Local government and health care: the historical perspective

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Abstract
Administrative tradition In the course of the century from 1848 to 1948 it was increasingly accepted that public provision of health care should be the responsibility of local government rather than the poor law authorities.1 Health care was recognised as the analogue of education; both services came to be administered predominantly by county councils and county boroughs; the various committees of these authorities concerned with health and education were the best endowed and most prestigious areas of local government administration. Over the course of a century, the suitability of local government for administrating personal and environmental health services became so widely accepted that it achieved the status of almost an unquestioned constitutional principle. At first the departments of the medical officers of health were predominantly concerned with public health, but by the first world war local authorities also controlled a vast institutional service connected with infectious disease, destitute sick people, and longterm confinement. It was therefore entirely understandable that such advanced thinkers as the Fabian society should advocate the extension of local government activity into the acute hospital sector. As early as 1900 the Fabians declared, “We must municipalise all our hospitals”.2 The Labour party was the most active (though not the only) advocate of a comprehensive health service administered by local government. Proposals for a comprehensive and free health service administered by local government were included in a Labour party planning document in 1919, one year ahead of the famous Dawson report.3 The Labour party already coined the name “National Health Service” for its projected comprehensive municipal health service. This view of the future of health care was shared by Sir Robert Morant, the great administrator and architect of the Ministry of Health, established after the first world war, and it persisted as the official philosophy of the health departments until 1945.4 Despite the general atmosphere of retrenchment, expenditure on the local authority health services in England and Wales expanded from pounds sterling5.6m at the turn of the century to pounds sterling51m at the outbreak of war, all of this in a largely non-inflationary environment. By 1935 local authority health services accounted for about 60% of expenditure on organised health care in Britain, the remainder being split evenly between the voluntary hospitals and National Health Insurance. The trend towards local government domination of the health services continued and was accelerated by the second world war.5 Change within the health services was too slow for progressive opinion. Laying down guidelines that were adopted by the Labour party, the Socialist Medical Assocation ordained that the “Health Service of the future will be administered by local authorities, supervised by the Ministry of Health, which will have charge of all the Health Centres of the nation.” “Health centre” was at this time the preferred term for an institution responsible for comprehensive health care. The planners added an important and ominous caveat relevant to Labour's eventual retreat from the local government idea: “The Ministry must, however, use to a much fuller extent than at present the powers that it possesses for compelling reactionary local authorities to carry out their statutory duties.”6

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