Mohammed T. Abou-Saleh

Principles and Practice of Geriatric Psychiatry.Editors: Professor John R. M. Copeland, Dr Mohammed T. Abou-Saleh and Professor Dan G. BlazerCopyright & 2002 John Wiley & Sons LtdPrint ISBN 0-471-98197-4 Online ISBN 0-470-84641-0120Development of Health and Social Servicesin the UK in the Twentieth CenturyJohn P. WattisUniversity of Huddersfield, Huddersfield, UKIMPERIAL BEGINNINGS: THE POOR LAW ANDTHE ASYLUMIn Britain, the twentieth century dawned in a blaze of imperialglory. Three years earlier, Queen Victoria’s diamond jubilee hadbeen celebrated across the globe with a splendid procession inLondon itself. The mood of the nation was confident, evenoptimistic, and world-domination was accepted almost as abirthright of the British people. Britain had survived the rigours ofthe Industrial Revolution and had come up fighting. Yet, at thistime, public health measures were rudimentary and confinedlargely to the establishment (in 1848) of sanitary authorities withmedical officers of health to oversee sewers and water supplies.The poor law was still in force and poor law institutions weremade deliberately unpleasant. This followed the principle of‘‘lesser eligibility’’, set out in 1834, which stated that thosereceiving poor law assistance should not be as ‘‘eligible’’ (wellprovided for) as an ‘‘independent labourer of the lowest class’’ 1 .For the poor sick this had been ameliorated, to some extent, bythe setting up of poor law infirmaries in 1868, but there was still avast gulf between these institutions and the voluntary hospitals,which were supported by rich philanthropists. Retirementpensions, even retirement itself, were things of the future andthere was an association between poverty, ill-health and old agewhich was recognized by an 1895 Royal Commission on the agedpoor.Mentally ill people were still incarcerated in large countyasylums. In 1808, partly as a response to the appalling conditionsin some private ‘‘madhouses’’, local magistrates had been giventhe power to set up asylums and in 1845 this provision had beenmade mandatory.From 1900 onwards, developments have been influenced bymajor world events, political philosophy, public opinion and thepower of pressure groups. The Boer War, starting in 1899,revealed the poor physical fitness and ill-health of many youngmen. Improvements in midwifery and child care were soonlegislated for, with school meals starting in 1906 and thenotification of live births, health visiting and the school medicalservice soon following. In 1908 the first national scheme for oldage pensions was set up to try to alleviate poverty amongst oldpeople. It was non-contributory and means-tested. Initially,recipients also had to be ‘‘of good character’’!The Royal Commission on the Poor Laws and the Relief ofDistress in 1909 considered most of the issues of domiciliary andhospital medical care. A minority report condemned the poor lawinstitutions as a public scandal, with the infirmaries understaffedand lacking skilled medical input 2 . Out of hospital, the poor lawdoctors had no contact with local authority public health services,the voluntary dispensaries were overcrowded and ineffective andthe medical clubs, financed by workers’ subscriptions, underpaidtheir doctors and did not cater for the chronic sick or dependants.The writers of this report dismissed the idea of a medicalinsurance system.Yet, in 1911, the establishment of such a system marked animportant development in the evolution of general practice in theUK. The medical profession fought for, and won, independenceand capitation fees rather than a salaried service, and administrationby insurance-based panels rather than local authorities 3 .Higher income groups, families and hospital care were excludedbut the scheme was nevertheless a qualified success.THE MINISTRY OF HEALTH:BETWEEN THE WARSIn 1918 the Ministry of Health for England and Wales was formedand the Minister quickly appointed a consultative council, whichin 1920 produced a report described by Pater 2 as ‘‘nothing lessthan the outline of a national health service’’ (p. 7). Their schememight well have avoided some of the split between generalpractitioners and hospital doctors that has been one of theproblems of the National Health Service (NHS) as it waseventually implemented.Control of the workhouses passed to local authorities in 1930,the beginning of the end for the poor law. After a post-war cashcrisis, the voluntary hospitals continued, becoming more specializedin acute care and leaving the chronic sick and infectiousdiseases to the local authorities. A number of reports pressed for amore coordinated hospital system and for universal healthinsurance. Knowledge was advancing. In 1935 Warren 4,5 beganher work in developing geriatric medicine and, a few years later,pioneers began to write of the issues concerning old people withmental illness 6–8 .Before the Second World War, the Emergency Medical Service(EMS) was set up to cope with expected severe civilian casualtiesfrom the bombing of cities. On the declaration of war, 140 000people, many of them elderly, were discharged from hospital over2 days 9 . The EMS also coordinated the work of the voluntary andlocal authority hospitals, providing the framework for the futureNHS Regional Hospital Boards. Physicians and surgeons fromthe elitist voluntary hospitals came face to face with theconditions of the poor law institutions.Principles and Practice of Geriatric Psychiatry, 2nd edn. Edited by J. R. M. Copeland, M. T. Abou-Saleh and D. G. Blazer&2002 John Wiley & Sons, Ltd