Historical context leading to Marjory Warren’s life work
The chain of events connecting care of older people a millennium ago with Marjory Warren’s assessment of 874 inmates of a large public assistance institution in West Middlesex in 1935 is lengthy and advanced sporadically. Fortunately, acceleration occurred in the mid-Victorian era stimulated by social unrest; passionate efforts of philanthropists and activists; and receptive governments.
The explanations for the public turmoil in the 1800s are complex. The population was increasing, with a shift from rural to urban areas to take advantage of industrialisation and better pay. Meanwhile, unemployment was rising, precipitated by demobilisation at the end of the Napoleonic wars. In the countryside, abuse of the tithe system, mechanisation of farming methods and falling wages, which culminated in the Swing riots, dismayed agricultural workers. Workhouse scandals in the 1840s, such as Andover and Huddersfield, alerted public concern. In the 1860s, a review of Metropolitan workhouses revealed buildings unfit for purpose, were badly lit, clearly overcrowded, poorly ventilated and lacked satisfactory sanitation.
The workhouse scandals revealed poor nursing standards. Untrained, usually illiterate female inmates, symbolised by Dickens’ Sarah Gamp, provided nursing care. Florence Nightingale responded with ABC of Workhouse Reform, which advocated separating the sick, insane, infirm, aged, children and others from remaining workhouse inmates. She established a training school for nurses in London, and introduced them into the workhouse system. Louisa Twining, a member of the tea family, joined the crusade and founded the Workhouse Nursing Association to promote suitable training for workhouse nurses.
Medical input into the workhouse was unedifying. Not until the 1843 Poor Law Amendment Act were Unions obliged to appoint properly qualified medical doctors. The meagre salary, which had to be used to pay for patient medication, deterred applicants. Appointments were made by competitive tender, which often resulted in the least qualified doctor submitting the lowest bid. In 1855, Dr. Joseph Rogers, medical officer at the Strand Workhouse, described unsatisfactory conditions, poor medical and nursing care with beds so close together that inmates had to get out at the ends rather than the sides.
Matters came to a head in the 1860s when gross neglect caused two deaths in infirmary hospitals. In 1865/66, the Lancet Commissioners reported that the ‘infirm’ workhouse inmates led a life like a vegetable, except that it preserved the doubtful privilege of sensibility to pain and mental misery. Florence Nightingale pressurised the great and the good to modernise workhouse nursing and won support from Dr. Rogers, Sir Edwin Chadwick of the Poor Law Commission and the Workhouse Visiting Society. Their combined efforts resulted in the 1867 Metropolitan Poor Act, which separated the Poor Law’s medical function from its social care. New workhouse infirmaries were built with improved medical and nursing care, upgraded ventilation, and patient space. Separate hospitals for infectious diseases and asylums for those with mental problems were constructed. Meanwhile, philanthropists such as William Armstrong, George Cadbury and Lord Rowton were building new accommodation for their workers and the homeless.
In 1929, the Local Government Act, presented to parliament by Neville Chamberlain, abolished the system of Poor Law Unions in England and Wales together with their boards of guardians, transferring their powers to local authorities. In 1944, Lloyd George, Prime Minister 1916-1922, added his mellifluous Welsh voice to the campaign for change:
‘A nation that lacks gratitude to those who have honestly worked for her in the past while they had the strength to do so, does not deserve a future, for she has lost her sense of justice and her instinct of mercy.’
Marjory Warren’s intervention
Thus, the strands of progress merged and presented Marjory Warren with her life’s work. In 1935, the West Middlesex Hospital took over the adjacent workhouse, previously administered by Middlesex County Council, and appointed Marjory Warren, then assistant medical officer, to assess/re-organise care of the 874 inmates. She discovered sixteen maternity patients, 144 ‘mental observation’ inmates, and 200 elderly or destitute able-bodied workers, who did not need a hospital bed. She examined and treated the remaining 514 patients, discharged many, gradually reducing her bed requirements and emptying three wards for use by physicians.
Three pioneers joined her crusade: Trevor Howell, Lionel Cosin and Eric Brooke. Howell established thriving research and geriatric units at St. James’, Balham; Cosin, originally a surgeon, concentrated on rehabilitation and created the first geriatric day hospital in Oxford; while Brooke established a geriatric unit at St. Helier Hospital, Carshalton. Ministry of Health officials, Dr. Edwin Sturdee and Lord Amulree, liaised with them. They had to solve the problem of 70,000 hospital beds occupied by chronic sick patients. Their continued presence would seriously impede the nascent NHS.
The Medical Society for the Care of the Elderly
Sturdee strongly encouraged Howell to bring the pioneers together. A meeting took place at St. John’s Hospital on September 26th 1947. Those present included Lord Amulree, Sturdee, Warren, Brooke, Cosin, Drs. Tom Wilson, and Alfred Mitchell. A purely medical society, the Medical Society for the Care of the Elderly, was instituted. Sir Ernest Rock Carling was proposed as President but when he declined, Lord Amulree accepted the post. Wilson became Treasurer and Howell Secretary.
Enlightened doctors, many demobilised from the armed services, joined the speciality. These included John Agate, Sir Ferguson Anderson, Philip Arnold, Tony Clark, William Davison, Hugo Droller, Wilfred Fine, Norman Exton-Smith, Oscar Olbrich, Thomas Rudd, Joseph Sheldon, John Wedgwood and Lyn Woodford-Williams. Their problems were immense. They had many hundreds of inpatients, usually scattered in several hospitals, with hundreds on waiting lists. They lacked investigative facilities, modern hospital accommodation and faced entrenched hostility from fellow doctors, administrators and the public. Medical and nursing staffing was deficient. To cap it all, patients occupying chronic sick beds considered they had a bed until they died! Fortunately, philanthropic organisations, such as the Nuffield and Ciba Foundations, were on hand to support research in geriatric medicine and gerontology.
Today, the fact that older people with complex co-morbidities form a substantive group among those admitted to hospital is well recognised, along with the understanding that this will be a growing challenge in the context of the world’s ageing population.
Many young doctors relish the considerable benefits in terms of independence and quality of life, that small changes to an older person’s medical care can bring. They enjoy the complexity of geriatric medicine, with its scope of multi-disciplinary involvement and the holistic challenges in prescribing and balancing the medical and social care aspects of many older people’s treatment.
This brief review of the historical background has necessarily omitted many individuals and truncated significant events. Shakespeare phrased it much better: ‘Thus far, with rough and all unable pen, our bending author hath pursued the story, in little room confining mighty men’.
So, as we celebrate 70 years progress, with BGS membership swelling from a handful of doctors in 1947 to over 3,000 multidisciplinary worldwide members today, and a burgeoning Age and Ageing journal, let us remember the words of Lord Amulree, who said what we are trying to do is to ‘Add Life to Years’. It was relevant when he said it and is applicable today.