Kim Price is an Honorary Visiting Fellow with the Centre for Medical Humanities at Leicester University, UK and is the author of our new book Medical Negligence in Victorian Britain: The Crisis of Care under the English Poor Law, c.1834-1900. Taking a closer look at charges of neglect against doctors in the nineteenth century, Kim Price tells us how the effects of the Victorian poor law weren’t too dissimilar from what we are experiencing in the welfare system today …
In Britain there are suggestions that present-day health and welfare budget cuts have been a contributory cause of medical negligence, both in and out of National Health Service (NHS) hospitals. In spite of the complex differences (and the intellectual pitfalls of comparing past with present), there are some striking parallels between medical negligence under the Victorian poor law and today’s analyses of the neglect of patients in Britain’s NHS. The controversial removal of a range of benefits for the disabled and chronically ill, at the same time as sweeping budget cuts and reorganisation of the NHS, has been vilified by critical observers across the political spectrum. It is feared that a lack of joined-up thinking in policy, and growing gaps between different health and social care providers, has led to vulnerable people disappearing from the healthcare radar or turning to acute care for chronic health problems that are better dealt with in community medicine. As this book has come to press, there were recurring themes in present-day healthcare that are strikingly similar in nature to those of the Victorian poor law. There have been seemingly preventable suicides of mentally-ill patients, the neglect of elderly and vulnerable patients in hospitals, recurrent issues in midwifery, institutional problems of cleanliness and hygiene, and chronic cases of mental and physical morbidity occupying already overloaded hospital wards for acute care – all of which has been underpinned by an adversarial legal system, ideologically-driven circuitous policies and the immediacy of national funding cuts in the wake of recession.
Although the modern Welfare State in Britain is clearly not the same as the poor law that came before it, twenty-first century cuts to national welfare provision in Britain seem to have some basic antecedents in the late-Victorian period. The crusade against outdoor relief was a policy which led to extraordinarily harsh cutbacks in expenditure on medical relief between the 1870s and 1890s. It appears to provide an allegory in its deep funding cuts to welfare provision as a reaction to national recession, and in its reliance on local variables in care services. The failure of Victorian poor law governance to recognise the causes of substandard care, or to acknowledge the part of the Local Government Board in a systemic spawning of negligence, lay in crusaders’ insistence that the withdrawal of outdoor relief could be covered by community level assistance (through private, charitable and voluntary means) and State institutional provision. As a result, there were cuts to medical relief without an accurate assessment of local services and workhouse infirmary provision. Ideological wilfulness during the crusade could not see or refused to acknowledge that there was a crisis of care unfolding.
Given historians’ views on the subject, medical negligence under the new poor law should be an anachronism. Before legal aid, the Welfare State or the NHS, the ‘pauperised’ patients of the workhouse system would appear to have had no expectation of patients’ legal rights and no recognisable path to recourse if they did. Accordingly, it is thought that they would have been able to access neither contract nor tort legal remedies. In so far as the administrative structures of the new poor law were created to manage pauperism – not medical care – facilitating standards of care and complaints of negligence seem anathema to its designers. Paupers’ ‘healthcare’ was provided in a ‘deterrent’ setting in which they supposedly had few rights and no income to bring a charge or action of negligence against a doctor.
In contrast to that depiction, this book brings forward new research and demonstrates that charges of neglect against poor law doctors occurred with surprising regularity and that pauper complaints were not ignored. The crisis of care, described in this book, could also be described as a crisis of managing aggrieved patients (and public opinion) under the new poor law. How the poor law coped (politically, legally, culturally and financially) with a large number of neglected and aggrieved patients, and deflected the white-noise of acerbic Victorian public opinion is a major thematic thread of this book. The search for accountability was as constant, unresolved and important then as it is in the present. As I conclude in Medical Negligence in Victorian Britain , ‘Historically, it seems that blame has remained at the core of legal redress in healthcare, despite a consistent discord with the parallel needs of patients and healthcare providers to locate and reform systemic faults. These are historic problems, rooted in law, economy and patients’ disenfranchisement.’ For anybody involved in the medico-legal and political landscapes of today’s internationally complex healthcare systems, there has never been a more pressing time to look back to the Victorian poor law and its legacy of managing medical neglect.
Medical Negligence in Victorian Britain: The Crisis of Care under the English Poor Law, c. 1834-1900, publishes later this month in the UK and April 2015 in the US, available via the Bloomsbury website.