The Sick in United Kingdom
The Sick and the Poor Law Board
In this issue about the sick, the book “English Poor Law Policy” [1] reads as follows: We have shown that, between 1834 and 1847, it was not contemplated that persons actually sick would be received in the workhouse, and that there was no trace in the documents of any desire on the part of the Central Authority to interfere with the usual practice of granting to them outdoor relief, which had not been in any way condemned or discredited by the 1834 Report. The same may be said of the Statutes, Orders, and Circulars of 1847-71. We find no suggestion that the boards of guardians ought not to grant outdoor relief in cases of sickness, or that sick paupers ought to be relieved in the workhouse. On the contrary, the exceptions specifically made in favour of sick persons seem to be even widened in scope. Thus, in 1848, the Central Authority laid it down that widows with illegitimate children were not to be refused outdoor relief, if the children were sick. By the Outdoor Relief Regulation Order of December 1852, it was definitely provided that outdoor relief might be given in case of sickness in the family, even if the head of the family was simultaneously earning wages. The same policy was embodied in the corresponding General Order issued on 1st January 1869, to certain Metropolitan unions. Further, in the panic about cholera in 1866, the Central Authority informed the boards of guardians by circular that in cases of emergency they might call in any medical and other assistance that was needed, and even provide whatever sustenance, clothing, etc., was required, apparently irrespective of “destitution” and of all General Orders, etc., to the contrary. Moreover, early in this period we note the beginning of the special definition of “destitution” as regards medical relief which has since been acted upon, that is to say, the inability to pay for the medical attendance that the nature of the case requires. Thus it was declared by the Central Authority in 1848 that the parish doctor might attend sick servants living in their master’s household, who were plainly not destitute in the ordinary sense, as not being without food and lodging, but who, if there were no wages due to them, might be unable to pay for medical attendance. A similar line of thought may be traced in that provision of the Act of 1851 which authorised boards of guardians to make annual subscriptions out of the poor rate to public hospitals and infirmaries, to enable these non-pauper institutions the better to provide “for the poor.” “The sick wards of the workhouses,” as the Central Authority explained in 1869, “were originally provided for the cases of paupers in the workhouse who might be attacked by illness; and not as State hospitals into which all the sick poor of the country might be received for medical treatment and care. So far is this, indeed, from being the case that at least two-thirds of the sick poor receive medical attendance and treatment in their own homes.” When in 1869-71, the Central Authority obtained elaborate reports showing, for all parts of England, the practice that prevailed of normally giving outdoor relief to the sick, and of taking them into the workhouse infirmaries only when this was called for by (a) the nature of the disease, (b) the wishes of the patient, or (c) the nature of the home, and then only where suitable infirmary accommodation was available, there is no indication that any objection was entertained to the policy of outdoor relief to this large class.
What is new in this period is the appearance, as a positive policy, of bringing pressure to bear on the boards of guardians to improve the quality of the medical attendance and medicine supplied. This led to an explicit disavowal, so far as regards the sick paupers, of any application to them of the principle of making the pauper’s condition less eligible than that of the lowest grade of independent labourers. It is noteworthy that this new departure applied to outdoor medical relief quite as much as to institutional medical treatment, in which it has subsequently been sometimes excused on the ground that the superior treatment is accompanied by a loss of liberty. The new departure took three directions. It was definitely laid down that the medical attendance afforded to the outdoor paupers was to be of good quality, and thus necessarily above that obtained by the poorest independent labourer, or even by “the poor” generally. This was the outcome of a long campaign on behalf of the poorer members of the medical profession, of which Wakley was the leader in the House of Commons, and the Lancet the efficient organ. In 1853 the Poor Law Board considered that the qualifications of the Poor Law medical officers “ought to be such as to ensure for the poor a degree of skill in their medical attendants equal to that which can be commanded by the more fortunate classes of the community.” On the suggestion of the House of Commons Committee on Poor Relief it was authoritatively enjoined on boards of guardians in 1865 by a special circular that they were to supply freely quinine, cod-liver oil, and “other expensive medicines” to the sick poor; although it must have been plain that such things were beyond the reach of the independent labourers consulting the “sixpenny doctor,” and even beyond the usual resources of the provident dispensaries of the period. Finally, in 1867, the Metropolitan Poor Act authorised the establishment throughout London of Poor Law dispensaries. These institutions were consistently pressed on the Metropolitan boards of guardians by the Central Authority, as having been successful in Ireland in reducing the amount of sickness among the poor, and as ensuring, not only regular and more successful medical attention, but also a sufficient supply of medicines and medical appliances of standard quality. By this elaborate systematisation of outdoor medical relief, the Central Authority not only put within the reach of the sick paupers medical attendance far superior to that accessible to the lowest grade of independent labourers, but even placed the sick pauper in the Metropolis, without loss of liberty, in a position equal to that of the superior artisan subscribing to a good provident dispensary.
The most remarkable change of front was, however, that relating to the institutional treatment of the sick. Down to 1847, it is not too much to say that “what may be called the hospital branch of Poor Law administration” was ignored alike by Parliament, public opinion, and the Central Authority. We have shown that the institutional provision for the sick was not so much as mentioned in the Report of 1834, and that it remained practically ignored in all the Orders, Circulars, and Reports of the Poor Law Commissioners. The same is true of the first eighteen years of the Poor Law Board. Few and far between are the incidental references to the “sick wards” of the workhouses. There is not even a hint of a suggestion that relief to the sick poor could most advantageously take the form of an offer of “the House.” On the contrary, it was held in 1848 that applicants for admission suffering from “fever” might even be refused admission, the relieving officer being enjoined to find lodging elsewhere for them, though how this was to be done the Central Authority did not, in 1848, say. In 1857, the Metropolitan Boards of Guardians were recommended to send such cases to the London Fever Hospital (involving a payment by the guardians of 7s. weekly). Finally, in 1864-5, we have an outburst of public indignation, at the condition into which the sick wards of the workhouses had been allowed to drift. The death of a pauper in Holborn workhouse, and of another in St. Giles’s workhouse, under conditions which seemed to point to inhumanity and neglect, led to an enquiry by three doctors (Anstie, Carr, and Ernest Hart), commissioned by the Lancet newspaper, the formation of an “Association for improving the condition of the sick poor,” and a deputation to the Poor Law Board.The publication of various reports on the workhouse infirmaries, in which terrible deficiencies were revealed, led to public discussion and Parliamentary debates. The Central Authority at once accepted the new standpoint. It made no attempt to resist the provision of the necessarily costly institutional treatment for the sick poor, whether or not their ailments were infectious or otherwise dangerous to the public. The progressive improvement of “the hospital branch of Poor Law administration,” to use the phrase of the Central Authority itself, which had in the preceding thirty years grown up unawares, was now definitely accepted as an important feature of its policy. Statutory powers were obtained for the provision of hospitals in the Metropolis by combinations of boards of guardians. Urgent letters were written pressing the boards of guardians to embark on the expenditure required to enable them to provide efficiently for the sick paupers. From 1865 onward, we see the Central Authority, on the public-spirited initiative of Mr. W. Rathbone and the Liverpool Select Vestry, pressing on the boards of guardians the employment of salaried and qualified nurses to attend to the sick paupers, whatever their complaints. We have even in 1867, so far as the sick are concerned, the explicit disavowal by the Central Authority of the very idea of the deterrent workhouse, which had formed so prominent a part of the policy of 1834-1847. Mr. Gathorne Hardy, speaking as President of the Poor Law Board, said “there is one thing … which we must peremptorily insist on, namely, the treatment of the sick in the infirmaries being conducted on an entirely separate system, because the evils complained of have mainly arisen from the workhouse management-which must to a great degree be of a deterrent character-having been applied to the sick, who are not proper objects for such a system.”
At first the new policy of the Central Authority for the institutional treatment of the sick took the form of the erection of special hospitals by “Sick Asylum Districts.” Presently, however, it came to the conclusion that this involved an unnecessary expense, and that it would be cheaper to revert to the idea of the Report of 1834, and use the existing workhouse buildings by a system of classification by institutions. So definitely was this recognised as a reversion to 1834 that the Central Authority actually quoted the passage of the 1834 Report in justification of its plan. From this point may be dated the adoption of the policy of the provision, in connection with the workhouse, but practically as a separate institution, of what is now called the Poor Law Infirmary. In 1870 the Central Authority took pains to collect special statistics as to the extent to which this recently developed provision for the sick was being taken advantage of. It observes (and, significantly enough, without expression of disapproval) that “the numbers on the lists of relieving officers may be swollen by poor persons who in previous years, though really poor, refrained from coming on the rates, but whom changes in the law or in the mode of its administration have since attracted.” “Workhouses,” it notes, “originally designed mainly as a test for the able-bodied, have, especially in the large towns, been of necessity gradually transformed in to infirmaries for the sick. The higher standard for hospital accommodation has had a material effect upon the expenditure. So again it has been considered necessary to attach to workhouses separate fever wards; and wherever it was possible, these wards have been isolated by the erection of a separate building.” The extent to which the Poor Law had become the public doctor was indeed remarkable. The number of persons on outdoor relief who were “actually sick,” apart from mere old age infirmity, and without their families, was found to be 13 per cent of the whole, equal to about 119,000. The number in the workhouses who were “actually sick,” irrespective of “the vast number of old people disabled by old age, but not actually upon the sick list,” varied in different unions from 14 to 39 per cent in the provinces, and up to nearly 50 per cent in some Metropolitan Unions; amounting, for the whole country, to about 60,000 actual sick-bed cases. Taking indoor and outdoor patients together, the total simultaneously under medical treatment in the twelfth week of the half-year ending Lady Day 1870, was estimated at 173,000, being three quarters of one per cent of the population, and perhaps one out of four of all the persons under medical treatment in the whole population. The story from this date is one continuous record, on the one hand of an ever-increasing number of patients treated, and, on the other, of never slackening pressure by the Central Authority to induce apathetic or parsimonious boards of guardians to expend money in making both the outdoor medical service and the workhouse infirmaries as efficient and as well adapted and as well equipped for the alleviation and cure of their patients-without the least notion of “the principle of less eligibility”-as the most scientifically efficient hospitals and State medical service in any part of the world. After 1867, indeed, there was developed, for the Metropolitan paupers suffering from infectious diseases, the splendid hospital system of the Metropolitan Asylums Board. At the very end of the existence of the Poor Law Board, Mr. Goschen seems almost to have been contemplating a yet further extension. “The economical and social advantages,” he observed, “of free medicine to the poorer classes generally as distinguished from actual paupers, and perfect accessibility to medical advice at all times under thorough organisation, may be considered as so important in themselves as to render it necessary to weigh with the greatest care all the reasons which may be adduced in their favour.”
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