|Pamela Dale, Honorary Fellow, University of Exeter||The UKAHN Bulletin|
|Volume 8 (1) 2020|
Recruitment and retention crises affecting health and care services have long interested historians. These have been explored in a variety of local, regional and national contexts with attention paid to similarities and differences between places as well as changes over time. In the UK, the politics and practices of the National Health Service have been at the centre of contemporary studies of recruitment and retention issues as well as an extensive historiography dealing with the period 1948 to date.1 However, staffing problems did not begin with the creation of the NHS. The new service inherited a very difficult situation; and was even imperilled by an acute and persistent shortage of nurses.2
Nursing has been the focus of many investigations and different groups of scholars have brought new insights (from women’s studies and social and labour history) to explain evolving recruitment and retention issues.3 Practitioner-researchers and practitioner-historians have also made significant and distinctive contributions to these contemporary and historical debates. In recent years a number of innovative methodologies have been developed to address new research questions posed by historians of nursing. A particularly fruitful line of inquiry has been the attempt to learn more about the rank-and-file staff providing nursing care. Painstaking research by Sue Hawkins on the social situation and career trajectories of nineteenth-century hospital nurses needs to be extended to other institutions and care settings in different eras.4
There have been major projects re-examining the lives as well as work of women providing some district nursing and midwifery services.5 These approaches have encouraged other scholars to pay more attention to biographical details (relating to institutions as well as individuals) within their own studies.6 Oral history and participant observation techniques have also added depth and richness to our understanding of the recent past, although caution is needed when framing studies and interpreting data.7 Helen Sweet and Rona Dougall drew on conversations as well as formal interviews to offer a really interesting comparison of the work of different generations of health visitors working on a remote Scottish island.8 The opportunity to hear the views of male as well as female practitioners is particularly valuable, and develops important work by Robert Dingwall whose classic study of student health visitors in the 1970s still provides a treasure trove of information.9 Unfortunately, for earlier periods, relevant information can be surprisingly elusive and, compared to some branches of nursing, health visitors (long identified as public health and/or community nurses) have received surprisingly little attention.
Part of the explanation for this is provided by Dingwall, Rafferty and Webster. They persuasively make the case that there is nothing ‘that specifically identifies health visiting as having a natural kinship to general nursing in the way that district nursing and midwifery were identified as specialist skills to be based on initial hospital training’.10 It is generally recognised that health visiting had diverse nineteenth-century origins. In the Edwardian period some, but not all, staff had a nursing background. Dingwall, Rafferty and Webster argue that contemporary actors thought nursing experience was useful but not essential to performing health visiting duties. They further argue that ‘the process by which health visiting was captured as a branch of nursing is not well understood’.11 However, they highlight supply and demand issues when looking at the national situation.12 Far less is known about developments in particular localities. The following Halifax case study captures the shift towards health visiting as a branch of nursing within both an evolving municipal service and an ongoing recruitment and retention crisis that was as severe locally as nationally. A focus on a single town allows appropriate attention to be given to the all-too-often neglected staff.
The neglect of health visitors
While some leading figures are celebrated in practitioner-histories there are very few named health visitors in other academic publications, including seminal work by Dingwall, Rafferty and Webster.13 This striking omission probably reflects the fragmentary nature of the documentary record. The situation is not helped by the way the actors (such as government officials), who created many of the surviving documents, treated health visitors as anonymous and interchangeable staff rather than named professional practitioners with ideas and opinions that were worthy of recording and attribution.
The archives of the Women Sanitary Inspectors and Health Visitors Association (WSIHVA) offer a different perspective but they are London based, voluminous (but incomplete), and not catalogued in a way that highlights many individual practitioners.14 They seem the key to unlocking more details about the national health visiting workforce but the large archive would need an unprecedented level of resources to mine successfully. Similar reservations would apply to any attempt to trace the alumni of particular training institutions. A more modest project concentrating on journals, such as The Woman Health Officer and Health Visitor: The Journal of the Health Visitors’ Association, would be a more reasonable proposition, although coverage is heavily skewed towards celebrating the contributions of senior and long-serving staff.15 While obituaries and retirement tributes are easy to locate via the contents page the value of other items cannot be discounted. A brief article on a regional meeting of health visitors hosted by Exeter City Council in 1943 offers surprising insights into the personal as well as professional lives of the staff.16
All these snippets of information help build a better picture of how health visitors lived as well as worked, the problems they encountered and the support employers tried to provide. With the interwar years identified as period of changing practice, as well as one with severe recruitment and retention difficulties, it seems imperative to look beyond the crude numbers, and understand more about how teams of health visitors evolved and how individual staff managed their careers within them.17 As health visitors were employed by county or borough councils (and indeed other local organisations) it seems necessary to return to the local records. Halifax makes an interesting case study because successive Medical Officers of Health (MOsH) were committed to health visiting as part of a comprehensive range of public health services. However, initiating a scheme of health visiting and then developing a team of staff proved unexpectedly difficult.18 These issues were explored at length in locally produced documents and were also the subject of detailed interwar discussions with the Ministry of Health.
Health visiting in Halifax
Miss Mary Watson Wayne was the first Halifax health visitor. The Halifax Health Committee (HHC) received many applications for the position of ‘lady health visitor’ and interviewed six candidates in January 1908. Miss Wayne was offered the job at a salary of £75 per annum, with an additional uniform allowance. The HHC minutes record that Miss Wayne came from Derbyshire More details about her qualifications were recorded in the MOH report for 1907/08: Miss Wayne appeared to have had some nursing experience and held certificates from the Royal Sanitary Institute (RSI) and the Central Midwives Board (CMB). The MOH seemed excited by the potential of the new service, and pleased by the contribution Mary Wayne was already making. Recorded visits to infants and midwives (core duties for the health visitor in Edwardian Halifax) increased rapidly.19
There were, however, unexpected difficulties; for example, the male sanitary inspectors prevented access to their office although Wayne (and her successor) was designated as a sanitary inspector for employment purposes.20 Although she worked as a sole practitioner her visits were quickly coordinated with the activities of a newly formed Halifax Public Health Union (HPHU) linked to the Guild of Help. This voluntary sector organisation had five teams of female volunteers who reported to their own lady superintendents: their aim was to make regular visits to all infants and notify the lady health visitor of any concerns. These arrangements created a significant workload and potential for conflict. The MOH claimed the scheme was running smoothly but Mary Wayne, who had only started work in February 1908, resigned in August 1908. The official reason for her departure was obtaining a more lucrative post but there were clearly other issues.
Miss Wayne was a professional woman, but she was also an outsider. Her successor Miss Alice M. Thompson was a local woman able to offer similar qualifications. It is probable that Miss Thompson had applied for the health visitor job when it was offered to Miss Wayne; an impression confirmed by the fact that the recruitment process was not reopened on Miss Wayne’s departure. In the interim period she had served as one of the five volunteer lady superintendents.21 Alice Thompson enjoyed a long and successful career in Halifax, with generous tributes marking her retirement on 25 June 1921.22 For several years she was also a sole practitioner but always worked closely with the HPHU volunteers with whom she seemed to have enjoyed an excellent relationship. When more staff were required, Miss Thompson was promoted to the position of senior health visitor and led an expanding team. Unfortunately records from World War One are incomplete, but it appears that even before 1916 Miss Thompson was receiving assistance from Nurse Wynll (employed as part of Halifax Corporation’s tuberculosis services).
A team of health visitors
The expanding team of Halifax health visitors can be recreated from available records for the period 1908 to 1939 (with later appointments tracked into the war years and beyond). Surviving information is not perfect, but has been checked against multiple sources wherever possible. The most complete staff lists are found in the annual reports of the MOH, but these tended to be written in the spring of the year after the one covered by the report.23 The convention was to supply a current staff list and discuss staff changes since the previous report, concentrating on events in the preceding calendar year.
The departure of long-serving staff usually attracted a comment in the Annual Report. An odd exception to this was Miss Wilson, who joined in 1931 and whose service in Halifax lasted more than 10 years, but her departure (between the abbreviated reports for 1941 and 1942) was not remarked upon. Less surprisingly, comparatively little is known about the staff who were appointed on a temporary basis or who stayed for less than a year. The attention given to changes amongst the health visiting team depended on the MOH writing the report; the inclusion (or not) of reports by the senior health visitor and/or female medical officer within the MOH report; and the purpose of the commentary. When staff turnover was identified as a problem arrivals and departures were discussed in detail. A total of 29 women worked as Halifax health visitors during the study period.
Information about the health visiting team was also collected from the minutes of relevant Halifax Corporation Committees (1907-1929).24 This revealed some discrepancies with the MOH reports, for example the minutes of the HHC list two women who were offered appointments but failed to take up their posts, thus never appearing on the staff lists. In September 1920 Miss Dorothy Clark refused the position offered; perhaps choosing to continue with her existing employer or seek an alternative job with better pay and conditions elsewhere. Uncertainty surrounds the situation of Mrs F. Scott, who was recruited from Pontefract but never worked in Halifax. It is possible that Scott’s domestic circumstances raised questions and despite initially being offered the job, she was subsequently encouraged to withdraw.
Halifax health visitors worked long hours and a young woman (married, widowed, separated or divorced) with dependent children would have been a risky appointment. Mrs Marshall (a widow, possibly a war widow) had a long career in Halifax but she was a local woman known to the MOH. The only other Halifax health visitor who was definitely recognised to be (or have been) married before 1939 was Mrs M. E. Dickens. She was noteworthy for her lack of health visiting qualifications as well as her marital status. However, the HHC minutes record that she resigned rather than left at the end of a temporary contract.25
In total 31 women appear in the records and the rest of this article will discuss the shifting form of the health visitor team in Halifax through their records. Discounting the three married women (Marshall, Scott and Dickens), the remaining 28 can be divided into two groups. Twenty (identified as ‘Miss’) were not only understood to be single but were usually qualified health visitors taking up permanent appointments. The other eight women were referred to as ‘Nurse’ without any indication of their marital status. Most were temporary staff, typically offering fewer qualifications.26
Since marriage was an important reason for abandoning a nursing career it is assumed that most if not all of the ‘nurses’ were single women.27 Marriage also ended some health visiting careers. In Halifax two of the 29 staff employed in Halifax and recruited before the end of 1939 left to marry; a figure that seems on the low side. Records from the 1940s and 1950s suggest Halifax women tended to train as health visitors as soon as possible after qualifying in nursing and midwifery. Many married soon after completing their health visiting courses and either left immediately or when pregnant with their first child. A question mark hangs over the interwar situation of Miss Louisa Wolstenholme, who married after more than ten years of service as a health visitor in Halifax. The MOH report that recorded her wedding in 1932 also noted that she and her husband had left the area, but in the brief period before their move she may have continued to work. Significantly it was ‘Mrs B (formerly Wolstenholme)’, who was thanked for her ‘many years of valuable and conscientious service’.28
There is some evidence that public sector workers in the town were amongst the ‘secretly married’ group who discreetly attended the local birth control clinic in the 1930s.29 Halifax Corporation certainly had a history of discovering female teachers who were meant to be single but were actually married, and there was a prurient local interest (captured in the press as well as official reports) in couples who lived together without being lawfully married. As health visitors were tasked with uncovering this sensitive information (as part of a concern with illegitimate births) there would have been objections to any hint of irregularity in their own personal lives. Mrs Scott (already discussed) was offered a job at a time when nursing was re-emphasising moral issues as part of the drive for post-registration professionalisation, and while there is no evidence of any impropriety on her part, she was a more difficult appointment than Mrs Marshall.30
Health visiting in Halifax 1914-1930
When there was only one health visitor in Halifax her arrival and departure made a mark. The growing team of junior staff proved more elusive. The increase in personnel was associated with a confused period when there was uncertainty about approved staff numbers. The First World War had placed unprecedented demands on Alice Thompson, the sole Halifax health visitor, who had assumed a range of new duties. Wartime conditions also disrupted the work of the volunteer visitors; a factor which was both the cause and effect of developing an infant welfare clinic (IWC) that gave a new institutional focus to the work from 1915. The IWC encouraged the involvement of a female doctor, who initially worked as a volunteer but who became a part-time and then full-time medical officer of the Corporation. Her changing responsibilities required a periodic reallocation of health visiting duties.
In the years during and immediately after the First World War, the Local Government Board (LGB), and later the Ministry of Health, encouraged and then pressed Halifax Corporation to appoint more health visitors. Miss Thompson (even with the help of Nurse Wynll) was already struggling when a severe measles epidemic compounded the problem of wartime dislocations. Mrs Marshall was initially hired as a temporary assistant but provided continuous service until retiring in 1939. Her lack of professional qualifications fuelled disputes about the number of staff that Halifax Corporation had and was meant to have. Since 1917, the Local Government Board had required local authorities to provide one health visitor for every 500 births.31 This figure was quickly revised to 1:400; and, in 1934, the Ministry of Health established the norm of 1:250 which is still used today. Halifax recorded 1794 births in 1914 and 1384 in 1919, and local records suggest Miss Thompson had one, then two, then three official assistants (sometimes including Mrs Marshall and/or a TB nurse) in the period 1916-21. By LGB standards therefore, and despite a falling birth rate and growing health visitor team, Halifax continued to be understaffed.
The position of first assistant health visitor was formally approved in 1917; a role occupied in quick succession by A. Carpenter, O. Bell and Elsie Oram. This high rate of staff turnover reflected recruitment and retention problems. Miss Carpenter was a qualified health visitor recruited from Stockport in September 1916. She accepted a permanent position but resigned after less than six months and left in February 1917. No further explanation was provided. However, the category ‘resigned’ tended to be reserved for those changing jobs which suggests that Carpenter left for a better post elsewhere
Her replacement, Nurse Bell (not a qualified health visitor) was hired on a temporary basis but served for two years (February 1917 to February 1919) because no other staff were available. In March 1919, Miss Elsie Oram replaced her. Promoted to the position of senior health visitor following Miss Thompson’s retirement in 1921, she led the department for almost three decades until retiring on the 31 December 1950.32
Recruitment and retention difficulties were exacerbated by the creation of additional posts in Halifax (and elsewhere) before a supply of suitably qualified staff was secured. In 1918 a position of second assistant was approved and occupied by Mrs Marshall who had worked in the department since 1916. It was the Ministry of Health that pushed for the appointment of a third assistant in 1920. The role proved difficult to fill on a long-term basis, with four names associated with the position even before Miss Thompson retired in 1921. Miss Dorothy Clark refused the job when it was offered but hopes of stability were raised by the arrival of Margaret Purlson. She was a fully-qualified health visitor recruited from Sheffield, a city with a strong reputation for health visiting. Unfortunately she did not stay long, starting work in Halifax in September 1920 but leaving before the 1921 staff list was compiled. The circumstances of her departure are unclear, but it is probable she sought a better job, as Halifax continually lost staff to other local authorities. Mrs Dickens (a midwife) provided temporary cover and, the position was then briefly vacant pending the arrival of Miss Lilian Eastwood.
The situation was, however, more complex than this. Miss Thompson officially had one, then two and then three assistants; but also drew on support from the tuberculosis nurse/visitor. Uncertainty surrounds the duties of Nurse Davis (a qualified health visitor appointed on a temporary basis in 1918) who was neither a replacement for the TB nurse nor an addition to the health visiting staff, The two teams of staff were combined in the 1920s before being separated again in 1930 Both reorganisations were prompted by the arrival of new MOsH (Cyril Banks and then George Roe); although the first was undoubtedly also influenced by the retirement of Miss Thompson and the promotion of Miss Oram.
Miss Oram (also titled Sister Oram) took over as senior health visitor in July 1921. Her old position as first assistant was filled by Louisa Wolstenholme (a fully trained health visitor originally recruited to the role of third assistant) with Mrs Marshall remaining as second assistant. There continued to be rapid turnover of third assistants with three women providing brief service in tragic circumstances. Lilian Eastwood had seemed an excellent appointment. She was fully qualified and already living in Halifax. Her sickness and death only weeks later shook the health department.33 Another local woman, E. M. Bates, provided cover for six months but she was a nurse not a health visitor. Her replacement, Miss Winfred Dorcus Overy, had excellent qualifications but only served from June 1922 until February 1924 before being forced to resign for health reasons.
Despite continuing evidence of recruitment as well as retention problems the team of health visitors was then expanded by the creation of another two posts from 1924. These were filled at various times by six new appointees and the formal inclusion of the TB nurse.34 The best qualified recruit was M. H. Sutcliffe, who was a nurse, midwife and health visitor. She provided excellent service from 1924 to 1930 before leaving to take up a better paid position. The well-qualified Mrs Scott was, as previously mentioned, recruited but never employed in Halifax. Another qualified health visitor, M. E. Maudsley only served for 13 months before moving to another job in November 1925. Miss Margaret Moore was then recruited as a trained health visitor and had a long and successful career in Halifax. Her colleague Miss G. Briggs was a trained nurse recruited as a pupil health visitor and later added to the permanent staff. Uncertainty surrounds the position of Millie McCormac. She was identified as a midwife and may have been providing temporary cover for vacancies. It is not inconceivable that she had also signed up for health visitor training, but she left after a year to marry and never joined the permanent staff.
The entire team was subject to a major re-grading exercise in 1927. Records mentioned Oram, Wolstenholme, Sutcliffe, Briggs and Moore, but omitted Marshall and Tindle (TB nurse) who were on the staff list for the year. It has to be assumed that they did not meet Ministry of Health requirements for recognition as qualified health visitors. The problems of recruiting and retaining qualified staff continued. After a brief period of stability, two health visitor vacancies were recorded on the 1929 staff list; although Mrs Marshall and Nurse Tindle continued to serve alongside Oram, Wolstenholme and Moore. The lack of personnel strained the team, and it was noted that overall visits had decreased in 1929 due to ‘staff sickness’.35 The situation continued to deteriorate with the MOH report recording that the ‘toddlers’ clinic was not held during 1931 owing to staff shortages and changes’.36
A new approach was required. Patterns of health visitor recruitment were already changing in Halifax. Gladys Briggs seems to have been appointed before she completed training as additional qualifications were added on later staff lists. This arrangement became increasingly common as staff shortages encouraged Halifax Corporation to sponsor women wishing to train as health visitors. For a variety of reasons this support was targeted towards nurses. The relationship between all branches of nursing, midwifery and health visiting has long interested social historians as well as historians of nursing.37 They agree that in the crucial interwar period it became increasingly common for health visitors to be recruited from the ranks of registered nurses. The reasons for this departure from previous practice are understood to be complex, with various factors shaping the supply of as well as demand for staff.38
The 1929 Local Government Act had allowed Halifax Corporation to appropriate the former Poor Law hospital known as St Luke’s, which was renamed, and reconfigured, as the municipal Halifax General Hospital. There were also efforts to coordinate this institution with other hospitals run by the council and other organisations. All these hospitals employed nurses, and both St Luke’s and the voluntary sector Royal Halifax Infirmary were important training facilities for general nurses. Improved access to this supply of nurses was certainly one local influence on changing health visitor recruitment. The location of training facilities was another.
In theory trained health visitors could be recruited from anywhere in the UK. However, many (at least 10 out of the 31) of the Halifax staff were living in the area served by Halifax Corporation when appointed. This made sense when making temporary appointments, and was probably a deliberate strategy. Local women were also taken on as pupil health visitors as there was an expectation (only partially realised) that they would want to work in Halifax after qualification. Of the 31 women identified from the records, only four were definitely recruited from outside Halifax (from Derbyshire, Pontefract, Stockport and Sheffield), suggesting that Halifax struggled to recruit nationally. Even within what might be called its own region, it appeared to be losing out to neighbouring authorities. Part of the explanation for this lay in the better pay and career opportunities available in larger departments; but access to training facilities was also an issue.
There are examples of Halifax health visitors receiving training at Leeds University (Miss Oram received post-qualification training there) and also in Bradford.39 However, these neighbouring centres (and indeed the health visiting courses offered at Bingley College and University College Hull)40 seemed to direct potential recruits towards service with the West Riding of Yorkshire County Council (whose area bordered that of Halifax), and the larger cities in the region. Leeds and Bradford were both noteworthy employers of female sanitary inspectors in the pioneering phase of the profession but regularly complained of losing staff to better paid positions in London.41 It was sourly noted that one Halifax health visitor had left for a better position in ‘Southern England’; but competition with neighbouring local authorities also had a negative impact on patterns of recruitment and retention.
Improved access to training was meant to boost recruitment, but had mixed results. Miss S. E. Briggs, recruited in April 1930 as a temporary clinic helper after completing her nurse training, joined the staff as a pupil health visitor three months later, and was given time off for health visitor training and to take her examinations. Once qualified she joined the Halifax team in July 1931 and proved a valued member of staff before finally retiring in 1956. Other recruits were meant to follow the same career path but none did. Recruitment and retention proved equally disappointing in the interwar years and later. In these circumstances, informal networks of extended kin and colleagues from nurse/health visitor training and hospital service were important.42 Miss S. E. Briggs was almost certainly related to Gladys Briggs (mentioned earlier) and may have been her sister. It was not unusual for sisters to work together as nurses and then health visitors. Miss Caroline A. Knuckey led the Exeter City Council health visiting service from 1916 to 1945 and her sister Barbara M. Knuckey worked alongside her for 25 years (1920-45).43
New challenges in the 1930s
Historians exploring the origins of the welfare state and the evolution of municipal health services point to the significant expansion of health visitor numbers in the years during and immediately after World War One.44 Lara Marks develops an important case study of health visiting in the capital, describing how different London boroughs responded to changing guidance from central government as well as local circumstances.45 Marks underlines the heavy workload imposed on staff, especially in the 1920s, but suggests that the falling birth rate in the 1930s ‘potentially allowed the health visitor more time to chat and find out the needs of each mother and her child, and indicate where to go for help’.46
The 1930s was thus an important decade for the development of health visiting, despite the lingering effects of the Great Depression and austerity measures. There was an effort to consolidate existing programmes of home visiting and clinic-based activities. At the same time there was a focus on coordinating and upscaling all municipal medical activities; projects that necessarily involved liaison with an increasing number of other statutory and voluntary sector providers.47 Snapshots of local services provided by the public health surveys that followed the implementation of the 1929 Local Government Act confirmed that health visitors did not work uniformly across the country but were involved with a diverse range of services. They could, and often did, include supporting school medical services, infant life protection duties, the care of disabled children, tuberculosis work, VD clinics, orthopaedic schemes, mental deficiency services, arrangements to control infectious diseases, vaccination programmes, health propaganda work, and the supply of home nursing equipment. Visiting inspectors from the Ministry of Health were determined to protect the amount of staff time devoted to core maternity and child welfare activities and eager to use health visitors to develop and improve other services. These competing concerns were highlighted in the 1932 Halifax Public Health Survey.48 One unusual feature of this investigation was Miss Oram’s role as a confidential informant. She was questioned at length about the operation of the whole of health department, not just the work of her health visiting team. Dr Williamson, from the Ministry of Health, was scrupulous about recording Miss Oram’s personal testimony on subjects ranging from local abortion practices, to the politics of the council, relationships between the different medical officers, and the reception of a newly arrived MOH. He clearly regarded Miss Oram as an excellent, even exceptional, officer; an opinion reinforced by comments from her colleagues. The 1931 MOH report mentioned that ‘Sister Oram, the Superintendent Health Visitor, has again done invaluable work in the supervision and organisation of the various services’.49 An almost identical tribute the following year added ‘her untiring efforts are much appreciated by all’.50
None of the other surveys consulted in this study accord any significant role to a health visitor. Indeed, when the neighbouring West Riding of Yorkshire County Council (WRYCC) was surveyed in 1934, not one of the large team of health visitors (112 whole-time staff employed by the county council and 63 part-timers who were officers of local nursing associations) were even named.51 This was surprising because the WRYCC maternity and child welfare services were praised by Dr Carol Sims for being ‘well-qualified, intelligent women; their records were clearly kept and were up-to-date’. Yet no individual was considered worth highlighting for their contribution.52 In other places, such as Devon, the health visitors were identified by name and were more closely questioned by visiting Ministry inspectors, but only about their own workload, visits, clinic duties and modes of transport.53
More generally, many of the survey reports commented on problems recruiting and retaining health visitors. In the WRYCC area improved salaries were seen as key to boosting numbers, although there was also interest in new training schemes and recruitment strategies.54 Pension arrangements were identified as a significant problem in Plymouth, although the MOH there drew attention to the ‘expense and other difficulties connected to the training of health visitors’.55 In Devon, the MOH and Miss Booker (the superintendent health visitor) expressed concern about government policies that allowed village nurse-midwives to perform health visiting duties but prevented well-qualified nurses from being employed as health visitors.56
All these issues shaped the recruitment and retention of interwar Halifax health visitors. Dr Williamson recorded that Miss Oram thought that only four of her six staff in Halifax were suitably qualified; and although the other two were due to leave shortly (one woman in her sixties presumably retiring) there was anxiety about who might replace them. While it must be inferred that Miss Oram was talking about Mrs Marshall, whose lack of qualifications had been an issue since her appointment in 1916, she continued to work in Halifax until 1939. It is, however, noticeable that Miss Oram increasingly relied on health visitor Margaret Moore to perform sensitive duties such as staffing the women’s VD clinic.
Halifax Corporation had repeatedly tried to upskill its interwar workforce. Williamson noted the MOH provided regular in-house training for Halifax health visitors. There had also been efforts to free staff time by making intelligent use of clerical support. Here Miss Oram played a vital role in running the office and over-seeing the work of various staff; being ready to personally take on difficult cases as required, and encouraged to attend a wide variety of regional and national public health conferences.57 Oram was credited with being highly-knowledgeable, very efficient and tactful in her dealings with her own staff, colleagues in the health department, and other important local actors.
While arrangements for health visiting in Halifax were particularly well planned, they were replicated in many urban areas. The ability to return to a shared office where records could be updated and cases discussed, providing an important source of personal as well as professional support. Rural practitioners, by contrast, in what was for many still the age of the bicycle, kept their records at home and communicated with their colleagues and superiors by letter and telephone. This was understood to be less satisfactory but there were few alternatives. In the enormous county of the West Riding of Yorkshire, for instance, a meeting of the WRYCC health visitor team would cost the County Council £72 in travel expenses (and this was in 1934 at a time when a whole-time health visitor only earned £180 pa).58 The Ministry of Health understood this point but were unconvinced by their arguments against employing a senior or supervising health visitor to better co-ordinate the work of the scattered staff.
The Halifax staff were a recognisable team, and the 1930s saw decreased staff turnover. Unusually the 1933 MOH report recorded: ‘…there has not been any serious illness amongst members of staff during the year. The personnel remains unchanged’.59 Stability encouraged service improvement. In 1936 it was recorded that ‘the number of visits paid shows a marked increase despite the fact that one health visitor had to deputise at the tuberculosis dispensary for a period of three months, in consequence of the death of the tuberculosis visitor [possibly Miss H Dukes]’.60 At this time the work of the maternity and child welfare (MCW) service health visitors was meant to be distinct from the tuberculosis service and they were listed separately. For this reason it is not clear if Miss Dukes was the unfortunate visitor who died or her replacement. She certainly appears on no other staff list; and a Miss P. A. Vaughan performed duties in Halifax as MCW and tuberculosis health visitor before and after a wartime absence, presumably for military service. Mrs Marshall finally left in April 1939, replaced on a temporary basis by Nurse Gummerson before Miss Kellett was appointed.
Interestingly, no staff changes were recorded in 1937 and 1938, and many of the staff already discussed formed the core of the Halifax health visiting service as it moved into the NHS era. When Miss Oram retired in 1950, the department was reorganised to formalise the role of superintendent health visitor. This post proved difficult to fill and leadership of the department was often left to the senior health visitor. Margaret Moore had been promoted to take over this job from Elsie Oram. She was well regarded by colleagues and much was made of the Coronation medal she received in 1953. Miss Moore retired in 1956, being replaced by Miss N. Dingsdale who had first appeared on the 1931 staff list. Miss Dingsdale was triple qualified as a nurse, midwife and health visitor and provided continuous service in Halifax until her retirement in 1962.
This article has concentrated on the 31 women who were appointed to undertake health visiting duties on behalf of Halifax Corporation between January 1908 and the end of 1939. When the service started Mary Wayne, and then Alice Thompson, acted as sole practitioner. A team of staff then evolved as new assistant health visiting positions were created. At times the tuberculosis nurse/visitor provided extra support and when Miss Oram retired in 1950, she had a total of six assistants. Apart from the two women who never took up their positions, the recruits provided valuable service (albeit of varied length) with no recorded complaints. However, the women were very different in terms of their backgrounds and careers.
Some careers developed as planned, with the officials who sponsored the training of S. E. Briggs rewarded by her many years of excellent service. In total seven staff, including the somewhat problematic Mrs Marshall, completed their careers in Halifax and only left on retirement. Retirements thus accounted for 24% of the 29 named women who took up roles in the health visiting services in Halifax. Six of the 29 women (20%) provided more than twenty years of service, and four (14%) exceeded 25 years. This final figure included a health visitor still employed by Halifax Corporation in 1962.
Other staff proved long-serving before moving on for various reasons. In addition to the seven staff already discussed, five health visitors worked in Halifax for more than five years (17% of the total of 29); four of them for more than 10 but less than 20 years (14%). The other health visitors offer a mixed picture. Most strikingly, twelve of the 29 (41%) worked in Halifax for less than a year and another six (21%) served between one and five years. These figures included temporary staff (three were explicitly identified in the records but there were others) whose lack of qualifications made them ineligible for permanent posts, but turnover amongst the recognised health visitors was also problematic. In addition to the known death of one health visitor, it is likely a second health visitor also died, giving a total of 2 out of 29, or 7%. Other departures related to marriage (2, or 7%) and personal health problems (2, or 7%) were also outside of the control of the health department.
More worrying were the three staff (10%) who ‘resigned’, and the four (14%) fully-qualified health visitors who left to take up other posts. It was explicitly stated that three of these jobs were better paid. It is assumed that some of the six or seven (depending on the aforementioned death in service) staff leaving for unspecified reasons also fell into these categories.61
Halifax Corporation had become resigned to the rapid departure of staff they clearly wanted and needed to retain. The new recruitment strategy which targeted local women for training, proved only a partial solution to this problem; and the new stability in the health visiting team evident at some points during the 1930s seems to have been achieved more by accident than design. The position certainly deteriorated through the war years and turnover accelerated in the early years of the NHS.
Halifax offers an interesting case study, but more work needs to be done before any strong conclusions can be drawn about the people attracted to interwar health visiting and the careers they developed. A starting point is a comparison with the recruitment of different cohorts of health visitors and/or the careers of other community nurses. Robert Dingwall, describing a later generation of student health visitors, was realistic about factors pushing and pulling nurses into the profession.62 Such analysis needs to be read alongside earlier presentations (by councils and others) of health visiting as a high-status, interesting and rewarding profession that would naturally attract excellent people. The way interwar nurses were/were not tempted to switch to health visiting and the impact this had on the wider profession and its subsequent development remain key research questions. Nurses were seen as a useful way of boosting numbers, but recruitment and retention problems became entrenched, and the competition for qualified health visitors meant staff could seek better pay and career advancement with other local authorities. In other cases, promising careers were ended (or at least severely disrupted) because of personal issues including poor health, or plans for marriage and motherhood.
Sweet and Dougall reached very similar conclusions from their study of district nurses. The position of district nurse was an important one that people took on at different stages in their careers, and many didn’t stay long.63 Staff turnover in all branches of community nursing adds to the difficulty of tracing careers. For health visitors, an additional layer of complexity was added by the diversity of the potential workforce before midwifery and nursing qualifications were made mandatory in 1925 and 1945 respectively. Sweet and Dougall drew on a 1926 survey to illustrate the lack of standardisation of health visitor training. Amongst 1,974 practitioners there were ‘twenty-two different kinds of certificates or varieties of experience, held in eighty-eight combinations, with some holding as many as five separate certificates’.64
To date the history of health visiting has been most concerned with professional milestones and changing working practices. Another branch of the literature has been concerned with the nature and purpose of the health visiting.65 These authors, taking a contemporary as well as a historical perspective, often adopt an overtly critical stance when probing relations between health visitors and their clients.66 What is missing from this analysis is an appreciation of workforce issues, and the personal experiences and biographical details of women working as health visitors. Historians of other branches of nursing have demonstrated the value of approaches that illuminate the experiences of rank-and-file practitioners as well as elite figures.
With health visiting arguably undergoing a number of transformations in the 1930s, this seems a period worth concentrating on. The comprehensive public health surveys of the time also offer interesting source material, some of which is reproduced above. Questions were designed to probe recruitment and retention issues, and many useful insights can be gleaned. The attention paid to pay and conditions also suggests that health visitors were seen as an important resource. Yet there was a paradox. Health visitors could have taken on more duties had more staff been available; their MOsH recognised their abilities and valued the way their training made them multi-skilled and able to deal with a variety of client groups. However, the insistence on extended training and advanced qualifications was a significant barrier to recruitment leading to understaffing and overwork. The recruitment and retention crisis of the 1930s thus created real problems for staff, employers, and the future development of the profession.
- For more extended literature review see Anne Borsay and Pamela Dale, ‘Mental health nursing: the working lives of paid carers from 1800-1990s’, in Mental Health Nursing: The Working Lives of paid Carers in the Nineteenth and Twentieth centuries, ed. by Anne Borsay and Pamela Dale (Manchester: Manchester University Press, 2015), 12-16.
- Claire Chatterton, ‘“The weakest link in the chain of nursing”? Recruitment and retention in mental health nursing in England, 1948-68’, in Mental Health Nursing, ed. by Anne Borsay and Pamela Dale (Manchester: Manchester University Press, 2015), 169.
- Mick Carpenter, Working for Health: The History of the Confederation of Health Service Employees (London: Lawrence and Wishart, 1988).
- Sue Hawkins, Nursing and Women’s Labour in the Nineteenth Century: The Quest for Independence (London: Routledge, 2010).
- Margaret Damant, ‘A biographical profile of Queen’s nurses in Britain, 1910-1968’, Social History of Medicine23/3 (2010), 586-601.
- Anne Borsay and Billie Hunter, ‘Nursing and midwifery: Historical approaches’, in Nursing and Midwifery in Britain since 1700, ed. by Anne Borsay and Billie Hunter (Basingstoke: Palgrave Macmillan, 2012), 1-20.
- Ibid., 1.
- Helen M. Sweet with Rona Dougall, Community Nursing and Primary Healthcare in Twentieth-Century Britain(London: Routledge, 2008), 180-2.
- Robert Dingwall, The Social Organisation of Health Visitor Training (London: Croom Helm, 1977).
- Robert Dingwall, Anne Marie Rafferty and Charles Webster, An Introduction to the Social History of Nursing(London: Routledge, 1988), 188.
- On the supply side nursing was a useful source of well-educated women and new health visiting careers opened opportunities for ambitious nurses. Demand was shaped by doctors, who were accustomed to working with nurses and valued their clinical skills. These became more important as clinic services developed to offer treatments as well as advice.
- Lara Marks and John Welshman offer important insights into the evolving work of different teams of municipal health visitors but as far as I can tell do not discuss the careers of individuals. Lara Marks, Metropolitan Maternity: Maternal and Infant Welfare Services in Early Twentieth Century London (Amsterdam: Rodopi, 1996); John Welshman, Public Health in Twentieth-Century Britain (Oxford: Peter Lang, 2000); Dingwall, Rafferty and Webster, Introduction to the Social History of Nursing, chapter 9.
- The Wellcome Library catalogue lists a collection of papers relating to the careers of seven health visitors but little work seems to have been done on them. See Wellcome Library, London (hereafter WL) SA HVA/G. 1-7.
- The Wellcome Library has an incomplete set of these journals. Some issues of Health Visitor (1972-91) are shelved but earlier publications need to be located within the archives of the Health Visitors’ Association. See WL, SA HVA.
- The Woman Health Officer, 16:12 (1943), 3.
- A series of Ministry of Health files at the National Archives deal with changing regulations concerning the training, qualifications and salaries of health visitors. NA, MH 53/114 (1938-47) is interestingly titled ‘difficulty in obtaining fully qualified health visitors’.
- Pamela Dale, ‘The contested appointment of the first Halifax health visitor: exploring the importance of local as well as national debates in the Edwardian infant welfare movement’, Transactions Halifax Antiquarian Society, 2020.
- Pamela Dale, ‘Challenges for the municipal regulation of midwifery: A Halifax case study’, Women’s History, 2/14 (2019), 14-19.
- For regulations governing the Edwardian appointment of female staff see Dingwall, Rafferty and Webster, Introduction to the Social History of Nursing, chapter 9.
- The other four were the wives of local notables.
- MOHR, 1921, 28.
- Halifax Borough Council, annual reports of the MOH are kept at the Local Studies Centre [LSC] at Halifax Central Library, reference 614 HAL.
- The minutes of Halifax Borough Council and all its committees were accessed in the bound volumes kept at the LSC, reference 352 HAL.
- Mrs Marshall was initially recruited as a temporary assistant in 1916 and was promoted to second assistant health visitor in 1918. Although she had no apparent qualifications, she undertook various duties before securing a permanent job, and went on to provide continuous service until 1939 (when it assumed that she retired).
- There was certainly scope for confusion. In the period 1919-21 MOH Neech wrote a list of staff into the annual reports but did not record all their qualifications. In Dr Alice Latchmore’s section of this (and later) reports she often described all her team as nurses. This title extended to women other records identified as qualified health visitors.
- For a discussion of nurses and marriage see for instance, Sue Hawkins, Nursing and Women’s Labour, Chapter 5.
- MOHR 1932, 54.
- Pamela Dale and Kate Fisher, ‘Contrasting municipal responses to the provision of birth control services in Halifax and Exeter before 1948’, Social History of Medicine, 23 (2010), 567-85.
- Sarah Chaney, ‘“Purifying the profession”: good character and the General Nursing Council Disciplinary Committee in the inter-war period’, Women’s History, 2:14 (2019), 9-13.
- Marks, Metropolitan Maternity, 173.
- In 1921 the health visitors were paid £140 a year and Miss Oram received £160.
- MOHR 1921, 28.
- Halifax had requested two additional staff, but the Ministry of Health chose to approve one then two positions.
- MOHR 1929, 63.
- MOHR 1931, 46.
- Borsay and Hunter (eds), Nursing and Midwifery; Dingwall, Rafferty and Webster, Introduction to the Social History of Nursing.
- Dingwall, Rafferty and Webster, Introduction to the Social History of Nursing, 186-9.
- Bradford Technical College trained most of the new staff in the late 1940s and 1950s.
- National Archives [hereafter NA], MH 53/58 health visitor training centres -Leeds University 1922; MH 53/59 – Leeds University 1925-28; MH 53/121 – Hull University College 1938-47.
- Pamela Dale and Kate Fisher, ‘Implementing the 1902 Midwives Act: Assessing problems, developing services and creating a new role for a variety of female practitioners’, Women’s History Review, 18 (2009), 427-52.
- These issues have been explored in far more detail in the context of hospital nursing.
- An incomplete series of Annual Reports of the Medical Officer of Health for the City and County of the City of Exeter are available at the Wellcome Library and Devon Heritage Centre [DHC], reference SB/EXE 614 EXE.
- Bernard Harris, The Origins of the British Welfare State: Social Welfare in England and Wales, 1800-1945(Basingstoke: Palgrave Macmillan, 2004), table 15.5, 236.
- Marks, Metropolitan Maternity, 171-177.
- Ibid., 173.
- Welshman, Public Health; Alysa Levene, Martin Powell, John Stewart and Becky Taylor, Cradle to Grave: Municipal Medicine in Interwar England and Wales (Oxford: Peter Lang, 2011).
- NA, MH 66/1071, Halifax County Borough – Survey Report by Dr D. J. Williamson.
- MOHR 1931, 49.
- MOHR 1932, 54.
- NA, MH 66/289 West Riding of Yorkshire Public Health Survey, Dr C. J. Donelan, 1934 (hereafter WRYCC SR), Maternity and Child Welfare (MCW) Section by Dr Sims, 15-21.
- WRYCC SR, MCW section, 18-19
- NA, MH 66/58 Devon Survey Report, appendix B.
- WRYCC SR, MCW section, 18.
- NA, MH 66/818 Plymouth CB, PH survey, LGA 1929, p.14.
- Devon Survey Report, appendix B.
- Pamela Dale, ‘The Halifax County Borough Public Health survey of 1931-32’, Transactions Halifax Antiquarian Society, 2021.
- WRYCC SR, MCW section.
- MOHR 1933, 55-6.
- MOHR 1936, 58.
- Many of these departures were missing from incomplete wartime reports. It is not suggested that contemporary actors were unaware of the circumstances.
- Dingwall, Social Organisation.
- Sweet with Dougall, Community Nursing, 56-59, especially table 2.2.
- Ibid., 37, authors quote notes from WSIHVA, Memorandum on Matters … September 1926.
- Anna Davin, ‘Imperialism and Motherhood’, History Workshop Journal, 5 (1978), 9-65.
- Celia Davies, ‘The health visitor as mother’s friend: a woman’s place in public health, 1900-1914’, Social History of Medicine, 1/1 (1988), 39-59.