Sutton, David A. (2009) The public-private interface of domiciliary medical care for the poor in ...

388 Pages·2009·9.37 MB·English

Sutton, David A. (2009) The public-private interface of domiciliary
medical care for the poor in Scotland, c. 1875-1911. PhD thesis.

http://theses.gla.ac.uk/1234/

Copyright and moral rights for this thesis are retained by the author

A copy can be downloaded for personal non-commercial research or
study, without prior permission or charge

This thesis cannot be reproduced or quoted extensively from without first
obtaining permission in writing from the Author

The content must not be changed in any way or sold commercially in any
format or medium without the formal permission of the Author

When referring to this work, full bibliographic details including the
author, title, awarding institution and date of the thesis must be given

Glasgow Theses Service
http://theses.gla.ac.uk/
The Public-Private Interface of Domiciliary Medical Care for
the Poor in Scotland, c. 1875-1911.

David A. Sutton

A thesis submitted in fulfilment of the requirements for the degree of PhD to
the University of Glasgow.
The Department of Economic and Social History Centre for the History of
Medicine
Faculty of Law, Business and Social Sciences

November 2008
© David Sutton August 2009
Abstract
This thesis explores domiciliary medical care for the poor in Scotland. Domiciliary care
is understood as medical care provided in the home by qualified medical practitioners, or
medical students. The poor are understood as those simply unable to ‘pay the doctor’ for
the services they received. Focus is upon service provision, and therefore this thesis is a
study of the different medical agencies engaged in the visitation of patients, and of the
diverse ways medical practitioners as agents of different medical services facilitated or
administered treatment. The period under focus is from 1875 to the National Health
Insurance Act, 1911. Particular focus falls on urban Scotland, and Glasgow and
Edinburgh. The interface between public and private provision is understood as the
distinction between services provided for paupers, the legal poor, and services provided
for the remainder, also unable to pay, and described as occupying ‘the boundary line
between self-support and parish help’. Three types of service provider are identified: the
poor law, medical charity, and medical missions.

The thesis is divided into four main parts, buttressed by an introduction and conclusion.

Chapter One sets the parameters to study of domiciliary medical care for the poor by
identifying a literature of home visitation, and by identifying pressing issues concerning
treatment in the homes of the poor of Glasgow and Edinburgh, like physical structure and
family.

Chapter Two is comprised of eight sections and looks at public provision in the form of
the poor law medical services. Of particular interest are the local management, and the
medical officers who provided the service. In turn focus is put upon the role of medical
relief under the Poor Law (Scotland) Act, 1911; the structure of outdoor medical services
in Glasgow and Edinburgh; the role of the local medical sub-committee of the parish
board; and the parochial medical officers and their work. A prosopographical approach is
taken to profile the parochial medical officers.

ii
Chapter Three, comprising five sections and conclusion, looks at private provision by
medical charity. At issue is the range of charity dispensaries that provided outdoor
services to the poor. A prospectus identifying the range of services is provided; outdoor
medical services in Edinburgh and Glasgow are detailed; the interconnection between
charity dispensary, domiciliary medical care, and medical educational requirements –
particularly in Edinburgh – is investigated; and new developments occurring at the start
of the twentieth century in health services requiring home visits are outlined.

Chapter Four is comprised of nine main sections plus conclusion and looks at private
provision by home medical missions. An overview of the literature of medical missions is
provided, before focus falls, in turn, on medical missions in Edinburgh; medical missions
in Glasgow; the medical work of medical missions; opportunities provided for women;
how medical missions work was justified against criticisms; differences between
providers; the response to provision from the Catholic immigrant community, and the
work of the St Vincent de Paul Society.

iii
Prologue: The historical continuity of domiciliary medical care
One morning in April 2007, musing on this thesis, I heard a radio reporter announce that
as part of a larger maternity services shake-up within three years every pregnant woman
1
in Britain was to be automatically offered the choice of a home delivery. This, it was
said, represented a volte-face in British medical policy. Later, reading coverage of the
announcement in the morning press, it quickly became apparent that this proposal was
marked not so much by change or advance but rather by return, and the continuity of
ideas and concerns about the safety, supervision, efficacy and efficiency of all forms of
2
professional home medical visit, maternity and otherwise. Maternity services are not the
point here, as this is not a thesis about midwifery (which as a unique form of home-based
service has a distinct history). Rather what are of interest are the commonalities that have
guided attitudes to all forms of medical domiciliary care and that underpin these debates.
Debates weighing advantages against disadvantages in domiciliary services, in Britain, go
back over more than a century. Thus under the headline “Women ‘not told of home births
risks’,” paraphrasing concerns attributed to the professor of obstetrics and gynaecology at
Leeds General Infirmary, a Daily Telegraph correspondent ran through a familiar series
3
of pluses and minuses attendant with all forms of home medical care. The journalist,
Womack, quoted that ‘home births were at least twice as likely to result in foetal death as
hospital births, even for women considered at low risk’. Home delivery as home
treatment meant withdrawal from the hospital and the security of immediate specialist
supervision: ‘I don't think women are being fully informed about the risks. All the safety
of pregnancy we have achieved in the last 50 years has depended on the ready availability
of intervention where necessary’. This was countered by a spokesperson from the Royal
College of Midwives, who contrarily suggested that: ‘there is some evidence to show that

1 rd
Talksport Radio (3 April, 2007).
2
Lindsay Reid, ‘Scottish Midwives 1916-1983: The Central Midwives Board for Scotland and Practising
Midwives’, unpublished PhD thesis (University of Glasgow, 2003), p. 2: ‘On the eve of the 1915
[Midwives] Act… most births (estimated at 95 per cent) of both the rich and the poor took place at
home…’
3
Professor James Drife, former vice-president of the Royal College of Obstetricians and Gynaecologists,
rd
paraphrased by Sarah Womack, ‘Women ‘not told of home births risks’’, The Daily Telegraph (3 April
2007), viewed via on-line edition <
rd
http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/04/03/nbirths03.xml> [accessed 3 April,
2007].
iv
for very low risk women, a home birth may be safer than a hospital birth’. Infection and
control were not the only issues in the balancing of the home and the hospital; cost was
another. Womack quoted other ‘experts’ that such a proposal, if carried through, would
prove entirely impractical for it would stretch the current health service beyond
achievable capacity. Jim Thornton, professor of obstetrics and gynaecology at
Nottingham, was quoted suggesting that such a move towards home deliveries would
prove a major financial drain on limited NHS resources. In announcing the shift towards
home care, health minister Ivan Lewis stated that just two per cent of hundreds of
thousands of births in England each year currently occurred in the home. His comparison
was Holland, where one- third occurred in the home. The government, in announcing the
initiative towards greater domiciliary services, made great play that treatment in the home
was a patient-centred initiative, one that promoted choice. The subtext here was that even
after a century of the primacy of the idea of the hospital as the safest, most controlled and
most scientifically successful arena in which to conduct medical procedures, given
choice, many mothers (like other patients) might still preferred delivery (like other forms
of medical treatment) at home.

Medical home visits as potentially dangerous (because transacted outside the orbit of a
specialist, supervised, high technology structure of the hospital) yet conversely a
potentially safer prospect (because of a parallel reduced exposure to virulent infections
found on wards); as potentially expensive (because requiring a high number of personnel
capable, willing and duly incentivized to man the visitation service) yet also potentially
money saving (reducing need for large scale capital investment); as diverting and time-
consuming and contrary to modern rounds of routinized, rhythmic practice yet something
that might be preferred over hospital stay by many patients if just given the choice; and
home visits also as a battleground between the vested interested of hospital practitioners
(reluctant to cede control over any ‘medical’ procedure) and other medical and
paramedical agencies: this thesis will show that there is nothing new in these arguments.

This mention here of debates surrounding the reintroduction of domiciliary-oriented
maternity services is merely to advance a broader point. It is one of the main arguments
v
and justifications of this thesis that assessment of all forms of domiciliary medical care
shows that the topic is marked by great thematic and historical continuity in terms of
advantages that are deemed to accrue by it and the frustrations that are faced in
implementing any such service. This is a salient point at a time when it seems that the
value and role of the domiciliary care is once again under review on various fronts: home
births seem set for a comeback, general practitioner visitation work has been under much
review in Scotland, sparked by fears of a declining out of hours call-out service; hospital
‘super-bugs’ are rarely out of the news, leading to constant revision of domiciliary-based
alternatives; and notions of a ‘fifth wave’ is refocusing the attention of various public
health officials on the value of ‘holistic’ or whole-person medicine that involves
knowledge of the patient’s health status in the broader context of their everyday home
environment.

Four decades ago, during a time when the special role of general practice within medicine
was being reasserted, Thomas McKeown and C.R. Lowe wrote on the pros and cons of
medical home visitation in a larger study of Social Medicine, noting that: ‘Care at home
had long been a feature of medical practice in Britain. Yet some people believe that it is
4
wasteful of the doctor’s…time.’ For McKeown and Lowe, whilst domiciliary care can
be a wasteful use of precious time, especially in homes inadequately resourced for
treatment of patients, visits by medical practitioners still have advantages. Visits can be
economic (as they require no physical plant infrastructure); they can be used to support
and draw pressure from hospital services; they can be good for determining trivial cases;
they are necessary for the most chronically sick and infirm; they are a useful addition to
the arsenal of measures employed in tackling infectious disease; they are a useful as a
mechanism to support relatives caring and convalescing for house bound patients; they
provide a platform for provision of a range of additional support services for patients, and
in determining extra-medical requirements; they help establish a personal link between
doctor and patient and thus enable said doctors to exert a greater domestic influence; and

4
Thomas McKeown and C.R. Lowe, An Introduction to Social Medicine (Oxford and Edinburgh:
Blackwell Scientific Publications, 1966), chapter 17: The home.
vi
home visits by practitioners can prove essential in the process of building up a sickness
profile of patients.

Discussing forms of home treatment in another context, a recent witness seminar of
eminent Scottish geriatricians also has lamented the ‘lost art’ of domiciliary visitation, in
5
sharp decline in that discipline since the late 1970s. Drawing on collective personal
experiences from medical visits carried out across Scotland between the 1960s and
1980s, variously the gathered doctors aired many of the pros and cons that had attached
to the system and to the experience of visiting patients (many of whom were poor). Home
visits, it was said, provided medical practitioners with ‘fantastic experience,’ with
‘noteworthy incidents,’ and opened them to ‘the full spectrum of things’. They provided
greater insight into the humanity of patients, poverty and the human condition, into how
illness manifests in everyday life, and how well equipped or otherwise were different
patient groups to cope with and manage their illness. Visits provided lessons in
practicality; they provided introduction and variety; and taught young doctors
resourcefulness, and how to ‘expect the unexpected’. They provided crucial aspects of
training, exposing young practitioners to ‘a florid pathology,’ and taught them how to
‘take histories on patient’s turf’. They thus improved negotiation and communication
skills, essential to the management of patients’ expectations. Although the concentration
of much of the resources of medical profession might be on acute cases, home visits
provide important and easily under-valued care service, as well as a logistical solution for
management and treatment of chronic, bed-ridden and terminally sick patients (not easily
catered for outside the home). Home visits assist over-capacitated services. It was
recalled that they were as much social as medical visits. They provided valuable
opportunity to reinforce and reassure families coping with illness. The experience of
home visitation was that some therapies were anyhow, in fact, better administered in the
home. Cons highlighted, on the other hand, included the fact that the attitude of those
visited is not always positive to the visiting doctor (being shaped by the sum total of

5
‘Domiciliary Visiting by Geriatricians: The Good Old Days?’ a witness seminar held at the Centre for the
th
History of Medicine (University of Glasgow, 4 May 2007). Arranged by Dr Keith Beard and Dr Malcolm
Nicolson (with joint publication due on the event) and recorded by the Royal Society of Physicians and
Surgeons Glasgow. Key speakers included Dr J. Davie, Dr W. Reid, Dr M. Roberts and Dr D. Kennie.

vii
experiences with officialdom including - on poor estates - the police, the clergy, other
social services, and bailiffs). Visiting medical personnel faced adverse and sub-standard
home conditions and domestic arrangements, and an in-ability to utilise latest, costly ‘big
machinery’ medical technology. They faced a ‘huge number of frustrations’: in co-
ordinating and supervising services; in synchronising with other medical personnel
during chaperoned or shadowed consultancy visits; in navigating difficult terrain to find a
home on drab and dangerous estates; and, more simply, the frustration of many times
failing to gain access and finding time wasted. There are ever-present problems of
transportation; of preserving physical security; and (in total) the problem of simply
justifying what often feels like an impractical use of limited time, energy and medical
resources.

This is the echo of history. A historical understanding of domiciliary medical care in a
specific historical context – such as provided here – can yield valuable lessons and serve
as counter-point to contemporary discussions (particularly at a time when national health
services are under such sustained pressure and constant review, and all sides of the
political debate seem to agree on but one thing, that the patient should be central). Whilst
the value to medicine of a domiciliary service has never seriously been in doubt amongst
medical professionals of different ages, attitudes towards it, due to attendant difficulties
in delivering it, have often been rather ambiguous; and the time and energy element have
often meant that it is the first service done away with when services become
overstretched. Historians, unlike medics, less ambiguously, have mostly tended simply to
ignore the subject.
viii
Contents Page
Abstract ii
Prologue iv
List of Tables and Figures xi
List of Appendices xiv
Abbreviations xvii
Introduction 1
Plan 13
Sources 26
Chapter 1: Setting the Parameters
1.1 A literature of home visitation 29
1.2 The homes of the poor of Glasgow and Edinburgh 44
Chapter 2: Public Provision – the Poor Law Medical Services
2.1 Medical relief and the Poor Law Act (Scotland) of 1845 52
2.2 The outdoor parochial medical services of Glasgow and Edinburgh 66
2.3 Local management and the medical sub-committee (MSC) 79
2.4 Re-profiling the Parochial Medical Officer (PMO) 90
2.5 Workloads; salaries; and locum tenens 108
2.6 Medical cases, medical treatment, and Applications for Relief 120
2.7 Conclusion 133
Chapter 3: Private Provision – Medical Charity
3.1 Medical charity and home visitation of the poor in Glasgow
and Edinburgh – a prospectus 136
3.2 Edinburgh’s outdoor medical charity services 162
3.3 Glasgow’s outdoor medical charity services 180
3.4 Charity dispensary, domiciliary medicine and medical education 188
3.5 The Fourth International Home Relief Congress, in Edinburgh,
June 1904, the treatment of tuberculosis, and infant-mother welfare 212
3.6 Conclusion 225
ix