History of geriatric medicine in the UK: historical background
In medieval times, sick people were cared for in monasteries. Some religious orders built hospital wings where elderly and infirm patients received better food and received special care. Later, convents adopted a nursing role.
Poor Laws were passed in Parliament in 1597 and 1601 to keep the “poor” off the street, and avoid vagrancy and possible lawlessness. The Poor Law system became a regime which provided not only for those without money, but also provided accommodation to those who were ill, chronically sick, single parent families, and orphans. Workhouses (later renamed poorhouses) started in the 1630s and by the end of the 1700s they had become asylums for the old, infirm, and insane. The conditions within were appalling and very harsh. At the time, poverty was believed to be associated with a decline in moral standards.
Thus individuals in poorhouses were prejudged and treated unfairly. Many more poorhouses were built in Victorian times under the 1834 New Poor Law, to curtail public spending on poverty. Until 1834 individual parishes were responsible for their own poor. Parishes were united after 1834 and larger workhouses were known as unions; there were about 700 such institutions. The editor of the Lancet campaigned for improvements within poorhouses. (A previous editor had famously described the workhouse wards as “ante chambers of the grave.”) Joseph Rogers, a reformer of workhouses throughout his career as a doctor, gave advice on the conditions in Victorian workhouses. “Workhouse medicine” failed its occupants; there was no casualty provision, no trained nursing staff, no drugs, and no surgical facilities. Conditions gradually improved for the inmates and laws were passed to safeguard their wellbeing.
The Poor Law ended with the Local Government Act of 1929. However, a two tier system of hospital care evolved. Power was transferred to local authorities who ran the infirmaries which developed from workhouses. Other hospitals were voluntary establishments, which enjoyed higher status and preferred not to admit older people. Elderly patients were considered as being of less interest for teaching and it was feared that they would block beds. These voluntary hospitals became the first teaching hospitals. The care of older people took place in former poor law hospitals, where staffing levels were poor and facilities inferior.
A Barton, G Mulley
Extract courtesy of the Postgrad Med J2003; 79:229-234 doi:10.1136/pmj.79.930.229