«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
Although the study did not set out to consider conflict with the guardians and charges of negligence as major components, they have been dealt with in detail as they arose directly from the working conditions of the medical officers and had a bearing on standards of care. As John Stewart and Steve King point out, a ‘war of attrition’ between guardians and medical officers would hardly be conducive to effective patient care.7 In addition, Kim Price considers the frequency of occurrence of charges of negligence to be some measure of the quality of medical practice.8 Nevertheless, many of the instances recorded in this study were not brought about by the practice of poor standards of patient treatment, although complaints by patients could be the stimulus for investigation. More often, it was the guardians’ need to exert control over medical relief that led to strained relationships. Despite this, many poor law patients in the nineteenth century benefited from the administrations of their medical attendants, the extent depending on how conscientious and caring an individual doctor was rather than his relationship with the guardians. This conclusion is in agreement J. Stewart and S. King, ‘Death in Llantrisant: Henry Williams and the New Poor Law in Wales’, Rural History, 15 (2004), p.81.
K. Price, ‘The Shape of the Iceberg’, in J. Reinarz and R. Wynter (eds), Complaints, Controversies and Grievances in Medicine, London, 2014, pp.129-46.
with Price’s claim that the quality of care in workhouse infirmaries can be judged almost entirely by the standards of their medical officers.9 That is not to say that nursing care was unimportant, but it was less patient-centred in the early years of the NPL, when even paid nurses carried out more household tasks than they gave personal attention to patients. Wolverhampton workhouse relied heavily on pauper nursing throughout the nineteenth century and the guardians were reluctant to take any steps that would require the employment of more paid staff.
Although Birmingham employed a greater proportion of remunerated nurses, the differentiation between them and pauper nurses was indistinct in the early years of the NPL, as inmates were taken on as paid nurses. This study confirms the high turnover of nursing staff previously reported, but could not identify a major cause for the frequent resignations. However, the heavy workload and harsh conditions may have led to many nurses resigning without wishing to disclose their reasons. Once training was introduced and it became more formalised toward the end of the century, standards of nursing care improved in terms of attitude to patient management, rather than the acquisition of specific nursing skills. One disadvantage of the nursing reforms was to drive men away from general nursing in workhouses and diminish their role within the developing nursing profession. General nursing standards were less than acceptable in workhouses such as Wolverhampton that relied on pauper assistance to supplement a few paid nurses. Whereas, even in the early days of the NPL, standards in Birmingham workhouse appeared to be similar to those in the voluntary hospitals and nursing staff moved between the two types of institution.
K. P. Price, ‘A regional, quantitative and qualitative study of the employment, disciplining and discharging of workhouse medical officers of the New Poor Law throughout nineteenth-century England and Wales’, (unpublished PhD thesis, Oxford Brookes University), 2008, p.336.
One of the objectives of the study was to ascertain by what point in the nineteenth century that Birmingham and Wolverhampton workhouses had become significant medical spaces. There is a consensus that an extensive system of poor law health care had developed in provincial England by the end of the nineteenth century.10 However, the point before then at which the workhouse became more medicalised and care improved is in dispute. Improvements occurred in the early 1870s as a result of the Metropolitan Poor Act, with better accommodation resulting from the erection of many new buildings and a higher standard of care in the new infirmaries separated geographically from the workhouse.11 However, Price maintains that the crusade against outdoor relief extended the less-eligibility principal to medical care in the workhouse and put pressure on guardians to cut costs. The result was lower care standards, brought about in part by the reduction in medical staffing.12 However, the crusade had no detrimental effect on the number of medical officers in either Birmingham or Wolverhampton, indeed they were increased in the mid-1870s in the former’s workhouse. The impact of the crusade waned and poor law infirmaries were providing sufficiently high standards of care to attract non-pauper patients by the early 1890s. They had also narrowed the gap between themselves and voluntary hospitals by this time.13 In this regard, Wolverhampton workhouse lagged behind the general picture, as standards did not improve substantially, including the appointment S. Fowler, Workhouse: The People, The Places, The Life Behind Doors, Richmond, 2007, p.164; A.
Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720Cambridge, 1994, p.247; D. R. Green, ‘Medical Relief and the New Poor Law in London’, in O.
P. Grell, A. Cunningham and R. Jütte (eds), Health Care and Poor Relief in 18th and 19th Century Northern Europe, Aldershot, 2002, p.240; A. Crowther, ‘Health Care and Poor Relief in Provincial England’, in O. P. Grell, A. Cunningham and R. Jütte (eds), Health Care and Poor Relief in 18th and 19th Century Northern Europe, Aldershot, 2002, p.207; S. King, ‘Poverty, Medicine and the Workhouse in the Eighteenth and Nineteenth Centuries’, in J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013, p.237.
K. Morrison, The Workhouse: A Study of Poor-Law Buildings in England, Swindon, 1999, p.116; R.
G. Hodgkinson, The Origins of the National Health Service: the Medical Services of the New Poor Law 1834-71, London, 1967, p.685; Fowler, p.164, Green, ‘Medical Relief and the New Poor Law’, p.240.
Price, ‘Regional, quantitative and qualitative study’, pp.109-10, 339.
Digby, p.247; Fowler, p.144.
of a resident medical officer, until the move to the new workhouse in the first decade of the twentieth century. This delay is surprising, as the guardians had accepted the responsibility of providing for sick paupers as early as the mid-1840s.
In contrast, medicalisation of the workhouse had taken place in Birmingham well before the NPL and standards of care did not diminish until the reductions in medical and nurse staffing in the 1850s. However, a gradual improvement commenced later that decade, reaching satisfactory levels 20 years later, so that by the 1890s, the infirmary was functioning similarly to a voluntary hospital. However, it is ironic that from that time, care deteriorated for patients who remained in the workhouse and remained so at least until the outbreak of war in 1914. The experience of Birmingham demonstrates that conditions could vary over time within a single institution and not necessarily for the better. Birmingham’s variability contradicts the typical narrative of the poor law medical service as one of steady progress toward the establishment of the National Health Service. The comparison between Birmingham and Wolverhampton demonstrates how poor law medical provision could be very different in two industrial towns situated only 15 miles apart. This example emphasises that caution is needed in generalising with regard to standards of care and in interpreting regional comparisons.
This analysis of the quality of care delivered in the two workhouses in the west midlands contributes to the debate over whether it was better or worse under the NPL than before. Proponents of the OPL point to a well-established medical service by the eighteenth century, with the arrangement of medical treatment an essential part of overseers’ duties.14 The quality of care was considered reasonable at worst and impressive at best and the authorities’ approach to medical provision sympathetic and generous.15 Michael Flinn takes the contrary view that, under the OPL, there was only a rudimentary medical service for the poor.16 The positive viewpoint is based on the range of outdoor medical relief provided by parishes and a standard of care that
underestimates the role of the workhouse, which Anne Crowther suggests was hardly ever used as ‘a centre for the sick’.18 The unimportance of this function of the workhouse has been challenged by Kevin Siena with regard to London. He asserts that workhouses in the capital provided a significant level of institutional health care by the early eighteenth century.19 He cites St Margaret’s workhouse in London, which increased its provision of sick rooms substantially within two years of its erection in 1725.20 He is supported in this view by Jeremy Boulton, Romola Davenport and Leonard Schwarz, who estimated that around 20% of inmates in St Martin’s in the Fields workhouse were sick in 1817-18. However, London’s response to the poor laws was different from that in the provinces, with its greater reliance on institutional care. Furthermore, the development of the majority of its workhouses occurred in the eighteenth rather than the nineteenth century.21 The situation outside the metropolis remains uncertain, but the proportion of sick inmates (17%) in the J. Lane, A Social History of Medicine, London, 2001, p.54; K. P. Siena, Venereal Disease, Hospitals and the Urban Poor: London’s “Foul Wards”, 1600-1800, Rochester, 2004; E. G. Thomas, ‘The Old Poor Law and Medicine’, Medical History, 24 (1980), p.1.
Digby, p.230; Thomas, p.3; I. Loudon, ‘The Nature of Provincial Medical Practice in Eighteenthcentury England’, Medical History, 29 (1985), p.27.
M. W. Flinn, ‘Medical Services under the New Poor Law’, in D. Fraser (ed.), The New Poor Law in the Nineteenth Century, London, 1976.
Digby, p.230; Loudon, p.27.
Siena, Venereal Disease, pp.136, 178.
K. Siena, ‘Contagion, Exclusion and the Unique Medical World of the Eighteenth-Century Workhouse’, in J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013.
D. R. Green, ‘Icons of the New System: Workhouse Construction and Relief Practices in London under the Old and New Poor Law’ The London Journal, 34 (2009), pp.265-68.
urban workhouse in Birmingham in the third quarter of 1818 equates its medical role with that of London workhouses.22 Thus Birmingham had a well-developed poor law institution, providing as good a quality of medical services as could be expected in the early the nineteenth century, with one resident and several visiting surgeons, plus paid nurses.
Historians who suggest that medical attention improved immediately after the NPL do so on the basis of studies of workhouse care, as there is no doubt that outdoor medical relief was restricted in the range and possibly the standard of care.23 The crusade against outdoor relief in the early 1970s lowered standards of assistance for outdoor paupers further.24 Irvine Loudon is not in agreement with this position, concluding that medical care under the NPL was inadequate due to low financial incentives for doctors, understaffing with surgeons and the stigma of pauperism, but his study is mainly concerned with outdoor relief.25 However, it is in accord with the general opinion that standards of medical services deteriorated in the majority of unions in the early years after the NPL.26 Thus, Birmingham guardians would have been exceptional in continuing to provide the same standard of care as under the OPL for more than a decade into the NPL. The decline did not occur in Birmingham until the PLB issued rules, orders and regulations for the government of the workhouse in January 1850, resulting in a reduction in the number of medical and nursing staff. In Wolverhampton, the low medical and nursing levels from the establishment of the Birmingham Central Library, Birmingham Board of Guardians, GP/B/2/1/2, 27 October 1818, 19 January, 1819; no information is available for Wolverhampton workhouse under the OPL.
Hodgkinson, p.64; N. Longmate, The Workhouse, London, 1974; D. Fraser, ‘The English Poor Laws and the Origins of the British Welfare State’, in W. J. Mommsen (ed.), The Emergence of the Welfare State in Britain and Germany, 1850-1950, London, 1981, pp.14-18.
Digby, p.244; Price, ‘A regional, quantitative and qualitative study’, p.339.
I. Loudon, Medical Care and the General Practitioner 1750-1850, Oxford, 1986, p.244.
Fowler, p.151; Digby, p.244; S. King, ‘Poverty, Medicine and the Workhouse’, p.237.
union suggest that care did not meet satisfactory standards until near the end of the century. Furthermore, the fact they remained unchanged throughout the nineteenth century in the face of increasing patient numbers meant there was a steady deterioration in the provision of care. The findings from this study again caution against generalisation and suggest that the variation in quality of care at different periods of time were not invariably influenced by national events or central authority diktat. Whether Birmingham and Wolverhampton were similar to other towns or exceptional requires further local studies.