NHS 70: Before 1948

George Campbell Gosling, University of Wolverhampton


The historian’s natural reflex, when someone else starts talking about their area of research, is to say: “Actually, it’s more complicated than you might think.” I expect to be fighting this urge pretty much constantly in the coming days, as we mark the 70th anniversary of the British National Health Service on 5 July.

When I tell people that I did my PhD on (short version) what it was like before the NHS and I’ve written a book about how payment worked in pre-NHS hospitals, I tend to encounter a common view of what life without the NHS must be like. A heartless world where the rule is pay or be left to die in the streets. When I say the reality was, in fact, more complicated than that, I’m often asked the same question:

So, are you saying things were better before the NHS?

No, is the short answer. The NHS was, in my opinion, a huge leap forward and the fact it delivered its health services free at the point of use to all was what made it so. There were, in some areas at least, high-quality and joined-up health services even before the NHS. But if you wanted to be sure of seeing a doctor or getting access to medicines, not being able to pay was a big deal. While mutual aid and National Insurance offered ways to pay in advance when times were good, being unable to pay did indeed mean going without for many people.

The situation in pre-NHS hospitals, however, was different. Most hospital beds, even before 1948, were in public hospitals. Many of these had their origins in the poor law, as workhouse infirmaries. By the 1930s they had often been brought under the control of the local authority as general hospitals for the community at large, but the stigma of pauperism lingered. Meanwhile, there were also voluntary hospitals – charities where doctors volunteered their services (building up professional experience for lucrative private practice) and most patients received either free or heavily subsidised care depending on their means.

Images: model of a hospital promoting the King Edward’s Hospital Fund (1932) Credit: Science Museum, London. Wellcome Images (Creative Commons 4.0)

This effectively means-tested system was run by the hospital almoner, later rebranded as the medical social worker, who had no say over whether a patient was admitted, but was in charge of asking them to make what she deemed an appropriate contribution to the hospital. The Lady Almoner is a crucial figure if we really want to understand how payment operated in the pre-NHS hospital.

Her job wasn’t only to set an appropriate rate (often free) for the vast majority of patients who had working-class incomes, but also to weed out middle-class patients. Their admission to the ordinary wards was considered an abuse of either charity (in the voluntary hospitals) or tax-payer funded welfare (in the public hospitals).

It’s not that the hospitals didn’t cater for middle-class patients, only that they were treated separately in a very small number of private rooms found in both voluntary and public hospitals. They were more comfortable and respectable, but also charged a commercial rate. Middle-class patients didn’t have the luxury of choosing to go private. They were medical consumers, but they had little choice about it.

For most people, who remained passive as patients and recipients of either charity or public welfare, the provision of healthcare free at the point of use was a form of liberation. That’s not to say everyone appreciated or wanted it. But it did set people free from the fear of what would happen if they couldn’t afford to pay the doctor.

So, I’m certainly not suggesting that the arrival of the NHS made no difference, though I do find myself explaining to those with strongly pro-NHS sentiments that what the NHS replaced was not entirely the nightmare of the bad old days. This puts me in mind of another question – one asked by Professor Barry Doyle in response to Professor Pamela Cox at the Social History Society’s 40th anniversary conference a couple of years ago.

In her time as Chair of the SHS, Pam has been a champion of the idea that social justice should be at the heart of social history, both in terms of what it is and how it is done. When she set out this principle in the discussion following the conference’s plenary roundtable, Barry asked:

Is it possible to have such a thing as a conservative social history?

I don’t believe that’s what I’m writing. Recognising the full picture, in all its complexity, should not undermine the value we place in the NHS. Instead, it should help us to understand the nature, and perhaps the boundaries, of that liberation, helping us to value the NHS for what it is and placing its defence on a sounder footing.


Read more in GC Gosling, Payment and Philanthropy in British Healthcare, 1918-48 (MUP, 2017)

A free open access e-book version is available via the OAPEN Library.


About the author: Dr George Campbell Gosling is Lecturer in History at the University of Wolverhampton, former Communications Officer for the Social History Society and general editor for the Social History Exchange. He is the author of Payment and Philanthropy in British Healthcare, 1918-48 (Manchester University Press, 2017) and articles including ‘Gender, Money and Professional Identity: Medical Social Work and the Coming of the British National Health Service’, Women’s History Review, vol. 27, no. 2 (2018), pp. 310-328.

One response to “NHS 70: Before 1948

  1. Thank you for the explanation. I was born in Dublin, 1947, at the Coombe Hospital. I have vague recollections of my mother referring very respectfully to a “Lady Almoner” at the hospital. The historical context of your article has provided missing links in my understanding of these overheard conversations of childhood. My mother was a very proud person, and I suspect that it would have been almost the universal experience of working-class Dublin women to have felt common sense gratitude and by no means demeaned by the help they received by the “Lady Almoner”.

    I agree with you that discerning the complexity of past structures and experiences is not a means of hindering the pathways to change but of managing change and ensuring that things of value are not needlessly discounted or discarded.

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