Introduction
Soon after the signing of the 1921 Anglo-Irish Treaty and establishment of the new independent southern Irish Free State in 1922 the country’s new leader, W.T. Cosgrave, outlined his vision for welfare and health care. He stated that the best sign of a true civilisation was how it treated its less well off and that ‘the condition of a nation’s poor indicated the character of the national mind’. Speaking of the on-going poor law reform, initiated during the Irish revolution (1919–21) and continued in the early years of the Free State, Cosgrave believed that ‘the new schemes …will be administered prudently and humanely, and that these schemes will win for themselves the confidence of the people’.Footnote 1 This article concentrates on poor law hospital provision and examines the extent to which Cosgrave’s claims materialised in the first decade of Irish independence.
While the poor law system in nineteenth and early twentieth century Ireland has been the focus of much recent historical research, its transformation in the post-1914 period has received limited attention.Footnote 2 Historical examination of medical provision in early independent Ireland has largely concentrated on administrative reforms undertaken in local government.Footnote 3 These insights provide the administrative, bureaucratic and political context for understanding the development of welfare provision. However, such work does not engage in recently developed historiographical debates, particularly evident in a British context, which have yielded fresh perspectives. Recent studies have focused on voluntary and municipal authorities in inter-war Britain and concentrated on various themes including health care economics, integration of services, regional trends in standards, levels of usage and party political influence on local health care.Footnote 4 Workhouse hospitals and poor law authorities have received less attention during this era, although recent work has explored the introduction of the 1929 Local Government Act in England and Wales, and the slow erosion of the older poor law principle of ‘less eligibility’ and the continued stigma associated with former poor law infirmaries.Footnote 5 This article contextualises the Irish experience within such wider understandings of health care and medical relief.
The reforms of the poor law undertaken in the first ten years of the Irish Free State are largely viewed as a failure.Footnote 6 One leading Irish historian, J.J. Lee, sardonically noted that these measures merely substituted an ‘odious and foreign scheme’ with an ‘odious and native’ one.Footnote 7 The financial insecurity of the nascent Irish Free State meant that health care and welfare were of secondary importance to cementing national independence. Also, the achievement of ‘economies’ and fiscal liberalism influenced the policies of the Cumann na nGaedheal government.Footnote 8 This contrasted with the Fianna Fáil government that came to power in 1932 and prioritised welfare reform.Footnote 9 It also oversaw the development of Irish hospitals with finance raised through the Irish Hospitals’ Sweepstakes lottery.Footnote 10 However, the break-up of the poor law system under the Cumann na nGaedheal government did represent a significant attempt at reform and predated the introduction of similar measures in the UK. The reforms amounted to the first formal break from the New Poor Law that was established initially in England and Wales in 1834 and in Ireland in 1838.
This article also concentrates on voluntary hospitals. The 1920s witnessed growth in patient fee-payment for hospital provision in Great Britain and Ireland. It has previously been highlighted that accessibility for the sick non-paying poor to such hospitals was at times limited.Footnote 11 This article examines how fee-payment influenced entitlement to voluntary health care and led to a demarcated system between the voluntary hospitals and former workhouse infirmaries. Such explorations contribute to understandings of not only the Irish case but also to the wider comparative literature on Great Britain and Western Europe.
Workhouse Infirmaries in Pre-independent Ireland
Irish Poor Law medical provision was transformed under the 1862 Poor Law Act, which opened Irish workhouse infirmaries to the general sick poor and no longer confined them to the destitute classes.Footnote 12 The act essentially established a hospital service for the poor law dispensary system that was set-up initially in 1851 and provided outdoor medical relief to the Irish poor.Footnote 13 The network of over 150 workhouses ensured that poor law infirmary provision far exceeded the other types of hospitals, mainly the county/city infirmaries and the voluntary hospitals. This was demonstrated in the 1906 Vice-Regal Commission on the poor law in Ireland. Between December 1904 and November 1905 workhouse infirmaries admitted a total of 79,800 patients. Of this figure 33,836 cases were classified as acute, 21,427 as chronic and 2,366 received midwifery services. Surgical attention was needed in 22,178 cases.Footnote 14 6,446 cases were tuberculosis or phthisis patients and another 5,635 received treatment for infectious diseases in workhouse fever wards.Footnote 15 This greatly exceeded the number that attended county/city infirmaries, which were the second most prominent type of Irish hospital. During 1905 county/city infirmaries treated 15,489 medical cases of which the vast majority were acute and a mere 917 chronic patients.Footnote 16 By the early twentieth century workhouses were central to the Irish poor’s health care and provided much of the acute, chronic and surgical medical services in local communities.
Although the poor law in Ireland was traditionally viewed unfavourably, advances were evident in the standard of care in many workhouse infirmary wards. The controversial issue of untrained pauper and inmate nursing had begun to be addressed in 1897 after the Local Government Board issued an order forbidding the practice.Footnote 17 By 1912 it was reported that 253 trained nurses and 361 sisters were engaged in workhouse nursing.Footnote 18 Some workhouses in larger urban areas such as in Belfast and Waterford began to train nurses.Footnote 19 By the 1910s the union infirmaries in Belfast, Cork and Galway also provided clinical training for student doctors.Footnote 20 The emergence of the large union hospitals as institutions for clinical instruction provided additional income from trainees’ fees. Involvement in medical education also led to a deeper relationship between the poor law and the medical profession; a trend mostly associated with the more prestigious voluntary sector.Footnote 21 Local provision, however, greatly varied and standards often depended on investment by boards of guardians. The 1898 Local Government (Ireland) Act provided poor law boards with loans for improvements to workhouse buildings from central government. Investment often determined the popularity of workhouse infirmaries within communities. The Kinsale workhouse infirmary in County Cork was considered popular amongst the poor after the local guardians upgraded the institution in the early 1900s.Footnote 22 Other poor law boards, such as Westport in the poor County Mayo, failed to invest and by the 1900s many were close to dilapidation.Footnote 23 The 1898 Act also provided for the conversion of workhouses into district hospitals under the management of boards of governors. This effectively allowed for the separation of hospital care from the poor law. The legislation was permissive and by 1919 only a single union – Castlecomer in County Kilkenny – had introduced the measure.Footnote 24 Similar to British circumstances, medical services for the poor were ad hoc and variable in coverage and quality.Footnote 25
One of the biggest criticisms of poor law hospital provision was the mixed workhouse and infirmary model of institution. Ideologically the workhouse system was originally based on the principal of deterrence and conditions were harsh so only the truly desperate would seek relief. In theory the sick poor were not to be subjected to such principles, but in practice they had to pass the workhouse gates and often underwent stigmatising and pauperising experiences including the wearing of pauper uniforms and living under disciplined regimes.Footnote 26 As in England, funding for poor law infirmaries was undifferentiated from the rest of workhouse expenditure and no specific income was set aside to support the workhouse sick or fund the workhouse hospital as a separate service.Footnote 27 Although the more workhouse infirmaries were viewed as institutions for the sick, elderly and infirm the harder it was to justify principles of deterrence; poor law hospital services remained associated with pauperism and poverty.Footnote 28
The separation of medical relief from ordinary relief under the mixed workhouse and infirmary system emerged as a central aim of early twentieth century reform. Such measures were recommended by both the 1906 Vice-Regal Commission on the Irish Poor Laws and the UK-wide Royal Commission on the Poor Law and Relief of Distress, which reported in 1909.Footnote 29 These recommendations were not implemented although the Liberal Welfare reforms of the era – most notably the 1908 Old Age Pension and 1911 National Insurance acts – altered workhouses in Edwardian Ireland. Between 1909 and 1920 the number of daily inmates dropped from 44,027 to 25,531 (see Table 1). The category of aged and infirm, the second largest cohort in Irish workhouses, witnessed the largest decrease. This was partly brought about by the removal of the pauper disqualification for the Old Age Pension in 1909, which according to the Local Government Board ‘had a very marked effect on poor relief statistics’.Footnote 30 The 1909 figure of 14,427 aged and infirm decreased to 5,825 in 1920. The leading Irish economic historian, Cormac Ó Gráda, has argued that the ‘impact of the pension on workhouse admissions was of paramount importance’.Footnote 31 Welfare measures introduced during the First World War including the separation and dependents allowances also lessened reliance on poor relief. Similarly, the wartime migration of labourers to Britain led to the ‘consequent opening for employment for the less fit’.Footnote 32 The number of sick inmates also decreased – albeit at a much lower rate than the aged and infirm – from 15,602 to 13,205. By 1920, 51.3% of inmates were categorised as sick compared to 35.4% in 1909. The primary function of Irish workhouses had become the delivery of health care.
Table 1: Categories of inmates in Irish workhouses on 31 March 1909–20. Source: These statistics are derived from the Local Government Board Annual Reports.
The 1911 National Insurance legislation was only partly introduced in Ireland. Under the Irish legislation insured workers were entitled to cash-benefits payable during sickness and a specific benefit for sanatorium treatment for tuberculosis sufferers. As in Great Britain, general hospital attendance was not included for the insured. Other restrictions on Irish insurance schemes existed. The prevalence of the dispensary system and opposition from the Irish Parliamentary Party and the Catholic Church towards increased taxation prevented the introduction of the legislation in its entirety in Ireland.Footnote 33 British medical benefits, including access to panels of doctors and medicines for the insured, were not extended and the Irish sick remained reliant on dispensary doctors or private practitioners for medical attention outside hospitals.Footnote 34
Reforms of the Poor Law in the Irish Free State
Momentous political events were soon to transform Ireland. The electoral rise of advanced nationalism and Sinn Féin in 1918 and the subsequent armed republican guerrilla campaign against British rule led to partition and the establishment of the independent Irish Free State and Northern Ireland, which remained in the United Kingdom. The Irish Free State brought about extensive reform of the poor law hospital service. Responsibilities for public medical services came under the newly created Department of Local Government and Public Health (hereafter DLGPH).Footnote 35 This process was initiated during the Irish War of Independence (1919/21) and continued after the establishment of the Irish Free State. Boards of guardians and poor law unions were disbanded and replaced by boards of public assistance and health, which were sub-committees of County Councils.Footnote 36 Acting along the 1906 Poor Law commission recommendations, a county home was established by each local authority for relief of the aged, infirm and chronic sick. In theory, certain categories of inmates, including ‘harmless lunatics’, ‘unmarried mothers’ and children, were to be relieved in separate institutions or boarded out; in practice these people were often relieved in county homes. County hospitals provided medical services including surgical facilities for each county. Many of the previously semi-independent county infirmaries were amalgamated with workhouses under the boards of public assistance and health. A network of district hospitals was also established on former workhouse sites for emergency and less serious medical cases.Footnote 37 These reforms represented the first major attempt to break-up the poor law and the sector’s effective municipalisation in either Great Britain or Ireland. In England and Wales significant reform was not brought about until the Local Government Act of 1929.Footnote 38 In Northern Ireland the 1927 recommendation of widespread poor law reform by the Departmental Commission on Local Government Administration was not forthcoming and the system remained in place until 1948.Footnote 39 However, a number of local authorities utilised the existing legislation and by 1938 eleven workhouses in the northern Irish state had been converted into district hospitals.Footnote 40 Others such as the Belfast workhouse had developed primarily into health care institutions and only provided limited ordinary relief to the able-bodied.
The right of the poor to medical relief in the new Irish Free State was reaffirmed. Those that were entitled to relief were defined as ‘any person who is unable by his own industry or other lawful means to provide for himself or his dependents the necessaries of life or necessary medical or surgical treatment’.Footnote 41 The DLGPH later claimed that the measures introduced remodelled ‘the system in accordance with Irish ideas’.Footnote 42 The department’s first annual report stated that the ‘main endeavour was to introduce a system of poor relief conforming to the wishes and sentiments of the people and providing efficiently and sympathetically for the needs of the poor’.Footnote 43 The department’s leading medical advisor, Dr E.F. Stephenson, stated that the ‘first aim [was] to have improved treatment for the sick poor’.Footnote 44 The Irish Free State’s attempt to provide assistance free of the pauperising poor law was reflective of wider attitudes towards welfare throughout Europe. In Britain the labouring classes were increasingly viewed as an important national resource deserving of non-stigmatising provisions. Reformers such as Beatrice and Sidney Webb widely articulated the need to break-up the poor law.Footnote 45 Similar objectives were behind German reforms in the 1910s and 1920s.Footnote 46 The spread of social democracy and the labour movement also led to the realignment of the welfare debate.Footnote 47 The right to welfare and health care was viewed as an important aspect of citizenship in an ever increasing political community of everyday people brought about by franchise reform.Footnote 48 The rhetoric of the new Free State resonated with such transnational attempts to dilute the nineteenth-century principles of deterrence that underpinned many poor relief systems.
Despite the desire to break-up the poor law, the National Health Insurance schemes were not extended during the early years of the Irish Free State. A 1925 government inquiry recommended the introduction of medical benefit to contributors. However, such measures were not introduced in Ireland until 1942.Footnote 49 While medical benefit including insurance for hospital attendance was not compulsory, local Friendly Societies could provide such cover on a voluntary basis. In practice this measure was limited and in 1927 a mere £32,135 out of a total expenditure of £628,498 on National Health Insurance went on non-cash payments including hospital-benefit.Footnote 50 Payments for sickness, disability and maternity cases made up the vast majority of health-related expenditure under national insurance legislation in Ireland. The lack of extended medical benefits in the Irish Free State contrasted with the French experience where extensive reform was introduced with the 1928 health insurance law, which covered up to a third of the French population with hospital and sickness insurance, and in Northern Ireland where medical benefit for insured workers was also introduced.Footnote 51 In southern Ireland the link between insurance and health services was weak and in contrast to Great Britain mutualism was not a major feature of Irish health care or hospital practices.Footnote 52 The limited development of social security ensured that health care remained based on a relief-type system in southern Ireland.
Case Study of Cork City and County Kerry
To examine the effectiveness of the reforms this article concentrates on case studies of two regions – County Kerry and Cork City. County Kerry had a largely rural economy with many of its 149,171 inhabitants in 1926 dependent on agriculture.Footnote 53 Much of the region was economically poor – particularly along the seaboard – and marked by a small farm economy. A general unskilled labourer class was prominent in the county’s towns. A more prosperous class of middle-to-large farmers in the countryside and shopkeeper/publican traders in the towns and villages was also common. After the reforms the medical services in Kerry consisted of the county hospital in the largest town, Tralee, which was on two separate sites and a combination of the former workhouse infirmary (acute and chronic cases) and the former county infirmary (surgical cases). District hospitals were established solely for non-surgical medical cases in the towns of Dingle, Kenmare, Listowel and Caherciveen; all former workhouse buildings. The district hospital in Killarney was also the county home, which acted as a centralised institution for ordinary relief cases.Footnote 54 There was not a large enough middle-class to sustain any general or specialist voluntary hospitals in Kerry besides a small cottage hospital on the remote Valentia Island. Large voluntary hospitals did exist in the neighbouring cities of Limerick and Cork and the sick from Kerry – particularly those that could afford travel costs and medical fees – often attended these hospitals.
Cork was the second largest city in the Irish Free State. The Cork County Borough had a population of 76,673 and the county in general had 365,747 inhabitants in 1926. As in most Irish and British provincial cities, a well-established voluntary hospital sector existed in Cork. Specialist institutions included a maternity and lying-in hospital; an eye, ear and throat hospital, and a fever and recovery hospital. General voluntary hospitals in the city included the Mercy, which was controlled by the Catholic religious Mercy Order, and the Victoria Hospital whose origins lay in the Protestant philanthropic tradition. Other general hospitals included the North Charitable Infirmary and the South Charitable Infirmary; these were semi-voluntary and received an annual grant from local government although the majority of their income came from charitable sources and they remained independently controlled. The total number of voluntary hospital beds in the city was circa 800.Footnote 55 The former workhouse and local authority institution – renamed the Cork County Home and District Hospital – was the largest hospital in the city and had 800–900 sick beds.Footnote 56 Many of these were for chronic long-term patients and it was estimated that merely 150 beds were designated for the acute sick.Footnote 57 The institution also acted as the county home and provided for 400 individuals in receipt of ‘ordinary’ relief. The Cork District Hospital and County Home was one of the largest institutions in the country and provided medical and poor relief to a daily average of around 1,200 people.Footnote 58 The centrality of the former workhouses to the life and death of the sick poor was demonstrated in 1926 when 18.5% of all deaths in Cork City were recorded in the institution. At a national level the rate was 14.6%.Footnote 59 In both County Kerry and Cork City the reformed poor law was the largest provider of hospital provision.
These case studies provide examples of the development of health care in two differing contexts. Cork City allows for an examination of an urban region that has not received attention to date. The large voluntary sector in the city provides insights into issues including the relationship between rate-aided and charitable hospitals; entitlement to and accessibility of voluntary hospitals, and the place of fee-payment in Irish health care. Cork City was representative of other urban areas in Ireland including Limerick and Dublin and many provincial British cities, which had both poor law and voluntary hospitals. County Kerry provides an example of a largely rural county where limited voluntary hospital provision existed; the county illustrates the challenges to health care development not only in the Irish countryside, but also in less densely populated and poorer rural regions generally.
Although a major objective of the reforms was to separate medical and hospital services from ordinary relief, the mixed workhouse and infirmary model continued in the institutions designated as county homes and district hospitals. Able-bodied inmates were removed from county homes, yet the institutions continued to provide for the the aged and infirm; children, and the destitute mentally ill or ‘lunatic class’. In Cork the lack of classification was highlighted during the government commission on poor relief which published its findings in 1927 [hereafter this will be referred to as the Commission of Sick Poor].Footnote 60 The Commission of the Sick Poor complained that the Cork district hospital and county home was not divided into definite and distinct parts.Footnote 61 The lack of segregation between medical and ordinary cases blighted the system not just in Cork, but in many parts of the country and it continued into the 1930s. In 1935 a government inspector complained: ‘generally it can be taken that the infirmary …is administered as an integral part of a county home’.Footnote 62 The same report highlighted that in Cork the ‘sick beds were scattered throughout the whole county home accommodation’.Footnote 63 Lone female parents or ‘unmarried mothers’ who were viewed as immoral continued to be relieved in such institutions. As a result many women refused to use the maternity services in the mixed county home and district hospitals.Footnote 64
In County Kerry, the county home and district hospital in Killarney were in the same building. The separate parts were merely divided by a ward system and makeshift partitions. However, the vast majority of inmates were in receipt of ordinary relief and on 31 March 1930 only thirty-one of the institution’s 441 residents were medical patients. Unlike the situation in Cork City, the majority of local authority medical cases in Kerry were not relieved in mixed hospitals and county homes; on the above date 199 patients were in district/county hospitals that catered solely for medical cases.Footnote 65 Countrywide the picture was somewhat varied. In Waterford the county home was a separate institution and not connected to any hospital and in Tipperary and Westmeath the county hospital and home were in the same building.Footnote 66 The lack of classification had long been a problem in workhouses and the reforms of the Free State failed to eradicate the issue where the county home and district hospital were contained in the same institution.
The precarious financial position of the new state after the upheaval of the Irish war of independence and civil war limited central government funding for the development of local medical services. The ‘troubles’ also left local government bodies with a fresh financial crisis and undermined the ability of local authorities to raise finance.Footnote 67 Many of the county and district hospitals were originally nineteenth-century structures and conditions were decrepit. In 1927 the chairperson of the Kerry Board of Assistance and Health, Kate Breen, believed that the county hospital for all non-surgical cases – formerly the Tralee workhouse – was ‘the most struggling and most miserable place she had ever seen’.Footnote 68 Similar conditions existed in other parts of the country. In Waterford City the Commission of Sick Poor reported that the ‘county hospital is located in a cheerless environment of old dilapidated structures’, and that the county hospital in Roscommon ‘cannot be deemed a suitable place for the treatment for the sick’.Footnote 69 In other areas conditions were somewhat better and county hospitals in Galway, Meath and Wexford were highlighted for praise in the commission’s report. Similar to previous experiences under the poor law; local and regional variation marked the standard of rate-aided medical care.Footnote 70 Overall the lack of substantial financial investment in former workhouse buildings hindered the development of these hospitals during the 1920s.
The most successful measure adopted in the Free State reforms was the reduction of non-medical classes in the former workhouses. On 1 October 1913, 26,761 inmates were recorded as resident in workhouses in the twenty-six counties that would become the Irish Free State. By 31 March 1927 this was reduced to 17,281 and the number on outdoor relief increased from 14,663 to 23,649.Footnote 71 Such a shift suggests that former workhouse inmates were now in receipt of assistance in their homes. The reforms helped to increase the popularity of the county and district hospitals. Notwithstanding the continued mixing of classes in some institutions, the majority of local authority hospitals were now designated solely for medical and surgical cases. Between 1926 and 1929 the annual number of patients rose from 51,880 to 58,105 indicating the system’s gradual growth.Footnote 72 In County Kerry this trend was apparent. During 1924 a total of 1,899 admissions were recorded in the six Kerry hospitals. By 1927 this had increased to 2,385 and by 1930 2,710.Footnote 73 Hospitals which provided solely for the acute sick witnessed the largest increase. The county hospital in Tralee had a rise in admissions from 757 in 1924 to 912 in 1930. Similarly the Caherciveen District Hospital witnessed an increase from eighty-one to 172 patients, and the Listowel District Hospital from 238 to 250. These institutions provided acute care and longer term chronic patients were transferred to the county home. In contrast to these trends, the Killarney District Hospital, which was on the same grounds as the Kerry County Home, witnessed a decrease from 425 admissions in 1924 to 299 in 1930.Footnote 74 These figures demonstrate that the mixed hospital/county home type of institution was increasingly unattractive while the other hospitals, which removed all classes of patient besides the acute sick, witnessed a modest growth in numbers.
In County Kerry the district and county hospitals had become somewhat disassociated from the relief of poverty (Killarney notwithstanding) and had the delivery of health care as their sole function. However, in Cork the reforms appeared to have been less effective. As already highlighted, the problem of mixing various types of patients – medical, surgical, acute, chronic, mental and tuberculosis – was particularly prevalent in the Cork County Home and District Hospital. An analysis of the social composition of those that entered the institution from the indoor registers reveals the continued close connection between poverty and rate-aided hospital provision.Footnote 75 Fifty-nine of the 578 patient sample had no residence demonstrating that the homeless or ‘tramp’ class – formerly known as ‘casuals’ under the poor law – still frequently turned to the institution.Footnote 76 A total of 202 patients were recorded as having some form of occupation. The vast majority (166) of this group were cited as labourers indicating that they were largely unskilled. Only twenty-two of the patients were skilled labourers or tradesmen, four were servants and the other occupations included two motor drivers and two ex-soldiers; a single nurse, engineer, merchant, fireman, civic guard (policeman) and coast guard. The majority, 332, gave no occupation on entry and these were largely females or the incapacitated poor. This indicates that the majority of patients in Cork were made up of the poorest classes in the city including the homeless and unskilled labourers. A very small number of skilled workers or middle class patients sought medical attention in the institution.Footnote 77
The length of stay of patients in the institution varied. The majority, 56.8%, stayed between two and thirty days and 8.6% stayed twenty-four hours or less. A substantial portion, 30.9% of the sample, remained for a period of between one and six months while 3.5% stayed beyond half a year.Footnote 78 The average length of stay was thirty-nine days. The differing periods of stay in the institution reflect its multi-functional uses, and the contrasting needs of the various categories of patient. The high prominence of short-stays indicated that many received acute medical and surgical attention along with traditional short-term ordinary indoor relief. The large proportion of longer-stay patients highlighted that the chronic, aged and infectious sick were also relieved in the institution. For many of these longer-term patients sickness and poverty went hand-in-hand.
Of the two case studies the reforms were most effective in County Kerry. The removal of all classes besides the acute sick from the county hospital and the majority of district hospitals made health care the sole purpose of these institutions. This helped to dilute past associations with pauperism and these hospitals witnessed an increase in admissions between 1922 and 1932. However, in institutions that remained connected to the county home – such as in Killarney and Cork City – the mixing of various categories remained a residual problem from the workhouse system. This limited the effectiveness of the reforms leading to a decrease in numbers in the Killarney District Hospital, and the continued predominance of the sick poor in the Cork County Home and District Hospital.
Fee-paying Patients and Changing Notions of Entitlement to Health Care
One of the most significant aspects of the Free State reforms was the amalgamation of the county infirmary and workhouse infirmary systems. Prior to Irish partition thirty-four county/city infirmaries and fourteen county fever hospitals existed. They were run by independent boards of management whose membership included representatives from the county or borough council who partly funded them, and leading local figures such as the clerical hierarchy and charitable subscribers. These institutions did not suffer from the taint of the workhouse and were not associated with destitution; they were acute surgical hospitals and did not provide for the long-term chronic sick. Under the Free State reforms many of these hospitals’ boards of management, including that of the Kerry County Infirmary, were disbanded and authority was placed fully in the hands of local authorities. Such amalgamations represented the expansion of local authority and state health care into a system which was previously largely voluntary. Some city infirmaries including the North and South Charitable Infirmaries in Cork and the Waterford County and City Infirmary maintained their independence from the state.
The merging of these infirmaries with local authority health care brought the issue of patient payment for medical treatment to the fore. Entitlement to medical relief under the poor law was poorly defined. Under the 1862 Act patients deemed capable had to make some financial contribution towards their care in workhouse infirmaries, although the vast majority of patients were too poor to pay. Workhouse medical officials did not receive payment directly from patients. Contrastingly, payment was common in county infirmaries where the leading medical official – the county surgeon – was often part-time and supplemented his income through patients’ fees and private practice. County infirmaries were generally viewed as hospitals for the ‘higher class of wage earner’ who could afford to contribute to their medical treatment.Footnote 79
The reforms of the early 1920s reaffirmed attempts to extract payment from patients. In Kerry on 12 June 1924 a mere seven patients in the county’s hospitals contributed to their maintenance.Footnote 80 The DLGPH wrote to the Kerry board complaining that
there is no machinery devised by which paying patients may be determined, and a large number of patients of each of the hospitals in the county can contribute towards their maintenance when they avail of treatment in our hospitals …patients are sent to our hospitals as the patients of private doctors.Footnote 81
Consequently, the department advised that patients be classed on the basis of the valuation of their property in rural areas and wages, salaries and businesses in urban areas.Footnote 82 The department insisted on means-testing and informed local officials that they should be satisfied ‘that patients being attended …are unable to afford the cost of their maintenance either wholly or partially’ and the clerks of each hospital were informed ‘to inquire into the circumstances of each patient on admission and to keep a separate register of those who could afford to pay’.Footnote 83 In Listowel town, County Kerry, attempts were made to get payment from former patients in the district hospital. Fees ranging from £1 4s to £37 15s were demanded and legal action was threatened against defaulters.Footnote 84 Recipients of medical relief in the Free State were subject to fresh means-testing and the emphasis was placed on the payment of medical treatment where possible.
The focus on fee-payment altered the nature of hospital provision provided by local authorities. In 1925 the DLGPH introduced regulations to govern the place of fee-paying patients in local authority hospitals. Under the order ‘County Hospital (Paying Patients) Regulations’ three categories of patients were to be treated in different wards; those who could contribute fully, those who could contribute in part and those who could not contribute at all. Doctors could also arrange private fees for patients in local authority hospitals, which was not the case under the poor law. Patients could pay for any extras including special nursing, medicines and appliances. This allowed for separate medical provision for patients willing to contribute to their treatment although it was stipulated that if full the poor would get preference.Footnote 85 These measures were previously called for by the medical profession and the Irish Committee of the British Medical Association.Footnote 86 These reforms also provided for different groups that increasingly turned to hospitals for health care. Private patients in private wards were an emerging patient category not just in Ireland but in other countries including Great Britain. This middle-class group was able to pay full medical fees and was catered for in the reformed system. Those who could pay in part were a second group: in urban regions most probably insured skilled workers in regular employment and small farmers and land owners in the countryside. The third cohort remained entitled to free medical care; these included the impotent poor, the unemployed, and unskilled and agricultural labourers.
The motivations behind the introduction of fee-paying wards were outlined by the DLGPH’s chief medical officer, Dr E.F. Stephenson, at the Commission of Sick Poor. While maintaining that the poor had ‘first claim’ to such hospital provision, Stephenson stated:
we think that the people whose money goes to provide those hospitals are entitled to some hospital treatment. When you ask the ratepayers to contribute large sums of money towards equipping and staffing the county hospitals they are entitled to some consideration.Footnote 87
During the commission he was asked whether these measures led to a preference for fee-paying patients and if the poor would be ‘elbowed out’; Stephenson stated that he never knew of such a case. He also believed that separate private wards were necessary as they ‘would avoid comparisons of dietary and treatment. The other way, the poor people will always be suspicious’.Footnote 88 However, there was some evidence that the poor were in competition with those who were willing to pay in some public hospitals. The services of the county surgeon were in high demand and the limited number of surgical beds ensured that waiting lists were reported in many regions including County Kerry. Under departmental regulations the poor had to be seen first, but one of the commissioners – Major Myles, TD (member of parliament) – was unconvinced, claiming that ‘these things [preferential treatment for private patients] are difficult to get at, but these things do happen’.Footnote 89 In the final report the commissioners stated that they received the impression in some hospitals that paying patients were more readily received than the poor.Footnote 90
The emergence of fee-paying patients demonstrated an important transformation in the role of rate-aided hospitals and the terms of entitlement to state health care. Medical care in public institutions was no longer solely for the relief of the poor, but was also to provide a health care service to those who were capable of paying. Leading government officials articulated the rights of such patients, which amounted to preferential treatment including the receipt of quicker and separate treatment from the poor. New terms of entitlement to health care were established with the ability to pay forming important criteria which determined access. The articulation of the rights of those who contributed financially through hospital fees and taxation resonated with wider notions of the ‘citizenship of contribution’.Footnote 91 Those who contributed to their own welfare and to that of the community were to receive a reciprocal set of entitlements. The emergence of such ‘economic reciprocalism’ has been identified as an important aspect of contributory schemes in the voluntary hospital sector in inter-war Britain. Access to such hospitals was to some extent founded on the notion of earning the right to hospital treatment by means of a financial contribution.Footnote 92 Similar concepts relating to entitlement were evident, although not dominant, in the early reforms of the Irish Free State.
Fee-Payment and Voluntary Hospitals
This section of the article concentrates on the emergence of patient fee-payment in voluntary hospitals in Cork City. Admission to the voluntary hospitals was traditionally partly confined to the ‘deserving poor’. In nineteenth-century Birmingham access to the city’s voluntary hospitals was often limited to individuals recommended by subscribers and those perceived as ‘undeserving’ and ill-behaved were occasionally denied medical treatment.Footnote 93 The reciprocal relationship between the receiver and benefactor of charity has been identified as a central dynamic of philanthropy. Those in receipt of such medical relief were expected to some way ascribe to the social, moral and religious norms of the boards of management and subscribers of these institutions.Footnote 94 Little if any historical work on admission policies in nineteenth-century Irish voluntary hospitals has been undertaken. However, the belief that the ‘deserving poor’ should receive medical relief away from the poor law was apparent throughout the nineteenth century and articulated by leading Catholic clergy such as Archbishop Cullen.Footnote 95 Entitlement to medical relief in Irish voluntary hospitals was most probably influenced by attitudes towards the ‘deserving’ and ‘undeserving poor’.
Irish voluntary hospitals – similar to their British counterparts – were better equipped, better staffed and more prestigious than poor law infirmaries and did not suffer from the ‘taint’ of the poor law. However, by the immediate aftermath of the First World War the voluntary hospital system in general was faced with financial crisis. The long-term tendency of hospital expenditure to grow faster than its traditional sources of charitable income was exacerbated by a short-term post-war funding crisis when subscriptions greatly fell off.Footnote 96 This crisis coincided with increased middle-class demand for hospital provision as technological advances in hospital care undermined traditional domiciliary care by private practitioners. In 1920 the president of the Royal Academy of Medicine in Ireland, R.J. Rowlette, highlighted that the drop in subscriptions had led to a greater reliance on fee-paying patients and limited the number of ‘free beds’ in Dublin hospitals.Footnote 97 In many hospitals the rise was very sudden. In the Meath Hospital in Dublin the income received from fees drastically increased from less than £100 in 1913 to almost £4,000 in 1918.Footnote 98 During 1918 the Adelaide Hospital in Dublin received £589 in patients’ fees. By 1931 this had increased to £6,646.Footnote 99 The emphasis on patients’ fees represented a major shift and voluntary hospitals could no longer be regarded solely as charities for the poor.Footnote 100
Patients’ fees were also important to the finances of the Cork voluntary hospitals. Canon Murphy of the South Infirmary informed the Commission of Sick Poor that ‘our funds are entirely inadequate to give free treatment to all who apply’. Admission policies in the hospital ensured that all accident or emergency cases were received. Other patients needed a letter of introduction from a subscriber or from a member of the committee of management to enter and such patients were ‘expected to contribute according to his means’.Footnote 101 Canon Murphy also believed that the South Infirmary hospital catered for ‘the better working class’. He claimed that the sick in the hospital were ‘not patients such as you would find in the union hospital …[and that] a strong sentiment exists among certain classes of the community against going to any hospital to which the taint of the old poor law system is attached’.Footnote 102 This is demonstrated in the lack of patients that were fee-paying and from skilled labourer or lower middle-class backgrounds in the Cork District Hospital’s indoor registers. Other anecdotal evidence suggests that many avoided seeking medical attention in the former workhouse. When plans to amalgamate the North and South Infirmaries with the District Hospital were put to Dr Patrick Gould he believed that ‘the people who contribute voluntarily [to hospital care] would object and would not be associated with the poor law system’.Footnote 103 Such an opinion was reported by the Hospital Commission which investigated hospital provision in the early 1930s. The commissioners stated that they were informed locally that plans to establish a municipal hospital in Cork would not be successful because a ‘large proportion of the patients treated in these [voluntary] hospitals were of the artisan and middle-classes who could pay something towards the cost of their treatment, and who would not avail of the facilities afforded by a central hospital’.Footnote 104 Evidently long-standing prejudices against the former poor law institution remained and few outside of the city’s poor were willing to utilise this form of health care.
Table 2: Paying and free patients in Cork and Irish Free State Voluntary and Semi-Voluntary hospitals, 1933. Source: The Hospitals Commission: First General Report, 1933/4 (Dublin: Stationery Office, Saorstát Éireann, 1939), 123–4.
Although accessibility to the city’s infirmaries was eased by ability to pay, nearly half of the patients in the South and North Infirmaries did receive free hospital treatment. This was higher than the national average (39.4%) of free patients in voluntary and semi-voluntary hospitals (see Table 2). The city’s other main general hospital, the voluntary Catholic run Mercy Hospital, had a patient body which was predominately fee-paying. Just over thirteen per cent of patients received completely free treatment in the hospital, indicating differences in the patient social composition between voluntary hospitals. The lack of contributory schemes similar to those in Britain implies that many patients paid fees out of their own pockets. The differing amounts of contributions demonstrated in Table 2 further highlights that some of these patients were made up of middle-class groupings who paid larger fees and skilled labourers who paid in part towards their treatment.Footnote 105 The voluntary sector in the city increasingly provided for private paying patients, lower middle-class and skilled labourers.
The issue of accessibility to voluntary hospitals for poor patients did emerge as a political issue in the early 1930s. Criticism of Cork’s voluntary hospitals admission policies came to the fore when an amending bill of the original Public Charitable Hospitals Act of 1930 was introduced into the Dáil (Irish Parliament) in 1932 by the new Fianna Fáil government which was backed by the Labour Party.Footnote 106 This legislation provided for the government’s administration of the Irish Hospitals Sweepstakes; an Irish-run international lottery designed to fund Irish hospitals.Footnote 107 Allegations were made by a number of TDs that voluntary hospitals failed to provide medical services to the poor. Brooke Brasier, an independent TD for the Cork South-East constituency, claimed there was ‘very considerable difficulty in getting deserving cases into these hospitals’.Footnote 108 The Fianna Fáil TD for Cork East, Martin Corry, stated that ‘from enquiries I have made since, I find that these hospitals are refusing to receive poor patients’.Footnote 109 The claims were not just related to Cork hospitals. The Parliamentary Secretary for the Department of Local Government and Public Health of the new Fianna Fáil government, Dr Con Ward, stated during the same debate: ‘I find it almost impossible to get a patient into a Dublin hospital at the present unless somebody is going to pay.’Footnote 110 In relation to Cork, the Hospital Commission, which was established in 1933 to administer the Sweepstakes money, was also critical of the voluntary hospitals in the city stating that they did not provide for the ‘needs of the very poor …[and] do not appear to cater for the type of patient for which the union caters’.Footnote 111 The commission also claimed that voluntary ‘hospitals do not propose to cater for the very poor’.Footnote 112 However, the emergence of the Sweepstakes gave the government some influence over the voluntary sector. In return for administering the Sweeps, all participating voluntary hospitals had to provide a quarter of their beds for free.Footnote 113
Claims that the non-paying sick were excluded from the voluntary hospital system were, however, exaggerated. Traditionally, and particularly in Cork, general voluntary hospitals provided acute medical care and did not cater for the types of illness that was common amongst patients in public institutions. Of the 140 beds in the Mercy Hospital, seventy-nine were for medical or surgical patients, thirty-seven were gynaecological beds, twenty-four for children and a mere four for isolation patients.Footnote 114 Similarly the North and South Infirmaries provided beds for acute medical and surgical cases along with children and accident cases. None of the general voluntary hospitals provided for chronic or infectious disease patients. The clinical difference in patients in voluntary and public institutions was demonstrated in the average length of stay in the respective hospitals. 18.9 days was the average stay in the Mercy, 23.8 days in the North Infirmary, and 21.4 days in the South Infirmary; the Cork District Hospital and County Home was 39.4 days.Footnote 115 Admission to voluntary hospitals was often a clinical as much as a financial decision. This was demonstrated by Canon Murphy of the South Infirmary who believed that ‘we have to discriminate on the grounds of the class of case and of the case of illness’.Footnote 116 Such evidence highlights the fact that voluntary hospitals often did not have the facilities for the type of sickness which was inextricably linked to poverty or old age – infectious disease, chronic and incurable diseases – for which the public rate-aided system catered.
Other developments ensured that the poorest patients and those disadvantaged by distance from urban areas received medical assistance in the better equipped voluntary hospitals. Under the 1862 Act local boards of guardians could pay the medical costs of patients who needed specialised treatment outside the workhouse infirmary. By 1910 a total of 3,631 patients had had their medical costs for non-poor law hospitals met by local boards of guardians although many of these were not sent to hospitals but to institutions for the ‘blind, deaf and dumb’.Footnote 117 This provision was extended under the Free State reforms. Local authorities made arrangements with voluntary hospitals to pay for patients that needed specialised treatment not available in public institutions.Footnote 118 In Kerry this measure was important because no general or specialist voluntary hospital existed. Regulations were drawn up by the board of public assistance that outlined the procedures involved in sending patients to voluntary hospitals in both Cork and Dublin. Not counting emergency cases, dispensary doctors had to send the patient initially to the county surgeon who then decided whether they needed such specialised treatment.Footnote 119 By the early 1930s Irish local authorities had paid for the treatment of nearly 11,000 poor patients in voluntary hospitals.Footnote 120
Conclusion
The 1930s brought a new era of hospital development in Ireland. The large sums collected by the Sweepstakes lottery transformed the hospital landscape and led to much badly needed investment in both public and voluntary hospitals which raised the general standard of hospital care. However, it was during the revolutionary period (1919–21) and the early years of the Irish Free State that widespread reform was initiated. This was partly reflective of the new Irish Free State’s desire to bestow rights upon its citizens and also resonated with wider international trends in the development of welfare systems. Increasingly attempts were made to remove the principles of deterrence and ‘less eligibility’ which permeated nineteenth-century welfare regimes, and to establish health care and welfare provisions more acceptable to populations. The Free State’s break-up of the New Poor Law and dismantling of the workhouse system was significant and represented the first effort at such reforms in Ireland or Great Britain. Although the potential of reform was limited by the precarious finances of the newly established Irish Free State, significant changes occurred; including the removal of all classes of patients/inmates from the majority of county and district hospitals who were not in need of acute medical care. This reform was particularly successful in County Kerry where the sole focus of all but one of the six institutions under the control of local authorities was the care of the acute sick.
The continued mixing of various classes of patient in the county home and district hospitals remained a significant blight on the system. Such institutions continued to be associated with poverty ensuring that they remained unattractive to those in the skilled labourer and the lower-middle classes. As evidenced in Cork these groups avoided the former workhouse and turned to the extensive voluntary hospital system in the city. These classes increasingly contributed to their health care either as full-paying private patients or subject to means-testing and paying in part. In some of the local authority hospitals, particularly former county infirmaries, similar practices developed. The emergence of fee-payment was rapid and by the 1930s voluntary hospitals had become increasingly reliant on such income, although, unlike the situation in Great Britain, mutualism did not emerge as an important dynamic in Irish health care. The rise in fee-payment was an important development in hospital provision and helped to accentuate the social and medical differences between patients in rate-aided and voluntary hospitals. However, to conclude that a demarcated and two-tiered hospital system emerged – one rate-aided for the poor and one voluntary sector where fee-payment determined access – is somewhat inaccurate. Accusations that the poor were squeezed out from the better equipped hospitals by private and contributing patients were unfounded to some extent. Large numbers did receive free treatment in voluntary hospitals, although the unwillingness of many to enter the former poor law hospitals remained. Furthermore, entry to hospitals was often determined by clinical decisions as much as ability to pay. The voluntary sector’s focus on curable acute medical and surgical services left little room for the types of sickness catered for in the ‘union’ hospitals, which were inextricably linked with poverty such as chronic illness and infirmity. Such patients often became impoverished because of their medical condition. Means-testing of patients in voluntary hospitals did occur but this did not necessarily lead to the poor being denied access to such hospitals. Also, local authorities, aware of the limitations of their own institutions, often paid for poorer patients to receive attention in the better equipped hospitals.
