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Sutton, David A. (2009) the Public-Private Interface of Domiciliary Medical Care for the Poor in Scotland, C. 1875-1911. Phd Thesis

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Sutton, David A. (2009) the Public-Private Interface of Domiciliary Medical Care for the Poor in Scotland, C. 1875-1911. Phd Thesis 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/ [email protected] 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 in Britain was to be automatically offered the choice of a home delivery. 1 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 professional home medical visit, maternity and otherwise. 2 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 of pluses and minuses attendant with all forms of home medical care. 3 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 Talksport Radio (3 rd 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, paraphrased by Sarah Womack, ‘Women ‘not told of home births risks’’, The Daily Telegraph (3 rd April 2007), viewed via on-line edition < http://www.telegraph.co.uk/news/main.jhtml?xml=/news/2007/04/03/nbirths03.xml > [accessed 3 rd 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
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