The Roots of Regionalism: Municipal medicine from the Local Government Board to the Dawson Report
The genesis of nineteenth century British state medicine is evident in the pioneering work of towns such as Liverpool in the 1840s, which adopted a reactive strategy to epidemic infectious diseases. Their response was the essence of ‘localism’ – temporary and geographically constrained policies, which did not challenge national laissez faire ideologies. Liverpool’s pioneering 1846 Sanatory Act [sic] became the blueprint for the 1848 national (but permissive) Public Health Act, which some historians have seen as the trigger for a progressive consolidation of public health. The 1866 Sanitary Act articulated the first principles of municipal medicine, providing legal authority and financial support for removing infectious patients from their homes into designated isolation facilities. Yet it was the advent of the Local Government Board [LGB] in 1871 that facilitated the expansion of municipal medicine, through grants and subventions. These were linked into a system of inspections, undertaken by staff with varying degrees of medical and sanitary expertise, who assessed need and existing provision, especially of the new municipal isolation hospitals.
Two key observations emerge from an analysis of the period 1871 to 1929, when the Local Government Act changes yet again the permutations of municipal medicine. First, the impact of increasing knowledge of provincial public health on the expectations and reactions of central government. There was a clear sense of comparative analysis emerging, despite the Webbs assertion in their 1910 book, The State and the Doctor, that there was no ‘systematic inspection, or audit of municipal hospitals’. Second, the creation of a further layer of regional bureaucracy after 1888, when the new county councils were permitted to cut across existing sanitary district boundaries, sees the beginning of planning medical services on an explicitly regional basis. In 1893, the same year as the Isolation Hospital Act, a survey by the British Medical Association concluded that a ratio of ten beds per 100,000 population was an appropriate requirement for isolation provision.
The development of these essentially geographical policies has not hitherto been examined. They predate Bertrand Dawson’s well-known 1920 Interim Report on the Future Provision of Medical and Allied Services, which presented the concept of a hierarchical regional health service which differentiated between primary and secondary care. This paper will examine the emergence of these trends, and examine to what extent they were conscious policy decisions, taken at a national level, or essentially locally negotiated and reactive to demands for medical care.
Sally Sheard is Professor of the History of Medicine, with an appointment divided between the Department of Public Health and Policy and the Department of History at the University of Liverpool. She is a health and social policy historian, with a special interest in the interface between expert advisers and policymakers in the UK and international organisations. She is a Wellcome Trust Senior Investigator, leading a five year project (2015-2020): The Governance of Health: medical, economic and managerial expertise in Britain since 1948.To read more about Sally’s latest research project, The Governance of Health: Medical, Economic and Managerial Expertise in Britain Since 1948, please visit the project web page.