then rose to call the attention of the House to the system of poor-law medical relief at present existing in England and Wales, with a view to its revision; and also to the large number of persons who annually become chargeable to the poor-rates from no medical relief being afforded to them in sickness, unless they become paupers. Although he knew nothing could be done during the present Session on this subject, he felt it his duty to point out the existing evils, and the remedies which might be applied; and he trusted the Government, during the recess, would take the matter into their serious consideration. He considered the system of medical relief to the poor one of the greatest blots in the system of poor-law relief, and one which led to a great amount of expenditure. He had only to state that there were between 3,000 and 4,000 medical poor-law officers having the care of 835,000 persons, to prove that their arrangements for medical relief must be insufficient, and the only check that existed against any maltreatment of the patients was that of placing the case-book on the table every board day. The Poor Law Board could not investigate such cases, and the boards of guardians were improper 135 persons to investigate medical treatment. Then with respect to the cost—there was great difficulty in ascertaining with any degree of accuracy the cost of the extra diet for medical comforts. In 1850 the cost of in-maintenance was 763,000l.; of out-maintenance, 2,808,000l.; of medical relief, 212,000l.; of vaccination, 25,000l.; and other expenses amounted to 1,325,000l. The late Mr. Charles Buller in 1848 stated that the system of extra nourishment had almost entirely risen under the new poor-law, and he mentioned one union in Essex in which 646l. had been paid for that purpose in one year. There could be no doubt that the extra cost in this respect was very considerable. The provision made for the medical officers was most scanty, particularly when they not only performed their medical duties, but provided medicines for the poor. He proposed that a medical inspector should be attached to the Poor Law Board, independent of the President, and that he should have the power of sending down an inspector, professionally educated, to inquire into any case that might be laid before him. He thought it most unfair to call on the medical officers to pay for drugs, and that it operated injuriously on the poor, inasmuch as in the case of expensive drugs it became a question between honesty and prudence on the part of the medical officer. To meet that difficulty he proposed that the boards of guardians should themselves find the drugs. He believed the changes which he now recommended would inflict no additional cost on the management of the poor, but would rather tend to decrease the amount of the rates. The next point to which he would allude was the case of the secondary poor. With the wages usually received it was almost impossible for poor persons to provide themselves with medical relief. In 1847, in conjunction with Dr. Wallis, he made some inquiries on this subject, and was actually startled at the number of persons who became paupers owing to sickness in both the rural and manufacturing districts. In looking at this matter, it was necessary, in the first place, to consider the wages of the poor in this country. Mr. Henry Mayhew estimated the labouring population at 4,000,000, and the average earnings of a poor man at 10s. per week. For clothing and provisions he put down 2s. 6d. per head in the unions. He then calculated the number of persons in a family at 3¼, and, adding 20 per cent for increased cost at home, he made the payments for 136 food, clothing, and fire, amount to 9s. 9d. per week, to which he added 1s. for rent, making 10s. 9d. Now, how was it possible for a man smitten with sickness, and with his children sick around him, to provide medical relief? Last year the Registrar General called the attention of the public to the fact of the great mortality of the children of the poorer classes, particularly in large towns. That officer attributed the evil to the neglect of these children by their parents; but he (Mr. Miles) believed that the poor man had as much regard for the health of his children as the rich man, but his wages would not allow him to send for medical aid, and the children, from the want of a few doses of medicine, often fell into diseases which carried them off. The registrar at Manchester said the poor could not afford to pay for medical relief, and that labourers would not pauperise themselves by applying to the poor-house, and that out of 252 deaths in that district not less than 156 were children under five years of age. He thought it was the duty of the House to urge upon the Government the necessity of an alteration of the present law, and especially of the extension to the poor in England of the system of dispensing drugs, which existed in Ireland. He did not anticipate that the right hon. Gentleman at the head of the Poor Law Board would be able to bring in a Bill this Session, in order to remedy the evils of which he had complained; but he was convinced that the right hon. Gentleman would give his mind to the subject during the recess, and he (Mr. Miles) trusted would be prepared with a measure next year.
Motion made, and Question proposed—
That this House will, at an early period, take into consideration the state of the Law as affecting the Medical Relief of the Poor.
§ MR. BAINES
I beg leave, in the first place, to apologise to my hon. Friend the Member for East Somerset (Mr. Miles), and to the House, for my absence at the beginning of this discussion. I can assure them that it was caused solely by a miscalculation, in which I was by no means singular, as to the time at which this subject was likely to come on. The speech of my hon. Friend has dealt with two topics of a very different kind, though both of great importance: first, the working of the present Poor Law as regards medical relief to the sick poor; secondly, to suggestion of certain new principles, never yet recognised by our laws, for the extension of such relief to persons 137 who are not actually destitute. Upon the former of these subjects, connected as it is with the department over which I have the honour of presiding, the House have a right to expect that I should enter into some little detail. The case of the sick poor is a subject which the House and the country will deem to be of the utmost importance, and deserving their most careful attention. It is well known that for many years after the passing of the Statute of Elizabeth, which is of itself silent as to medical relief, no systematic provision of the kind was made; and it was not till the latter part of the last century that anything deserving the name appears to have been established in England. Indeed, till the passing of the Poor Law Amendment Act in 1834, the system of medical relief for the poor was of a very partial and most unsatisfactory kind. It is true that in many parishes there was a person called the parish doctor, who was not required to possess any particular qualification, who made his contract with the overseers, and was responsible to no one else, though often performing his duties in the most negligent and unfeeling manner. After the passing of the Poor Law Amendment Act, a very different system was adopted. The country was divided into districts, each placed under the care of regularly qualified medical officer, all of whom were responsible to the Poor Law Commissioners. In 1838, a Committee of this House was appointed to consider the working of the new system. They made two specific recommendations for its improvement: one, that the medical officers should in no case be engaged by tender—a mode justly considered to be derogatory to the profession; the other, that the size of the districts for medical relief should be reduced. Both these recommendations were carried out by a General Order of the Poor Law Commissioners, issued in 1842. In 1844, another Committee of this House was appointed, on the Motion of Lord Ashley, to examine further into the subject of Poor Law Medical Relief. Much evidence was taken, and many very conflicting opinions were expressed by the witnesses. One of the most distinguished professional authorities, Mr. Guthrie, formerly President the College of Surgeons, distinctly stated as one of the results of the new system, that "an infinitely greater amount of medical relief is now furnished to the poor than before the passing of the Poor Law Amendment Act." At the close of their inquiry, the Committee contented themselves with 138 reporting to the House a bulky volume of evidence, unaccompanied by any suggestions or recommendations whatever. One result, however, of these Parliamentary inquiries has been to induce the then Poor Law Commissioners and their successors, the present Poor Law Board, to pay a constant attention to the whole subject of medical relief, with a view of adopting every suggestion of a practical nature for its improvement. There can be no question that the supply of medical relief to the poor has become more and more liberal. In 1838, the total cost of such relief for the poor in England and Wales was 136,000l.; in 1844, it was 166,257l.; and in 1852, it was 212,050l. This is exclusive of the amount paid to the medical officers for vaccination, which amounted last year to 25,894l. One result of the Parliamentary inquiries was the establishment of extra fees for certain operations requiring extraordinary labour or care. These extra fees amounted in 1840 to 5,499l., and in 1852 to 30,727l. Another change of an important character has taken place in the total number of medical officers. In 1838, the whole number employed in the care of the sick poor was 2,091; in 1852 it had been augmented to 3,233. This had arisen in part from the abridgment of the medical relief districts, many of which were originally too large. With regard to the qualifications of the medical officers, the Poor Law Board think they ought to be such as to ensure for the poor a degree of skill in their medical attendants equal to that which can be commanded by the more fortunate classes of the community. For this reason, a rule has been established, requiring a double qualification, medical and surgical; and this rule is always insisted upon, except in special cases, where from the circumstances of the district a literal compliance with it is impracticable. One great advantage of the system of medical relief under the Poor Law Amendment Act, as compared with that which preceded it, is to be found in the strict responsibility under which the officers constantly act. They are all directly responsible to the Poor Law Board; and I undertake to say that no case of alleged neglect or maltreatment of the poor on the part of a medical officer is ever brought before that Board without leading to an immediate and searching inquiry. I am happy to say that such complaints are few; I think them very few, considering the great number of medical officers throughout the country, and considering also that the vigilance of rival prac- 139 titioners, or that of the benevolent persons who are always anxious to protect the poor against neglect or ill treatment, would be sure to bring forward every complaint which had even the semblance of being well founded. Speaking of them as a body, I believe that the medical officers discharge their important duties to the poor with great diligence, ability, and humanity. In those cases of real neglect or misconduct which do sometimes occur, the Poor Law Board think themselves bound to enforce the responsibility of the medical officer very strictly. Any gross case would be followed, as a matter of course, by a summary dismissal; and even a mere venial one might entail a censure, which of itself would be no slight punishment to a professional man. But though on the one hand his responsibility is strictly enforced, for the protection of the poor, yet on the other the Poor Law Board are most anxious to protect the medical officer against anything like injustice or oppression. He finds in them a defence against any cabal by which he might otherwise be unjustly borne down. There is one point upon which, as many hon. Gentlemen opposite well know, the Poor Law Board have shown themselves able and willing to render very important aid to the medical officers. Low as the present scale of their remuneration is, a great many efforts have been made within the last three years, especially by some of the agricultural unions, to reduce it still lower. The depreciation in the value of agricultural produce has been generally urged in such cases as a ground for the reduction of the salaries of medical officers. It could not be effected without the sanction of the Poor Law Board; and, I believe I may say, that in every case which has come before them, the Poor Law Board have thought it right to withhold their sanction. Looking, then, to the various points upon which I have now touched, I may confidently ask the question, whether the system of medical relief to the poor has not been undergoing constant improvement ever since the passing of the Poor Law Amendment Act, which of itself effected a very great improvement upon the system previously existing? I am far from saying that the present is not capable of being further improved, and the Poor Law Board will gladly avail itself of any really practical suggestion for that purpose. My hon. Friend the Member for East Somerset has made one or two suggestions, as to which I cannot but express considerable doubt. With regard 140 to a different mode of supplying drugs (which are now furnished by the medical officer), very conflicting opinions were expressed before the Committee of 1844. I find, however, that a witness of great authority, Mr. Keate, formerly President of the College of Surgeons, expressed great doubt whether any better system than the present could be adopted; and the same view was taken by other witnesses of great intelligence. Then, it is suggested by my hon. Friend, that there should be one medical inspector at least connected with the Poor Law Board. I can assure him, however, that this provision would be deemed wholly inadequate and almost worthless by those who have contended for giving to the Poor Law Board a medical or semi-medical character. It has been gravely argued, that one of the Poor Law Commissioners, if not all of them, should belong to the medical profession; that there should be a physician-in-chief, a surgeon-in-chief, and a large and costly staff of permanent medical inspectors. My hon. Friend has said, that Mr. C. Buller entertained an opinion favourable to the appointment of one or more medical inspectors. I have the best means of knowing from those with whom Mr. Buller was in the most confidential intercourse, that although he did at one time entertain an opinion of this kind, yet that he found the subject involved in greater difficulty the longer he considered it. The House will remember that the Poor Law Board have full power with regard to every question of a medical character which may come before them, and submit the facts to the highest professional authorities, and to obtain the best professional advice. For example, a question arose lately as to the sufficiency of certain sanitary arrangements in one of the workhouses, and it was a question of considerable difficulty and of great importance. The Poor Law Board requested the President of the College of Physicians, to have one or two medical gentlemen of undoubted skill and reputation, who might investigate the subject fully and report their opinions. Two gentlemen were so appointed, and they gave the most satisfactory information and advice, upon which the Board had no hesitation in acting. It has been said that no one but a medical man can investigate properly any of those charges of neglect or malpractice which are occasionally made against a medical officer, and which may involve questions attended with the most serious consequences to his professional 141 character. I think it might as justly be said, that no case of what lawyers call mala praxis on the part of a medical practitioner, should ever be tried by a judge and jury, unless they were all physicians, surgeons, or apothecaries. The inspector in the one case (who is usually a gentleman thoroughly accustomed to deal with evidence), acts as the judge and jury do in the other, upon the evidence brought before him, and has always the power of calling in the best professional testimony for the purpose of informing and guiding his judgment upon any point of difficulty. In some special cases, when it has appeared advisable to do so, the Poor Law Board have associated with their inspector a medical assessor, for the purpose of investigating questions of peculiar difficulty or complexity. The illustrations which I have now given will probably induce my hon. Friend to doubt whether it really can be essential to have a permanent medical staff attached to the Poor Law Board. With regard to that part of my hon. Friend's speech, in which he suggested that medical relief should be provided out of public funds for persons who were not destitute, I will only observe, that when such a proposition is brought distinctly before the House, I shall be ready to express my opinion upon it. A gentleman of great ability and benevolence, Dr. Wallis of Bristol, and who is also, I believe, a constituent of my hon. Friend, has recommended that such aid to an unlimited extent should be furnished at the public cost to all persons having incomes under some fixed amount; I believe 40l. a year is the limit suggested. The example of Ireland has been appealed to upon this point. The experience under the old system of dispensaries in Ireland is said to have been very unfavourable, and the new system has been too recently introduced to warrant any very distinct conclusions as to its working. Whenever a specific proposition is made for the adoption in this country of such a plan as that suggested by my hon. Friend, it will deserve great consideration how far it may have a tendency to weaken the motives for economy and forethought in the humbler classes of the community, and to slacken efforts for the preservation of that independence which is so essential to the respectability and to the true happiness of each individual. With respect to my own immediate province, the administration of the existing Poor Law, I can assure my hon. Friend, that every suggestion with which 142 he may favour me for the improvement of the system of medical relief, shall receive the most careful and respectful attention. With that assurance, and as he has now had an opportunity of bringing his views before the House and the country, I trust that he will not think it necessary to press his Motion to a division.
§ SIR JOHN TROLLOPE
thought it would be superfluous to follow his right hon. Friend in all his points; but he felt bound to confirm the opinion of the right hon. Gentleman, that the medical relief of the poor was not only in a satisfactory, but in a gradually progressing state; and to acknowledge that the poor received every care from the Board over which his right hon. Friend presided. He (Sir J. Trollope) could confirm him in the statement that there was a very great improvement in the mode in which the relief to the poor was administered, and in the character of those who were selected to dispense it. There was also a great improvement in the medical officers, and in their qualifications for the discharge of their duties; and he could most distinctly confirm his right hon. Friend in what he had said with respect to the cases which were brought before the Poor Law Board, of neglect of duty and maltreatment—that very few such cases were brought before the Board while he had the honour to preside over it, and that when any charge was made, it received the most earnest attention, and that dismissal, when called for, had invariably followed. During the year in which he had held office, not more than four or five cases of neglect of duty, or maltreatment of patients, had been complained of; and he thought the House would agree with him that this was a very small number, considering that upwards of 4,000 officers were employed in administering medical relief. His hon. Friend the Member for Somerset (Mr. Miles) desired to extend poor-law medical relief to what he called secondary poor, especially in cases of sudden sickness and casualties. Now, with regard to this class of persons, the greater portion, especially those of the more prudent character, belonged to sick clubs, or some other of the numerous benefit societies which existed throughout the country. In his part of the country, for instance, after the passing of the Poor Law Act in 1835, some benevolent person set about establishing medical clubs; the poor of the surrounding neighbourhood became ready subscribers to it, the amount of the 143 subscription being a penny a week, and the rest of the expenses being made up by the charitably disposed inhabitants of the districts. He could speak strongly of the great benefit these clubs had proved to that class of the poor. It promoted their feelings of independence, prevented them from becoming paupers, and gave them an opportunity of calling in any medical man whom they thought proper. And he could assure the House that this privilege of calling in any medical man whom they chose, was greatly valued by the poor, who had their fancies as well as other people. He would ask his hon. Friend if these sort of societies would not be altogether discouraged by his proposal? It would also discourage the affluent who subscribed to the dispensaries and infirmaries which abounded throughout the land. The great objection to it was, the difficulty of drawing the line between parties who should and who should not be entitled to relief. At present, the complaint made by charitable societies was, that parties obtained assistance who could well afford to pay for medical advice; and he was afraid that complaint would be found to increase, if the proposal of his hon. Friend were adopted. If they granted this relief to those one degree removed above the poor, he apprehended that they would do away with this class of charities altogether, and thus do away with a great national benefit. The object of vaccination was for a totally different purpose. It was to protect the public health, and to prevent the spread of disease. The question of medical inspection under the authority of the Poor Law Board, was brought under the notice of the Commissioners by another gentleman, also from Somersetshire. A medical gentleman from that county had communicated with the Board, suggesting that such officers should be appointed, and stating, in addition, that he should he happy himself to make one of them. He (Sir John Trollope) then instituted an inquiry into the circumstances of the case. He found that this suggestion had also been brought under the notice of Mr. Buller and his hon. Friend who had preceded him in that office. It was found that it would occasion endless expense, and accordingly it was not deemed prudent to suggest it to Her Majesty's Government. With respect to the other suggestion of Dr. Wallis, it was submitted to the Chancellor of the Exchequer, who said that it was a question of such magnitude that he could not prudently submit it 144 to Her Majesty's Government. The consideration of expense was a secondary one, provided that adequate benefit could be obtained in proportion to it. The principle was a new one, and full of danger in the extent to which it might be carried—dangerous to the finances of the country. With respect to the payment of the medical officers under the Poor Law Board, he was free to confess that it was inadequate in many respects; but the House would recollect that the salaries were not altogether under the control of the Poor Law Board. The boards of guardians through the country recommended the amount which they considered necessary; and it was a question which ought to be left to those gentlemen who were elected guardians to superintend the finances and affairs of their immediate neighbourhood. They were informed by his right hon. Friend that the scale of salaries was gradually improving; but if these salaries were largely augmented, there would probably be a call upon the Treasury to take the whole of of them upon itself. He believed that the medical officers were improving both in character and knowledge, and they had found that the cases of complaint were exceedingly few, and, when made, not always well founded,
§ MR. WODEHOUSE
could confirm everything that had been said with respect to the medical officers, and he was sure his hon. Friend the Member for Somerset-shire (Mr. Miles) had no intention of disparaging the administration of the Poor Law Board; he only regretted that he had not brought the subject forward at an earlier period of the Session. He believed the system was conducted on too niggardly a scale; the salaries were niggardly, and the allowances were niggardly; there ought not only to be an extended relief, but a better quality of relief. He thought that there was no subject more deserving of the attention of the Executive Government. He hoped the hon. Member for Somersetshire would renew his Motion from time to time.
§ MR. BARROW
warned the House of the danger of tampering with the administration of the poor in this manner. It would be but tempting those to apply for relief who could do well without it; and it would do far more harm in breaking down that independence of spirit which led them not to accept relief, than it would do good by thus offering it. He had made some inquiries in his own county, and he had 145 found that so far from men having a difficulty in procuring medical relief from charitable resources, the great complaint was, that these charities were too often encroached upon by parties who could well afford to pay for medical attendance.
then replied, and said that he was contented with having brought the subject before the notice of the House, and that he would accordingly withdraw his Motion.
§ Motion, by leave, withdrawn.
§ MR. AGLIONBY
moved for certain returns connected with the Woods and Forests, when
Notice taken, that forty Members were not present; House counted; and forty Members not being present, the House was adjourned at a quarter before Nine o'clock.