Professor Hamish Maxwell-Stewart (Keith Cameron Chair of Australian History, University College Dublin/University of Tasmania). Convict Health on the Voyage to Australia. Due to recorder malfunction the lecture ends a little early.

Speaker

Professor John Stewart (Glasgow Caledonian University)

Title

Health care systems in Britain and Ireland in the nineteenth and twentieth centuries: the international, national and sub-national contexts

Event

Healthcare systems, regional and comparative perspectives in Britain and Ireland, 1850-1960, a conference convened by Dr Sean Lucey, at CHOMI, 8-9 June 2012

Summary

This paper argues that it is, of course, understandable and legitimate to see the historical development of healthcare systems in Britain and Ireland as deriving from the policies, actions and particularities of individual nation states – indeed this is how welfare history is generally written. However, it is suggested that it is also important to note, first, the international context. This is for three reasons: the constraints on individual nation states imposed by supra-national bodies such as the European Union and the International Monetary Fund and even, in certain cases, by other nations; the notions of welfare regimes and welfare peripheries which suggest that individual nations nonetheless share commonalities of social policy practice and approach – so, for instance, Esping-Andersen famously clustered welfare states into social democratic, corporatist, and liberal regimes; and the significant role of policy transfer and learning whereby ideas and practices are consciously shared, adopted, and adapted across national boundaries.

Second, and somewhat by contrast, it is also clear that within individual nation states there have historically been sub-national/regional differences in policy formation, implementation, and outcome. This is most obviously the case in overtly federal political systems such as that of the United States but also occurs within purportedly ‘unitary’ states such as the United Kingdom. These arguments are illustrated and supported by recent developments in the historiography of welfare; and by specific welfare policies and practices in Britain and Ireland from the middle of the nineteenth to the middle of the twentieth centuries.

John Stewart

Professor John Stewart’s research interests range broadly across modern British history. His work has focused on the history of health care provision and social policy, with an associated emphasis on the history of child welfare. His research research topics have included: municipal medicine in inter-war England and Wales; child evacuation policies in wartime Scotland; and welfare provision in ‘peripheral’ areas of the United Kingdom and Europe.

Speaker

Dr Sally Sheard (University of Liverpool)

Title

The Roots of Regionalism: Municipal medicine from the Local Government Board to the Dawson Report

Event

Workhouse Medicine in Ireland 1850-1914: Comparative and Regional Perspectives, a conference convened by Dr Sean Lucey, at CHOMI, 8-9 June 2012

Summary

The genesis of nineteenth century British state medicine is evident in the pioneering work of towns such as Liverpool in the 1840s, which adopted a reactive strategy to epidemic infectious diseases. Their response was the essence of ‘localism’ – temporary and geographically constrained policies, which did not challenge national laissez faire ideologies. Liverpool’s pioneering 1846 Sanatory Act [sic] became the blueprint for the 1848 national (but permissive) Public Health Act, which some historians have seen as the trigger for a progressive consolidation of public health. The 1866 Sanitary Act articulated the first principles of municipal medicine, providing legal authority and financial support for removing infectious patients from their homes into designated isolation facilities. Yet it was the advent of the Local Government Board [LGB] in 1871 that facilitated the expansion of municipal medicine, through grants and subventions. These were linked into a system of inspections, undertaken by staff with varying degrees of medical and sanitary expertise, who assessed need and existing provision, especially of the new municipal isolation hospitals.

Two key observations emerge from an analysis of the period 1871 to 1929, when the Local Government Act changes yet again the permutations of municipal medicine. First, the impact of increasing knowledge of provincial public health on the expectations and reactions of central government. There was a clear sense of comparative analysis emerging, despite the Webbs assertion in their 1910 book, The State and the Doctor, that there was no ‘systematic inspection, or audit of municipal hospitals’. Second, the creation of a further layer of regional bureaucracy after 1888, when the new county councils were permitted to cut across existing sanitary district boundaries, sees the beginning of planning medical services on an explicitly regional basis. In 1893, the same year as the Isolation Hospital Act, a survey by the British Medical Association concluded that a ratio of ten beds per 100,000 population was an appropriate requirement for isolation provision.

The development of these essentially geographical policies has not hitherto been examined. They predate Bertrand Dawson’s well-known 1920 Interim Report on the Future Provision of Medical and Allied Services, which presented the concept of a hierarchical regional health service which differentiated between primary and secondary care. This paper will examine the emergence of these trends, and examine to what extent they were conscious policy decisions, taken at a national level, or essentially locally negotiated and reactive to demands for medical care.

Sally Sheard

Sally Sheard is Professor of the History of Medicine, with an appointment divided between the Department of Public Health and Policy and the Department of History at the University of Liverpool. She is a health and social policy historian, with a special interest in the interface between expert advisers and policymakers in the UK and international organisations. She is a Wellcome Trust Senior Investigator, leading a five year project (2015-2020): The Governance of Health: medical, economic and managerial expertise in Britain since 1948.To read more about Sally’s latest research project, The Governance of Health: Medical,

Speaker

Dr Ciarán Wallace (Trinity College, Dublin)

Title

Feverish activity. Dublin Corporation and the smallpox outbreak of 1902

Event

Healthcare Systems: Regional and Comparative Perspectives in Britain and Ireland, 1850-1960, organised by Sean Lucey, hosted by CHOMI, UCD, June, 2012.

Summary

When smallpox broke out in Dublin in 1902 the municipal council reacted promptly. With 255 confirmed cases in the city’s overcrowded tenements, and a further 1,400 requiring isolation, this threatened to become a major epidemic. Despite its reputation for inefficiency, the council launched an impressive campaign to contain the disease. As existing fever-beds in the voluntary hospitals rapidly filled, the city’s Fever Refuge, a stand-by isolation unit, swung into action and expanded its facilities. Soon the council had to contract a private convalescent home to handle the overflow. Most impressive of all, however was the building and staffing of a 50-bed temporary hospital in only three weeks. By July 1903 Sir Charles Cameron, Medical Superintendent of Health, reported that the crisis was over. Even the Dublin Sanitary Association, perennial critics of the city’s health provision, congratulated the council on its success.

The civic response to the smallpox crisis tells us a great deal about public health provision at the turn of the twentieth century. This paper will consider some key questions emerging from the events of 1902-03. How did the city manage this public health crisis and what role did the voluntary hospitals play? What was the state’s responsibility in the crisis and did it give the city sufficient powers to enforce a resolution? The combined efforts of hospitals, councils and central government had a sudden impact on the lives of the patients and their families. Patients had been removed to hospital, their families were held in isolation, clothing and bedding incinerated and their rooms disinfected. How did those on the receiving end of all this activity react? The council’s legal authority to compel its citizens was far from clear, and interesting challenges to this vigorous public health campaign emerged. While the population was largely cooperative there were some cases of resistance. What do these challenges tell us?

The 1902 outbreak also illustrates the relationship between government as legislator, and the city council as service provider. Increasingly, local government was becoming the vehicle for delivering national policies on healthcare and sanitation. In a major overhaul, the 1898 Local Government Act had empowered the city to deal with a wide array of issues, both chronic and acute. The difficulty arose, however, when expensive emergencies called for greater resources than local rates could afford. This paper will consider how, as its role in public health grew, the local council operated between voluntary hospitals and the state. 20 Finally, the paper will assess the Municipal Council’s fight against the 1902-03 outbreak in the context of these evolving relationships. It will argue that Dublin’s voluntary hospital sector was not equipped to cope with such a situation and that only the city had the resources to tackle the crisis.

Ciaran Wallace

Ciarán Wallace’s research focuses upon urban history during the early modern and modern periods. This includes the role of civil society in national and community identity formation. My doctoral thesis involved a social and economic analysis of local election candidates. He has also worked on aspects of the history of Dublin, and is interested in Scottish-Irish comparisons, civic pageantry, political cartoons and ephemera.

Speaker

Dr Steven Thompson (Aberystwyth University)

Title

The mixed economy of care in the South Wales Coalfield, c.1850-1950

Event

Healthcare systems, regional and comparative perspectives in Britain and Ireland, 1850-1960, a conference convened by DrSean Lucey, at CHOMI, 8-9 June 2012

Summary

The mixed economy of care is an idea that many historians have utilised as a means to conceptualise the welfare system of any country. It has been used to demonstrate the existence of and interaction between different providers of welfare and medical services, and has served as a useful reminder that the state was not the only nor indeed the main provider of welfare in the past. In the work that has utilised this concept, historians and other writers have emphasised the ways in which the mixed economy of care varied, both over time and between different states, but they have failed to give sufficient attention to the numerous and fascinating ways in which the mixed economy of care varied between different regions within states.

This paper adopts a regional perspective and outlines the particular developments and influences that led to the distinctive mixed economy of care that characterised the South Wales Coalfield from the mid-nineteenth century to the midtwentieth century. The region had some of the lowest levels of Poor Law institutional and voluntary hospital provision in the whole of Britain, and was marked by a relative absence of philanthropic and paternalistic resources and services. In the place of these providers, it was the labour movement that attempted to fill the gap and offered a range of welfare, health-care and medical services through a variety of self-help and mutualist organisations or, at least by the early twentieth century, through the influence it attempted to wield through Labour Party councillors on local authorities in the region.

Such factors led to a mixed economy of care that was very different in character and scope than that for other regions of Britain during the period and one in which a labourist perspective determined that the earning capacities of male workers were to be prioritised over the needs of other sections of the community. In addition, this distinctive mixed economy of care left the region as one of the most poorly provided for regions in the whole of Britain by the mid-twentieth century, though one that did, in various ways, influence the post-war reorganisation of welfare and medical services under the Labour governments of 1945-51. In these various ways, the paper emphasises the particularities of coalfield regions in terms of medical and welfare provision, the distinctiveness of south Wales relative to other coalfields, and the highly differentiated nature of the mixed economy of care across Britain during the century or so before the creation of the welfare state.

Steven Thompson

Dr Steven Thompson BA, Ph.D (Wales) is a historian of the modern period with specific interest in the history of Wales and Britain in the nineteenth and twentieth centuries. His research interests include the history of medicine, the provision of welfare, and labour history. His current research is focused on the mixed economy of medical and welfare provision in south Wales from c.1780 to 1950. He also has research interests in the history of carnival, music and musical culture in Wales, and the history of sport.

The Church of Scotland and the mixed economy of health and welfare provision in Glasgow, c. 1900-1950 – Dr Janet Greenlees (Glasgow Caledonian University).

Speaker

Dr Stephen Soanes (University of Warwick)

Title

Transformation or stultification? The first fifteen years of voluntary mental treatment in London (1930-1945) and Dublin (1945-1960)

Event

Healthcare systems, regional and comparative perspectives in Britain and Ireland, 1850-1960, a conference convened by DrSean Lucey, at CHOMI, 8-9 June 2012

Summary

This paper will explore the extent of the adaptations made to mental hospital service provision following the Mental Treatment Acts in the UK (1930) and Ireland (1945). It focuses particularly on the case of the London County Council. On the basis of this analysis, the paper will then offer some parallels with (and divergences from) the implementation of the 1945 Mental Treatment Act in Dublin. The papers argues that mental hospital providers in these capital cities framed the potentialities of these Acts in similar ways, even as they responded to the local contexts that helped determine decisions over their implementation. In each case, these Acts legislated for the admission of voluntary and temporary patients. Prior to these enactments, mental hospital admission had rested principally on a judicial process of certification; subsequently, patients and their families at least nominally obtained greater control over the timing and duration of institutionalisation. How far these new groups of patients warranted distinctive institutional provision became a topic for debate at a local level between psychiatrists, mental hospital committees and local authorities. It is this set of discussions that the present paper examines, through an analysis of mental hospital committee records and correspondence that offers to suggest how far special provision was deliberately made for these voluntary and temporary cases.

The paper concentrates principally upon the London County Council, which in 1930 set up a Mental Treatment Act Sub-Committee to consider changes to existing services in order to accommodate voluntary and temporary patients. This evidence is compared with the experience of Dublin’s mental hospitals after 1945, to suggest how far international precedent, existing institutional provision and prevailing economic and social imperatives influenced services in both countries. Amongst those changes discussed are the developments in outpatient treatment, modernisation of mental hospital buildings and development of ancillary aftercare services.

Previous assessments on the radicalism of these enactments have diverged. For Helen Boyle (President, Royal Medico-Psychological Association), writing in 1939, the UK’s Mental Treatment Act had represented ‘the greatest practical advance’ hitherto made in psychiatry. In contrast, the historian Niall MacRae (2008) has concluded that despite the promise of the Act, a ‘stultifying regime prevailed in the decades that followed its 16 implementation. Brendan Kelly (2008) has further emphasised the failure of the comparable Irish Act of 1945 to reduce in-patient numbers or establish new institutions that might lead to further change. Nevertheless, Kelly has also argued that the Act may have had a ‘decisive influence’ on Ireland’s mental hospital system; particularly in the diminution of the stigma it brought to in-patient treatment. Through an analysis of these debates, this paper offers to suggest what determined the shape of services for patients following the Mental Treatment Acts. Whereas previous studies have tended to focus on the national implications of these laws, this paper will suggest that local circumstances proved vital in shaping the provision mental hospitals made in the fifteen years after their introduction.

Why have a Catholic hospital at all? The Mater Infirmorum and the NHS – Dr Peter Martin (Queens University Belfast)

Workhouse medicine in Ireland 1850-1914: comparative and regional perspectives

Speaker

Professor Virginia Crossman (Oxford Brookes University)

Title

Workhouse medicine in Ireland 1850-1914: comparative and regional perspectives

Event

Healthcare systems, regional and comparative perspectives in Britain and Ireland, 1850-1960, a conference convened by Dr Sean Lucey, at CHOMI, 8-9 June 2012

Summary

Following the establishment of the poor law system in 1838, workhouse infirmaries provided the only source of hospital medicine in many rural districts of Ireland, while in the major cities workhouse hospitals accommodated far more patients than all the voluntary hospitals combined. Medical historians have tended to be dismissive of the role of the poor law in the development of the Irish healthcare system emphasising poor facilities and inadequate staffing. Moreover, the stigma associated with poor law institutions is believed to have deterred many people from seeking treatment. This paper provides a reassessment of workhouse medicine. It explores the changing character of the relief system and the workhouse population in the post-Famine period, examines regional differences and highlights local variations in the nature and quality of medical services provided, and analyses efforts to improve standards of hospital accommodation and patient care.

Virginia Crossman

Virginia Crossman is Professor of Modern Irish History at Oxford Brookes University. She is a fellow of the Royal Historical Society and a Higher Education Academy Registered Practitioner. She has published extensively on aspects of government and administration in nineteenth and twentieth century Ireland; most recently on the history of the Irish poor law. Her current research focuses on vagrants and vagrancy.

Speaker

Professor Mary E Daly  (University College Dublin)

Title

Can we speak of healthcare systems in twentieth century Ireland?

Event

Workhouse Medicine in Ireland 1850-1914: Comparative and Regional Perspectives, a conference convened by Dr Sean Lucey, at CHOMI, 8-9 June 2012

Summary

The term ‘healthcare systems’, is a concept that emerged in modern management. There are real dangers in applying it retrospectively to retrofit a coherent structure on medical institutions that emerged over centuries because of initiatives by individuals, religious communities or municipalities. The health services provided by the Irish Poor Law can be seen as the first Irish ‘healthcare system’ – with defined geographical and administrative structures and criteria to determine eligibility, but this system was never wholly separate from the provision of private medicine. Many dispensary doctors supplemented their income by attending private patients and other institutions outside the Poor Law medical system. Although the Hospital Commissioners – the state agency established in the 1930s to allocate the money accruing from the Irish Hospitals Sweepstake – can be seen as recognising two distinct streams of hospital and institutional treatment – voluntary institutions, and state institutions – the term ‘systems’ implies that each was viewed, not as a series of individual institutions, but in a more systemic manner. Yet there was considerable competition between voluntary hospitals, and the relationship between voluntary and local-authority hospitals was not clear-cut. Patients transferred readily between the two, as did staff, and in some instances treatments were duplicated unnecessarily between the two, and state-funding for patients was provided in both sectors.

It is also apparent that both hospital sectors offered scope for initiatives with respect to treatments and diagnostics by medical practitioners – though this freedom was undoubtedly greater in the voluntary than in the local authority sector. Most of the critical initiatives in medical treatment such as coronary by-pass surgery, advanced renal treatment, or preventative measures against coronary diseases originated in the voluntary sector, as did initiatives regarding the care and treatment of mentally-handicapped children. The fact that clinical training of medical students was almost entirely concentrated in the voluntary hospitals gave those hospitals a status in the hierarchy of services that the local authority hospitals could not attain. One question raised in this paper is whether the Department of Health and the Irish health service in general, implicitly left voluntary hospitals with primary responsibility for innovation within Irish hospital medicine?

Although the Hospitals Commissioners in the 1930s planned for a hospital system that would have combined the resources of voluntary and local-authority hospitals, this was never 9 implemented, and in the subsequent decades voluntary and state hospitals were treated as separate entities to the extent this it is impossible to find data giving the total numbers of hospital beds, hospital medical staff or patients treated in Ireland for these years. The FitzGerald Report ,1968, was yet another attempt to co-ordinate both types of hospital in a coherent fashion, but the ensuing opposition (mainly from the county hospitals and their supporters) meant that this did not happen, and the new health reforms introduced in 1970 – which saw the establishment of Regional Health Boards – left both sectors with separate funding streams.