«MEDICAL CARE IN THE WORKHOUSES IN BIRMINGHAM AND WOLVERHAMPTON, 1834-1914 by ALISTAIR EDWARD SUTHERLAND RITCH A thesis submitted to the University of ...»
1867. By the 1840s, a movement for workhouse reform developed, stimulated by reports of insanitary and overcrowded conditions and scandals involving the deaths of paupers. The Lancet commissioned workhouse surveys and one of its commissioners, Dr Ernest Hart, outlined the reformers’ demands in an article which he entitled The Condition of Our State Hospitals, a term he used to describe the infirmaries of the workhouse.93 The resultant MPA established, in London, separate asylums for lunatics and imbeciles, institutions for isolation of those with infectious diseases and dispensaries for outdoor medical relief. Thus, a system of medical care, with both inpatient and outpatient facilities, was instigated. It recommended resident medical officers with one to every 150 patients. The result was that, by 1888, there was hardly one union in the capital without a separate infirmary.94 The act represented an explicit
common fund was established to pool the poor law levies and all parishes and unions were combined into one district, the Metropolitan Asylum District, under the control of one board. The result was a centralised hospital system and the President of the Poor Law Board (hereafter PLB) had, in effect, signed ‘the birth certificate of England’s first regional hospital board’.96 The inauguration of state hospital services for the poor in London represented, in Gwendoline Ayer’s view, ‘a significant step Ibid., p.171.
E. Hart, ‘The Condition of our State Hospitals’, Fortnightly Review, III (1885), p.218.
G. M. Ayers, England’s First State Hospitals and the Metropolitan Asylums Board, London, 1971, p.17.
towards socialisation of medical care in this country’, and Frederick Cartwright was of the opinion that it was ‘the first step towards a National Health Service’.97 From this time, demands began to arise for the state to intervene directly in health care and take responsibility for social and economic conditions of the population with the result that appropriate government measures steadily increased.98 In the same year, the principles of the act were extended to the whole country, so beginning the process of taking hospitals out of workhouses and firmly establishing the hospital branch of the poor law. These separate infirmaries began to be selective in admitting only those with acute illness, leaving the workhouses to accept the remainder, who were predominantly the chronic sick. Hodgkinson considers this differentiation between
development of poor law medical care as the ‘greatest success of the workhouse’.100 Nevertheless, as Alysa Levene has pointed out, the state of affairs by the time of the Local Government Act in 1929 was a ‘patchwork of local provision and uneven services in medical care for the poor’.101 The NPL made no recommendations for a medical service and the PLCs never envisaged that acute illness would be a reason for admission. However, medical relief became an increasingly frequent reason for admission to the workhouse. Sickness has been viewed traditionally as a major cause of poverty by restricting earning power, but more recent insights into the relationship between poverty and sickness have Ibid; F. F. Cartwright, A Social History of Medicine, London, 1977, p.159.
P. Thane, Foundations of the Welfare State, London, 1982, p.vii; C. Webster, The National Health Service, Oxford, 1998, p.2; D. Fraser, The Evolution of the British Welfare State, Basingstoke, 2003, p.148.
Ibid., p.64; Longmate, p.194; Fowler, p.150.
A. Levene, ‘Between Less Eligibility and the NHS: The Changing Place of Poor Law Hospitals in England and Wales, 1929-39’, Twentieth Century British History, 20 (2009), p.323.
shown that the poor were more likely to suffer ill health.102 Sick inmates formed a substantial group within the workhouse population, from 10% in 1847 to 30% in
1867.103 It is likely they remained around this proportion into the early twentieth century as, in 1915, 32% of inmates of poor law institutions were accommodated in sick wards or separate infirmaries.104 Poor law institutions provided 81% of the country’s hospital beds by 1861, so it is not surprising that, ten years later, some workhouses could be described as the ‘first public hospitals’ and those in the larger towns as ‘infirmaries for the sick’.105 This trend has led to claims by some historians that the medical service was the great success of the NPL, on the basis that it improved and widened the range of medical facilities and laid the foundation for the development of the National Health Service in 1948.106 Alternatively, other welfare historians maintain that medical care declined immediately after the implementation of the NPL. Funding was restricted, sick inmates were subjected to the harsh workhouse regime, infirmaries were under-staffed and MOs frequently undermined by guardians over the treatment of patients.107 However, there is more agreement that it did improve in the later part of the nineteenth century.108 Gestrich, Hurren and King (eds), p.24; Tomkins, ‘“Labouring on a bed of sickness”’, p.52. Health inequalities were first reported in the Black Report in 1980 (published in P. Townsend and M.
Davidson (eds), Inequalities in Health, London, 1988) and received more detailed analysis in R. G.
Wilkinson, Unhealthy Societies, London, 1996.
Hodgkinson, pp.147, 467.
Crowther, Workhouse System, p.89.
D. Fraser, Evolution of the British Welfare State, Basingstoke 2003, p.100; Hodgkinson, p.451; D.
Ashforth, ‘The Urban Poor Law’, in Fraser (ed.), The New Poor Law in the Nineteenth Century, p.148.
Hodgkinson, pp.64, 696; Fowler, p.150; Flinn, pp.48-49, 66; I. Loudon, ‘Medical Practitioners 1750-1850 and the period of medical reform in Britain’, in A. Wear (ed.), Medicine in Society, Cambridge, 1992, pp.220, 246; Marland, p.70; Longmate, p.194.
Price, pp.266, 339, 345; Marland, p.93; A. Digby, Making a Medical Living: Doctors and Patients in the English Market for Medicine, 1720-1911, Cambridge, 1994, p.244.
Crowther, Workhouse System, pp.160-62; A. Tomkins, ‘The Excellent Example of the Working Class: Medical Welfare, Contributory Funding and the North Staffordshire Infirmary from 1815’, Social History of Medicine, 21 (2008), p.14; Digby, Pauper Palaces, pp.168-69; Brand, Doctors and the State, p.86.
The PLCs did not initially intend that a test of need should be applied to sick, disabled and older paupers, but their Seventh Annual Report in 1841 did extend the principles of less-eligibility and deterrence to those seeking medical relief and this was given further emphasis in the Longley Report in 1874.109 As a result, paupers admitted to the workhouse because of sickness or disability were subjected to the workhouse test
concession was a special dietary to provide a better standard of nutrition.110 In the late 1860s, the PLB reversed the policy of less-eligibility in relation to the sick, and its president, the Conservative politician, Gathorne Hardy, declared that the deterrent principle was no longer appropriate. Despite this, many provincial unions were slow to implement the change and in Birmingham and Manchester the sick were still subjected to the workhouse test in 1888.111 According to Jeanne Brand, the medical care of paupers remained ‘hedged with a persuasive atmosphere of deterrence’ and Jonathan Reinarz and Leonard Schwarz remind us that workhouses ‘retained both their medical and punitive functions’.112 Medical Care in the Workhouse There has been a lack of research on the nature and role of the medical care offered within urban workhouses; a lack that this study seeks to redress. Furthermore, much of the historiography of workhouse medicine has focussed on specific areas, such as mental illness, contagious disease during epidemics or on specific groups, such as King, Poverty and Welfare, p.29; Hodgkinson, p.60; Williams, p.97.
Webb and Webb, English Poor Law History, pp.319-20; Flinn, p.65; Hodgkinson, p.542; J. Brand, ‘The Parish Doctor’, Bulletin of the History of Medicine, 35 (1961), p.110.
Brand, ‘The Parish Doctor’, p.98; Reinarz and Schwarz, p.4.
those with venereal disease, rather than the full range of physical disease and disability within the institution and its infirmary, as is proposed in this study. Within the historiography of poor law medicine, the emphasis has been on the medical profession and the professionalisation of its MOs to the neglect of local medical practice. The history of Battle Workhouse by Margaret Railton and Marshall Barr is one of the few detailed studies of medical care in a poor law institution, but is basically a developmental account of its transition into a general hospital.113 A regional perspective of poor law medical services is covered in Pickstone’s description of all types of medical institutions in the Manchester region. It deals with the complex interrelationship between the hospitals and their communities and concludes that comparative urban history has much to offer in elucidating the determinants of medical services.114 In a study of Shrewsbury hospital in the eighteenth century, Tomkins demonstrates that paupers who were admitted had a different experience to other patients, in particular a much higher death rate.115 Green has outlined the development of poor law institutions in London and how they served as a basis for the state’s responsibility for the health care of its citizens. Nevertheless, he highlights how medical relief was an important element of poor law policy in the metropolis, with around 15% of inmates classed as sick, compared with just over 10% in the provinces.116 Jeremy Boulton, Romola Davenport and Leonard Schwarz provide a local study of a London workhouse, St Martin in the Fields, concentrating on mortality rates, which were high due to the admission of patients who were very young, very old or in a dying state. However, they include descriptions of individual M. Railton and M. Barr, Battle Workhouse and Hospital 1867-2005, Reading, 2005.
A. Tomkins, ‘Paupers and the Infirmary in Mid-eighteenth-century Shrewsbury’, Medical History, 43 (1999), pp.208-27.
D. 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 pp.226-27, 240.
patients’ experiences of illness.117 Their chapter is included in the most recently published volume on medical aspects of the poor law, Medicine and the Workhouse.118 Although the contributions focus on care within the workhouse, most include consideration of outdoor medical relief because of the close inter-relationship between the two types of relief. Many authors concentrate on distinct groups within the workhouse such as older inmates, patients with venereal disease, children and epileptics. Although considerable new evidence is presented, the volume draws out the need for additional microstudies of workhouses, especially under the NPL.119 Consequently, there is a continuing need for intensive local exploration of the nature of medical practice and the setting in which it took place, in order that new insights and interpretations may lead to a better understanding of the poor law medical service.120 Poor Law Medical Officers The most detailed and extensive review of the medical services of the NPL is The Origins of the National Health Service by Hodgkinson.121 Derek Fraser considers its value has been diminished because the study is so voluminous and remorseless in pursuit of detail and its scope is limited to the early period of the NPL.122 It charts the progress made toward competent nursing and qualified medical personnel and details J. Boulton, R. Davenport and L. Schwarz, ‘“These ANTE-CHAMBERS OF THE GRAVE”?
Mortality, Medicine and the Workhouse in Georgian London, 1725-1824’, in J. Reinarz and L.
Schwarz (eds), Medicine and the Workhouse, Rochester, 2013, pp.58-85.
J. Reinarz and L. Schwarz (eds), Medicine and the Workhouse, Rochester, 2013.
Negrine, ‘Medicine and Poverty’, pp.1-3.
R. G. Hodgkinson, The Origins of the National Health Service: the Medical Services of the New Poor Law 1834-47, London, 1967.
D. Fraser, ‘Biographical Notes’, in D. Fraser, The New Poor Law, pp.197-98.
piecemeal improvements were belatedly achieved. There were increasing pressures for MOs to admit the sick to institutions rather than provide domiciliary care. These included the condition of the person’s home, the degree of family support, the workload of the doctor and whether he could provide adequate drugs out of his meagre salary. One important development by the late 1860s was the establishment of workhouse medical officers (hereafter WMOs), most of whom only had duties in the institution and some of whom were resident. Most workhouses had one MO, though in London it was often two. Guardians also employed the services of visiting physicians and surgeons to attend to the needs of sick inmates. Hodgkinson considers that institutional medical relief was humane by the standards of the time, whereas Kim Price is of the opinion that understaffing resulted in a failure to provide basic care.123 According to Stewart and King, the conflict that existed in many unions between guardians and MOs was unlikely to lead to effective or conscientious medical care.124 What is clear is that the standard of poor law medical care varied greatly throughout the country, although there is some indication that better conditions may have existed in the larger industrial cities.125 In Victorian England, the social status of poor law MOs was low, both within the medical profession, where they were regarded as third-rate practitioners, and the poor law administration, where guardians treated them as servants. The main reasons for this were that they were poorly paid, worked for a state service and treated patients Hodgkinson, p.129; Price, p.237.
Stewart and King, p.81.
Rose, pp.169-71; Crowther, ‘The Later Years’, p.50; Brand, Doctors and the State, p.96.