
e proximity of private surgeries to the hospitals was no coinci-
dence. It was very much the norm for the honorary medical stas of the
voluntary hospitals to also keep private practice.79 For example, Dr
Patrick Watson-Williams was the Bristol Royal Inrmary’s rst Honor-
ary Aurist and Laryngologist, and later Honorary Consulting Surgeon
in the Ear, Nose and roat Department until his death in 1938.80
is was a major department, which treated around one-in-ten inpa-
tients and nearly as high a proportion of non-casualty outpatients.81
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Middle-class medicine 145
roughout this busy period of hospital work he maintained a private
surgery a lile over a mile away from the hospital, in the middle of
Clion Village.82 is was normal practice. All sixteen of the visiting
consultants listed as medical ocers in the Bristol Royal Hospital’s
1939 report were also listed with private surgeries in the local directo-
ry’s medical list for the same year.83 All of these surgeries, some shared
or with shared consulting rooms, were located within a small area in the
centre of Clion. Although they worked both in the hospital and with
private patients, there appears to have been lile appetite for bringing
the two together through middle-class admissions.
Another alternative might have been for the middle-class patient to
seek care in an institution other than a hospital, specically a nursing
home. Indeed, Lindsay Granshaw has noted that the development of
private hospital medicine ‘ran alongside the establishment in Britain of
numerous nursing-homes’, which she describes as ‘eectively small
private hospitals for the middle classes’.84 Once again, in Bristol these
tended to be found in wealthy areas, with nearly one-third of all those
in the city located in Clion.85 Of the thirty-six nursing homes operat-
ing in and near Bristol in 1934, twenty-one advertised as oering
medical services, nineteen maternity, seventeen chronic, seven surgical,
two convalescent or rest, one acute and another nervous disease ser-
vices.86 Although no gures are available for their number of beds, it is
likely that combined they were far greater than those for private patients
in the city’s hospitals.
As with general practitioners, however, nursing homes suered from
rather contrasting reputations. In 1935, a parliamentary debate on
paying patients revealed an assumption held by many in the House of
Lords that there must be a demand for middle-class beds in voluntary
hospitals specically because of the poor standard of the private nursing
homes. Amongst them was the Labour peer Lord Sanderson, who
declared ‘many nursing homes’ to be ‘very bad and most of them very
expensive’, as well as not being equipped for increasingly technologi-
cally elaborate and costly procedures.87 From the other side of the
chamber, the Earl of Malmesbury spoke of a widespread and ‘increasing
horror – I say it with all respect – of nursing homes’.88 By contrast, some
of the elite nursing homes were commonly known as private hospitals
despite having no resident medical sta, such as St Mary’s and St
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146 Payment and philanthropy in British healthcare, 1918–48
Brenda’s in Clion. ese nursing homes branded as private hospitals
would have been well-positioned to meet middle-class demand beyond
the wards of the voluntary hospitals.
Certainly there were very few middle-class beds in Bristol’s voluntary
hospitals and likely many more in the city’s great many nursing homes,
but we should consider what alternative hospital admissions might have
been possible. If the middle classes were, in fact, being treated in hos-
pital when sick before the NHS, then there are two remaining possible
explanations. One is that it might not have been the voluntary hospitals
at all where they were receiving treatment, that is to say the middle
classes may have been catered for in the municipal hospitals. Indeed,
we know that both before and aer appropriation, Southmead Hospital
was making limited provision for private patients at a moderate rate.89
With ten private beds in 1933, the city’s public sector accounted for
two-hs of the total.90 Moreover, we do know that such practices
continued into the 1940s.91
e scale of this later provision in Bristol or more widely, however,
remains unclear. A recent major work on interwar municipal medicine
makes only passing reference to public hospitals taking fee-paying
private patients.92 Contemporary sources were less likely to record
municipal private beds than those in the voluntary hospitals, with some
of the regional wartime surveys not including any such gure and
others giving only patchy coverage. is was most likely caused by the
same confusion over the denition of a ‘pay bed’ as with the gures for
some voluntary hospitals, suggesting payment in the ordinary wards of
public hospitals was normal practice by this time. e gures that were
included in these reports suggest only one region – the North West of
England – fully counted private beds in municipal hospitals. ey
counted large wards in former workhouses (Crumpsall’s thirty beds and
Withington’s forty-six beds in Manchester, and Birch Hill’s twenty-six
beds in Rochdale) as well as two municipal maternity hospitals with six
beds (the Municipal Maternity Home in Warrington) and eight beds
(Helm Case Maternity Home in Kendal).93 As in the voluntary hospi-
tals, the North West gures show private provision in the municipal
hospitals located typically in general hospitals and, when in specialist
institutions, those were most commonly maternity hospitals.
In total this comes to 116 private beds in the North West municipal
hospitals, a notable amount but still only 13 per cent of private beds in
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Middle-class medicine 147
the region’s voluntary and public hospitals combined. Yet we cannot be
sure if Bristol (or any other part of the country) saw the same propor-
tion of private beds located in public hospitals, since no ‘pay beds’ were
recorded for any of Bristol’s public hospitals (and only a scaered few
in other regions) despite the fact we know Southmead took private
patients. However, if the number of private beds at Southmead remained
unchanged over the 1930s, then the public–voluntary split would be
very similar in Bristol to that recorded in the North West. Whereas
some modest growth may have gone unrecorded and uncommented
upon, it is highly unlikely that Bristol’s public hospitals saw an expan-
sion of private provision on a scale adequate to explain the local short-
age of private beds in the voluntary hospitals.
Travelling for treatment
Of the three possible explanations considered, only alternative admis-
sion to private nursing homes appears convincing. Yet there is no evi-
dence that this was a bigger factor in Bristol than in other cities. We
must therefore turn to our nal possible explanation, which is the
complex position of Bristol within the region, to can gain some under-
standing of this unusual situation. is suggests the middle classes of
Bristol were prepared to travel to receive treatment in voluntary hospi-
tals elsewhere.
If we look rst at patients from all wards, both general and private,
we nd that the majority of patients at the Bristol Royal Inrmary in
1930, for example, were local to the institution: 6,173 of the year’s 8,734
patients were listed as being from Bristol and District. Most of the
remainder were from either Gloucestershire or Somerset, including
large numbers from both the nearby areas of Avonmouth and Sea Mills
(103) and Shirehampton (124). ere were only occasionally patients
from as far aeld as Worcester, Swindon and Salisbury, and a much
larger number (293) from Wales.94 Overall, patients were prepared to
travel to Bristol when necessary.
For middle-class patients the necessity would have been to travel the
distance of a lile over ten miles, between Bristol and Bath, in both
directions. While Bath might appear the regional centre for middle-
class medicine from the far greater number of private beds in its hospi-
tals, we should not overlook which hospitals had private wards. From
Bristol, the nearest private bed in a specialist ENT hospital was in Bath.
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148 Payment and philanthropy in British healthcare, 1918–48
From Bath, the closest private bed in a homeopathic or maternity hos-
pital was to be found in Bristol.95 Bristol was not displaced by Bath,
therefore, but was in fact the junior partner in a dual hub of private
hospital provision in the South West region; and this should be seen as
the primary reason for the startlingly low level of middle-class provision
made in the city’s voluntary hospitals.
is becomes clearer still when we combine the gures (shown in
table 4.5) for the counties of Gloucestershire and Somerset, including
the cities of Bristol and Bath respectively, revealing 356 of this wider
area’s 3,369 voluntary hospital beds were private. At 10.6 per cent this
proportion of beds for private patients is higher than average and not
so far behind the 12.6 per cent found in London.96 With 0.276 private
beds per 1,000 people in the two counties, the middle-class population
was beer catered for than in most parts of the country. Middle-class
patients were simply not treated alongside working-class patients. We
already know they were treated in separate wards, commonly on other
oors or in another building, but in this case also oen away from the
city. Where Bristol was very much the regional centre for the hospital
treatment of the working classes, the middle classes typically went
elsewhere.
Pay beds after 1948
Placing our focus on the idea and the act of payment both heightens
and diminishes the signicance of 1948 as a watershed in the history of
British healthcare. Despite the principle of medical services free at the
point of use, patient payment has always had some role within the
NHS.97 Indeed, those limited ‘pay beds’ present in the pre-NHS hospi-
tals as the only means of securing treatment for middle-class patients
were continued and became a means for those with cash to opt out of
the public health service. Although private practice was entrenched and
even encouraged within the NHS, it remained contentious, leading to
private surgery fees being capped in 1953 at seventy-ve guineas,
although allowed to rise to 125 guineas in exceptional circumstances.98
As the Teaching Hospital Association commented in the mid-1970s:
‘Private practice, when conducted in hospitals, has always been a maer
for controversy ever since the voluntary hospitals rst began to provide
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Middle-class medicine 149
beds for paying patients and so, if it continues, it will certainly and
unavoidably remain so.’99
It was at this time that Harold Wilson and his Secretary of State for
Social Services, Barbara Castle, launched the only serious aempt to
abolish them. She instructed the new Health Services Board to phase
them out, starting with those under-utilised, but with only modest
success. When Labour took oce in 1974 there were almost 5,000 pay
beds in the NHS.10 0 When Margaret atcher arrived in Downing
Street ve years later there remained 3,000 pay beds in NHS hospitals
across England and Wales. Less than two months aer taking oce it
was declared:
e Government believes that people who wish to do so should be free
to make arrangements for their private medical treatment and intends to
repeal the legislation for the phasing-out of pay beds which was intro-
duced by the previous Government. e Health Services Board will be
abolished and the Social Services Secretary’s power to allow NHS hos-
pitals to be used for private practice will be restored.101
Despite a ‘ceiling’ on the amount of private practice and a promise of
legislation to ensure, echoing the calls of the 1930s, ‘that services for
private patients should not prejudice services for NHS patients’, the place
of pay beds within NHS hospitals was reasserted. Yet, just as numbers had
been low in Bristol before 1948, so they continued to be thereaer. By the
mid-1970s there were just six under-used pay beds at the new Bristol
Maternity Hospital and another three at Southmead Hospital.102 A few
years later, aer thirty years of the NHS, there were none le in the city.
Conclusion
In some respects Bristol bucked regional and national trends in its
hospital provision for middle-class patients, perhaps surprisingly given
its large middle-class population and clear status as a regional centre for
hospital services. Yet, before the NHS, the city’s general voluntary hos-
pitals never had more than twenty private beds between them, even
though such hospitals were where the overwhelming majority of private
beds were to be found nationally. At the same time it was home to a
higher than average share of private beds in specialist institutions, in
common with other regional hospital centres, such as Birmingham.
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150 Payment and philanthropy in British healthcare, 1918–48
Understanding these contradictions and idiosyncrasies requires us to
place the local situation not only within the national context, but also
to consider the city within the regional picture.
Ultimately, however, the evidence presented in this chapter points
to a relatively straightforward conclusion: treating the middle classes
was a marginal aspect of the services provided by the pre-NHS hospi-
tals, with access limited to the 3 or 4 per cent of hospital beds set aside
for them. Middle-class patients were treated in voluntary hospitals
more oen than public ones, but even there private beds were never as
much as 9 per cent of the total. While these private beds took over more
of the hospital than usual in London, in Bristol it was the opposite.
Placing Bristol in its regional context brings the level of private provi-
sion into line with a general southern concentration. e fact this hap-
pened away from the region’s hospital centre highlights the degree to
which the city’s hospitals remained un-democratised in this period. e
limited provision made for the middle classes, especially striking in
Bristol, supports Paul Bridgen’s argument that the voluntary hospitals
ultimately failed to become the provider of hospital services to the
middle classes.103 However, this is not to say they were conservative
institutions, reluctant to adapt to a new era. e small but steady stream
of middle-class patients admied was in itself a notable change and part
of a wider reinterpretation of the patient contract. What remained con-
sistent, however, was what group of society primarily constituted ‘the
hospital class of patient’.104
is traditionalism only characterised one part of a dual system that
allowed the medical profession to combine hospital work and private
practice. It was an arrangement to which the honorary consultants and
private patients alike appear to have been wedded. Whether there was
less demand amongst the middle classes than might have been assumed,
they were being treated elsewhere or a combination of the two, what is
clear is that the treatment of private patients was far from a central func-
tion of either the public or the voluntary hospitals before the NHS.
Notes
1 Henry Burde, Pay Hospitals and Paying Wards throughout the World: Facts
in Support of a Re-Arrangement of the English System of Medical Relief
(London: J.&A. Churchill, 1879), p. 85.
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Middle-class medicine 151
2 BSC, DM980 (30), Bristol Hospitals Commission 1941, Evidence of the
Bristol Hospitals Fund, appendix 1; and DM980 (12), Income Limits le,
Extracts from General and Purposes Commiee minutes on Income
Limits, 27 August 1943.
3 John Stevenson, British Society 1914–1945 (Harmondsworth: Penguin,
1984), p. 119.
4 London Metropolitan Archives [hereaer LMA], A/KE/185, King’s
Fund, Voluntary Hospitals (Paying Patients) Bill [hereaer VHPPB],
Dra Statement for the Information of the Promoters (condential),
revised dra, 27 March 1935.
5 LMA, A/KE/185, King’s Fund, VHPPB, Information for Promoters (con-
dential), 27 March 1935.
6 Richard Lewis, Robina Nixon, and Barry M. Doyle, Health Services in
Middlesbrough: North Ormesby Hospital 1900–1948 (Middlesbrough:
Centre for Local Historical Research, University of Teesside, 1999), pp.
43–5.
7 For a discussion of how these factors led to the diversication of hospital
funding, see Martin Gorsky, John Mohan, and Martin Powell, ‘e Finan-
cial Health of Voluntary Hospitals in Interwar Britain’, Economic History
Review, 55:3 (2002), 533–57.
8 Charles Rosenberg, e Care of Strangers: e Rise of America’s Hospital
System (New York: Johns Hopkins University Press, 1987), pp. 237–61.
9 Paul Bridgen, ‘Voluntary Failure, the Middle Classes, and the Nationalisa-
tion of the British Voluntary Hospitals, 1900–1946’ in Bernard Harris and
Paul Bridgen (eds), Charity and Mutual Aid in Europe and North America
since 1800 (London: Routledge, 2007), pp. 216 and 228. Given its focus
on the King’s Fund, this sits well alongside F.K. Prochaska, Philanthropy
and the Hospitals of London: e King’s Fund, 1897–1990 (Oxford: Claren-
don Press, 1992). Lewis, et al., Health Services oers some local analysis,
although the existing literature provides lile context for such an
investigation.
10 See Steven Cherry, ‘Beyond National Health Insurance. e Voluntary
Hospitals and Hospital Contributory Schemes: A Regional Study’, Social
History of Medicine, 5:3 (1992), 455–82.
11 V. Zachary Cope et al., ‘Hospital Survey: e Hospital Services of the
South-Western Area’ (London: HMSO, 1945), p. 128.
12 Bridgen, ‘Voluntary Failure’, p. 216.
13 It is for this reason that the term ‘private bed’ is used here instead of ‘pay
beds’.
14 For more details of these confusions see George Campbell Gosling,
‘Charity and Change in the Mixed Economy of Healthcare in Bristol,
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152 Payment and philanthropy in British healthcare, 1918–48
1918–1948’, unpublished PhD thesis, Oxford Brookes University, 2011,
pp. 249–52.
15 King’s Fund, VHPPB, Information for Promoters.
16 e Hospitals Year-Book (1933).
17 Ibid.
18 BRI, Faculty Minutes, 17 February 1926.
19 BRI, 29 June 1926.
20 BRI, 16 February 1928, 17 February 1926 and 19 October 1932.
21 For Mount Hope gures, see Cope et al., ‘Hospital Survey’, p. 32. For other
private beds gures, see e Hospitals Year-Books, 1933–47.
22 TNA, MH 66/1068, ‘County Borough of Bristol’ by Allan C. Parsons
(Ministry of Health, 1932), p. 142.
23 BRO, 35717/I/7/d, Notice to Miss L Morse at the Almshouse from Public
Health Commiee asking for contribution to cost of stay at Southmead
Hospital 1941.
24 George Campbell Gosling, ‘ “Open the Other Eye”: Payment, Civic Duty
and Hospital Contributory Schemes in Bristol, c.1927–1948’, Medical
History, 54:4 (2010), 477. See also Lewis et al., p. 7; and Cherry, ‘Insur-
ance’, p. 470.
25 King’s Fund ‘Information for the Promoters’.
26 George Campbell Gosling, ‘e Patient Contract in Bristol’s Voluntary
Hospitals, c.1918–1929’, University of Sussex Journal of Contemporary
History, 11 (2007), 8.
27 BRO, BCM, 1 January, 1930, p. 253.
28 Ibid., p. 250.
29 Ibid., p. 251. Further evidence for continuity is oered by the Ministry of
Health’s report, which gave numbers for private patients before and aer
appropriation. See Parsons, ‘Bristol’, p. 142.
30 BCM, Report of the Health Commiee, 1 April 1930.
31 C.F.W. Illingworth, J.M. Mackintosh and R.J. Peters, Scoish Hospitals
Survey: Report on the Western Region (Edinburgh: Department of Health
for Scotland, HMSO, 1946), p. 58.
32 Lord Moran, HL Deb 16 April 1946, vol. 140, cc. 822–823.
33 Aneurin Bevan, HC Deb, 30 April 1946, vol. 422, c. 44.
34 Hospitals Year-Book (London: CBHI, 1933).
35 Hospitals Year-Books (1933–47).
36 Burde, Pay Hospitals, pp. 104 and 131. For Home Hospital proposals see
ch. 11, pp. 101–30.
37 Keir Waddington, Charity and the London Hospitals 1850–1898 (Wood-
bridge: Boydell Press, 2000), p. 89.
38 LMA, St Chad’s Hospital for paying patients, Report for 1923, p. 8
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Middle-class medicine 153
39 TNA, MH77/13, John Dodd to Ernest Brown MP, 9 June 1943.
40 John Pickstone describes a similar situation at the Manchester Royal Inr-
mary in Medicine and Industrial Society: A History of Hospital Development
in Manchester and Its Region (Manchester: Manchester University Press,
1985), pp. 259 and 265.
41 Hospitals Year-Books (1933–48).
42 Hospitals Year-Book (1938); Cope et al., ‘Hospital Survey’.
43 Ibid.
44 See Waddington, Charity and the London Hospital, pp. 91–3.
45 Cope, et al., Survey.
46 Hospitals Year-Book (1938), p. 204; Pickstone, Manchester, p. 265; C.F.W.
Illingworth, J.M. Mackintosh and R.J. Peters, Scoish Hospitals Survey:
Report on the Western Region (Edinburgh: Department of Health for Scot-
land, HMSO, 1946), p. 58.
47 Bristol Homeopathic Hospital, Report for 1937, p. 29.
48 BRI, Faculty Minutes, 29 June 1926.
49 Tania McIntosh, A Social History of Maternity and Childbirth: Key emes
in Maternity Care (London: Routledge, 2012), p. 64; Jane Lewis, e Poli-
tics of Motherhood: Child and Maternal Welfare in England, 1900–1939
(London: McGill-Queens University Press, 1980), p. 120.
50 Elizabeth Peretz, ‘Maternal and Child Welfare in England and Wales
between the Wars: A Comparative Regional Study’, unpublished PhD
thesis, Middlesex University, 1992, p. 73.
51 Barry M. Doyle, e Politics of Hospital Provision in Early 20th-Century
Britain (London: Pickering & Chao, 2014), pp. 101–2.
52 For the coercion view see also the work of Ann Oakley, including Women
Conned: Towards a Sociology of Childbirth (New York: Schocken Books,
1980). For more recent works aording greater agency to women, see
Lara Marks, ‘ “ey’re magicians”: Midwives, Doctors and Hospitals:
Women’s Experience of Childbirth in Eat London and Woolwich in the
Interwar Years’, Oral History, 23 (1995), 46–53; McIntosh, Maternity
and Childbirth; Alison Nuall, ‘Taking “Advantage of the Facilities
and Comforts … Oered”: Women’s Choice of Hospital Delivery
in Interwar Edinburgh’ in Janet Greenlees and Linda Bryder (eds),
Western Maternity 1880–1990 (London: Pickering & Chao, 2013),
pp. 65–80.
53 See Doyle, Politics of Hospital Provision, pp. 66, 133 and 192–3.
54 Radclie Inrmary, Annual Report (1924); Barne House Survey Com-
miee, Social Services in Oxford: A Survey of the Social Services in the Oxford
District, Volume 2 (Oxford: Oxford University Press, 1940), p. 141, cited
in Peretz, ‘Maternal and Child Welfare’, p. 77.
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154 Payment and philanthropy in British healthcare, 1918–48
55 For a further discussion of the limited choices of the pre-NHS pregnant
patient-consumer see George Campbell Gosling, ‘e Birth of the Preg-
nant Patient-Consumer? Payment, Paternalism and Maternity Hospitals
in Early Twentieth-Century England’ in Jennifer Evans and Ciara Meehan
(eds), Perceptions of Pregnancy om the Seventeenth to the Twentieth Century
(London: Palgrave Macmillan, 2016).
56 Addenbrooke’s Hospital, Annual Reports for 1935 and 1936.
57 Daniel M Fox, Health Policies, Health Politics: e British and American
Experience, 1911–1965 (Princeton: Princeton University Press, 1986);
Charles Webster, ‘Conict and Consensus: Explaining the British Health
Service’, Twentieth Century British History, 1:2 (1990), 115–51.
58 A.M.H. Gray and A. Topping, Hospital Survey: e Hospital Services of
London and the Surrounding Area (London: HMSO, 1945); Ernest Rock
Carling and T.S. McIntosh, Hospital Survey: e Hospital Services of the
North-Western Area (London: HMSO, 1945).
59 Gray and Topping, London Survey, p. 1; Willam G. Savage, Claude Frankau
and Basil Gibson, Hospital Survey: e Hospital Services of the Eastern Area
(London: HMSO, 1945), p. 1.
60 J.W. Struthers and H.E. Seiler, Scoish Hospitals Survey: Report on the
South-Eastern Region (Edinburgh: Department of Health for Scotland,
HMSO), pp. 57–104.
61 Scoish gures gleaned from R.S. Aitken and H.H. omson, Scoish
Hospitals Survey: Report on the Northern Region (Edinburgh: Department
of Health for Scotland, HMSO, 1946); R.S. Aitken and H.H. omson,
Scoish Hospitals Survey: Report on the Eastern Region (Edinburgh: Depart-
ment of Health for Scotland, HMSO, 1946); R.S. Aitken and H.H.
omson, Scoish Hospitals Survey: Report on the North-Eastern Region
(Edinburgh: Department of Health for Scotland, HMSO, 1946); C.F.W.
Illingworth, J.M. Mackintosh and R.J. Peters, Scoish Hospitals Survey:
Report on the Western Region (Edinburgh: Department of Health for Scot-
land, HMSO, 1946).
62 Herbert Eason, R. Veitch Clark and W.H. Harper, Hospital Survey: e
Hospital Services of the Yorkshire Area (London: HMSO, 1945).
63 Cope et al., ‘Hospital Survey’, pp. 164, 178 and 188.
64 Ibid., pp. 172 and 178.
65 R.S. Aitken and H.H. omson, Scoish Hospitals Survey: Report on the
Eastern Region (Edinburgh: Department of Health for Scotland, 1946),
pp. 2–3.
66 BMICS, Report for 1929, p. 6; Western Daily Press and Bristol Mirror, 20
July 1939.
67 BRI, Faculty Minutes, 18 September 1929.
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Middle-class medicine 155
68 Ibid., 16 March 1927.
69 BMICS, Report for 1932, inside front cover.
70 BMICS, Report for 1930, p. 2.
71 BMICS, Report for 1937, inside back cover.
72 Bristol Reference Library, Bristol Hospitals Fund, Reports.
73 Prochaska, King’s Fund; Nick Hayes, ‘ “Our Hospitals”? Voluntary Provi-
sion, Community and Civic Consciousness in Noingham Before the
NHS’, Midland History, 37:1 (2012), 84–105.
74 An estimate of 1930s GP home visit fees ranging from 5s 0d to 10s 6d,
based on the advertisement columns of the British Medical Journal, is
presented in ibid., p. 88.
75 David Lloyd George, ‘e Insurance of the People’, Birmingham speech,
10 June 1911 (London, 1911); Anne Digby and Nick Bosanquet, ‘Doctors
and Patients in an Era of National Health Insurance and Private Practice,
1913–1938’, Economic History Review, 41:1 (1988), 74–5 and 88.
76 George Bernard Shaw, ‘Preface on Doctors’ to e Doctor’s Dilemma in
Pygmalion and ree Other Plays (New York: Barnes & Noble, 2004), p.
191; BRI, Report for 1926, p. 10. On the treatment see also A.T. Todd, ‘A
Note on the Action of a Lead-Selenium Colloid on Cancer’, Lancet, 12
March 1927, p. 575.
77 Bristol Directory 1919, pp. 866–9; Bristol Directory 1923, pp. 949–52;
Bristol Directory 1930, pp. 1030–4; Bristol Directory 1939, pp. 1320–5.
78 Rosenberg, Care of Strangers, p. 248.
79 See Anne Digby, Making a Medical Living: Doctors and Patients in the
English Market for Medicine, 1720–1911 (Cambridge: Cambridge Univer-
sity Press, 1994), p. 125.
80 BRI, Report for 1938, p. 15.
81 Ibid., p. 36.
82 Wright’s and Kelly’s annual directories list Dr Watson-Williams’s surgery
at 2 Rodney Place, Clion Down Road.
83 BRH, Report for 1939, p. 12; Bristol Directory 1939, pp. 1320–5.
84 Lindsay Granshaw, ‘e Hospital’ in W.F. Bynum and Roy Porter (eds),
Companion Encylopedia of the History of Medicine (London: Routledge,
1993), vol. 2, p. 1194.
85 is is in keeping with the trends noted in Martin Powell, ‘Coasts and
Coalelds: e Geographical Distribution of Doctors in England and
Wales in the 1930s’, Social History of Medicine, 18:2 (2005), 245–63.
86 Nursing Homes 1934, pp. 83–5.
87 Lord Sanderson, HL Deb 2 April 1935, vol. 96, c. 467.
88 Earl of Malmesbury, HL Deb 2 April 1935, vol. 96, c. 476.
89 BRL, BCM, Report of the Health Commiee, 26 September 1933.
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156 Payment and philanthropy in British healthcare, 1918–48
90 Parsons, ‘Bristol’, p. 142.
91 BRO, 35717/I/7/d, Notice to Miss L Morse at the Almshouse from Public
Health Commiee asking for contribution to cost of stay at Southmead
Hospital 1941.
92 Alysa Levene et al., From Cradle to Grave: Municipal Provision in Interwar
England and Wales (Bern: Peter Lang, 2011), p. 134.
93 Ernest Rock Carling and TS McIntosh, ‘Hospital Survey: e Hospital
Services of the North-Western Area’ (London: HMSO, 1945), pp. 156,
160, 162, 172, 174 and 178.
94 BRI, Report for 1930, pp. 45–6.
95 Cope et al., ‘Hospital Survey’, pp. 164–96.
96 Hospitals Year-Book (1938).
97 See John Eversley, ‘e History of NHS Charges’, Contemporary British
History, 15:2 (2001), 53–75.
98 MRC, MSS.2920/847/26/5: Ministry of Health, Pay-Bed Regulations
Revised: Some Reductions in Hospital Charges Likely, 18 March 1953.
99 Fourth Report of the Expenditure Commiee: ‘NHS Facilities for Private
Patient’, p. 295 cited in Department of Health and Social Security, e
Separation of Private Practice from National Health Service Hospitals: A
Consultative Document’, September 1974, Appendix A.
100 MRC, MSS.2920/847.306.1: Department of Health and Social Security,
e Separation of Private Practice from National Health Service Hospi-
tals: A Consultative Document’, September 1974; MSS.2920/847.306.3:
Department of Health and Social Security, Higher Charges for Private
Patients in NHS, 8 March 1978.
101 MRC, MSS.2920/847.306/4: Department of Health and Social Security,
‘Private Practice of Medicine – Government Announces its Proposals’, 25
June 1979.
102 MRC, SA/MWF/C.22: Box 20, Department of Health and Social Secu-
rity, ‘Hospitals or Groups of Hospitals in England Where in 1975 and
1976 the Occupancy of Private Pay Beds Was No Higher than 50% of the
Current Number of Beds Authorised’.
103 Bridgen, ‘Voluntary Failure’.
104 BCM, 10 October 1933, Report of the Health Commiee, 26 September
1933.
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