The Central Authority was willing to consider any proposal to amend the law, so as to allow of the compulsory removal to the workhouse of sick persons who had no proper lodging accommodation.[669] But even to a person who had refused to enter the workhouse, the guardians were not to deny outdoor medical relief if sick,[670] and in no case were the sick to be removed from their homes unless certified by the medical officer as physically able to endure the journey.[671] There was thus, even between 1871 and 1885, no explicit reversal, on grounds of Poor Law principle, of the old policy which, it will be remembered, had not been condemned by the 1834 Report of outdoor relief to the sick. If a "destitute young husband or wife were sick," Mr. Sclater-Booth, speaking as President of the Local Government Board, told the House of Commons in 1876, "they would not be taken into the workhouse, but would receive outdoor relief."[672] Two years later the Central Authority actually declared itself in favour of supplying to the sick poor who were under domiciliary treatment, not only medical attendance and maintenance, but also skilled professional nursing. There was, it said in reply to influential medical pressure, "nothing to prevent the guardians supplying such assistance," and the Central Authority was even "desirous of encouraging this arrangement as much as possible," though the insufficient supply of qualified nurses was likely to "render impracticable for some time to come any general application of the system of paid nurses in the treatment of the poor at their own homes."[673]
Meanwhile, however, the substitution of indoor for outdoor relief in the case of the sick[674] was being supported on grounds, not of Poor Law principle, but of medical efficiency. The transformation of the workhouses into what the Poor Law inspectors themselves began to call "State hospitals" made more striking than ever the contrast between the light, clean, and airy newly-built infirmary ward, with trained nurses, a resident doctor, complete equipment, and a scientifically determined dietary, on the one hand; and the insanitary and overcrowded hovel or slum tenement, on the other, in which the sick pauper had no other food than was provided by the pittance of outdoor relief, no further nursing than his family could supply, and no better medical attendance than the grudgingly accorded order on the district medical officer could command. Quite irrespective of "Poor Law principles," the case for institutional rather than domiciliary treatment of nearly every sick case became, to the medical experts who now advised the Central Authority, simply overwhelming. "The treatment which in sickness the poor receive in workhouses constitutes," said the Central Authority in 1878, "one of the most valuable forms of medical relief. With a considerable portion of the population, indeed, it is the only mode in which, when overtaken by sickness, their medical needs can be adequately met."[675] This policy led not only to an incessant pressure on boards of guardians to provide the "State hospitals" which had, from 1865 onwards, been expected from the guardians of all populous unions,[676] but also to a positive encouragement of sick persons, whether or not actually destitute in the technical sense of the term, to take advantage of them. We see this first with regard to infectious diseases. The hospitals of the Metropolitan Asylums Board, maintained out of the Poor Rate exclusively for paupers, and technically only workhouses like any others, soon came to be used, free of charge, by smallpox and fever patients who were not paupers.[677] It became the official policy, well understood by the Central Authority, to get removed to these Poor Law institutions every patient, whether destitute or not, who could not be adequately isolated at home.[678] Already in 1875 the Central Authority expressly authorised the medical superintendent to admit without an order any smallpox or fever patient presenting himself, if refusal to admit might involve danger,[679] and in 1887 it expressly permitted even non-urgent cases to be admitted on the certificate of any medical practitioner.[680] Nevertheless, in 1877 the Central Authority was still taking the line that "the hospitals ... of ... the Metropolitan Asylums Board are essentially intended to meet the requirements of the destitute class, and that the admission ... of persons not in need of poor relief is altogether exceptional."[681] Two years later, however, by a statute promoted by the Central Authority itself, the Metropolitan Asylums Board were expressly empowered to receive non-pauper patients, though only under contracts with the local public health authorities, by which they were to be paid for.[682] We cannot discover which vestries and district boards, if any, entered into such contracts. Not until 1883, when these fever and smallpox hospitals had been a dozen years in use by non-paupers, was the position temporarily legalised by the Diseases Prevention Act of 1883[683]—a measure also carried by the Central Authority itself—which, whilst leaving these hospitals as Poor Law institutions, administered by a Poor Law authority, and kept up out of the poor rate, declared that admission, treatment, and maintenance therein should—whether the patients were or were not otherwise paupers—not be deemed parochial relief, or carry with it any disqualification whatever.[684] Since that day we have the remarkable spectacle of the Poor Law Authorities, Central and Local, annually congratulating themselves on the fact that, year after year, they were managing to attract into these expensive Poor Law institutions, for gratuitous maintenance and treatment, a larger and larger percentage of the total number of cases notified.[685]
A similar enlargement of the sphere of the Poor Law institution has, of late years, been going on in other than infectious cases. "The poorer classes generally," to use Mr. Goschen's words, "as distinguished from actual paupers," came more and more to appreciate the practical distinction between the workhouse and the Poor Law infirmary; and, especially in the Metropolis and the large towns, the latter became more and more freely used as a general hospital.[686] This tendency was facilitated in London by the operation of the Metropolitan Common Poor Fund established by the Central Authority itself, which, from 1870 onward, bore the bulk of the cost of maintenance of the Poor Law infirmaries, as of the hospitals of the Metropolitan Asylums Board.[687] The Central Authority saw with approval the increasing attractiveness of these institutions, not only in London but throughout the country. In an official memorandum communicated to all boards of guardians in 1892, it observed that: "The sick poor can usually be better tended and nursed by skilled nurses in well-equipped sick wards than in their own homes; and the regularity, neatness, and order of the wards tend to diminish the repugnance to entering the workhouse, which is often evinced by the sick poor of the better class when reduced to want by failing health."[688] It did not refuse to permit them to be made use of by paying patients, where—as is usually the case in rural districts—no "non-pauper institution" was available. "If," writes the Central Authority in 1902, there is "a sick person who is in receipt of an allowance from a benefit club or similar society," and who "is unable to obtain in a non-pauper institution such treatment as the illness from which he suffers requires," the Central Authority will "offer no objection to his admission to the workhouse infirmary."[689]
To those boards of guardians who clung to the policy of "deterring" the sick poor from obtaining medical relief—which, as we have shown, Mr. Gathorne Hardy had, on behalf of the Central Authority, in 1867 expressly repudiated[690]—all this official encouragement to enter Poor Law institutions seemed revolutionary. The fact that the sick poor came more and more to draw a distinction between the workhouse on the one hand, and the Poor Law infirmary or isolation hospital on the other, appeared seriously objectionable. When it was noticed that the Central Authority officially styled the separate institution for the sick "an asylum for the sick poor,"[691] or "the hospital," or simply the "infirmary,"[692] the Manchester guardians revolted, and definitely instructed their medical and relieving officers "to avoid using the word 'hospital' or 'infirmary,' and simply to use the word 'workhouse.'"[693] Other boards, we believe, insisted—although "the infirmary" was an entirely distinct institution—that it should be entered only through the workhouse itself. Against this lingering objection on grounds of Poor Law policy to get the sick cured in the most efficient way, we see the inspectorate in the later years more and more explicitly protesting. "I wish it were possible," said Mr. Preston-Thomas in 1899, "to get rid of the name of workhouse (which, by the way, has become singularly inappropriate), for I believe that it is to the associations of the name rather than to the institution itself that prejudice attaches. The disinclination of the independent poor to enter the hospitals of the Metropolitan Asylums Board, which was considerable at first, has now practically vanished, and I do not see why there should not be the same change of feeling with regard to Poor Law infirmaries in the country."[694]
In the same spirit we see the Central Authority in these three decades persistently pressing Boards of Guardians to build new workhouse infirmaries.[695] The report becomes current in the Poor Law world that Local Government Board officers, in interviews, went so far as to say that a certain board of guardians was morally guilty of manslaughter in refusing to embark on extensive new building operations. The official architect's criticisms on the Poor Law infirmary plans submitted to him are all on the lines of making these into up-to-date general hospitals. The proposals sanctioned by the Central Authority go up to a capital outlay of £350 per bed. The Central Authority even sanctions special hospitals established by the guardians at the expense of the poor rate, for particular classes of patients, such as the "West Derby, Liverpool and Toxteth Park Hospital, ... for the reception of persons suffering from tuberculosis," many of whom are so little destitute that they pay the cost of their treatment and maintenance;[696] or, as at Croydon, Kingston, and Richmond, "for the reception of epileptic and feeble-minded persons," who cannot be certified as of unsound mind.[697] Persons in receipt of medical relief only are no longer disqualified as paupers from being registered as Parliamentary and Municipal electors, and it has even been held that admission to a Poor Law hospital, sick asylum, or infirmary because of ill-health, and for the purpose of being medically treated, amounts to medical relief only, even though it incidentally involves also maintenance at the expense of the poor rate.[698] By 1903 we have the Central Authority laying it down in general terms, "that it is the guardians' duty to provide for their sick poor, and no sanction ... is necessary to sending such cases to institutions for curative treatment ... and ... paying reasonable expenses involved in so doing."[699] The Central Authority seems, indeed, to exhaust official ingenuity in securing the best possible treatment and also the comfort of the patients in the sick wards.[700] Any reasonable fee may be paid for calling in consultants whenever the medical officer thinks it "necessary or desirable," without any special sanction being requisite.[701] We need not recite the constant struggle to get more nurses and better. As early as 1879 a president could (perhaps with some ministerial optimism) declare that: "in the new infirmaries I have succeeded in abolishing pauper help almost entirely."[702]
The guardians are reminded that the epileptics are especially to be incessantly accompanied by trained nurses, lest they should be suffocated in their fits.[703] The sick men in the workhouse may be allowed tobacco and snuff, the sick women tea, in addition to that prescribed in the dietary table.[704] The doctor is expressly reminded that it is his duty to "order such food as he may consider requisite." [705] When a complaint was made that beer was supplied in a Norfolk workhouse, the Central Authority refused to interfere with a "beer allowance" to sick paupers, given and renewed from week to week by direction of the medical officer.[706] The guardians are even reminded of the importance of providing illustrated books and newspapers for the sick.[707]
Meanwhile the standard of equipment, of resident medical attendance, and especially of trained nursing[708] required by the Central Authority in the Poor Law institutions is constantly rising, in correspondence with the progress of hospital science. We see all this reflected in the advice and criticisms pressed by the inspectorate on the boards of guardians. "The workhouses of a past and bygone age," says Mr. Hervey in 1903, "are no longer refuges for able-bodied, but are becoming every day more of the nature of State hospitals for the aged, sick, and infirm. As such, they should be furnished with the very best nursing procurable."[709]
(iii.) The Municipal Medical Service
It may be that it is on the Public Health side, which was in 1871 added to the Poor Law work of the Central Authority, that we may trace the influence of the suggestion that was under discussion at the Poor Law Board under Mr. Goschen's presidency, just prior to its merging in the Local Government Board. The idea 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"—which the new permanent secretary, Sir John Lambert, may have brought back from his official visit to Ireland—finds a certain expression in the Public Health Act of 1872, re-enacted with additions in 1875, which created "one local authority for all public health purposes in every place, so that no area should be without such an authority, or have more than one." In the rural districts the board of guardians became this authority. As such they came under a series of responsibilities based upon ideas diametrically opposed to those of the Poor Law. Instead of confining their action to actual applicants for help, they had to search out cases of nuisance or dangerous disease. Instead of restricting their administration to those who were willing and anxious for it, they were charged with compelling to be done all that was required. Instead of being limited in purview to a small class specially stigmatised as paupers, the guardians had to consider the whole population as needing their attention without distinction of class or subjection to stigma. They were expressly authorised, not merely to repress nuisances, but to provide hospitals "for the use of the inhabitants," without any limitation to infectious or any other diseases.[710] They were even empowered, with the consent of the Central Authority, to "provide or contract with any person to provide a temporary supply of medicine and medical assistance for the poorer inhabitants of their district."[711] The Central Authority eagerly pressed on the local authorities the policy of the new Act.[712] We see the Poor Law inspectors—who were "in possession of the views of the (Local Government) Board on the subject"—explaining to boards of guardians in unions having rural districts their new duties; the future work of their new Public Health staff of medical officer of health and sanitary inspectors; and their responsibility for maintaining and improving the health, not of paupers only, but of the whole community.[713] We are not here concerned with the progress of public health administration, in which the boards of guardians cannot be said to have been apt or willing disciples. It is not to the boards of guardians, in 1907 still the sanitary authorities in non-urban districts, that we owe the elaborate medical organisation of an up-to-date Public Health Department, with its peripatetic health visitors and diagnosing doctors, its milk depots and campaign against infantile mortality, its gratuitous supply of anti-toxins and diarrhœa medicine, its gratuitous hospitals and sanatoria no longer confined to smallpox and fever. We need only notice here the gradual appreciation, by the Central Authority and the Poor Law inspectors, of the intimate connection between shortcomings in the public health service and an excess of pauperism. Even from the narrowest standpoint of Poor Law principles, the causal connection between disease and pauperism could no longer be ignored. "The effect of bad house accommodation on the health of the poor," writes Mr. Bagenal in 1902, "has often been demonstrated by experts in public health. Not only are serious illnesses more frequent, but damp and draughty dwellings lower vitality to such an extent that the bodily vigour and activity, as well as the spirits, are affected, and the system becomes unable to withstand actual disease. Families are often pauperised on account of sickness produced by living in unhealthy conditions. Labourers also often become permanently disabled, and fall upon the rates, owing to premature old age brought on by insanitary houses. To prevent sickness and to prolong the working term of a labourer's life must be a gain to the ratepayers, as well as to all classes of the community."[714] To take only one specific instance, in the Redruth Union the reason for a high average of pauperism in 1906 was found in the large amount of destitution produced by "miner's phthisis," and the great number of widows and orphans which it caused, "the total number of persons pauperised owing to this special cause being ... 333," besides other cases of infirmity of the miners themselves. "A substantial proportion of the excessive pauperism in the Redruth Union is thus accounted for."[715]