Daunton M. The Cambridge Urban History of Britain, Volume 3: 1840-1950
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From to the Fulham clubs were financed partially from the London
branch of the National Council for Social Services and from the Mayor of
Fulham’s appeal and resulting Unemployment Scheme; premises were provided
free by the London County Council and a local business guaranteed running
expenses. Although the new Labour council in the mid-s opposed volun-
tary help on the grounds that it was the role of the state to provide assistance, the
mayor did not withdraw support until when he argued that the establish-
ment by the national government of the Unemployment Assistance Board
relieved the borough from the need to provide help for able-bodied, unemployed
men, even though the Fulham Fellowship did not see its work as ‘assistance
work, it is social and personal . . . bringing men and women together that is of
very real benefit’.
124
The voluntary provision of urban medical services, notably district nursing
and voluntary hospitals, illustrates two characteristics of voluntary provision in
the interwar years: the increasing proportion of finance from the state or munic-
ipality for services rendered on its behalf; and attempts to coordinate provision.
An urban innovation beginning in Liverpool in , voluntary associations
employing nurses for a salary to do visiting nursing in people’s homes were all
located in urban areas until the late s. By they covered per cent of
the population of England and Wales. In both large cities and small towns, from
Birmingham to Banbury, charity went further in the s than the s. It
provided only one third of the cost rather than the whole cost; it made up the
difference between the cost of the service and the amount which those
benefiting could afford to pay from their own resources, from mutual insurance
or from public authorities on their behalf. At the same time, charity changed
from provision for the poor by the well-to-do to contributions by house-to-
house collection among all classes, contributory schemes for the better off,
increasingly important public grants and service to all.
125
Rising population and
boundary extensions in Birmingham gave impetus to negotiations among the
existing associations which led to the amalgamation of six societies covering
different parts of the city into a single city-wide association (City of Birmingham
District Nursing Association). Yet, the difficulties of coordination among
fiercely independent voluntary associations were apparent as several other soci-
eties joined only later and three remained outside entirely.
126
The financial difficulties of voluntary hospitals, apparent before ,
mounted thereafter as equipment became increasingly expensive, and demand
and specialisation grew. Like the district nursing associations voluntary hospitals
– apart from cottage hospitals – were essentially urban institutions, though
Marguerite Dupree
124
Ann Oakley, Man and Wife – Richard and Kay Titmuss: My Parents’ Early Years (London, ), pp.
–, –. See also R. H. C. Hayburn, ‘The voluntary occupational centre movement
–’, Journal of Contemporary History, (), –, and Pilgrim Trust, Men without Work
(Cambridge, ).
125
Braithwaite, Voluntary Citizen, p. .
126
Ibid., pp. –.
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usually with rural catchment areas. During the interwar years, in contrast to the
late nineteenth century, their sources of finance diversified from legacies and
subscriptions to include state support and increasingly contributory schemes and
pay beds, especially in England, which made their services available to the better
off. The voluntary hospitals were highly dependent on local economic prosper-
ity and were especially vulnerable to the effects of the depression in what became
Special Areas in the s. In Newcastle, for example, the habit of firms making
large donations, once interrupted, was not resumed on the same scale, and hos-
pitals which had developed workplace-based contributory schemes were vulner-
able to the fate of large employers. Provision was highly variable across the
country, from large prestigious teaching hospitals to struggling general hospitals.
Unlike district nursing associations, voluntary hospitals required finance for non-
recurrent capital expenditure, traditionally provided through fundraising cam-
paigns, legacies and large donations. Given prevailing levels of poverty in many
industrial towns such as Sunderland, it was impossible to raise capital through
charitable appeals, asking local people to provide the money. The financial
difficulties of voluntary hospitals led to attempts to coordinate them and develop
uniform standards. Before the First World War the King’s Fund attempted to
facilitate coordination of the London hospitals, and nationally voluntary hospi-
tals associated both to lobby the government for aid (receiving £ million from
the government immediately after the First World War) and, paradoxically, at the
same time to preserve their independence. With the Local Government
Act it became government policy to encourage the coordination of municipal
and voluntary hospital services, though their only means was loan sanction for
local authority capital projects and it had little impact. The Special Area
Commissioners, however, had more success. Without powers to intervene in the
location of industry, they devoted much of their financial assistance to easing
social conditions including capital grants to voluntary hospitals to meet approx-
imately per cent of the cost. These required government representation on
the hospital boards of governors for accountability, and the Commissioners and
Ministry of Health used the grants to promote coordination of services and to
constrain competition and duplication with other hospital services in an other-
wise largely unplanned system of urban welfare provision.
127
During the Second
World War the government’s Emergency Medical Service coordinated hospital
services, including voluntary hospitals, and after the war, despite their strong
desire to retain their separate identity, their proven inability to provide adequate,
universal, comprehensive care led to their forced absorption into the National
Health Service (NHS).
128
The provision of social services
127
John Mohan, ‘Neglected roots of regionalism? The commissioners for the Special Areas and
grants to hospital services in the s’, Social History of Medicine, (), –; S. Cherry,
Medical Services and the Hospitals in Britain, – (Cambridge, ), pp. –.
128
Finlayson, ‘Moving frontier’, –.
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Pawnbroking, as we saw above, was a quintessentially urban means of bridg-
ing the gap between income and expenditure with pawn shops, yielding a gross
profit of – per cent on turnover, concentrated in city-centre areas of densely
packed working-class housing. Although the absence of pawnbrokers on new
housing estates did not stop the habit of pawning, after the number of
brokers and the amount of business declined despite the problems of unemploy-
ment and short-time working. They suffered from the new competition of banks
and building societies offering immediate liquidity, from the rapid growth of
hire-purchase schemes overcoming the need to pawn in order to purchase new
articles, and from the growth of public pensions and unemployment relief.
129
At the same time that the mutual aid friendly societies were declining after
, the industrial life assurance companies expanded among the working class,
as endowment policies designed to give an annuity at a certain age grew dramat-
ically in popularity, replacing ‘whole life’ policies that yielded a lump sum at
death. This change in the type of industrial assurance purchased reflected the
decline in infant mortality and increased adult longevity. Thus, there was a
change in the pattern, similar across urban areas, of widespread burial club mem-
bership and more restricted friendly society membership, to one of endowment
policies from industrial life assurance companies after providing contrac-
tual saving for private old-age provision.
130
The income of industrial assurance
companies increased from £. million in to £. million in and
‘practically every family, even the very poorest’, from York to Bristol had taken
out industrial life policies.
131
Unlike unemployment insurance administered by civil servants, an alternate
channel for the provision of social welfare existed for health insurance with com-
mercial insurance and friendly societies receiving a subsidy from public funds for
providing their members with access to basic medical care from general practi-
tioners and with sickness benefit. This partnership of the approved societies with
the state attracted criticism from historians and contemporaries throughout the
interwar years. As mentioned above, the approved societies, particularly the
large, commercial insurance companies, accumulated substantial reserves during
the First World War which they maintained afterwards and were reluctant, for
reasons of business competition, to pool with smaller societies or raise benefits.
Yet, as Noelle Whiteside argues, these reserves were not sufficient to extend
health insurance to dependants even though societies agreed about the desirabil-
ity of extending the scope of the scheme, and the societies saved the govern-
ment money by absorbing the administrative overheads.
132
The Beveridge
Report echoed the criticisms that benefits varied among societies and were not
Marguerite Dupree
129
Johnson, Saving and Spending, pp. –; Tebbutt, Making Ends Meet, esp. ch. .
130
Johnson, Saving and Spending, pp. , , , .
131
Finlayson, ‘Moving frontier’, .
132
N. Whiteside, ‘Private agencies for public purposes: some new perspectives on policy making in
health insurance between the wars’, Journal of Social Policy, (), –; Finlayson, Citizen,
State and Social Welfare, p. .
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universal in coverage; it called for ‘a single Approved Society for the nation’, i.e.
the national state. In the Labour government dissolved the partnership
begun in between the government, on the one hand, and the commercial
companies and the waning mutual aid friendly societies, on the other, and made
national insurance solely the responsibility of the state.
133
Central government expenditure on social services rose fivefold between
and from £ million to £ million, underpinned by the ability of
income tax to ‘command consent’ and increase revenue in contrast to other
European countries.
134
The major increase took place within the first four years
when expenditure rose from £ million in to £ in , due largely
to new emergency commitments to unemployment relief. Once the initial com-
mitments were made, changing levels of unemployment accounted for much of
the subsequent fluctuations in expenditure.
Between and the British government inadvertently both under-
took the substantial and irreversible extension of state expenditure and pre-
vented the poor law from resuming its pre-war role as the principal source of
relief for those unable to support themselves. During the war families of ser-
vicemen received assistance, protecting them from the poor law, in the form of
separation allowances which, unlike the insurance system, provided benefits for
wives and children. As soldiers returned at the end of the war it was impossible
to withdraw this form of assistance, and the government introduced the ‘out-
of-work donation’ for ex-servicemen and then civilians which provided non-
contributory, non-poor law support for the unemployed and maintenance for
their families. Although the scheme was temporary, its commitments were per-
manent; failure to maintain existing commitments might well have provoked
revolution. Unemployment insurance introduced in to a few trades was
extended, as had long been intended, in to the rest of the working class
(except agricultural workers and servants). Introduced in to cope with
short-term cyclical unemployment, however, the insurance scheme of was
inadequate to cope with the downturn of the economy in the autumn of
and the start of long-term mass unemployment. The insurance scheme was
bankrupt by July , but the commitments forced the government to provide
‘uncovenanted benefits’ to those faced with the poor law when their fifteen
weeks of entitlement expired and to supply benefits for dependants.
135
Although
the level of benefit was cut by per cent under the ‘Geddes axe’, reinstated by
the Labour government in and cut again in , this acceptance of
responsibility for unemployed workers and their dependants was a major con-
cession. Yet, rather than the lynchpin of a new system of welfare provision,
unemployment relief undermined other innovations particularly in housing,
health and education.
The provision of social services
133
Finlayson, ‘Moving frontier’, ; Finlayson, Citizen, State and Social Welfare, pp. –.
134
Daunton, ‘Payment and participation’, –.
135
Vincent, Poor Citizens, p. .
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After the major increase in central government expenditure on unemploy-
ment relief between and , the cuts in provision to prevent further
growth coincided with restrictions that arose from the old concern for indis-
criminate relief and from ambiguities surrounding insurance contributions and
restricted entitlements. As mentioned above, there was an increasing proportion
of families whose income was augmented by relief payments and associated
intervention with multiple means tests separating the poor from relief. Forty
insurance acts passed between and attempted to reconcile the ambi-
guities of
benefit generated by membership of a scheme with support justified by member-
ship of society; benefit designed for the breadwinner with support given to all his
dependants; benefit guaranteed by contribution with support conditional on beha-
viour; benefit intended for occasional loss of work with support required for long-
term unemployment and benefit funded by actuarial practice with support
financed by Treasury subsidy.
136
Around the attempts to meet the crisis of unemployment a new pattern of
local government emerged during the interwar years which still left much local
variation, if not discretion to local authorities. The new pattern emphasised both
the difficulties central government and local authorities had in achieving the
greater degree of uniformity and the higher minimum standards that came to be
demanded for the provision of social welfare. This pattern also featured the
trade-off between local accountability, on the one hand, and the uniformity
achievable through central government finance and administration, on the other.
Although local government expenditure was restricted by the limits of the rate
and municipal trading basis of local government finance (as John Davis describes
in Chapter ), it maintained a constant per cent of the increased government
expenditure on social services during the interwar years. The period was marked
both by the declining importance of rate income for local authorities and by the
growing importance of central government grants which accounted for per
cent of income in and per cent in .
137
An increasing proportion of
the grants were not allocated to specific purposes. If central government subsid-
ised rates from taxation, some of the national income could be distributed from
richer to poorer parts of the country; yet, at the same time central government
could demand more control over local policy and restrict local initiatives.
This increasing central government contribution to local government
finances, together with local variations in the operation of the poor law, led to
Chamberlain’s Local Government Act of and the abolition of the Poor Law
Guardians, though not the poor law. The area and population covered by the
Marguerite Dupree
136
Ibid., p. .
137
A. Peacock and J. Wiseman, The Growth of Public Expenditure in the United Kingdom (London,
), pp. , , , .
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individual local authorities that distributed poor relief were small, particularly in
Scotland where they were single parishes in contrast to the clusters of parishes
or unions in England and Wales. After the demand that the central govern-
ment should equalise the burden of unemployment across the country led to a
series of battles in mining communities in North-East England and South Wales
and most prominently in the London borough of Poplar. In the face of low pay
and casual employment, rather than structural unemployment, the Poplar guar-
dians refused to operate the strict means tests of the poor law. They argued that
relief should be paid according to need at a level equivalent to wages rather than
below, and they argued they should not pay high rates to cope with the area’s
social problems when wealthy areas had few paupers and low rates. The Poplar
guardians went to jail over their demand for subsidies from the wealthier par-
ishes of London. The government responded by a further redistribution of funds
among London parishes and allowed the guardians to arrange Exchequer loans,
but several authorities fell into even worse debt while ignoring relief scales. In
the mid-s Chamberlain brought in several acts to curtail expenditure, cul-
minating in the acts which abolished the guardians and shifted their duties to the
committees of enlarged local authorities. The local authority Public Assistance
Committees would be able to provide more expensive and wide-ranging ser-
vices, but the votes of the poor would have far less weight in the larger author-
ity committees, making it more difficult to exert pressure to ignore relief scales.
Thus, with the absorption of the administration of the poor law by local
authorities in , and subsequently with the Treasury taking first financial
responsibility and then in administrative responsibility for unemployment
relief, there was a marked loss of local accountability for relief functions. But, as
L. J. Sharpe and Kenneth Newton suggest, the alleged ‘loss’ may have enhanced
the capacity of local government to act in other areas, as structural unemploy-
ment meant that those local authorities with the highest unemployment were
those whose capacity to meet the increase in relief payments was weakest.
Shifting responsibility to the authority with responsibility for the whole of the
national economy during the s and more emphatically after the Beveridge
Report and National Insurance Act of , they argue, was a vital gain for local
authorities.
138
A similar argument can be made for the provision of health services, particu-
larly hospital services. Local government was dominant in provision of health
services in the interwar years, particularly in England after the Local
Government Act shifted the administration of poor law health services to local
authorities, and planners assumed that local government would provide health
services in the future. The London County Council in the s was ‘arguably
The provision of social services
138
L. J. Sharpe and K. Newton, Does Politics Matter? The Determinants of Public Policy (Oxford, ),
p. .
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the largest hospital authority in the world, rivalling in size the entire voluntary
sector of England and Wales’.
139
Yet, local government was not well equipped
for provision of health services, because both the local government areas and
local government finance were inadequate. There was much discussion by
Fabians and geographers of a new pattern based on the regionalisation of local
government and the prime example of the inefficiency of the existing system
was health. It was these services, particularly the general and specialist hospital
services, which were seen to gain most from reorganisation along regional lines;
regionalisation would bring substantial economies of scale, more uniform stan-
dards and better career structures for staff. Hospital services especially required
an area larger than existing local authority areas.
The difficulties in the s of providing coherent, uniform hospital services
with local authorities leading the way in cooperation with voluntary hospitals
can be illustrated by the differing problems the Scottish Office had in imple-
menting the Local Government Act in three different urban areas. In Glasgow
it was difficult to convert the existing poor law institutions into general hospi-
tals under the control of the local medical officer of health as poor law recip-
ients, usually elderly, chronically ill patients still required accommodation,
though only intermittent medical attendance and not continuous skilled nursing
care. Implementation required funding for extra accommodation and a reorgan-
ised GP service so there could be both an extension of surgical facilities and
more specialised assistance for the elderly, the chronically sick and children.
140
In
Lanarkshire it was difficult to obtain local authority cooperation. The act
resulted in seven authorities – one county council and six burghs – each with its
own provision for infectious diseases, TB, child welfare and poor relief. Together
with twenty voluntary hospitals the county had forty separate bodies providing
institutional care. Because hospitals were seen to need elaborate equipment and
specialisation, the Scottish Office argued that the local authorities on their own
could not provide the necessary services; cooperation was essential and it would
not allow any of the existing authorities to develop by themselves. Although the
county and other burghs agreed to participate in a new, large county hospital,
the burgh of Motherwell refused, wanting to build a new block for the sick poor
at its poor house. Despite the ‘bait’of a Special Areas grant, agreement was never
reached.
141
In Greenock, with its damp climate and northerly exposure contrib-
uting to ‘perhaps the worst record of public health in Scotland’, it was impos-
sible to secure the agreement of the local voluntary hospital, afraid of a possible
rival, for a new local authority hospital for the non-pauper chronically ill.
142
Ideas in favour of the regionalisation of local government were widely
diffused by . If local government must be reorganised on a regional basis,
Marguerite Dupree
139
C. Webster, The Health Services since the War, vol. (London, ), p. .
140
I. Levitt, Poverty and Welfare in Scotland – (Edinburgh, ), pp. –.
141
Ibid., pp. –.
142
Ibid., pp. –.
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and health services organised along local government lines, then health services
should be organised on regional lines. This vision of the future was opposed by
the medical profession and local government associations which fought to main-
tain the status quo. By the Economist argued that health costs were the
highest expenses for local government after education. It was beyond the capac-
ity of the existing local government structure to administer health and particu-
larly hospital services successfully and it might lead to the collapse of all local
government services, particularly education and housing in which local varia-
tion was more acceptable. Thus, it would be better to surrender one sphere, the
health services, relieving local government of the cost and fund it from the
Treasury, than surrender in all. Aneurin Bevan adopted such a scheme, seeing it
as politically acceptable to doctors and the local authorities association and as
having the greatest chance of success, though he viewed it as an interim, tem-
porary arrangement, undesirable in the long term due to its lack of democratic
accountability, but acceptable in the short term until there was local government
reform and the NHS could come back to local government.
143
There was still a vital place for local authorities and voluntary organisations in
the provision and organisation of services connected with social welfare, despite
the transfer from local to national government of assistance by cash payments
in the interwar years, and even after and the creation of the NHS with its
tripartite structure of regional hospital boards, local authority services and
general practitioner services. Equally, from the perspective of urban history an
essential point is that variations in the complex mix of agencies mattered in terms
of life and death, particularly in the interwar years, as the provision of maternal
and infant welfare services illustrates.
National legislation relating to maternal and infant welfare services between
and included the Maternal and Child Welfare Act of which
enabled local councils and voluntary institutions to apply for grants of up to
per cent of expenditure on services including infant welfare clinics, paid mid-
wives, health visitors, day nurseries, milk and food for needy mothers and
infants. Provision was not mandatory and was highly dependent on local inter-
pretation and policy making, as well as on local socio-economic circumstances.
Maternal and infant welfare services were more comprehensive in London than
elsewhere. ( per cent of London boroughs put in half or more of the services,
compared with per cent of county boroughs and per cent of county coun-
cils.) But, within London provision was highly variable reflecting diversity of
socio-economic conditions among boroughs and the autonomy of local author-
ities. Lara Marks has shown that there was not always a direct relationship
between social deprivation and mortality patterns. For example, Stepney was
The provision of social services
143
C. Webster, ‘Regionalisation of local government and the origins of the NHS’, paper given to
the Symposium on the National Health Service: Its Past, Present and Future, Wellcome Institute
for the History of Medicine, July .
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one of the poorest boroughs with a great deal of casual labour and high popu-
lation density, but it had lower rates of maternal mortality than Woolwich, a less
densely populated district predominantly of skilled artisans, or the more pros-
perous boroughs of Hampstead and Kensington, due in part to the relatively
good maternity care available through the large number of teaching hospitals in
Stepney. Moreover, the richer borough of Kensington had higher infant mor-
tality rates than the poorer Woolwich. Stepney and Woolwich, which had more
local authority funds committed to maternal and infant welfare services, had a
greater reduction in their infant mortality rates than Hampstead or Kensington
which were politically more conservative, providing fewer municipal services
and relying more on the voluntary sector. Yet, it was not a straightforward issue
of local authority versus voluntary provision. Many of the interwar schemes
stemmed from previous voluntary initiatives, sometimes in collaboration with
local authorities. Voluntary organisations, often supported by government
grants, continued to play an essential role in the provision of maternal and child
welfare into the interwar years; the extent depended on the precedent for such
work in each individual borough and was shaped by their political outlook.
Municipal provision appeared earliest in Woolwich which had few middle-class
residents and a strong Labour council, while council initiatives were less impor-
tant in Stepney which had a weak Labour party but many voluntary agencies
before the First World War, particularly organisations of Catholic and Jewish
immigrants as well as teaching hospitals. Rather than disappearing in the s
with the rise of the Labour party in Stepney, these voluntary organisations were
incorporated into municipal provision. In Kensington and Hampstead voluntary
organisations based on their large upper and middle classes dominated maternal
and infant welfare services, with the local council of the National Council for
Social Welfare in Hampstead promoting effort and initiating cooperation
between voluntary and state activity.
144
Variations in levels of provision – and complex mixtures of voluntary and local
authority services – existed in urban areas outside London as well as within the
metropolis. Elizabeth Peretz found that local attitudes influenced provision in
Merthyr Tydfil and Oxford as well as in Tottenham. Tottenham, which escaped
the worst of the depression, had a strong Co-operative Labour presence and a
dwindling charitable middle class throughout the interwar period. Its services
were a source of civic pride, offering the widest range, the most generous scales
and free access to some services. Merthyr Tydfil was Labour-dominated, yet in
comparison to Tottenham it had a restricted maternity and child welfare service,
though as a depressed area it attracted some charitable help. The relatively poor
Marguerite Dupree
144
Marks, Metropolitan Maternity, pp. –, –, ; L. Marks, ‘Mothers, babies and hospitals:
“The London” and the provision of maternity care in east London –’, in V. Fildes, L.
Marks and H. Marland, eds., Women and Children First: International Maternal and Infant Welfare
– (London and New York, ), pp. –.
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service was partly attributable to the lack of money within the council. It had
difficulties raising rates, other expenses were high and so there was not enough
money even to match the national grants. Moreover, the councillors wanted
more money given to families so they could buy the goods and services they
wanted rather than being reliant on a variety of means-tested, narrowly pre-
scribed goods and services. Maternal and child welfare was seen to be the patron-
ising domain of the Liberals and Conservatives in the area and was scorned by
wives who were proud of their households and maternal ability. Oxford also had
few services and most were organised by charitable groups ‘under the licence’ of
the local authority; there was little take up of the few free services. It was pros-
perous enough to have provided full services and to have encouraged poorer
mothers to claim what they needed for free. Yet, the councillors, most of whom
were Conservatives or Liberals who also sat on the committees of voluntary
organisations in the city, regarded local authority services ‘as the expensive
option, to be used only when voluntary organisations had failed’, and they were
concerned not to undermine self-help, debating in whether mothers
should pay to attend infant welfare clinics so they would appreciate them
more.
145
(v)
A changing balance among the sectors of the mixed economy of welfare char-
acterised the provision of social welfare in urban Britain during the period
between and , both overall and within towns and cities. In general, in
the mid-nineteenth century, after the New Poor Law of restricted the uni-
versal and comprehensive provision of the Elizabethan poor law for poverty and
health care, voluntarism, combined with local authority provision (both munic-
ipal and the poor law) provided for the social welfare needs of the inhabitants of
Britain’s towns and cities. In the late nineteenth and early twentieth centuries
financial crises for both the voluntary sector and local government, together
with a growing conviction that they and the poor law neither could nor should
provide sufficiently for their needs in an increasingly urban society, led to a
growing reliance on national finance and administration, contractual entitlement
and further narrowing of the risk pool. Sometimes these changes were in con-
junction with, but often they bypassed, local authorities and voluntarism.
Poverty and health were seen to require more uniform provision and higher
minimum standards than other services. As Pat Thane argues, voluntarism and
local authority provision were an integral part of the ‘minimal’, ‘enabling’central
state in the mid-nineteenth century, allowing the central government to con-
The provision of social services
145
E. Peretz, ‘The costs of modern motherhood to low income families in interwar Britain’, in
Fildes, Marks and Marland, eds., Women and Children First, pp. –; Peretz, ‘Infant welfare’.
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