Voluntary organizations and the provision of health services in England and France, 1917–29

ABSTRACT As the First World War came to an end, governments in the UK and France began the process of planning for reconstruction. In both cases health services emerged as key features of the post-war settlement with ambitious new Ministries of Health proposed to coordinate and deliver essential services. Public health infrastructure was at the heart of these plans, with the physical and social conditions that caused disease to be the focus of state activity. But there was also a need to take on key causes of mortality and improve the institutional infrastructure necessary to challenge old and new threats to life. Yet neither the funding nor political will existed to overhaul service provision in these areas. As a result, in both countries it was necessary for voluntary organizations to fill many of the gaps in provision expected or promised by the new state commitment to health care. To meet these tests a number of interested parties – the Rockefeller Foundation, the Red Cross, the Croix-Rouge Française, the Order of St John, voluntary hospitals and local charities – extended their work. Their contributions underpinned an extensive mixed economy of provision that ensured the reconstruction of health services in a way that met at least some of the promises of government. This article focuses on three key areas of voluntary involvement in health in post-war Britain and France: maternity and child welfare services; hospital services, especially tuberculosis provision; and accident response, in particular ambulance services. It argues that while local and national governments focused on improving health through environmental transformations, the voluntary sector stepped in to extend personal services aimed at saving individual lives, curing those suffering from specific diseases and preventing deaths through better education and care.

conditions that caused disease to be the focus of state activity.But there was also a need to take on key causes of mortality -infant mortality and tuberculosis -to provide more and better institutional treatment for all, and, increasingly, to address the growing challenge of roadside emergency response as road traffic accidents grew in the aftermath of the conflict. 2Legislation and enquiries followed, for example the 1918 Maternity and Child Welfare Act in Britain, yet neither the funding nor the political will existed to overhaul service provision in these areas. 3As a result, in both countries it was necessary for voluntary organizations to fill many of the gaps in provision expected or promised by the new state commitment to health care. 4o meet these demands a number of interested parties -the Rockefeller Foundation, the British Red Cross, the Croix-Rouge Française and associated organizations, St John Ambulance, voluntary hospitals and local charities -extended their work (and the scope of their activities).Their involvement underpinned an extensive mixed economy of provision that ensured the reconstruction of health services in a way that met at least some of the promises of government.Building on the research conducted for the AHRC funded project, 'Crossing Boundaries: First Aid in Britain and France', and a Rockefeller Archive Center bursary, 5 this article focuses on three key areas of voluntary involvement in health in post-war Britain and France: maternity and child welfare services; 6 hospital services, especially tuberculosis provision; 7 and accident response, in particular ambulance services. 8It suggests that while governments focused on improving health through environmental transformations, the voluntary sector stepped in to extend personal services aimed at saving individual lives, curing those suffering from specific diseases and preventing deaths by better education and care. 9It will argue that a historiographical focus on central state failure has led to an under-estimation of the significant growth of health care provision in the years before the arrival of the welfare state.
The destruction and demographic losses of the First World War, along with the sacrifices made on the home front, prompted governments to find ways to recognize and reward the people.Reconstruction narratives focused on building a better world, with housing at the centre in England -homes for heroes -while in France the emphasis was on reconstructing the liberated regions, like Lille, and building services for veterans. 10Although historians, like Laborde and Purseigle, have considered the intellectual debate surrounding growing state intervention in the two nations, this approach offers less to this article than the work of Winter, Dwork, Murard and Zylberman, and others who have studied the development of services, especially infant services, during the war years. 11What emerged from these moves was a state infrastructure and funding regime which created the environment in which local initiative -both municipal and voluntary -could flourish. 12These schemes were driven by demographic imperatives arising from the physical loss of war casualties and the potential loss from falling or curtailed birth rates.As the Bishop of London told an audience during England's 'Baby Week' of 1917, 'The loss of life in this war has made every baby's life doubly precious.' 13he focus was not just promoting healthy births and birth rates, but also tackling the 'social diseases' seen to be crippling the population, with tuberculosis (TB) at the centre of concern.It was these factors that put health at the heart of reconstruction, but in a way that would mobilize the whole population in a partnership of public and private, voluntary and municipal.
Much interwar health historiography revolves around the idea that expectations fuelled by discussions of reconstruction were not met. 14In Britain the Ministry of Health, established as the war ended, appeared to offer the chance to coordinate and advance health -especially delivering a fit and healthy population.Yet the general opinion is that the Ministry of Health failed, proving to be narrowly focused, poorly resourced and unadventurous, choosing the promotion of personal responsibility narratives over the creation of effective curative and preventative services. 15In particular, it was seen as toothless in the face of recalcitrant local authorities unable or unwilling to spend, and equally unable to face down the powerful interests in the medical profession and voluntary hospitals. 16In a similar vein, health remained a limited objective of the post-war French state, focused, as they were, on physical reconstruction and hampered by an inflationary spiral that restricted spending. 17or does the historiography generally treat the voluntary responses well.Shaped by post Second World War state-led universalist thinking, and despite calls at the time from William Beveridge for a diverse approach, the mixed economy and the voluntary sector have often been seen as second best. 18Even historians like Martin Gorsky, with a clear understanding of the key role of the non-state sector in health provision, remain critical of voluntary activity. 19Yet, in the aftermath of the First World War, the role of the central state in health provision was restricted to public health and oversight of the mixed economy of curative and personal services.In both Britain and France the Ministry of Health or its proxy welcomed the part played by non-state bodies, even the Catholic Church. 20Health may have been at the heart of reconstruction, but the role of government was to facilitate, not to provide.
One reason why the effectiveness of health reconstruction has been undervalued is that many historians have focused on the work of central government or the Ministries of Health. 21Yet most personal and curative health was provided at the local level by local actors, whether public, private or voluntary. 22This article reflects this local dimension, utilizing evidence and examples from the work of hospitals, municipal public health services and voluntary first-aid organizations in the industrial cities of Middlesbrough, Leeds, Sheffield and Norwich in England and Lille, Rouen, Le Havre and Angers in France.Though not like for like matches, the cities chosen have much in common economically, socially and demographically.Leeds and Lille were early industrializers with a strong regional presence.Rouen and Angers are ancient cities with a similar profile to Norwich.Middlesbrough and Le Havre exploded in the nineteenth century, creating towns with large working classes but weak elites.Sheffield offers a contrast to Leeds and Lille as a more insular and masculine city. 23In addition, research has been undertaken in the Rockefeller Archive Center and the archives of the Order of St John in London, as well as published journals of a national and international scope.Together, these sources, especially the use of local archives and those of non-state agencies, allow us to understand the process of health reconstruction from a variety of angles and levels, providing a more nuanced, and optimistic, view of the period.

Infant welfare
The First World War built on the fears of 'racial decline' and national inefficiency that had dominated the Edwardian period in Britain and had been a concern in France since the last quarter of the nineteenth century. 24For the British, gradual reductions in the birth rate among the upper and upper middle class in the 1870s spread through the social structure over the next generation, prompting the formation of voluntary organizations like the Eugenics League and stimulating government interest, including extensive analysis of the class and professional distribution of births shown by the 1911 census. 25he latter made clear that falling birth rates had reached the lower middle and upper working class.These findings, along with anxiety caused by the poor physical 'quality' of recruits volunteering during the Boer War and the subsequent Interdepartmental Committee on Physical Deterioration, turned the spotlight on mothers and babies. 26lthough the infant mortality rate had been falling sharply in England in the early twentieth century, it still remained at around 100 per 1000 live births until the war and was significantly higher than this in a number of towns and cities. 27 The huge personal tragedy of the loss of one in 10 babies was amplified by growing concerns about the size and 'quality' of the population in the face of military threats from nations like Germany.
For France, high infant mortality in the late nineteenth century accompanied a rapidly falling birth rate that preceded trends in Britain.Thus, in the 1870s, when the birth rate in England and Wales was still 35.5 per 1000 women it was already as low as 27 per 1000 women in France; while that in England and Wales fell to 27 per 1000 women in 1910, the French figure was just 19 per 1000, the lowest in Europe.But infant mortality remained high in France, the late nineteenth century seeing annual rates of 155-177 per 1000 births in the 1880s rising to 180 in the mid-1890s before beginning a very sharp fall to 111 in 1910, a comparable figure -and trend -to England.As a result, by the eve of the First World War France had the lowest proportion of young people (under 21) and the largest proportion of elderly people (over 59) in their population of any country in Europe. 28As in Britain, this led to considerable public debate about the effects of population decline, especially as France saw the rapid demographic and economic growth of the neighbouring German Empire. 29aced with these demographic challenges, the First World War proved a significant catalyst to services in the area of maternity and infant welfare.Prior to the war there had been growth in a mixed economy of service provision.In England, the Midwives Act and birth registration legislation had encouraged local authorities, especially in urban areas, to set up infant welfare committees and to start employing health visitors to monitor newborn babies. 30In Norwich, these developments included a milk depot, based on the pioneering centre set up in Huddersfield in 1904 by a volunteer organization. 31In Leeds the council's work was largely delivered by a voluntary body, the Leeds Babies' Welcome, which established a growing number of centres across the city, while in the Scottish city of Glasgow, support for pregnant and new mothers was delivered entirely by the local authority. 32Pre-war France had also seen the appearance of infant saving initiatives.Indeed, the French were at the forefront of attempts to develop transnational approaches to infant welfare.Ten years before Huddersfield, Leon Dufour had created the first Goutte de Lait and consultation des nourrissons at Fécamp, which set a model for infant welfare services.Although the French system was clearly led by medics, as in Britain, it relied heavily on voluntary support to deliver the educational and welfare services on the ground. 33uilding on these developments, the war saw significant changes in the mixed economy of infant welfare provision.In England the Maternity and Child Welfare Act of 1918 formalized the obligation of local authorities to ensure that a maternity and child welfare service was instituted. 34The Act instructed local authorities to establish a Maternal and Child Welfare Committee, which had to include at least two female members and could co-opt members from outside the council chamber.The Act also made grants of up to 50% of the cost of services for expectant and new mothers and instructed the local committee on how to oversee these services. 35But these grants were not just for the council: they could also be used by non-statutory partners.Across the country, a wide range of models developed from services delivered entirely by the municipality -as in Sheffield -to services where most of the day-to-day work was undertaken by voluntary organizations, with the assistance of some council-paid medical and nursing staff. 36For example, in the heavy industrial town of Middlesbrough, the Medical Officer for Maternity and Child Welfare, Dr Grace Dundas, used her experience of both forms of delivery (in Ramsgate and Leith) to shape a mixed service for her town.She organized five centres in various premises including the American Red Cross Centre and the Settlement Hall.These each opened one afternoon a week for weighing, consultations for expectant and nursing mothers and infants undertaken by the Medical Officer and her nursing staff, but each also opened on a second day for social and work activities.Focused on sewing, the sessions were run by volunteers who would help the mothers make simple maternity and baby clothes.The centres also had nurseries run by voluntary workers, and the service was able to provide some emergency maternity bags, as well as food and milk at cost price or free in necessitous cases. 37In Leeds, the mixed economy was even more extensive, with 13 centres across the city at its peak in 1932.Although some were very basic, overall the service was very well reviewed by the Ministry of Health inspector, Dame Janet Campbell, in 1932. 38n the other hand, in Sheffield, joint action with the voluntary Motherhood League was wound up in 1918.From that point, council-run services were highly centralized, prompting criticism that the city centre facility was overcrowded, bureaucratic and inconvenient for suburban mothers. 39n France the impact of the war was extreme on the already fragile birth rate.The pre-war rate of 18 per 1000 halved to just 9.1 in 1916 and had only recovered to around 12.4 by 1919. 40he period saw the emergence of employer-led, voluntary family allowance schemes, especially in the heavy industrial areas of the north and the east. 41Under the influence of British and US organizations, especially the Rockefeller Foundation, the League of Red Cross Societies and the American Red Cross, voluntary organizations began to train and deploy large numbers of visiteuses d'hygiène. 42The constituent parts of the Croix-Rouge Française in Angers, the Union des Femmes de France and the Société de Secours aux Blessés Militaires, established a training school in the aftermath of the war for health visitors and hospital nurses, and across the country, UFF and SSBM members engaged in extensive support of the health services. 43In Toulouse, in 1927, UFF nurses worked in the anti-cancer centre and took part in child welfare work in homes 'at the standard of lady visitors'.In Paris they could be found running crèches and nursery schools. 44Yet their roles also caused significant tension in a country where religious animosity was strong, and the law ostensibly prevented the state promotion of religion.But, as will also be seen in hospitals, it proved impossible for the emerging welfare state to turn its back on the vast well of Catholic women of all social classes and levels of commitment willing to offer their time and expertise to the caring and health services. 45

Institutions and the challenge of tuberculosis
The focus on infant health and welfare was a nascent issue given a significant boost by the immediate and longer-term impact of the First World War.However, the war's impact on hospital services, especially tuberculosis provision, as well as the role of the voluntary sector in recovery and reconstruction, was more subtle.The scale of voluntary involvement in the provision of institutional health services prior to the Great War in both Britain and France is not widely appreciated.In Britain almost all acute, specialist and general hospital treatment and care was provided by what was called the voluntary sector. 46Established by groups of private individuals for the charitable provision of care to the sick and needy poor, these institutions received no state funding before the First World War -they were even excluded from the provisions of the National Insurance Act of 1911 -nor were they able to charge for services. 47As a result they relied entirely on fundraising through legacies, donations, gifts and subscriptions, as well as on the free services of most of their medical staff.Although they employed a growing number of professional nurses and gave small honoraria to their trainee house staff, all of the physicians, surgeons and other specialist medicks worked for free, undertaking honorary roles as a means to develop skills, pursue research and make themselves known to potentially lucrative private patients. 48omplementing or supporting the voluntary sector was the much larger state provision.Prior to the war this was divided between two authorities.Councils were responsible for infectious disease institutions, including curative tuberculosis, mental health services and, increasingly, maternity hospitals.These were funded by local taxes, some state support and access to government loans.They did not charge for infectious disease treatment but did for maternity.From 1911, National Insurance helped meet some of the cost of TB treatment and provided a payment to the insured towards maternity costs. 49he largest provider, however, was the poor law through local boards of guardians.By the end of the nineteenth century the English poor law system was largely a health service, with the vast majority of institutional inmates elderly, infirm, chronically ill, pregnant or the mentally ill taken in for observation and rarely transferred to the asylum.The recognition that the function of the workhouse was changing prompted the creation in the more populous areas of separate Poor Law Infirmaries (PLI), which slowly acquired differentiated wards, trained nursing staff and medical oversight -although patients did not choose the PLI for treatment. 50he situation in France was a little more complex: all three types identified above were managed within a single authority. 51Hospitals had 'public personality' and were overseen by a committee drawn from the council and the department, chaired by the mayor.They were also tasked with providing care to the local sick poor and again were not supposed to admit paying patients. 52But reflecting their origins in the religious welfare state, their funding was complex and included donations and legacies, investment income from land and property, local entertainment taxes and, in some cases, subventions from the municipal authority to meet the cost of the local poor. 53Although hospitals were included in the growing social safety net of the state and could borrow from central government for capital projects, they still relied on free medical services. 54ore importantly, despite the separation of church and state in 1905, the vast majority of nurses were still drawn from religious communities, which gave their services in exchange for board and lodgings. 55he First World War had a number of effects on institutional healthcare that prompted a mixed economy approach to reconstruction.The first was financial: the war unleashed inflation on an unprecedented scale, especially in France.Prices increased around threefold in Britain between 1914 and 1920, while in France it was nearer sixfold. 56The effect was to starve the hospital system of money.In Britain, inflation and war eroded the voluntary funding mechanism, as subscriptions remained largely static while prices rocketed.This was compounded by wartime losses among the elites and the middle class, and a disengagement of the younger generation from associational culture -though this may have been exaggerated. 57The voluntary hospitals appealed to the government for help, but the response from their Onslow Commission was disappointing.A small fund was established to be distributed to the hospitals if they established joint committees with the local authority providers and looked to explore ways of coordinating resources and patients.Although joint committees were established to access the funds most, like the one in Middlesbrough, quickly stopped meeting, and the two sectors returned to their separate paths, aided by an equally steep deflation that eased pressure on bank balances. 58he situation in France was more severe and longer lasting, compounded by the effects of the war on many institutions in the north.In Lille, prices increased by 100% in 1921, leaving institutions unable to buy essentials or meet the cost of heating and lighting. 59Moreover, the system of payment by prospective budgeting -where the Hospital Commission estimated the cost of the following year's delivery on the basis of the previous year -broke down completely, necessitating cost-cutting and endless recourse to the council and department for in-year subventions. 60In northern cities like Lille, occupation and war damage prevented any expansion of services, while in Rouen and Le Havre, whose hospitals had treated thousands of war casualties, the inflationary conditions prevented them from restoring their institutions to their prewar condition.In Le Havre, the Commission were unable to repaint the wards for eight years after the conflict, while the immediate post-war years saw a shortage of bed linen, as existing stocks had been worn out by the huge increase in patient turnover during the war. 61he financial crisis that afflicted both countries prompted very different responses, with the British voluntary sector devising a non-state response; in France it pushed the government towards the creation of a health insurance scheme. 62The initial move by many of the bigger hospitals in England was to introduce patient charges. 63But charges went against the spirit of the voluntary hospitals.They also raised questions around what should be charged for and how to account for the reliance on voluntary funding for capital projects and the free service of the medical staff. 64These questions were answered to some extent by the rapid expansion of hospital mutual contributory schemes.The schemes had first appeared in the late nineteenth century, mainly in the north of England.They were established by workers who collected small weekly contributions and gave them to the hospitals in exchange for greater access for their members. 65In the aftermath of the War, hospitals came to rely increasingly on the schemes as their core income in exchange for some managerial influence.However, the hospitals were keen to emphasize the charitable or philanthropic nature of the contributory schemes.To this end they attempted to limit membership to lower paid workers -the same people who would have benefitted from charitable treatment; insisted that membership of a scheme did not buy a right to admission, only to free treatment if admitted on a doctor's recommendation; made it clear the money transferred by the schemes was a donation, not a per capita payment for services received; and that this voluntary donation underpinned the institution's charitable function to the sick poor and did not compromise its overall philanthropic objectives. 66The Sheffield Penny in the Pound scheme (as it came to be known) had emerged out of the Onslow Commission's encouragement to joint working at a local level. 67It brought together the city's four voluntary hospitals, but also began to build a relationship with the municipal service and the Poor Law authorities that led to some early patient allocation. 68The scheme maintained close relations with the labour movement, and the Contributors' Council was chaired by the Labour Party alderman, Moses Humberstone.Indeed, in most cases Labour politicians supported contributory schemes and played a prominent role in their management. 69Overall, these schemes stabilized the voluntary sector after the inflationary shock, providing a non-state response in the face of government failure.
The financial crisis in France did not prompt a similar voluntary response in the general hospital system.Indeed, the early 1920s were characterized by tension between the local hospital commissions and the local authorities over who would fill the growing hole in the income, although the discussion was interestingly still couched in the language of a charitable obligation to the sick poor.In Le Havre, one of the worst hit towns, the hospital commission insisted the council pay its subvention in line with the charges the town imposed on the 'charitable establishments' (the hospitals) in a way that adequately represented the money they spent for 'the treatment of the sick poor of the town'. 70A more notable associational response was seen in the case of tuberculosis treatment.In Britain, TB care and treatment received a significant boost from the government just before the war, when National Insurance included a sanatorium benefit for early TB sufferers, while government grants were made available to meet half the cost of treatment. 71This windfall came as many of the smallpox isolation facilities recently created by local authorities became largely obsolete, allowing them to be converted to tuberculosis treatment, as happened in Leeds. 72City centre tuberculosis dispensaries were also launched by municipalities with track and trace systems and disinfection regimes based on the experience of typhoid. 73n France, the relatively poor state of hospital commissions even before the war meant tackling diseases like tuberculosis and later cancer fell to the voluntary sector or Pasteur Institute medics, like Calmette in Lille.74 Calmette developed a dispensary regime, which he launched at the beginning of the century, and managed to attract some support for the method from prominent progressives like Leon Bourgeois.But despite Bourgeois' support, it was not possible to get a state response through parliament, and it was only with the outbreak of the war and the sudden epidemic of TB among the troops that action was taken.The high number of troops affected prompted a response by the military, who set up a system of dispensaries for discharged soldiers to stabilize the illness and educate them on how to live safely with the disease.Based on the rapid roll-out of these military facilities, the government was persuaded in 1916 to pass a law requiring departments to set up dispensaries on the Calmette model, although the law did not stipulate which sector should provide these.75 Lack of funds therefore held up their creation until the arrival of the Rockefeller Foundation towards the end of 1917 saw the injection of substantial sums -largely to the American Red Cross -to launch the programme.76 Rockefeller's European operation in the last year of the war represents the clearest manifestation of external humanitarian aid for reconstruction.It ensured the effective establishment of the tuberculosis dispensary system in France and revolutionized the domiciliary nursing networks in the country. Whle in France the Rockefeller mission, and particularly nurse Frances Crowell, set about creating a system for training health visitors -or public health nurses as the Americans preferred to call them -who would take the message about the safe management of TB into the homes of sufferers, as well as treating their symptoms.77 They took this further by supporting the training regimes at the Faculty of Medicine and the Training School for Nurses and Social Workers in Lyon, institutions with which they maintained a long term relationship.78 But the widerranging legacy was with the integration of the UFF and SBM into the network of TB dispensaries established during and after the war.
The role of anti-tuberculosis activity was central to the work of the UFF throughout the 1920s, demonstrating the presence of a mixed economy of health service delivery in France.In Angers a dispensary was set up in 1920 under the direction of an Association du Dispensaire. 79It saw patients at the building and organized visits to patients' homes.The committee brought in volunteer women who would make clothing for the sick and provide breaks for them in the countryside and by the sea.By the late 1930s, it had distributed over 100,000 francs and volunteers had made 4300 objects for TB sufferers. 80vidence from the Bulletin of the UFF shows the centrality of this work to the role of the association in peace time and the mixed economy that maintained it.Thus, in Bailleul, a small town in the Nord department, a partnership between the municipality -who donated land and a small retaining subscription -the Ligue du Nord contre la tuberculose and the central UFF led to the establishment of a dispensary in 1927. 81At a more prosaic level, operating income for anti-tuberculosis campaigning was raised by conventional associational means, like the ball held in Lens in 1927 or the charity sale in Le Havre that raised 15,000 FF in the same year.But this involvement came at a price.The national UFF was running three anti-tuberculosis establishments by the mid-1920s, but these were running at an annual loss of over 100,000 FF, a substantial sum and one that the treasurer thought might be threatening the viability of the association. 82In the area of tuberculosis campaigning it is clear that voluntary action was at the heart of a mixed economy, initially stimulated by the impact of the war and the involvement of a major international foundation, but sustained and enhanced by hundreds of local activists organized by the UFF and other voluntary organizations.

Roadside accident responses
The third area that will be briefly touched upon is roadside accident responses, especially first-aid posts and ambulance services, a topic that has received very little historical attention.The First World War played a major part in developing and popularizing motor vehicle transport. 83Cars, and especially lorries, saw significant improvements while thousands of men and women gained experience of driving. 84In the post-war period France and Britain continued to dominate the European motor industry while US multinationals extended their production, leading to sharp increases in ownership, especially in the UK after 1924. 85There were more, faster, cars travelling on unregulated roads and in competition for space with horse-drawn vehicles, bicycles and pedestrians.In every case the car dominated -often with fatal consequences. 86The War had also developed the knowledge and technology to address these new dangers: ambulances, communications networks, first-aid training and traumatology.But in the early post-war period the state was slow to respond to this new, modern challenge, and once again it is evident that the development of effective ambulance provision was the work of a mixed economy across a wide range of providers -although the voluntary response was stronger, and better organized, in England.
The First World War had seen significant advances in the ambulance as a mode of field transport, with the motorized vehicle ultimately replacing the horse-drawn carrier in a number of theatres. 87In the civilian context, ambulances had a complex heritage before the war.In most English cities their main use was to move infectious cases to and from the infectious diseases hospital, with James Newsom Ker arguing that tolerance of the isolation ambulance in late nineteenth-century London was a major breakthrough in the acceptance of public health over personal freedom. 88The emergence of key first-aid organizations also saw the appearance of increasingly sophisticated means of moving the injured from the site of the accident to a doctor or hospital.In England the St John's Association and Ambulance Brigade was formed in the 1870s and quickly grew in the country's industrial north.It initially focused on providing training in first aid to workers, but gradually developed a wider social function, including the provision of ambulance services for general use by the community.In late 1882 St John's Ambulance Brighouse (in Yorkshire) established the first Ambulance and Invalid Transport Corps, equipped with four Ashford Litters, seven stretchers and eventually a horse-drawn vehicle designed and built by the St John pioneer, John Furley.On the eve of the war, the Leeds Workpeople's Hospital Fund, a contributory scheme supporting the city's hospitals, presented a motor ambulance to Leeds General Infirmary. 89However, other ventures failed, with an attempt to establish an accident focused horse ambulance service for London in the 1880s proving unsuccessful. 90n France, first-aid organizations developed, but with a stronger focus on war preparation and education.The two lead organizations, the UFF and the Société de Secours aux blessés militaires (SSBM), had formed in the later nineteenth century and together had trained a significant number of nurses and auxiliaries to support future military mobilization by the outbreak of the First World War.They also developed a range of courses for the general public, but these were less extensive than the workplace and street-focused activities of St John or even the British Red Cross. 91However, they did not get directly involved in the provision of civilian ambulances.Work in industrial and street settings was taken up by the Société Des Secouristes Français, founded in 1892 to provide training that would 'ensure the survival of the sick or wounded, while waiting for a doctor to arrive'. 92The removal of the injured fell to the police and the fire service, with telephones appearing across Paris to report incidents. 93ollowing the war, motorized ambulances began to circulate more widely, making their way to hospitals, municipal health departments and the local units of the British Red Cross and the St John's Ambulance Brigade.Much of this was underpinned by voluntary effort.In 1923, the students of Sheffield University raised enough in their annual 'rag' to provide an 'up-to-date' Daimler ambulance for the Sheffield Hospital Council for the use of all of the city's hospitals. 94The magazine First Aid carried regular stories of St John's Brigades around the country acquiring new ambulances and by 1928, Plymouth could boast six vehicles. 95Moreover, the quality of the vehicles and the training of the drivers and teams improved over time to supplement the emergency services provided by local police forces.At the same time, patient transport fleets were being built up by both hospitals and contributory schemes.By the end of the 1920s, Sheffield Hospital Council had acquired six ambulances, mostly for moving patients, and the Leeds Workpeople's Hospital Fund had a smaller fleet, demand for which was rising steadily. 96The early 1930s saw the formalization of joint working between the voluntary and public sector.In Sheffield the Hospital Council brokered an amalgamation of the ambulance services of the voluntary hospitals, municipal hospitals (mainly isolation institutions) and the City Watch Committee, whose vehicles were used for street accidents.This joint working was underpinned by the provision of St John's first-aid volunteers, who managed patients during their transport, with women providing the bulk of the support. 97lthough the various parts of the Croix Rouge Française had been involved in ambulance provision during the First World War, staffing around 100 vehicles, they did not continue the work after the War.As a result, the Croix Rouge played a limited role in addressing the road accident crisis of the inter-war period.They were involved in training the personnel of the roadside first-aid posts (secours sur routes) which were the main response to road accidents in rural France. 98But emergency transport remained the responsibility of police and the fire service. 99 key stimulus to the development of an ambulance service in both England and France was the rise in road traffic accidents.The number of motor vehicles on British roads rose from 331,000 in 1919 to 2.2 million in 1929 and 3.1 million by 1939; in France they rose to 1.5 million in 1933, growth which saw deaths and injuries rising sharply. 100n Britain, deaths increased to over 7000 a year by 1930 and stabilized at just below that figure until the Second World War, while injuries on roads had passed 200,000 per annum by 1931. 101In France the situation was similar, with recorded road deaths escalating from 2000 in 1925 to 3000 just three years later. 102In cities such as Newcastle, Sheffield and Paris, 'ambulance' boxes appeared where the public could report accidents and where first-aid materials were held for use in an emergency. 103But many road collisions were happening in suburban and rural areas, where emergency services and even medical provision was limited. 104Away from the English cities it was often the volunteers of St John or the British Red Cross that responded first.This initial response to the road crisis by St John was 'bottom up' -local groups initiating their own road schemes -but in 1927 the central committee suggested all areas adopt a 'Road Scheme'.This included first-aid boxes on the roadside, treatment tents, ambulances and road patrols in cars, motor cycles and bicycles, especially at weekends and on the roads near the coast. 105his was a mixed economy approach.St John -along with the British Red Cross (BRC) -provided the first response to the road accident crisis.Through their daily work and more specifically their weekend and holiday road schemes, they were invariably the first to provide help, alert medical services and take victims to the doctor or hospital.
Although some areas, like Sheffield, had a well-developed ambulance service -and road patrols -in the 1920s, most communities relied on ad hoc volunteer action.St John and the BRC worked closely with the police, for example on Sheffield's 'Sunderland Boxes', and with AA and RAC on road patrols, as well as with the local medical profession. 106Indeed, in many areas hospitals and the police relied on St John and the BRC to provide ambulances in emergencies.But the central St John organization became increasingly concerned that government was not taking a role.They pushed for the service to be the responsibility of the nation and by 1929 were asking that it be taken over by the publicbut this did not happen, and much of the work of roadside ambulance services remained in voluntary hands until the Second World War. 107imilar developments were seen in France, especially on the isolated roads on the route to the south.These developments were promoted by automobile associations like Touring-Club and the regional Automobile-Clubs, and led to government recognition in 1929 for a joint organization, the Union Nationale des Associations de Tourisme (UNAT).They promoted first-aid training and, more significantly, a network of postes de secours (aid posts) in rural areas.By the early 1930s there were around 2000 such posts in a network covering 15,000 kilometres.As in England, the operation of these was initially voluntary, but in 1930 the government gave a substantial grant to cover the setup costs of an increased number of posts.However, the running of the posts remained voluntary, with many managed by café owners in villages along the main roads. 108

Conclusion
Looking back on the end of the First World War from the vantage point of the post-Second World War welfare state with its discourse of state-led universalism, the health settlement of 1918 has usually been seen as a failure.In Britain, the Ministry of Health is often characterized as a missed opportunity smothered by conservative forces and financial stringency. 109In France, despite the urging of politicians like Edouard Herriot, health took a back seat to bricks and mortar reconstruction.Political instability and self-interested parliamentarians were able to hold up reform of the state health system for most of the 1920s. 110But these assessments miss the significant progress made in both countries by the mixed economy of providers operating mainly at a local level.Councils and departments, associations and leagues, voluntary hospitals, wealthy individuals and, occasionally, international organizations like the Red Cross and the Rockefeller Foundation, helped to reconstruct both nations and peoples and to build and renew democratic health systems focused on personal and curative services for a growing proportion of the population.Central governments, with their focus on public health and prevention, had neither the inclination or the infrastructure to deliver a modern health service. 111Voluntarism proved innovative in finding new funding models, identifying new health needs and even in shaking up the state's own field of public health education.As key partners in post-war health reconstruction they invariably provided the substance to the politicians' hyperbole.The contribution of voluntary responses was essential in the building of national social welfare systems, often in partnership with the local state, and in allowing both Britain and France to reconstruct and construct a democratic health system.Urban Ambulances in Britain."Thanks to Rebecca and Shane for giving me access to this important paper prior to publication.For the early history of ambulance services run by the St John Ambulance Association, see Corbet Fletcher, Annals of the Ambulance Department, p. 30 and passim.91.Koechlin-Schwarz, Union de Femmes de France.92.https://www.croixblanche.org/federation-nationale/historique/.93.Wanecq, "Sauver, Protéger et Soigner."94.Sheffield Royal Hospital, Annual Report 1923.Sheffield, 1924, 7.  95.For Guildford's new ambulance, First Aid, March 1925.Chivalry, May 1928.96.Leeds Workpeople's Hospital Fund, Annual Report 1932, 17; and Sheffield Hospitals'  Council, Annual Report 1930, 14.  97.Sheffield Hospitals' Council, Annual Report 1930, 13-17.98. Croix Rouge Française, Union des Femmes de France, 7. 99.See note 93 above.100.Laybourn and Taylor, Battle for the Roads, 2. 101.Laybourn and Taylor, Battle for the Roads, Table 1 .2,3.  102.Wanecq, "Sauver, Protéger et Soigner," 176.103.Wanecq, "Sauver, Protéger et Soigner," 71-6; First Aid, November 1927, 142; and  December 1927 , 157 104.Law, Experience of Suburban Modernity; Luckin, "War on the Roads"; and Wanecq, "Sauver, Protéger et Soigner."105."Editorial: Road Service Scheme," First Aid, January 1927; and "Editorial: Road Service Scheme," First Aid, February 1927.106.St John Ambulance Gazette, September 1929, 235.107.Chivalry, September 1929.108.Wanecq, "Sauver, Protéger et Soigner," 181-90.109.Lowe, "Erosion of State Intervention."110.Smith, Welfare State.111.For state focus on public health and mass eradication campaigns see the League of Nations, International Health Yearbook 1924-30 (vols.I-VI).The research was funded by Arts and Humanitries research Council (AHRC) grant [AH/N003330/ 1], 'Crossing Boundaries: The History of First Aid in Britain and France, 1909-1989, PI Rosemary Cresswell'.I benefitted from a Rockefeller Archive Center Grant in Aid November 2017 round [#421071] Bursary in 2017 to study the work of the International Health Board's work in France and Central Europe.I also received funding from the History Research Group at the University of Huddersfield.Barry Doyle is Emeritus Professor of Health History at the University of Huddersfield.He has worked extensively on the history of hospitals in England, France and Central Europe, including a book on urban hospitals in northern England and a University of Huddersfield funded project on the economics and politics of hospitals in interwar Poland, Czechoslovakia and Hungary.His current work focuses on the history of first aid in Britain and France with Rosemary Cresswell and a project on hospital care in Britain's sub-Saharan colonies between the wars.