Uneven zenith: towards a geography of the high period of municipal medicine in England and Wales

Journal of Historical Geography, 14, 3 (1988)260-280

Uneven zenith: towards a geography of the high period of municipal medicine in England and Wales Roger Lee

The history of the welfare state is usually treated in an a-geographical manner. A sketch of an argument that this perspective is limited prefaces an empirical assessment of the significance and uneven geography of local government expenditure on welfare services during the inter-war period. Data are presented in real terms (at 1975 prices) and used to describe the financial contribution to the provision of such services made by the local government system as a whole, by urban local government and by individual cities. The conclusion outlines a number of caveats that must surround the interpretation of the data but suggests that the findings are not only relevant to the work of geographers and historians in the field of health and welfare history but more generally that they indicate the need to supplement the history of the welfare state by its historical geography. The welfare state, it is said, "is very much a time-bound concept . . . . the end product of a very long historical process", tl] But is it also a product o f geography? Despite the complexity implied in Derek Fraser's list of seven broad sets o f influences on the making o f its history t2] should we not also recognise that the welfare state is a place-bound concept and the p r o d u c t of a geographicallyvaried set of processes? This paper is a tentative and partial reference to research on these questions. It attempts to discern not the subtleties of the welfare response in individual localities [3] but the extent to which this response was geographically uneven, at least within the urban system o f England and Wales, [4] and to begin to provide a descriptive framework with which to assess the significance o f this unevenness for the making o f the welfare state.

What has geography got to do with the development of social policy? This question is prompted not by disciplinary defensiveness or imperialism but by a lacuna. A spaceless view of history implies a geographical uniformity o f response (or at least an unproblematic geography o f response)--and only a response to the forces making for change. It also encourages a top-down structural view o f the role o f ideas, benevolence, pragmatism, bureaucracy, ideology, conspiracy, capital-logic, gender relations, class struggle, culture, d e m o c r a c y - - t h e list o f formative influences u p o n the m a k i n g of the welfare state is certainly longer than F r a s e r ' s - - t o the exclusion o f geographically-uneven or place-bound and locally-directed influences u p o n change. But does this omission

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of geography matter; does it make any significant difference to our understanding? Arguing that social reproduction in capitalist society involves accumulation, class struggle and crisis, David Harvey insists that the conditions under which these processes occur are crucial. In parallel with Fraser he points out that close attention has been paid to historical conditions, including "the formation of necessary social and institutional supports", [5] but goes on to suggest that the geographical conditions have been neglected. Conditions within an urban region as well as the ways in which cities are incorporated into or rejected by the dynamic international division of labour are central to the concrete reality of what is otherwise the abstract notion of the circuit of capital. The relative significance of the items in Fraser's list of "the different realities of contemporary perception ''[6] on the evolution of the welfare state, may be specified only in the prism of the geographical conditions in which they take place and are experienced. But this is to say little more than that a variable geography of society influences the outcome of social processes; that the design and administration of the welfare state, for example, should be sensitive to the geographically-varied conditions of social reproduction. However, Harvey goes further than this: "putting the geography back in", he argues, "immediately triggers concern for the urbanization of capital as one of the key conditions under which struggles o c c u r " . [7] An implication of this argument is that Allen Scott's one-way Is] "chain of conceptual relations 'E91linking the capitalist mode of production to urbanization (or the urban land nexus) should more properly be regarded as a two-way street. Scott sees urbanization "as a secondary social event" which emerges "through a succession of mediations out of the broad structure of capitalist society". [1~ The logic of the capitalist mode of production informs the logic of civil society (the sphere of individual decision-making and behaviour) and the state (a sphere of collective action) which, in their turn, inform the logic of private and public decision-making in urban space. It is this process of structured decision-making from which the urban land nexus is finally derived. Collective action "underpinned and motivated by the piecemeal, but continual and effective intervention of the State ''[~11 is made necessary within urban capitalism because of the impotence of private decision-making to cope with the conflict inherent in capitalist social relations and the crisis-prone process of accumulation. So despite the sequence--from Robert Owen to Henry F o r d - - o f private experiments in reproductive welfare, the concentrated geography of urban production prevails against exclusive forms of socialization and reproduction amongst industrial workers, whilst competitive labour markets within urban regions offer a profound disincentive to individual capitalists inclined unilaterally to improve the living conditions of their labour force. And so in this--as in other failures of private action--a collective solution emerged "to manage the produCtion and reproduction relations of capitalism at large". [121 Not the least important of such collective interventions involves both the provision and managed consumption of goods and services necessary to ensure the process of reproduction. Leaving aside the functionalism of these arguments, a major difficulty with them relates to their closure around the concept of the "ultimately durable and . . . irreducible ''[13] capitalist mode of production. Such a perspective tends to overlook the notion that any mode of production is itself the product of the

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struggle to create a workable set of social relations t14] in a particular geographical and historical context and that challenges to the established order may change it from within or even replace it. t151Scott's chain of logic certainly begins to come unstuck when confronted with local government. To be sure the local state may be regarded as "a purposively constituted . . . " and "integral apparatus of the capitalist state" and may be reduced to little more than "a conduit or a means to an end". [16]But within a liberal democracy, decentralised local government is also supposed to be "a means of facilitating the will of individuals ''tiT] and of limiting the autonomy of the state by encouraging consent or disagreement. This Jeffersonian notion of decentralisation is intended not so much to bring the state closer to the people but to provide for a range of choice and preference: to politicise geography. The practice, however, is more prosaic. The possibilities for expressing individual choice in the Tieboutian sense t~8] are limited not only by class, gender and racial segregation but by the geography of land use and labour markets within and between cities. A d d to this the restrictive effect of limitations on local autonomy and the influence of "empirical rules of efficiency and scale ''t~9j on service delivery and we begin again to invoke a chain of logic. But that is precisely what we a r e doing: this is the logic of liberalism rather than of the mode of production. For Ralph Miliband, however, the geography of uneven development is much more important. Local government, he writes, [2~ is not merely an extension of central government and administration, it "is the voice of the periphery, or of particular interests at the periphery". [zq Not only does this suggest substantive geographical variations in local politics, [221but, for John Dearlove, [23]it implies a certain autonomy "both from the concerns of the central state and the impact of the dominant classes". Against the ultimately undemocratic logic of liberalism with its doctrines of natural rights, it allows a place for local politics and points to the potential importance of local social processes in and on the state. Such an argument suggests that the origination as well as the implementation of social policy may be revealed as a profoundly geographical process. Both may be shaped by the dynamic of geographically-uneven development and the particularity of the living and working places created by and contributing to the process of social reproduction. Just as the realization of the urbanization of capital (or, more generally, the inherent geography of the circuit of capital) enforces an appreciation of the geographical conditioning of accumulation, so uneven development connects politics and the making of social policy to the uncertainties of the formative geography of social reproduction. Insofar as the history of welfare is a history of adjustment to the changing social geography of capitalist society, it is also a product of that geography. [241 But how may such generalised arguments be explored in empirical substance? A reliance on case studies may prove to be misleading: "researchers may be drawn to 'radical' areas and see certain processes at work in having apparent effects, only to find that different processes are having much the same effect elsewhere". E251This paper retreats from the terrain of case studies to a description of the significance and uneven response of local government in raising and spending money on welfare provision within the urban system of England and Wales. In this sense it is crudely quantitative in approach although the financial aspects of local government--as of any part of the state--are quintessentially the stuff of politics in raising the central question of legitimacy. The paper

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establishes first the contribution of the local level of the state apparatus to expenditure (presented in real terms) on welfare, then goes on to consider the role of urban local government and, finally, the uneven response of individual localities. In this way it tries to establish a case for a geography as well as for a history of the making of the welfare state.

How municipal was municipal welfare? The title of this paper is derived in part from John Pickstone's study of hospital development in the urban region of Manchester. During the crisis-ridden inter-war years, the "(I)nitiative in welfare matters lay", according to Pickstone, t26l "increasingly with labour or progressive liberal politicians, and with women trained in the suffrage campaigns . . . . Hence the high period of municipal medicine" dependent upon the "slow but apparently inexorable advance of local government welfare". Pat Thane tzvJ develops this point: During the inter-war years central government devoted little attention or energy to health problems . . . . ; rather local authorities were the major source of initiative and of increased expenditure.

According to such arguments, local authorities were not only the major providers of collective health and welfare services in the inter-war period but they were the main source of policy development too. The period saw extensions and improvements in social welfare--pensions, health insurance, long-term unemployment relief, housing subsidies and the struggle to redefine the poor law (which had some success in the form of legislative changes)--but unevenness of provision and pragmatism in the making of policy remained characteristic. Nevertheless, despite the increased, economically-induced central control over cash payments--for poor relief and unemployment for example--the production of services was less directly affected despite the introduction (in the 1929 Local Government Act) of a block grant to replace many percentage grants made by the centre in aid of local services. So how important was local government in the provision of welfare? If geography is to be a significant factor in the development as well as the implementation of social policy, its effects must be allowed to influence the creation and design of that policy as well as its output in the form of service delivery. Was municipal medicine municipal merely in the sense that municipalities administered policies and resources emanating from the centre? One kind of answer to such a question is to explore the nature of central-local relations. Here there is widespread agreement that the inter-war period was not merely the high period of municipal medicine but the zenith of the autonomy of local government. I281Another but necessarily related answer is to explore the location of responsibility within the state system for expenditure on the output of social policy. "As late as the first decade of this century, virtually all public (domestic) goods and services enjoyed by the (British) citizen were", according to Christopher Foster et al. [29], "supplied by local government". In 1905 central government spent only about 30p per head (1975 prices) "on a motley collection of social, economic and environmental services". E3~Although local government expenditure fell from 51.1 to 44.8% as a proportion of total government expenditure in the U K between 1905 and 1913 and fell drastically during the war, it had risen again to 19.9% by 1920 and continued to rise from then on to reach 38.8% in 1936 at a level of local expenditure twice that of the pre-war

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period. [31] However, a more realistic picture of the relative significance of local government may be obtained by excluding expenditure on the national debt, military services, administration and overseas services, so concentrating attention upon the domestic delivery of state-provided services (Fig. 1). Throughout the period, local government accounted for well over half the total expenditure on service delivery and, from 1922 to 1938, for between 33.8% and 42.1% of expenditure on 'social services'. [321 By way of comparison, local government accounted for under 39% of total state expenditure on service delivery in 1955 and for less than a quarter of expenditure on social services. Within the local government system in England and Wales, expenditure in real terms on health care (like expenditure on virtually everything else) grew relatively slowly during the 1920s (at an average annual rate of 2.1% in real terms). But it accelerated rapidly during the three years to the turn of the decade 80-

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Figure 1. Contribution of local government to state expenditure on the delivery of public services in the United Kingdon 1890-1955 Source: Recalculated from Peacock and Wiseman fn. 31, Tables A 15 and A 23

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and again from 1930 to 1938 (Fig. 2) when the growth rate of expenditure amounted to over 20% p e r a n n u m . I331 In contrast, total rate fund expenditure grew by only 2.5% p e r a n n u m in the 1930s. As a result, health expenditure absorbed an increasing but always small proportion of total expenditure on rate fund services. Nevertheless, in comparative terms (Fig. 3), expenditure on health care by local authorities between 1921 and 1937 grew from just over one quarter to over three quarters of the level of expenditure they had achieved on the eve of the creation of the National Health Service. Thus, if measured in terms of expenditure on the provision of welfare facilities and the delivery of services in the inter-war period, local government remained an almost equal partner with the central state at a time when central controls were far less intrusive than they are today. [34jFurthermore, the rate of growth of local government expenditure on health care far outstripped the growth in total

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expenditure and was, especially during the 1930s but in the late twenties too, rapid by any standards. Clearly, the institutional framework of the state allowed the influence of the local level of the state apparatus to be felt in the development of social policy. And at the local level it was the urban system which was the dominant quantitative influence upon the provision of health care.

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The role of the urban system in the delivery of local services It is one thing to claim that the local level of the state apparatus is endowed with a major responsibility for the provision of services--even it it can also be argued that local governments have immunity from the centre and powers of initiation over the localityt351--but quite another to demonstrate that localities (as opposed to a part of the state system) exert a significant influence upon service delivery. The rest of this paper presents some prima-facie evidence to this effect. It looks first at the urban system as a whole. Between 1921 and 1937 the population of the urban system in England and Wales grew relatively slowly (Table 1). This sluggish growth was accounted for mainly by a loss of over 340,000 people from the L o n d o n County Council (LCC) area counteracted by a growth of just over 870,000 people in the county boroughs. The net effect of these population movements was a small reduction in the proportion of the population living within the urban system of England and Wales. This period represented a turning point for the urban system. F r o m 1921 the Census reveals that its share of the population of England and Wales began to decline from the maximum of 45% in 1921 to 44% in 1931 and 39% in 1951. At the same time the smaller urban centres of England and Wales continued to increase their share of igopulation. Despite its declining share of population, expenditure on rate fund services within the urban system continued to increase at a rate faster than that in England and Wales as a whole (Table 2). Between 1930 and 1937 expenditure in the urban system grew by 3.1% per annum as compared to 2.6% per annum in England and Wales. However, the receipt of local services by the population who make use of them is more usefully measured by per capita figures. Table 3 shows that substantial real increases in expenditure characterised the local authorities within the urban system--which exceeded both the levels of and growth in expenditure in England and Wales as a whole. The differential between levels of expenditure in London and the provinces narrowed during the period. A similar pattern (and partial explanation of the differentials in Table 3) is observable in the case of expenditure on health care (Table 4) but with a much more pronounced differential between L o n d o n and the provinces.

TABLE 1 Population change m the urban systemm England and Wa&s 1921 1937

County Boroughs (CBs) Metropolitan Boroughs (LMBs) Urban system England and Wales

1921

1937

12,541,990

13,413,000

4,484,523 17,036,513 37,886,699

4, [41,100 17,554,100 41,031,000

Proportion (%) of total population in: CBs 33.1 LMBs 11.8 Urban system 45.0

32.7 10.1 42.8

Sources: Calculated from Local Taxation Returns and Census 1951.

%change 1921-1937 6.9 -7.6 3.1 8.3

268

R. LEE TABLE 2

Expenditure change in the urban system of England and Wales 1921-1937 (s millions, 1975 prices) 1921

County Boroughs (CBs) Total current 813.2 Rate fund 415.8 LCC and MetropolitanBoroughs (LMBs) Total current (1) 378.7 Rate fund (1) 278.0 Urban system Total current 1191.9 Rate fund 693.8 (1930) 1322.4 England and Wales Total current 2161.5 (1930) Rate fund 765.7 Proportion (%) of England and Wales expenditure in: CBs Total current 37.6 (1930) Rate fund 32.8 LMBs Total current (1) 17.5 (1930) Rate fund (1) 15.0 Urban system Total current 55.1 (1930) Rate fund 47.8

1937

%change 1921-1937

1886.2 1135.5

131.9 173.1

557.5 473.7

47.2 70.4

2443.7 1609.2

105.0 131.9 (1930-1937) 21.7

1609.2 4405.5 3268.2

103.8 (1930-1937) 18.2

42.8 34.7 12.7 14.5 55.5 49.2

(1) Figures of expenditure for London are estimated by taking total expenditure by the MBs and adding to that expenditure by the LCC minus the amount paid under precept to the LCC by the MBs Sources: Calculated from the area/population/valuation tables and the aggregate tables in the Local Taxation Returns; and from Foster et al. Appendix 1.4.Al-see fn. 29

The increased significance of the urban system in the provision of health care services in England and Wales is the result of the very rapid growth of expenditure on hospitals, especially the new General Hospitals in London. This growth had been stimulated by the 1929 Local Government Act which encouraged local authorities to take over responsibility for the Poor Law hospitals. State finance and the zeal of the L o n d o n County Council and some metropolitan boroughs served to substantiate the primacy of the capital as the major national centre of hospital medicine. By 1937, L o n d o n accounted for almost a quarter of national expenditure on centralised health care. Expenditure on community care in the urban system also grew rapidly, clearly outstripping the growth rate for expenditure on health care in England and Wales. However,

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TABLE 3 Per capita expenditure on rate fund services in the urban system o f England and Wales 1919-1937 (s 1975 prices) 1921 County Boroughs London (1) Urban system England and Wales

33.15 62.00 40.75 (1930) 69.48

1937

% c h a n g e pa 1921-1937

84.66 114.39 91.67

9.7 5.3 7.8 (1930-1937) 2.1

79.65

Sources: as for Table 2 and Census 1951 Note (1): see note 1 on Table 2

TABLE 4 Expenditure on heakh care M the urban systemofEngland and Wales1921-1937 (s millions, 1975 prices) 1921

1937

% c h a n g e pa 1921 1937

County Boroughs ( CBs) Centralised (1) 17.5 56.0 Community (2) 7.1 22.6 of which M C W 5.5 13.1 Total 24.6 78.6 LCC and Metropolitan Boroughs (LMBs) Centralised 2.8 48.7 Community 2.7 6.9 of which M C W 2.1 4.3 Total 5.6 55.6 Urban system Centralised 20.4 104.7 Community 9.8 29.5 of which MCW 7.7 17.4 Total 30.2 134.2 England and Wales Total 85.7 241.8 Proportion (%) of total expenditure on health care in England and Wales CBs 28.7 32.5 LMBs 6.5 23.0 Urban system 35.2 55.5

13.7 13.8 8.4 13.7 101.5 9.4 6.4 56.1 25.9 12.5 7.9 21.6 11.4 in:

Sources: calculated from the aggregate tables in Local Taxation Returns Notes (1) Centralised health services include hospitals, sanatoria, dispensaries etc (2) Community health services include maternity and child welfare services, disease prevention, the welfare of the blind and vaccination (3) Maternity and child welfare services

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R. LEE

this growth was fuelled largely by the emergence o f new responsibilities such as the care of the blind. Maternity and Child Welfare services ( M C W ) - - t h e largest single c o m p o n e n t of community care services--grew relatively slowly when compared to the general growth in expenditure on health care. Thus the growth o f centralised health care not only served to increase the relative importance of health as an item in the budgets o f the urban system (from 4.4% in 1921 to 8.3% in 1937) but shifted the balance of expenditure on health decisively away from both community-based care towards centralised provision (from 67.5% in 1921 to 78.0% in 1937) and away from the provincial cities. The provinces accounted for 81.5% of expenditure on health care in the urban system in 1921 but for only 58.6% in 1937. The reasons for these shifts lie both in national policy decisions and the nature of the medical technology being advanced by those decisions, and in the uneven response of local authorities. The net effect was that L o n d o n which, in 1921 spent half the amount allocated per head of population to centralised health services in the urban system, spent twice the a m o u n t in 1937 (Table 5). In L o n d o n at the start of the period in 1921 almost 50% of the health care budget was devoted to community care. The figure for the county boroughs was 28.7%. By 1937, however, community care in L o n d o n was very much the p o o r relation in terms of claims u p o n resources, accounting for 12.4% of the much enlarged expenditure on health care. The more limited development of hospitals outside L o n d o n meant that community-based resources were very much more significant in the budgets of the provinces. Nevertheless, L o n d o n also led in the provision of resources to maternity and child welfare despite the more rapid growth in the provinces. TABLE 5

Per capita expenditure on health care in the urban system of England and Wales 1921-1937

(s 1975 prices) 1921

1937

%change pa 1921-1937

1.40 0.56 0.44 1.96

4.18 0.97 5.86

12.4 12.6 7.5 12.4

0.63 0.61 0.48 1.24

11.75 1.66 1.04 13..41

110.3 10.8 7.3 61.3

1.20 0.58 0.45 1.77

5.96 1.68 0.99 7.64

24.8 11.9 7.5 20.7

2.26

5.89

10.0

County Boroughs (CBs)

Centralised (1) Community (2) of which MCW Total

1.68

LCC and Metropolitan Boroughs (LMBs)

Centralised Community of which MCW Total Urban system

Centralised Community of which MCW Total England and Wales

Total

Sources: as for Table 2 and Census 1951

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Thus far, the argument has been that the local level of the state system retained a significance in the provision of services during the inter-war period and that within local government the urban system as a whole retained a distinctive character, with pronounced differentials between London and the provincial cities. The final stage of this empirical delineation of local distinctiveness in service provision is a summary consideration of the effect of the range of places within the urban system upon the pattern of service delivery. Cities and expenditure on welfare in the urban system

The geography of expenditure on welfare services within the urban system during the inter-war period was highly variable in space and time. Figure 4 shows the evolution and extent of this geographical uneveness with respect both to tax effort (as measured by the size of rate poundages) and to expenditure per head on total rate fund services. What is notable about the picture that emerges is the trend to increased unevenness over time--especially in tax effort--and the contrast in levels of variability in expenditures per head between London and the provinces. This is a helpful context in which to set the findings relating to individual cities. Despite the overall trend towards increased variability in the urban system as a whole, there is a high degree of consistencyI361in the behaviour of individual places between 1921 and 1937 (Table 6). The predominance of consistently "high" taxers points up the significance of the local scarcity of taxable resources to fulfill political ambition. Figure 5 represents the geography of consistently high and low tax effort and expenditure. The patterns t371 reveal the difficulty of raising resources in the underdeveloping regions of the country, the inner cities and the smaller urban centres. Cases in point here include St Helens, Stoke, Walsall and East Ham, all of which sustain high taxes and high expenditure. Low rates of expenditure in the north east are matched by indifferent tax effort. At the other extreme, the larger, regional and more affluent cities are able to impose relatively low levels of tax whilst in some cases--the classic examples being Blackpool and Eastbourne--sustaining high levels of expenditure. By contrast, the big northern cities--Manchester, Liverpool, Bradford and Leeds, sustain high levels of expenditure only by levying relatively high rates. Expenditure on individual services--such as Maternity and Child Welfare (MCW)--might be expected to be more varied than total levels of expenditure as policy preferences may the more easily be pursued (Fig. 6). Nevertheless, although the level of variability of expenditure on Maternity and Child Welfare is high, especially with respect to tax effort, it remains fairly consistent over the period although once again, London remains far more variable than the County Boroughs (Fig. 7). Given the far higher levels of overall variability of expenditure on MCW in the urban system, the consistency of the behaviour of individual places is the more remarkable (Table 7). Again, the uneven relationship between political ambition and the availability of resources underlies the differences between tax effort and expenditure revealed in the table. This point is substantiated by the geographies of tax effort and expenditure revealed in Fig. 8. These maps attempt to show the distribution of consistently high and low levels of taxation and expenditure on MCW. Some notable aspects include the preference revealed by St Helens for MCW--despite its difficult financial position overall, the significance of the eastern London

272

R. LEE 30-

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boroughs and northern industrial towns in continuing to maintain high levels of expenditure, the low levels of taxation and spending in affluent London, southern cities, seaside towns and the middle-ranking regional centres and the insignificance of north eastern cities--an apparent indifference which contrasts with other industrial regions. Figure 9 combines these indicators of tax effort and expenditure on Maternity and Child Welfare to reveal the extremes of policy preference and outcome in the urban system. The weighting (see caption to Fig. 9) attached to tax effort in this map lends emphasis to the extremes of differences

273

MUNICIPAL MEDICINE TABLE6 RFS: Consistency o f financial behaviour in the urban system 1921-1937

(percentage ofplaces in each category N = l l l / l l 2 )

Tax effort (1) Expenditure per head (2) a b

High

Low

Total Consistently Inconsistent (h/l) moderate h 1 t

27

18

45

64

2

1

3

26 23

26 23

52 46

52 58

6 2

2 8

8 10

Sources: calculated form summary tables and area/population/valuation tables in Local Taxation Returns Notes (1) Urban system considered as a whole N = 112 (2) CBs and MBs (excl the City) considered separately and summed (N= 83 and 28) (a) excluding London precepts (c) including London precepts

TABLE 7 MCW." Cons&tency o f financial behaviour in the urban system 1921-1937

(percentage of places in each category N = 111/112)

Tax effort (1) Expenditure per head

High

Low

Total Consistently Inconsistent (h/l) moderate h 1 t

26

19

45

46

7

4

11

21

21

42

59

7

4

11

Sources: calculated from MCW tables and area/population/valuation tables in Local Taxation Returns

in local p r i o r i t y g i v e n to M C W in the u r b a n system. B u t the inclusion o f the e x p e n d i t u r e i n d i c a t o r o f policy o u t c o m e s h a r p e n s the definition o f t h o s e p l a c e s - - S t H e l e n s , B e r m o n d s e y , L i n c o l n , S h o r e d i t c h a n d P o p l a r are the e x e m p l a r s - - w i l l i n g a n d a b l e to o v e r c o m e local r e s o u r c e c o n s t r a i n t s a n d those, like O x f o r d , S o u t h e n d , the C i t y a n d o t h e r affluent s o u t h e r n u r b a n places t h a t e n d o w M C W w i t h a l o w p r i o r i t y a n d s p e n d relatively little u p o n it. Conclusions: so wharf

T h i s p a p e r is s i m p l e - - i f n o t s i m p l i s t i c - - i n the e x t r e m e . I t p r e s e n t s a large a m o u n t o f financial d a t a , e x p r e s s e d m a i n l y in real r a t h e r t h a n c u r r e n t terms, o n Consistently extreme financial behaviour within the urban system of England and Wales: Rate Fund Services 1921-1937 (a) tax effort (b) expenditure per head Explanatory note: The size of each circle is indicative of the consistency (i.e. number of years from 1 to 5) in which each place conforms to the criteria of consistency outlined in fn. 24. Places are also distinguished as to whether they are consistently above or consistently below the statistical average for the urban system as a whole. The few inconsistent places (see fn. 24) are similarly indicated with square symbols Figure 5.

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the significance of local government and municipalities within the state system for the delivery (as measured by expenditure) of welfare services--especially health care services. How significant are its descriptions? Two qualifications--which point in the direction of future research--are necessary but two generalisations also seem to be justified. One of the underlying difficulties in attempting to disaggregate national figures on welfare expenditure during the inter-war period is that a great deal of provision--including hospital provision--was made by voluntary and charitable institutions. As these themselves were locally run their contribution was highly variable: it may have drawn upon local political discourse or may have reacted to such discourse. Similarly, their relationship with local authorities ranged from cooperation to conflict whilst the effect of national changes in the financing of municipal hospitals for example could be to transform the financial health of these voluntary institutions. It is very difficult if not impossible to gather reliable and genuinely comparative data on such informal interventions for the urban system as a whole although studies of individual localities may reveal the relative significance of their role. Conversely, however, such local studies cannot place their locality in any kind of comparative relationship with other localities. A second qualification is, perhaps, rather more obvious and direct. The indicator used in this paper to measure the involvement of local government in

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welfare provision is that of expenditure. To a certain extent this is justifiable in that the getting and allocation o f material resources point both to local legitimacy and to local priorities. The problem is that there is no direct correlation between financial commitment and either the quantity or quality--to say nothing of the effectiveness--of the services so provided. Nevertheless, the fact that the data are presented in real terms enables an appreciation o f the extent and growth of service expenditure and a comparison of behaviour in the local government system. Some sort of measure is attempted

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Figure 8. Consistently extreme financial behaviour within the urban system of England and Wales: Maternity and Child Welfare Services 1921-1937 (a) tax effort (b) expenditure per head

MUNICIPAL M E D I C I N E

279

of the changing role and significance of the local level of the state system in financing welfare provision before the emergence of a nationally-administered welfare state. The relative importance of cities as service providers within that system may be gauged at a time when the role of cities within the geography of advanced capitalist nations was being rewritten. The extent of inequality and its geography provide a helpful context for studies of individual places or the nationwide provision of services. But more than that the pronounced and surprisingly consistent uneven geography of expenditure suggests that geography may not be an incidental aspect of the provision of welfare services at this time. No analysis of this geography is presented here but the empirical description of geographically-uneven development indicates that such an analysis would be worthwhile and that the role of place is an unjustifiably neglected aspect of the history of the welfare state.

Department of Geography and Earth Sciences, Queen Mary College, Mile End Road, London E1 4NS Notes [1] D. Fraser, The evolution o f the British welfare state (London and Basingstoke 1984) xxi [2] Ibid. Foreword. The seven perspectives are labelled whig, pragmatic, bureaucratic, ideological, conspiratorial, capitalistic and democratic, xxii [3] See, for example, J. Mark-Lawson, M. Savage and A. Warde, Gender and local politics, ch. 11 in L. Murgatroyd et al., Localities, class andgender (London 1984); E. Peretz, Poor mothers in prosperous areas, Paper to conference on "Localities and politics in interwar Britain", Queen Mary College, London, April, 1987; G. Rose, Politics, locality and culture in 1920s Poplar, Paper to conference on "New directions in cultural geography", University College, London, September 1987 (Institute of British Geographers, Social Geography Study Group) [4] A shorthand term used here to include all County Boroughs in England and Wales and the Metropolitan Boroughs of the LCC [5] D. Harvey, The urbanization o f capital (Oxford 1985) 163 [6] Fraser op. cit. fn. 1, xxx [7] Harvey op. cit. fn. 5, 163-164 [8] A. J. Scott, The urban land nexus and the state (London 1980). Scott does suggest that the chain of conceptual relations underpinning this work is not entirely unidirectional as a number of"durable" (p. 6) features of the urban environment modify its progress. However, "the internal dynamics of the urban system are in the end direct, but highly distinctive, transformations and intermediations of the social and property relations of the capitalist mode of production" (p. 137) [9] Ibid., 6 [10] Ibid., 2 [11] Ibid., 123 [12] Ibid., 141 [13] Ibid., 6 [14] R. Lee, Social relations and the geography of material life, in D. Gregory and R. Walford (Eds) Horizons in human geography (London and Basingstoke 1988) [15] J. Urry, The anatomy o f capitalist societies (London and Basingstoke 1981) argues that the struggle of labour to improve its living conditions has had the effect of enabling the reproduction of capitalist social relations [16] G. L. Clark and M. Dear, State apparatus. Structures and language o f legitimacy (London 1984) 138, 162 [171 Ibid., 164 [18] C. Tiebout, A pure theory of local government expenditures Journal o f Political Economy 64, 416-424

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[19] [20] [21] [22] [23] [24]

Clark and Dear op. cit. fn. 16, 171 R. Miliband, The state in capitalist society (London 1973) 49 This voice is backed by local electoral legitimacy See, for example, P. Cooke, Theories ofspatialplanning and development (London 1983) ch. 9 J. Dearlove, The reorganisation of British local government (Cambridge 1979) 244 There is some recognition of this point in J. Clarke, A. Cochrane and C. Smart Ideologies of welfare (London 1987) [25] M. Savage, Understanding political alignments in contemporary Britain do localities matter? Political Geography Quarterly 6, (1987) 53-76 [26] J. V. Pickstone, Medicine and industrial society: a history of hospital development in Manchester and its region (Manchester 1985) 6 [27] P. Thane, Foundations of the welfare state (London 1982) 196 [28] see, for example, J. Dearlove and P. Saunders, Introduction to British politics (Oxford 1984) 380-393 [29] C. D. Foster, R. Jackman and M. Perlman, Local government finance in a unitary state (London 1980) 49 [30] Ibid. [31] A. T. Peacock and J. Wiseman, The growth of public expenditure in the United Kingdom (London 1967) Table A-20 [32] Peacock and Wiseman define social services to include education and child care, health, national insurance, national assistance, housing and food subsidies: ibid. 183. If those items, including transfer payments, not relevant to local government could be excluded the comparison would be more meaningful and would show local government to be even more significant in the delivery of social services [33] The definition of health being used here is that of Foster et al., op. cit. fn. 29, 109. It includes maternity and child welfare, hospitals, sanatoria and dispensaries etc and a number of unspecified items [34] B. Keith-Lucas and P. G. Richards, A history of local government in the twentieth century (London 1978), ch VIII point out that the really significant growth in the imposition of central controls on local government came primarily during the Second World War [35] G. L. Clarke, A theory of local autonomy Annals of the Association of American Geographers 74 (1984) 195 208 [36] Consistency was measured here primarily in terms of extreme performance. For a place to be considered consistent in its behaviour it had to conform to the following conditions: 4 or 5 years out of 5 (1921, 1923, 1930, 1933, 1937) ( = ) 1 standard deviation above/below the mean; or 3 such years plus 1 year above/below the mean; or 2 such years plus 2 years above/below the mean; or 1 such year plus 3 years above/below the mean. In addition, places falling consistently between + 1 and - 1 standard deviation are regarded as consistently moderate, whilst those appearing occasionally in the high/low categories but failing to fulfill the criteria outlined above are regarded as inconsistent in financial behaviour [37] Reminiscent of those reported by the Hicks for 1938: J. R. and U. K. Hicks, Standards of local expenditure (Cambridge 1943)

Congratulations to Professor Sir Clifford Darby H i s t o r i c a l g e o g r a p h e r s t h r o u g h o u t the w o r l d w e r e d e l i g h t e d to r e a d in the N e w Y e a r H o n o u r s ' List o f the a w a r d b y H e r M a j e s t y the Q u e e n o f a k n i g h t h o o d to E m e r i t u s P r o f e s s o r H . C. D a r b y " f o r services to the s t u d y o f historical g e o g r a p h y " . O n b e h a l f o f the i n t e r n a t i o n a l c o m m u n i t y o f historical g e o g r a p h e r s , the Journal o f Historical Geography e x t e n d s to Sir C l i f f o r d w a r m e s t c o n g r a t u l a tions o n this u n i q u e p e r s o n a l a c h i e v e m e n t a n d p u b l i c a c k n o w l e d g e m e n t o f his singular c o n t r i b u t i o n to o u r subject.