Sick or Healthy? The Urban North Between the Wars

This article explores the local mixed economy of healthcare in two of England’s largest cities – Leeds and Sheffield – between the late Edwardian period and the outbreak of the Second World War. It examines the level of service provision across the period to identify areas of strength and weakness and considers the extent to which these were determined by local political priorities. It examines indicators of success, such as falling death and infant mortality rates, increased access to treatment in hospitals and clinics and improved outcomes for those treated. Finally, it assesses the degree to which the mixed economy was able to develop a coordinated approach despite limited and ineffective central state direction. In particular, it looks at how local authorities and voluntary providers worked together in areas like Infant and Child Welfare, Maternity provision and general acute treatment to build the healthy city. Overall it suggests that this mixed economy, operating within a policy environment shaped by local urban cultures and needs, was able to deliver extensive health care improvements which belie the conventional pessimistic assessments of the period.

The popular view of health and health services in the years before the NHS is one of inadequacy and government failure, especially in the depressed industrial north of England. But this view is increasingly being challenged by a more nuanced understanding of the state of the nation's health, especially the importance of local initiative. In a period with limited central government direction or intervention local and regional systems underpinned the delivery and effectiveness of British healthcare services. As a result, most, if not all, material improvement in health conditions and provision took place at the level of the city or town while a significant part of the growth in provision of, and access to, healthcare was facilitated outside the state by voluntary, mutual or commercial providers. 1 Historians are increasingly recognizing this with a growing body of local work examining hospital provision on the one hand and public health initiatives on the other. Yet much literature still focuses on a generalized approach which fails to capture the breadth and depth of the urban voluntary hospitals, while many of the negative assessments of municipal public health have drawn on anecdotal or polemical sources at the expense of the extensive output of the country's medical officers of health (MOsH). Moreover, while local authorities were very active in promoting health between the wars, much of the overall improvement was delivered by a complex mixed economy of health care provision which saw the local state in its various forms work together with a highly developed voluntary sector, especially the general hospitals, private practitioners, mutual organizations and commercial providers. 2 Together they oversaw significant improvements in life expectancy, massive growth in service provision and a marked democratization in access to that provision.
What was public and personal health and healthcare like in the interwar period and how has our understanding of these topics changed in recent years? To date, much of the historiography has been dominated by pessimistic accounts focused on the failure of health policy, especially the seemingly ineffectual Ministry of Health and its inability to address health inequalities. 3 Attention has been drawn to the mixed outcomes of efforts to reduce infant mortality, widespread evidence of malnutrition and a failure to tackle the problem of maternal mortality. 4 Particularly significant in the latter case was Irvine Loudon's contention that poor hygiene and antiseptic practices among medics meant medical interventions, especially in institutions, left women at risk of puerperal sepsis. In relation to public health and medical services, Charles Webster's influential articles of the mid-1980s 5 and his official history of the NHS, still dominate the field. In these he laid down a social democratic vision of the inter war period which emphasized the failure of government policy, the highly detrimental impact of unemployment and poverty on individual health and the chaotic and inefficient operation of hospital services across the country, arguing course they lacked access to health services of even decent minimum standard, let alone the advances in medical science'. 6 Older accounts have also emphasized the weakness of the National Health Insurance system which continued to exclude both dependents and general hospital treatment, Webster stating: The worst affected were working-class women. As dependents, they were excluded from meagre National Health Insurance (NHI) medical provisions. They lacked the material resources adequately to support their families and were therefore forced to deny themselves medical assistance or even an adequate diet. 7 In a similar manner, others have contended that access to health care for women, children and the elderly was closed down by the growing emphasis on acute specialisms in the voluntary hospitals and commensurate restrictions on outpatient services. 8 In all of these analyses there is an implicit assumption that available resources and their quality remained fixed, with even generally optimistic studies emphasizing the prevalence of charity in the provision of health care, the continuation of the poor law as a means for delivering health services, a lack of coordination and huge Officer of Health Sheffield, Annual Reports, 1920-39. 6  inequalities between the wealthy south and depressed north. 9 Institutional provision has also been criticized, summed up in Rodney Lowe's influential textbook, The Welfare State in Britain since 1945, with its assertion that 'voluntary hospitals had to turn from their original purpose, the free treatment of the poor, to care for those who could afford to pay for their treatment' while the poor had to rely on local authority hospitals, creating an unnecessarily complex system. 10 Together these studies have tended to dismiss the evidence of improvement presented by the Ministry of Health, local Medical Officers of Health and the voluntary sector while relying on the highly partial impressions of journalists and political campaigners on the one hand and cutting edge scientists on the other, to support claims of failure. 11 Recent research has offered a more sustained challenge to this version of events with John Pickstone, Barry Doyle, Jonathan Reinarz and George Gosling providing closely researched accounts of health services in Lancashire, Yorkshire, Birmingham and Bristol 12 while Martin Gorsky and John Mohan have offered a more cautious revision of the situation in the South West and North East of England along with some national trends. 13 In a similar vein, Martin Powell, John Stewart, Alysa Levine and Becky Taylor have revised understanding of municipal and poor law services and Bernard Harris has delivered a balanced synthesis of health between the wars. 14 Steven Thompson's research into sanitary and health services in industrial south Wales tempers these more optimistic accounts by showing that, in smaller towns and mining areas, infrastructure and health provision improved more slowly. 15 Moreover, there is evidence that this was an era of substantial improvement in both health indicators and health provision. Thus, the Infant Mortality Rate (IMR) roughly halved between 1910 and 1940the English figure falling from 89 to 50 per thousand between 1919 and 1939 ( Fig. 1) while life expectancy at birth rose by more than eighteen years in the same period. 16 But many accounts do highlight the stubborn persistence of maternal mortality, especially as a result of puerperal sepsis. Irvine Loudon argued that in the early twentieth century it was the birth attendant and the location, rather than social class, that determined the safety of childbirth, with hospitals seen as particularly dangerous locales. 17 Alice Reed has developed this for non-urban areas suggesting doctors were the attendant most closely associated with fatal outcomes for mothers. 18 Moreover, Loudon's thesis points to the introduction of sulphonamide drugs in 1936 as the key to tackling maternal deaths, especially from sepsis, a view which has gained wide acceptance. 19 These trends were accompanied and facilitated by increases in other health amenities, including the extension of WC toilets to most urban homes, increasing presence of indoor water supply, the eradication of most fatal infectious diseases and the substantial growth in hospital provision and treatment, especially for women and children. 20 In the latter case the part played by the widespread development of hospital contributory schemes has not yet been fully appreciated in generalist texts on health in the inter war period while the expansion of municipal and expoor law provision has been either minimized or seen as a missed opportunity and its relationship with the voluntary sector largely misunderstood. 21 Why have the improvements recorded in interwar health indicators been largely ignored by historians? In the main it is because research has focused on the central state, and especially the Ministry of Health, with many authors looking for evidence of government planning, direction and initiative. Yet interwar healthcare was delivered by a complex kaleidoscope of providers with the level of service provision in many cities largely 15 S. Thompson, Unemployment, Poverty and Health in Interwar South Wales (Cardiff: University of Wales Press, 2006). 16  determined by local needs, local cultures and local political priorities. It was these factors, rather than the Ministry of Health or the vagaries of the economy, that determined health outcomes and services. 22 Although some historians have seen this local variation as a sign of weakness in the pre-1940 system, it is apparent that it also provided the opportunity for localities to shape services appropriate to their needs.
So how did this mixed economy operate? And how effective was it in delivering medium term improvements to the health of urban dwellers in the challenging economic conditions of the 1920s and 1930s? This article will explore the local mixed economy of healthcare in two of England's largest cities -Leeds and Sheffieldbetween the end of the First World War and the outbreak of the Second World War. It will consider indicators of success, such as falling death and infant mortality rates and increased access to treatment in hospitals and clinics. It will examine the level of service provision across the period to identify areas of strength and weakness and will consider the extent to which these were determined by local political priorities. Finally it will assess the degree to which the mixed economy was able to develop a coordinated approach despite limited and ineffective central state direction. In particular, it will look at how local authorities and voluntary providers worked together in areas like venereal disease (VD) treatment, Infant and Child Welfare, Maternity provision, cancer therapy and accident and emergency to build the healthy city. It will suggest that this mixed economy, operating within a policy environment shaped by local urban cultures and needs, was able to deliver extensive health care improvements that belie the conventional pessimistic assessments of the period.

Sheffield and Leeds
Sheffield and Leeds were two of the five most significant provincial cities in England in terms of population and economic and political importance. 23 Sheffield, with a population of almost 500,000, was the centre of the fine steel and cutlery industries and had diversified into heavy engineering, especially munitions, just before the First World War. 24 However, as a result of this reliance on heavy industry, the city's economy suffered for most of the inter war period with unemployment affecting 32.5% of the male workforce in 1921 remaining high throughout the twenties, then rising to a peak of 58,100 in 1932equivalent to 34.1% of the insured population. 25 It was only after 1934 that improvements in demand and the start of rearmament permitted a fragile revival through the second half of the thirties. Leeds, with a slightly smaller population, owed its industrial prominence to its role as the centre of the Yorkshire wool industry. However by the beginning of the twentieth century the economy had diversified and could boast a significant engineering sector, especially to the south of the city, as well 22  as a rapidly growing ready-made clothing industry in the north and east. 26 The latter industry employed increasing numbers of women and was focused on the large factories of Hepworth, Burton and Price. However, the continuing importance of textiles, engineering and coal mining meant male unemployment was notable in interwar Leeds with peaks in 1921 and again in 1932though measuring its overall impact is difficult given the large number of women workers in the economy. However, the peaks were lower and the recovery quicker in Leeds than Sheffield with the later 1930s giving an air of prosperity which had been missing since before the war. 27 The West Riding of Yorkshire was clearly a depressed area for much of the interwar period where one might expect significant health problems linked to poverty to emerge and for the development of ameliorative healthcare services to be restricted by the relative weakness of the tax base and the charitable sector. 28 Yet the evidence does not support such a hypothesis and indeed there are some important indicators of success. Three, Infant Mortality (IMR), the overall death rate (DR) and Maternal Mortality (MMR), have been used as barometers of national and regional health in the interwar period, with historians pointing to apparent slow improvements in England and significant differentials between regions of the United Kingdom and other countries. They have also been used to demonstrate the success of progressive local authorities in the face of weak leadership from the Ministry of Health. 29 This next section will consider the trends in IMR, the death rate and MMR in Leeds and Sheffield to suggest evidence of better than average outcomes.
Historians have tended to play down the decline in infant mortality across the period, focusing on it only in the early 1930s (when it saw a small increase) or comparing it unfavourably with other countries. 30 Yet the evidence from Leeds and Sheffield is that improvements were significant and sustained even in these areas badly affected by the depression.
As we can see from Campbell and the City's MCW medical officer, Dr Rhoda Adamson. In a 1933 report, Campbell noted that women took to work to compensate for male unemployment and that while '[i]t is difficult to obtain definite information as to the general health of the mothers and young children … the general impression of the medical officers is that it is showing some deterioration, and that there is more anaemia and minor ill health among the women and more rickets among the children'. 31 Adamson thought 'the general nutrition of the women was probably less good than before', pointing, in particular, to a rise in minor cases of rickets, especially among two and three year olds who were not eligible for any municipal support. 32 Yet this situation was temporary and by 1935 the decline in the city's IMR was clearly back on trend.
The experience of the death rate was much the same. That in Sheffield ran at or below the national average for the whole of the period while from a higher base the figure for Leeds fell sharply in the first half of the 1920s but then remained notably above the average for the rest of the period. Even in that most stubborn of inter war death rates -MMRsignificant strides were evident before the introduction of sulphonamides. 33 Undoubtedly the MMR in both cities mirrored the national figure or was probably a little above it for most of the 1920s at between four and five per thousand. Yet by 1939 both Leeds and Sheffield had rates below the national average of 2.97 and in the case of Leeds the rate had been falling faster than nationally since 1934. Thus it is evident that not only was health improving in Leeds and Sheffield, it was improving faster than nationally, especially in the key indicators of Infant and Maternal Mortality.

Accessing Hospitals: Local Needs
Underpinning healthcare provision across Britain was National Health Insurance. Introduced in 1911 and covering almost 20 million working and lower middle class employees by 1938. NI provided access to a 'panel' doctor, a contribution towards maternity costs and some tuberculosis institutional provision. 34 However, unlike many European schemes, it did not cover the spouses and children of members or, crucially, pay for hospital treatment. These exclusions may well have driven innovation in institutional funding and ultimately democratized access to the hospital ward. 35 In particular, it helped to shape the mixed economy of institutional provision which operated in cities like Leeds and Sheffield between the wars. Until recently there was a tendency to play down the improvements in access to health care, especially hospitals, with the experience of London too often taken as a proxy for the nation as a whole. 36 There has been a growing body of research undertaken into local hospital systems although much of this literature has focused on funding models and the voluntary hospital sector, with fewer studies interested in the growth in either hospital beds or patient throughput. 37 Indeed a number of the studies that do explore these issues tend to emphasize limitations on growth or use area utilization rates to underplay the extent of increases in patient numbers. 38 Yet examination of the situation in Leeds and Sheffield suggests a significant increase in the volume of and access to hospital services. In Sheffield there were two large voluntary general hospitals plus institutions for womenincluding maternityand children, while in Leeds the voluntary sector provided one of the largest general hospitals outside London along with a highly developed dispensary, a maternity hospital and a separate hospital for women but no specific accommodation for children. 39 The borough councils provided extensive provision for infectious diseases including pulmonary and non-pulmonary tuberculosis (TB), although neither ran their own VD or Maternity institution before 1930. Both cities had two large poor law infirmaries that were appropriated in the 1930s. 40  maternity beds and reconfigure provision for TB although they also included some (mostly unwanted) mental health accommodation. But in the main they dealt overwhelmingly with chronic cases, the elderly and certain types of infections. 42 From the mid-1930s the expanded municipal services were developing acute and surgical work along with some outpatient departments and in Sheffield the Public Health Committee opened a casualty unit at the Northern General to complement the A&E departments at the city's two voluntary hospitals. 43 Some figures will give a sense of the increase in access. In Sheffield the four voluntary hospitals provided 840 beds (including convalescent accommodation) in 1919 but this had risen to 1293 by the outbreak of the Second World War. This expansion included pre-and post-operative units and some private beds for the rising number of patients who either could not afford or increasingly did not want to use private nursing homes. 44 There was a particular growth in accommodation for women and children and a significant addition in maternity beds at the end of the period. It is more difficult to trace the trajectory of local authority provision but by 1938 Sheffield Corporation managed around two and a half thousand beds across their seven institutions as well as having a stake in the metal health provision of West Riding County Council. 46 In addition to extensive TB and infectious diseases (ID) coverage, there was an important reallocation of beds to extend provision for maternity, surgical, medical and orthopaedic facilities in the years after 1929. As a result the numbers treated increased enormously. In 1919 voluntary and municipal hospitals in Sheffield (excluding the Poor Law Infirmaries) admitted 11,000 inpatients, saw around 100,000 outpatients and 60,000 casualty and accident victims. Twenty years later (and following the appropriation of the PLIs) the number of inpatients had tripled to 35,000, outpatient attendances had grown fivefold to half a million while casualty figures had doubled to just over 120,000.
The situation in Leeds was very similar with bed numbers growing from 600 to 1100 in the voluntary sector while the appropriation of the poor law buildings in 1934 brought the total number of municipal beds to 2700 by 1938. As in Sheffield, relatively few of these former workhouse beds were medical or surgical, but an increasing number were for maternity while more operative cases were being taken. 47 As the result of a less extensive building programme in the voluntary hospitals of Leeds, patient numbers only doubled from 20,000 to 40,000 with a comparable doubling of outpatient attendances from quarter to a little over half a million. Casualty attendees also saw a doubling in this period. Put another way by 1938 roughly one in five of the population of these cities benefitted from in or outpatient hospital treatment a yearcertainly not a figure that suggests a closing down or restriction of the numbers that were able to gain access to hospital services. As these figures suggest, there was a huge increase in demand for hospital-based treatments in the years after the First World War in part driven by the greater access to general practitioner services facilitated by NI, in part by school medical inspection and in part by a growing faith in the efficacy of institutional medicine. All providers had to explore a variety of strategies to meet that demand. 49 Although there were few new voluntary hospitals built in interwar Englandin these cities only the Leeds Public Dispensary was new to the in-patient market after 1918demand could be met by extensions, a tactic adopted in different ways in Sheffield and Leeds as the growth in bed numbers shown in Tables 1 and 2 suggests. 50 But extensions were expensive and disruptive and not all of the older hospitals were well placed for largescale physical growth. 51 In many cases increased capacity was achieved by reorganization, by moving staff out, utilizing space in basements and yards, by building up instead of out and after 1930 by withdrawing certain services. For example, in Sheffield there was a steady movement of nurses out of the main buildings to dedicated accommodation while in the municipal sector both Nether Edge in Sheffield and St Mary's in Leeds were limited to particular patient types, especially maternity and advanced TB. 52 A second strategy was to increase throughput by shortening the stay of patientsin voluntary hospitals this fell by around 20% while in the municipal sector the gains were even greater. 53 These gains were not bought by discharging patients irresponsibly but by more effective and efficient use of convalescent and post-operative facilities both through institutions run as annexes and through the work of the Almoners departments. Thus, in Sheffield the Fulwood complex was developed to provide a site to house pre-operative patients and then take them back after a few days acute treatment at the main hospital. 54 Leeds General Infirmary had access to extensive convalescent facilities at Cookridge while the Leeds Workpeople's Hospital Fund worked closely with the Almoners to allocate patients to their three convalescent Homestwo for women and one for men. 55 Almoners are often associated with the management of paymentand this was undoubtedly one of their functionsbut by the 1930s the women employed in the larger hospitals were more like nascent medical social workers identifying the needs of patients, especially at discharge. 56 They developed close relationships with a range of social service and charity providers as seen in Fig. 2, to ensure the prompt and safe discharge of patients.
Services were made more efficient by greater specialization of in and outpatient provision. 57 Outpatient departments increased and diversified from traditional specialisms in medical, surgical, ophthalmic, Ear, Nose and Throat (ENT), skin, X-Ray and massage to incorporate light treatment, venereal diseases, mental health, orthopaedic and fracture, neuropsychological, diabetes, chiropody and dentistry. 58 Moreover, this expansion of clinics did not just increase patient throughputit also reflected the changing demand for hospital treatment. At the beginning of the period most patients sought treatment for serious, even life-threatening, conditions but by the Second World War departments were dealing with problems like squints, ingrowing toenails and supporting the early phase of community focused mental health services. In the case of the orthoptics clinic at Sheffield Royal Infirmary, it was anticipated the new department would reduce the amount of surgery, cut costs and free beds. 59 Undoubtedly there is evidence that patients, and more importantly GPs, were using the OP and Casualty departments of hospitals rather than relying on the NI system. 60 Indeed the situation reached crisis point in Sheffield in mid-1932, sparking a bitter row between the hospitals and the general practitioners as Moses Humberstone, chair of the Sheffield and District Association of Hospital Contributors, launched a scathing attack on the growing number of patients who 'have come to look upon the hospitals as their family doctor' and the doctor who, at the slightest hint of difficult patients, was too 'ready to tell them that he could do nothing further and they had better go to hospital'. 61 But this was not a continuous complaint, with most of the huge expansion in OP visits prompted by developments in hospital policy. Thus, there were increasing numbers of patients discharged to outpatient departments while the annual report of the Sheffield Royal Infirmary noted in 1930 that the OP department 'has become largely consultative and is therefore of great value to those who could not obtain such services in any other way'. 62 Moreover, specialization in outpatients was accompanied by the growth and improvement of casualty provision which could still serve as the poor man's general practice as it had before the war. 63 Indeed in Leeds the Public Dispensary maintained its free general service to the city centre population by providing a casualty, ENT, dental, massage, eye, and general service which was very well reviewed by the Hospital Surveyors of 1945 who noted that: this Dispensary and Hospital fulfils a very valuable and useful function in the hospital service of Leeds and is a type of institution which might well be established in other large centres of population as a definite relief to the over-pressed out-patient departments of the general hospitals. 64 In Sheffield the casualty departments at the Royal Infirmary and the Royal Hospital were relieved by the opening of a unit at the municipal City General to serve the north of the city. Together these different approaches ensured that free and specialized treatment remained available to a wide range of local citizens despite the notional introduction of charges.
As this reference to the developing municipal service suggests, the 1930s saw a significant expansion of the range of provision available. But this was largely complementary to the voluntary sector. Historians have tended to maintain the view either that the municipal hospitals were second rate, under-funded and residual or that they were potentially the future of the health services but were held back by the arrogant voluntary providers hell bent on stifling their ambitions to become modern acute general hospitals. 65 While both of these situations could be found across the country, the reality was that councils were limited in what they could do and how they might develop. 66 Thus they retained an obligation to treat infectious diseases, including TB, and their access to finance for large-scale new projects was limited, especially in the early 1930s. But they did have both the scale and experience to deal with long-term illnesses and the 'incurable'. 67 Moreover, they were required to seek payment for medical and surgical treatment 68which deterred some potential patientsas did the poor law heritage of the new general hospitals. Yet where cooperation occurredand it often didcitywide services could improve and we will see how this played out in these two cities.

Accessing Hospitals: Local Cultures
The weakness of the National Insurance Act, especially in relation to women and children and hospital treatment, has been highlighted. 69 As suggested by the discussion of outpatient and casualty services, options did remain for the uninsured of Leeds and Sheffield (and many other cities). Moreover, in both cities the use of almoners could ensure that patients received free treatment on the basis of clinical need. 70 Thus over a quarter of all patients in Sheffield received free hospital treatment, the vast majority being women and children. At the other extreme there were increasing numbers of patients who either paid part of the cost of their treatment on the ordinary wardsone in eight of the patients in Sheffieldor sought private treatment. 71 In the latter case Colonel Tetley of the Leeds Hospital for Women explained: We think there is a demand for this sort of accommodation, partly because there are a great many people who can't afford to pay charges for nursing homes and partly because it is often difficult to find, outside a hospital, the facilities for diagnosis and treatment and for immediate medical attendance in the event of an emergency occurring during treatment, which the ordinary hospital patient receives at a voluntary hospital. Many people who are moderately well off and who have subscribed or do subscribe to hospitals, now often feel that in times of sickness they themselves cannot obtain the modern facilities for treatment which they are helping to provide for the ordinary hospital patients. 72 In these cities private wards first appeared for maternity and women patients but had opened for general cases in both Sheffield Royal Hospital and Leeds General Infirmary by the outbreak of the war. 73 However, for the bulk of patients it was the rise of hospital contributory schemes that ensured free treatment, if not always prompt access to a hospital bed. 74 Both Leeds and Sheffield could boast very impressive schemes covering hundreds of thousands of citizens and raisingin the case of Sheffield -£200,000 a year by the outbreak of the Second World War. 75 It was suggested that these schemes squeezed the sick poor out of the voluntary hospitals yet this seems unlikely given both the expansion of outpatient services and the fact that in Sheffield the Penny in the Pound Scheme provided 80% of hospital income but scheme patients made up only 60-65% of all patients treated. 76 The Penny in the Pound Scheme was created in 1922 by the four voluntary hospitals in Sheffield to collect contributions from the city's workers at a rate of one penny in every pound of wages earned. The scheme was managed by Sheffield Hospital Council who distributed the income to the institutions on the basis of the number of patients they treated in the year. The Council also funded other related services, like ambulances and rehabilitation (Fig. 3). The Leeds Workpeople's Hospital Fund, dating from the 1880s, ran on similar principles but it was independent of the hospitals and run entirely by a committee of working men. 77 Contributors were ordinary working people, the group who had found greatest difficulty in accessing treatment without the humiliation of charity. As one supporter of the system noted as late as 1940, the founders of the Fund in Leeds had 'got together and said the position was not good enough for them, and that they desired, as Englishmen, to be independent of charity in their medical services' although he noted 'They still had to rely to some extent upon the State and upon charities, which was a thing Englishmen abominated. He hoped that some day, perhaps not far distant, they would pay every penny of the cost of medical services in the City'. 78 Crucially, it needs to be recognized that these were not insurance schemesthey did not ensure privileged access to treatment, just free treatment if admitted, although the schemes did undoubtedly democratize access by basing admission solely on medical need.
Moreover, the payments made to hospitals were block grants rather than direct payments for individual treatment costs on a daily rate as found in Europe. 79 Furthermore, the schemes helped to promote joint working both within the voluntary sector and between the voluntary and local state providers. Thus, from the early 1920s the Sheffield scheme allowed for the treatment of its patients in the poor law infirmary in an emergency, an arrangement which was continued and developed in the 1930s following appropriation. 80 A similar arrangement followed in Leeds and by the end of the thirties more than 4000 patients a year were receiving treatment in local state hospitals in both cities at the expense of the contributory schemes, a situation which helped ease waiting lists for non-urgent cases and to raise the status and experience of the municipal institutions. 81 Accessing Hospitals: Local Political Priorities Health services and outcomes were also shaped by political economy and personality, especially the personalities of the Medical Officers of Health and the chairs of the Health Committee. 82 The rapid improvements in infant mortality and the excellent performance in relation to maternal mortality in Leeds were the outcome of a local economy in which there were a large number of women workers who paid into and received benefits from the hospital contributory scheme. 83 This resulted in a very extensive provision of maternity beds in Leeds in both the municipal and voluntary sector permitting a rise in the proportion of institutional births in the city from 17% to 52% over the twenty years from 1918 to 1938. Moreover, contrary to suggestions by Loudon and Lewis,84 this growth seems to have been driven by demand (not professional ambition) and as has been seen, actively helped to check the impact of puerperal sepsis. 85 Thus, in 1933 Dame Janet Campbell noted that: The comparatively low rate in Leeds is probably due to easily accessible facilities for inpatient maternity treatment and to a medical school, which not only ensures consultant obstetricians, but encourages a high standard of practice among private doctors … Better use is being made of Ante-natal clinics, and the midwives are working satisfactorily with the M. and C. W. service. It will be interesting to see whether a permanent reduction has commenced in the maternal death rate. 86 This institutional development was supported by an extensive network of largely voluntary maternity clinics across the city covering almost every ward and supported by a central clinic visited by a consultant obstetrician. 87 This service was originally promoted by the Medical Officer of Health and seems to have been backed by both Labour and Conservative municipal administrations, suggesting the non-partisan acceptance of the mixed economy of healthcare provision between the wars. 88 Conversely, the decision to reverse the appropriation of the Leeds poor law institutions at the end of 1930 was shaped very strongly by party and personality. 89 Leading Conservative, Alderman Martin, who became chairman of the Public Assistance Committee following the landslide Tory victory in the city's 1930 council elections, saw municipal hospitals as an unnecessary luxury that would attract too many expensive patients and undermine the strength of both the voluntary sector and the recently launched contributory scheme. In keeping with Conservatives elsewhere, he believed that bringing hospitals under the control of the health committee would encourage excessive use while making it more difficult to recover costs from the patients. Indeed, in 1933 he told the Ministry of Health surveyor that: 'The ordinary avenue of admission of non-urgent cases to the Hospitals should be through the relieving officer. He [Martin] does not approve of making it too easy for people to obtain benefits at the public expense or of too much "spoon feeding" of the populace'. 90 However, following the Conservative defeat in the 1933 elections Labour dusted off their plans for appropriation 91 while the next Conservative administration elected in 1936with Alderman Martin now chairing the Health Committeecontinued to develop the services and create a provision which was very highly regarded by the surveyors of 1945. 92 In Sheffield, where Labour ruled almost without a break from 1926, health was an important political priority but up until the end of the period it was not shaped so clearly by ideology. 93 The early development of the Penny in the Pound Scheme and the Joint Hospitals Council meant that Sheffield hospital policy was moving in a collaborative direction from the mid-1920s. Given the nature of the local economyheavy industry with a large number of accidents among the employed male workforce casualty units, an efficient ambulance service and orthopaedic and fracture departments were the central concerns. 94 Moreover, for most of the period the city council saw housing as the key to good health and promoted extensive slum clearance and a new housing policy somewhat in advance of those in Leeds. 95 Over the course of their thirteen-year rule the socialist administration built over 20,000 homes, slightly more than the 18,000 built by Leeds in the same period. 96 Moreover, for politicians and medical officers in cities like Leeds and Sheffield slum clearance and atmospheric pollution were still the real priorities, not the little understood science of nutrition. 97 It was probably this emphasis on environmental improvement, and the high priority given to TB provision, which accounted for the impressive falls in death and infant mortality rates in Sheffield. On the other hand, these developments owed little to the unimpressive maternity and child welfare service that faced criticism from a Ministry of Health inspector in 1934 and certainly lacked the coverage and commitment shown in Leeds. Arguably this state of affairs owed something to the weaker economic and political position of women in Sheffield but also, it was felt, to the weakness and conservatism of the MOH who focused his attention on childhood tuberculosis. 98 Contrary to the established view, local politics also played a positive part in the effective development of collaborative working within and between the sectors of the mixed economy of health care. Historians often point to 'exceptional' examples of cooperation in Oxford, Liverpool, Manchester and Birmingham to demonstrate the more general absence of effective joined up working. But this is in part because documents about joint services in these cities were collected by the Ministry of Health in 1938 and are easily accessible to historiansa case of random source survival feeding historical interpretation. In fact, cooperation could be found in many places by the end of the 1930s. 99 Yet the outcomes of cooperation were not exactly as might be expected nor were the developments linear. 100 Moreover, coordinated approaches emerged despite limited and ineffective central state direction, for while the Ministry of Health urged joint working at various stages throughout the inter war period, it did nothing to enforce it and often shied away from intervening in local arrangements. 101 In Sheffield co-operation and coordination between the sectors was extensive in the early 1930s, building on the work of the Hospitals' Council and the Penny in the Pound Scheme. The quick appropriation of the poor law infirmaries saw rapid reorganization of municipal hospital services to make the best, most efficient use of the two newly acquired institutions. 102 Close working between the two voluntary general hospitals had been facilitated by the sharing of funding streams and this gradually extended to include both the women's and the children's hospitals 103 while the University played an important part in these developments, promoting a joint faculty approach amongst teachers and consultants. The joint advisory committee set up by the voluntary hospitals and the city council after the Local Government Act approved a major scheme of city wide rationalizationprobably one of the most comprehensive and effective anywhere in the country. 104 Mainly focused on extending and improving the services of the local authority through a new maternity unit, casualty unit and operating theatres, it was facilitated by the poor financial state of the voluntary hospitals at the time. The development also included a separate scheme to take waiting list patients for treatment in the municipal City General on a complicated system of finance. 105 However, there does seem to have been a souring of relations between the two sectors in the later 1930s, especially following the merger of the two voluntary general hospitals and the launch of their million pound appeal to build a new super hospital in the city centre. 106 Overall, however, the city showed what could be achieved by cooperation and coordination in the interest of patients, doctors and the university and indeed was seen as a model by the British Hospitals Association. 107 In Leeds developments were more contested and slower, with continuing divisions within and between the sectors until the mid-1930s. Yet even before this date joint working was apparent in certain key areasmost notably VD treatment where the Medical Officer of Health unified and coordinated the treatment of the disease across all three sectors. 108 Although coordination of the bulk of the services was delayed both by the refusal of the city to appropriate the poor law infirmaries until 1934 and by the resistance of the Public Dispensary to joint working within the voluntary sector, from 1935 onwards rapid advances were made which saw cooperation, particularly around maternity services. 109 Here, as in Sheffield, the demand was met by a rationalization of resources with the Leeds Maternity Hospital focusing on first time mothers and complicated cases, the municipal hospital taking the bulk of multiparea women and an extended infant and child welfare service with municipal midwives operating under the 1936 Act managing home deliveries and ante and post-natal care. 110 Although sulphonamides were clearly very important in reducing maternal mortality the development of these multi agency services also contributed significantly to the successand probably to the rapid decline in infant mortality in both cities in the later 1930s.
A similar willingness to share resources was seen in the case of casualty management, especially in Sheffield which did not have the benefit of a large outpatient focused dispensary like Leeds, and in the treatment of the new 'scourge of cancer'. 111 In both cities the development of radium treatment was focused on the voluntary hospitals with the support of the Yorkshire Council of the British Empire Cancer Campaign and other voluntary assistance. Furthermore, in both cities it was agreed by the respective hospital councils to pool resources and create joint voluntary/municipal facilities before the passing of the 1939 Cancer Act. 112 In Sheffield the plan for a new Radium Institute elicited a donation of £100,000 from the city's leading philanthropist J.C. Graves, while the Leeds plan, which centred on upgrading the facilities at the General Infirmary, was one of the first acts of the city's Joint Advisory Council and included close cooperation with the West Riding County Council. 113 Moreover, these plans envisaged cancer centres that would provide specialist services for most of Yorkshire (in 1945 Leeds General Infirmary opened a clinic in Hull) along with Derbyshire, Nottinghamshire and Lincolnshire in the case of Sheffield. They were to act as the pinnacle of a regional system where institutions in neighbouring towns were to undertake less specialist and outpatient treatments cooperating with the central institutions on the long-term treatment of patients. 114 This new challenge brought by increased longevity, made joint working essential for both the initial reception and longer-term treatment of the condition as prior to the Cancer Act of 1939 local providers received little support from central government.

Conclusion
The health of England's interwar urban dwellers remains a topic of debate as does the reach and effectiveness of the available health services. This article has shown that pessimistic assessments of both health indicators and access to health services, especially in the urban north of England, are in need of revision. In particular, it contributes to the growing body of work that emphasizes the importance of local needs, local cultures and local politics in the shaping of provision and the efficacy of the services delivered. In keeping with recent research, it also stresses the significance of the mixed economy of provision as voluntary providers worked with or beside the local state to deliver a range of services from hospitals to infant welfare. Underpinning many of these developments was gender as the increasingly female dominated economy of Leeds prompted improved maternity and child welfare services while the heavy industry of Sheffield saw particular advances in the field of orthopaedics. In both of these examples, public-voluntary partnerships were essential to success. These local cultures saw the successful development of hospital contributory schemes that ensured access to general and specialist treatment for the vast majority of the population in nationally renowned institutions. Contrary to pessimistic assessments, the introduction of charges and the development of contributor schemes did not squeeze out the working classindeed it was the middle class who increasingly demanded access to the benefits of the cities' excellent hospitals. Finally, local, rather than national, politics were at the heart of health service provision. This has often been seen as a problem, with public-voluntary and regional jealousies and penny-pinching councils holding back rational integration. Yet, in both these cities politicians, council officials and hospital administrators worked quietly to build a range of collaborative services that laid the base for the post-war NHS. Overall, to understand the state of interwar urban health we need to focus more on the local experience, to understand the workings of the mixed economy and to consider change over time.