- Friday, 11 July 2008
- Written by Kate Smart
Before the establishment of the NHS in 1948, the provision of health care was inextricably bound up with religion and controlling the poor. What is clear is that capitalism has never been able to provide health care for working people and they have been forced to rely on charity and philanthropy.
Role of religion
Much of the early care for people who were ill was provided by religious communities where care was provided by monks and nuns attached to monasteries. Some were independent and had their own endowments, usually of property, which provided income for their support. Most hospitals were founded for specific purposes such as leper hospitals, or as refuges for the poor and it was not until later did hospitals become multi-functional. Not all hospitals cared for the sick and there were establishments to house the dying or infirm but the purpose was not cure or even care but to keep the ill poor off the streets.
The Poor Laws
The 1601 Poor Law created a national system for relief, paid for by levying local rates or property taxes. It was essentially to force the poor to work, including children as apprentices, and provide limited relief for those too ill or old to work, the so called ‘impotent poor’. Some older people were accommodated in parish almshouses, though these were usually private charitable institutions. Almshouses were religious institutions in existence from the 10th century - in the middle ages the majority of hospitals functioned as almshouses. For the landowners, poor relief provided a way of controlling the 'lower orders' and reinforced a sense of social hierarchy.
The 1834 Poor Law Amendment Act introduced sick wards in parish workhouses. Although intended for the people in the workhouses, the wards soon became full with sick poor people from the parish in general, prompting the state to assess how best this situation could be dealt with. In 1854 there was a report of a Select Committee on Medical Poor Relief and while much of the evidence given to the Committee favoured extending the medical services of the Poor Law to a much larger section of the population - through schemes such as free dispensaries - this was ignored and the care of ill people was left to a few philanthropists to provide. It was not until 1929 that hospitals were finally transferred from the Poor Law to local authority committees.
The early hospitals
It was not until the eighteenth century that the modern hospital began to appear, staffed with physicians and surgeons. Nine hospitals were established throughout the country but the word 'hospital' was also used for institutions concerned with people and their families who were poor or destitute, as part of the Poor Law provisions. In London, for example, the only medical hospitals in the 1700s were the Royal Hospitals of St Bartholomew and St Thomas. There were other hospitals for special categories, such as Greenwich for injured sailors and refugees, the Magdalen Hospital founded to rescue ‘penitent prostitutes’ and the Marine Society for Educating Poor Destitute Boys. Between 1719 and 1750 five new general hospitals were founded in London and one of these was Guy’s Hospital, founded in 1724, from a bequest by a wealthy merchant Thomas Guy. Guy was a stock speculator investing in government securities, including £42,000 worth of shares in Britain's official slave-trade organisation, the South Sea Company. He amassed a large fortune but was well known for paying his workers a pittance.
19th century medical care
Medical care was principally private or voluntary and people had to pay for anything they needed. Medical care tended to deal mainly with serious illnesses. Local authorities of large towns provided municipal hospitals, maternity hospitals, hospitals for infectious diseases like smallpox and tuberculosis, as well as hospitals for the elderly. However, due to the social upheaval caused by industrial revolution, there was a large growth in unemployment and poverty. Sickness became a primary cause of poverty so the Poor Law authorities were forced to develop 'infirmaries' for sick people. Although initially resisted by the state, the number of infirmaries grew very rapidly. At first, in order to access an infirmary a person had to be a pauper. However, if a person was classified as a pauper then they were also unable to vote. It was not until 1885 that the law which required people to be paupers to use the infirmaries was abolished.
There were a few philanthropists and social reformers who tried to provide free medical care for the poor. In 1828, William Marsden, a young surgeon, opened a dispensary for advice and medicines - the 'London General Institution for the Gratuitous Cure of Malignant Diseases'. This four-storey house in one of the poorest parts of the city was conceived as a hospital, to which the only passport should be poverty and disease. Treatment was provided free of charge to any destitute or sick person who asked for it - the demand for his free services was overwhelming. By 1844 his premises, now called the Royal Free Hospital, was treating 30,000 patients a year. Despite consultant medical staff giving their services free of charge, they had to rely on money from legacies, donations, subscriptions and fund-raising events. However, in 1920 it was on the brink of bankruptcy and so forced to ask patients to pay towards their treatment, just like every other voluntary hospital in the country.
Mentally ill people and those with learning disabilities were treated even worse than the poor. They were locked away in large forbidding institutions, not usually for their own benefit, but to keep them out of society. The ruling class was happy to foster the view, especially in the 17th century, that if mad people behaved like animals they should be treated like animals. The Bethlem Royal Hospital (also known as Bedlam) was the world's oldest psychiatric hospital, established in 1330. Conditions were consistently barbaric and the care amounted to little more than restraint - violent or dangerous patients were manacled and chained to the floor or wall and it became infamous for the brutal ill-treatment given to ‘inmates’. In 1675 it moved to new buildings outside London’s city boundary and by the 18th century people used to go there to watch ‘the lunatics’. Entry was free on the first Tuesday of the month and for a penny a person could peer into their cells, view the "show of Bethlehem" and laugh at their behaviour, often of a sexual nature or violent fights. Visitors were permitted to bring long sticks with which to poke and enrage those incarcerated there and in one year alone (1814) there were 96,000 visits. Conditions in institutions like Bedlam were so bad that many patients became worse, not better.
In 1773 a Bill passed the Commons to regulate private ‘madhouses’ but it was thrown out by the Lords. The following year it became essential to produce a medical certificate confirming insanity before rich people could be locked away. For the wealthy there was also the alternative of being an individual private patient of a doctor or clergyman. However, the rights of poor people were totally disregarded and as they were not a useful commodity to the industrialists, they did not want their healthy workers wasting time caring for their family members who might be mentally ill.
The first attempt to regulate what we now know as GPs was through the 1815 Apothecaries Act. Apothecary was the also offered general medical advice and a range of services including minor surgery and midwifery. The Act introduced a compulsory apprenticeship and a formal qualification and required individuals to have instruction in a range of subjects including anatomy, botany, chemistry and physics - in addition to six months' practical hospital experience. It also gave the Society of Apothecaries the right to examine and license apothecaries. Soon a licence from the Society became the commonest qualification among GPs, although by 1840 it was estimated that only about a third of those practising medicine were qualified by examination. They sold medicines to surgeons, physicians as well as patients but for the working class the cost of treatment and care was often out of their reach. In addition to medicines they would also sell tobacco! historical name for a medical person who formulated and dispensed drugs but they
Beginnings of a welfare state?
It was not until the 1911 National Insurance Act that basic medical cover for the working population was given. Access to a doctor was free to (male) workers who earned less than £2 a week but this didn't necessarily cover their wives or children, nor did it cover other workers or those with a better standard of living. Hospitals charged for services, though sometimes poorer people would be reimbursed. Even so, it meant paying for the service in the first place, which most could not afford. The need for free health care was becoming widely recognised but the capitalists were not prepared to support it.
Throughout history, health services and the medical profession have been used as a means of social control. Whether it’s forced sterilisation of whole sections of the population or as a gatekeeper to services and benefits, the medical profession has always acted to support the interests of the capitalist class.