BERKELEY ^ LIBRARY UNIVERSITY OP CALIFORNIA ^ SOCIAL ^':i.fa:?c- CMMINOLCQY UB. SCHOOL OF SO^^.IAL WELFARE UNIVERS... C- CALli-ORNIA iERKEUfcUtCAUFORm SCHOOL OF SOCIAL WELFARE UNIVERSITY OF CALIFORNIA giAK£i-iI it CALIFORNIA Vj-''-*-*'*-% ,K THE BREAK-UP OF THE POOR LAW THE BREAK-UP OF THE POOR LAW: BEING PART ONE OF THE MINORITY REPORT OF THE POOR LAW COMMISSION EDITED, WITH INTRODUCTION BY SIDNEY & BEATRICE WEBB LONGMANS, GREEN AND CO., 39 PATERNOSTER ROW, LONDON, NEW YORK, BOMBAY AND CALCUTTA. 1909 CONTENTS kitlaaat^ PAOK Introduction . . . . . . ix CHAPTER I The General Mixed WoRKHorsE of To-day . 3 (A) The Promiscuity of the General Mixed "Workhouse — (B) The Un- specialised Management of the General Mixed Workhouse — (C) The Universal Condemnation of the General Mixed Workhouse — (D) Why the General Mixed Workhouse has continued to exist — (E) Con- clusions. CHAPTER II The Outdoor Relief of To-Day . . . .26 (A) Local By-Laws as to Outdoor Relief — (B) The Practice as to Outdoor Relief^(C) The Cause of the Failure of the Present Administration of Outdoor Relief — (i.) The Destitution Officer — (ii.) The Many- Headed Tribunal— (D) The Scotch Inspector of Poor— (E) The Suggested Abolition of Outdoor Relief— (F) The Substitution of Charity for Outdoor Relief — (G) Conclusions. CHAPTER III Birth and Infancy . . . . . .83 (A) The Provision for Birth and Infancy made by the Destitution Authority — (i.) Domiciliary Treatment of Expectant Mothers and Mothers with Infants — (ii.) The Workhouse as Maternity Hospital — (iii,) The Workhouse as Infant Nursery — (B) Voluntary Agencies for Pro- viding for Birth and Infancy — (i.) Rescue Homes — (ii.) Maternity Hospitals — (iii.) Domiciliary Midwifery Agencies — (iv.) Day Nur- series — (v.) Infant Asylums — (vi.) The Insufficiency of the Voluntary Agencies — (C) The Supervision of Birth and Infancy by the Local Health Authority — (i.) Provision of Midwifery — (ii.) Provision of Hygienic or Medical Advice — (iii.) Provision of Milk — (D) The Need for a Unified Service dealing with Birth and Infancy — (E) Con- clusions. V *^ 23 vi CONTENTS CHAPTER IV TAOK Children under Rival Authorities . , .136 (A) Children under the Destitution Authority — (i.) "Boarding-out . within the Union " — (ii.) Boarding-out in Scotland, and " Boarding- / out without the Union" in England and Wales — (iii.) Certified / Schools and Institutions — (iv. ) Scattered Homes — (v. ) The Boarding / School of the Destitution Authority — (vi. ) The Receiving Home — 1/ (vii.) Children of Unfit Parents— (a) The " Ins-and-Outs"— (&) The Children of Vagrants — (c) The Abandoned Child — (d) The Assump- tion of Parentage — (B) Children under the Police Authority — (C) Children under the Education Authority — (i. ) Medical Inspection and Treatment— (ii. ) School Feeding— (D) The Failure of the Destitution Authority to relieve Child Destitution — (E) The Super- session of the Destitution Authority by the Local Education Authority — (F) Conclusions. CHAPTER V The Curative Treatment of the Sick by Rival Authorities 212 (A) The Medical Service of the Poor Law — (B) Domiciliary Medical Treatment under the Poor Law^(C) The Restriction of Domiciliary Medical Treatment — (D) The Hospital Branch of the Poor Law — (E) The Defects of the Poor Law Medical Service traced to their Root — (F) The Treatment of the Sick by Voluntary Agencies — (G) The Treatment of the Sick by the Public Health Authoiities — (i.) Municipal Hospitals — (ii.) Notification and Disinfection — (iii.) Supply of Medicines and Anti-Toxin — (iv.) Municipal Out- patients' Departments — (v.) Pediculosis and Scabies — (vi. ) Health Visiting — (vii.) Municipal Home Nursing — (viii.) Diagnosis — (ix.) Home Aliment — (x.) The Characteristics of the Public Healtli Authority's Treatment of Disease — (H) The Need for a Unified Medical Service — (I) Conclusions. CHAPTER VI The Mentally Defective ..... 295 (A) The Rival Authorities for the Mentally Defective — (B) The Mentally Defective under the Poor Law — (C) The Mentally Defective under the Local Lunacy Authorities — (D) The Recommendations of the Royal Commission on the Feeble-Minded — (E) The Withdrawal of the Mentally Defective from the Poor Law — (F) Conclusions. CHAPTER VII The Aged and Infirm . . , .309 (A) The Three Policies of the Destitution Authority — (B) The Aged and Infirm under the Destitution Authority of to-day — (C) The Estab- CONTENTS vii PAOE lishineut of National Pension Scheme — (D) The Need for Diversified Provision for the Aged and Infirm— (i.) The National Pensioners — (ii.) Provision for Persons ineligible for National Pensions — (iii.) Local Pensioners — (iv.) The Helpless Aged — (v.) The Infirm and Per- manently Incapacitated under Pension Age — (E) Conclusions. CHAPTER VIII Charge and Recovery by Local Authorities . .364 (A) Charge and Recovery by the Destitution Authority — (i.) Contributions by Relations — (ii.) The Device of Relief on Loan — (B) Charge and Recovery by the Public Health Authority — (C) Charge and RecoA-ery for the Maintenance of Children by the Education Authority and the Police Authority — (D) The Need for Uuiforniity of Principle and Judicial Adjudication in Personal Assessments — (E) Conclusions. CHAPTER IX Settlement and Removal ..... 401 (A) The Game of "General Post" — (B) The Proposal to abolish Settlement and Removal — (C) The Provisions necessary in the Reformed Admiuis- tration — (i.) Safeguards for the Local Health Authority — (ii.) Safe- guards for the Local Authority for the Mentally Defective — (iii.) Safeguards for the Local Education Authority — (D) Conclusions. CHAPTER X Grants-in-Aid . . . . . .411 (A) England and Wales outside the Metropolis — (i. ) The Relief to the Local Ratepayers — (ii. ) Discrimination in Favour of Desirable Expenditure— (iii.) Giving Authority to Central Control — (B) The Metropolis — (i.) The Relief to the Local Ratepayers — (ii.) Discrim- ination in Favour of Desirable Expenditure — (iii.) Giving Authority to Central Control — (C) Scotland — (i.) The Relief to the Local Rate- payers — (ii.) Discrimination in Favour of Desirable Expenditure — (iii.) Giving Authority to Central Control — (D) Ireland — (i.) The Relief to the Local Ratepayers — (ii.) Discrimination in Favour of Desirable Expenditure — (iii.) Giving Authority to Central Control — (E) What should be the Terms of the National Subvention — (i.) It ehould be a Grant, not merely an Assignment of Revenue — (ii.) It should be Dependent on Local Efficiency — (iii.) It should be Applied to Definite Deliberately Selected Services — (iv.) It should be Con- ditional — (v. ) It should be based on a Scale of Distribution according to Need and Ability— (F) Conclusions. viii CONTENTS CHAPTER XI PAGE Supervision and Control by the National Government 458 (A) The Orders— (B) Audit— (C) A Court of Appeal— (D) The Inspectorate — (E) The Poor Law Division of the Local Government Board — (F) The Need for Specialised Central Control — (G) Conclusions. CHAPTER XII The Scheme of Reform . . . , .499 (A) Schemes that we have Rejected — (i.) The Continuance of a Denuded Destitution Authoiit/ alongside of other Local Authorities providing for the Poor — (ii. ) The Monopoly of Public Assistance by a Deter- — > rent Destitution Authority — (iii.) The Extension of Public Assistance by a Disguised and Swollen Poor Law — (B) The Scheme we Recom- mend— (i.) The Supersession of the Destitution Authority — (ii.) The Distribution of the Services of the Destitution Authority — (a) The Duties to be transferred to the Local Education Authorities — (6) "'" The Duties to be transferred to the Local Health Authorities — (c) The Duties to be transferred to the Local Pension Committee — (d) The Duties to be transferred to the Local Authority for the Mentally Defective — (iii.) New Machinery for the Co-ordination of Public «— w Assistance — (a) The Registrar of Public Assistance — (6) The Public Register — (c) Charge and Recovery — (d) Sanction of Home Aliment • — (e) The Registrar's Receiving House for Omitted Cases — (/) The Registrar as National Pension Officer — (g) The status of the Regis- trar — (C) The Conditions of Eligibility for Public Assistance — (D) Disfranchisement — (E) The Sphere of Voluntary Agencies — (F) The Practical Application of the Scheme — (i. ) The Rural Counties — (ii.) The Metropolis— (iii.) Scotland — (iv.) Ireland — (v.) The Depart- ments of the National Government — (G) Some Theoretical Objections answered — (i.) The Integrity of the Family — (ii.) The Withdrawal of the Destitution Officer — (iii. ) The Economy of Efficient Adminis- tration — (iv.) The Right to Relief — (H) Summary of Proposals. Summary of Conclusions and Recommendations . .574 INTRODUCTION The Poor Law Commission of 1905-9 can hardly fail to be epoch-making in the history of the English Poor Law. For what we believe is the first time since 1834, a public inquiry into the Poor Law has ended without paying even lip-homage to the "principles of 1834." A Koyal Commission of eighteen members, including half-a-dozen members of the Charity Organisation Society, half-a-dozen Guardians or ex-Guardians, and four official representatives of the Local Government Boards of England, Scotland and Ireland, has unanimously recommended *' a clean sweep " of the English Poor Law and Poor Law organisa- tion, together with all its most characteristic principles. Although the Majority Report is flanked by half-a-dozen dissents — of which the longest is here republished — the members of the Commission are remarkable in the extent of their revolutionary unanimity. All the Commissioners, without exception, agree that drastic changes in the Poor Law and its administration are urgently required ; all agree that the "principles of 1834," whatever they once were, are now hopelessly antiquated and inapplicable to the present state of things ; ^ all agree even in discarding the very terminology of the Poor Law, to which adminis- trators and paupers alike have grown accustomed, in order to mark the completeness of the break from the past ; all agree that the Boards of Guardians in town and country alike must imperatively and immediately be replaced by 1 "The administrators of the Poor Law," we are told in the Majority Report, "are, in fact, endeavouring to apply the rigid system of 1834 to a condition of afVairs which it was never intended to meet. What is wanted is not to abolish the Poor Law, but to widen, strengthen and humanise the Poor Law " (par. 337 of Chapter I. of Part VL of Majority Report). ix X INTKODUCTION some other Authority ; all agree in condemning, and in recommending for abolition, the General ]\iixed Work- house, which has been, for seventy-five years, the charac- teristic feature of English Poor Law administration ; all agree that the treatment of the children, the sick and the aged needs to be greatly improved. Similarly, all but two out of the eighteen agree that the Union area, which has dominated English administrative geography for more than half a century, must disappear from the map ; that the future unit of local administration must be the County Borough and the County ; and that the County Borough Councils and County Councils must add to their other functions those hitherto discharged by the Boards of Guardians. There has, we think, never been a representa- tive Royal Commission, constituted of members of such diverse opinions, dealing with a subject of so great an extent, and of such far-reaching importance, which has, after three years' investigation, found itself agreeing with so much unanimity to conclusions of such sweeping character.^ There is one point, amid all this unanimity, to which we wish to call attention. The Minority of the Commis- sioners protest — as we think, rightly — against the terms in which the Majority have thought fit to speak of the Poor Law Guardians of England and Wales. In passage after passage of the Majority Report, the blame for the failure of the present Poor Law is laid on their shoulders. They are condemned by implication, not only of incom- petence, but of worse. " The work," we are told, " is tending more and more to fall into the hands of persons who, caring more for their own interests than for those of the community, direct their administration more towards 1 The Commission consisted of Lord George Hamilton (Chairman) ; Sir Samuel Provis, Sir Henry Robinson, Mr. J. Patten-MacDougall, and Dr. Arthur Downes, of the Local Government Boards for England, Ireland and Scotland ; Mr. F. H. Bentham, Mr. V. Chandler, and Mr. George Lansbury, sometime Chairmen of the Boards of Guai'dians for Bradford, Chorlton and Poplar respectively ; Mr. C. S. Loch, Secretary of tlic Charity Organisation Society ; the Bishop of Ross, Rev, Thory Gardiner, Mr. T. Hancock Nunn, Rev. L. R. Phelps, Professor W. Smart, Rev. Russell Wakefield, Chairman of the Central (Unemployed) Body for London ; Miss Octavia Hill, Mrs. Bosanquet and Mrs. Sidney Webb. Tlio O'Conor Don was a member until iiis death ; and Mr. Charles Booth until his resignation on account of ill-health. INTEODUCTION xi the attainment of popularity than towards a solution of the real problems of pauperism." We see no warrant for such a description of the 646 Boards of Guardians in England and Wales, or of their 24,000 members. What we have personally witnessed, all over the country, in the ten years that we have been specially studying English local administration, is an enormous amount of devoted, patient, disinterested service of the community, by men and women who have spent large parts of their lives in an onerous and disagreeable duty, for which they receive neither recognition nor thanks. We regret that the work thus done for three-quarters of a century by the Guardians of the Poor has not been better appreciated. We believe it to be true that, from first to last in English Poor Law history, no public honour of any kind has been awarded for even the longest, the most faithful, and the most eminent service as a Poor Law Guardian. Yet we make bold to say that the work which Boards of Guardians have done has been just as important to the community, and just as onerous and disinterested, as that of the Town Councils, and that there has been as large a proportion of honest men on the one body as on the other. What the Eoyal Commission of 1905-^ was confronted with was, not any special delinquency on the part of the 24,000 Guardians of the Poor, but an astonishing amount of overlapping, confusion and waste resulting from a gradual process of supersession of the Poor Law by other public activities. Broadly speaking, the Boards of Guardians make a failure of their job, put what zeal and devotion into it they may, not because of the personal shortcomings of their members, but because their work is nowadays cut into on all sides by other public Authorities, which are better equipped than the Boards of Guardians for their specialist functions. This point the Majority of the Commissioners have either missed or ignored. In 1834 the Poor Law Commissioners were faced with the difficulty that there existed, up and down the kingdom, no public authority to which they could entrust the ad- ministration of the public provision for any of the classes of persons whom they had to deal with. There was in xii INTRODUCTION 1834 no Health Authority in existence responsible for the prevention and treatment of disease, and having its own hospitals and medical staff. There was no service of sani- tary inspectors and health visitors, charged to search out disease as a public nuisance. There was in 1834 no Education Authority, taking in hand the schooling of the children, and having its own elaborate network of schools and staff of teachers. There was no service of school attendance officers, visiting systematically the homes to discover whether the children are receiving efficient educa- tion. There was in 1834 (outside the Metropolis) no force of salaried police, whose duty it is to prevent the public nuisance of vagrancy. There was, we may add, in 1834 even no systematic prison organisation, such gaols as existed being mere dungeons dispersed among entirely autonomous Lords of Manors, Close Corporations and the County Justices. There was, of course, no idea of curative or reformatory treatment of the persons compulsorily detained. There was in 1834 no general public provision for lunatics, outside one or two progressive counties. There was no public provision at all for idiots, defectives or epileptics. There was in 1834 no public authority dealing, as the Distress Committee of the Borough or Urban Dis- trict Council now assumes to do, with Unemployment. There was in 1834 no idea of a national service of pensions, providing superannuation for all over 70 who need it. The Poor Law Commissioners of 1834 were therefore com- pelled to recommend that a new authority should be established, to deal with all the classes for which public provision had then to be made ; and this provision, how- ever diverse in character it needed to be, was governed by the only factor then common to all the classes, namely, that of being in need of public aid. This was called destitution. The problem before the Poor Law Commissioners of 1905-9 was very different. It is no longer possible to unite, under one authority elected for the purpose of relieving destitution, all the provision made by the State for those in receipt of public assistance. Quite apart from the question of relieving destitution, there have grown up, INTRODUCTION xiii in the course of the seventy -five years, extensive systems of pubUc provision, out of the rates and taxes, for particular classes of persons, costing, in the aggregate, much more than the whole Poor Law expenditure. For the children of the whole country, irrespective of the affluence of their parents, the State now provides — usually gratuitously and in the other cases far under cost price — the whole service of education, from the kindergarten to the University. For various sections of these young people — more exten- sively than is commonly realised — the State provision of education is accompanied by partial or complete mainten- ance. We do not here allude to the tens of thousands of children in endowed and publicly-aided secondary boarding- schools. But leaving these out of account, it is interesting to note that the State provision of maintenance with education outside the Poor Law now extends to more than a hundred thousand children, some of them because they are the best (scholarships which cover maintenance), some of them because they are the worst (reformatory schools), and some for indiscriminate reasons, including the undesir- able character of the parents, the children's truancy, or the children's physical or mental shortcomings (industrial schools, residential schools for the blind, crippled, etc.). In not a few cases the Local Authorities actually run their own boarding-schools — at a lower cost per head, be it noted, than the new Cottage Homes of the Boards of Guardians. All this public assistance to the children is without the stigma of pauperism, whether the parents are bad, good or indifferent. With regard to the sick, there has grown up a Public Health service, ubiquitous in scope and becoming ever larger in volume, for the prevention of all diseases, irrespec- tive of the wealth or conduct of the persons concerned ; and for the cure (including maintenance in hospital and domiciliary treatment) of those deemed specially injurious to the community. More than 700 Municipal Hospitals are now maintained by the Local Health Authorities. Every year this notion of the protection of the community is advancing on the idea of merely relieving the individual. In 1906 it was made the duty of the Education Authority xiv INTRODUCTION to provide repeated medical examination of all the millions of children in the public elementary schools ; whilst food and medical treatment were to be provided where abso- lutely required. All this is without the stigma of pauperism ; and the question of which of the services should be rendered quite gratuitously, and which of them should be made the subject of a nominal and quite inadequate fee, has ceased to be a matter of general principle, and is now one of mere administrative expediency in each case. With regard to the great army of the mentally defec- tive of all grades, whether lunatics or idiots, epileptics or chronic inebriates, or merely feeble-minded, it has just been authoritatively declared by a powerful Royal Commission that, henceforth, these are all to be treated by the com- munity in respect not of their poverty, but of their defect ; and that the whole of them should be removed, once for all, from the sphere of pauperism and of the Boards of Guardians. With regard to the persons over 70, there is now, m every County and County Borough, a Local Pension Committee, awarding Old Age Pensions at the expense of the Exchequer, entirely unconnected with the Poor Law. With regard to the able-bodied in need of assistance, there has latterly grown up an extensive network of Distress Committees under the Unemployed Workmen Act of 1905. But this did not begin with Mr. Gerald Balfour's Act or Mr. Long's Joint Committees. We see it initiated by the Local Government Board itself in 1886, in the cele- brated circular calling on the Municipal Authorities to take the treatment of the Unemployed out of the Poor Law. The whole purpose and intention of this municipal organisation has been to provide something other than the Poor Relief for the whole class of workmen unemployed through no fault of their own, irrespective of whether or not they were technically destitute. At the other end of the able-bodied class, we have the recommendations of the 1906 Departmental Committee on Vagrancy that the vagrant should henceforth be dealt with not by the Poor Law Authority but by the police, and the incorrigible wastrel by a penal settlement — in both cases INTRODUCTION xv irrespective of whether or uot they apply for relief, or are technically destitute. There is, in fact, no section of the great pauper host, which the Poor Law Commissioners of 1834 indiscriminately placed under the care of the Boards of Guardians, of which, in 1909, they are left in undis- turbed possession. The costly provision made by the Poor Law Authorities of the United Kingdom — who will, this year, be spending nearly twenty millions sterling on Poor Relief — is thus overlapped at all points. What the Poor Law Authorities are doing for the infants, the children, the sick, the mentally defective, the aged and infirm, and the unemployed able-bodied man or woman respectively, already forms (or is on the point of forming) only a frac- tional part of the public provision made from the rates and taxes for each of those very classes ; and a part that can- not be marked off from the rest by any significant charac- teristic — not even by the 1834 attribute of " being in a state of destitution." The majority of the Commissioners have chosen to ignore the silent upgrowths of the past half a century which have, on the one hand, produced so costly and waste- ful an overlapping, and on the other, have left behind them the Boards of Guardians and the Poor Law Division of the Local Government Board, without any fault of the persons concerned, in a state of antiquated inefficiency. The Majority Report, implying that the cause of the failure of the Poor Law is to be found in the personal shortcomings of the 24,000 Poor Law Guardians, proposes the setting up again what is practically the same system of Poor Relief, with new members and under another name ! The proposed constitution is significant. Though the County and County Borough Councils are to find the whole of the money, they are to exercise absolutely no control. A complicated hierarchy of partly nominated and non- elective committees, controlled by all sorts of outside agencies and not responsible to the electorate, are to have an uncontrolled power of deciding the new Poor Law policy, and of spending the County Rate. The whole proposal seems inspired by the determination, at all hazards, to free the new '* Public Assistance Authority," xvi INTRODUCTION into whose hands not only the pauper but also the Unem- ployed workman and the child found hungry at school are to be thrust, from any electoral control. But this is not all. The non-elected Public Assistance Committees are themselves to be virtually controlled by statutory " Volun- tary Aid Committees," to be constituted on the lines of the Charity Organisation Society, and to be eligible for grants from the Public Assistance Authority out of the rates. To these committees, we are told, applicants are to go in the first instance. If they are refused assistance by the Voluntary Aid Committees, they may, of course, apply to the new Poor Law Authority. But that Authority is to make it a principle that the assistance it affords is to be " in some way less agreeable " than that which the Volun- tary Aid Committee would have given. Thus, the new Charity Organisation Committee is to have the power of setting the standard of what the Poor Relief is to be. We do not think the case is mended by the bewildering change of names. What is proposed by the Majority, in substitu- tion for the relief afforded by the Distress Committees to the Unemployed, and for the meals supplied to the hungry children by the Education Authorities, as well as for the work of the Boards of Guardians, is, for all the novel terminology, essentially the present Poor Law under non- elective administration. Plus ga change, plus c'est la meme chose ! With Majority proposals of this character, the dissen- tient Minority ^ felt compelled to present an alternative Report covering the whole ground ; bringing out the essential fact of the overlapping and duplication of services, and concluding with an Alternative Scheme of Reform. Their Report is divided into two independent parts, the one dealing with the various sections of the non-able- bodied, and the other with the able-bodied or unemployed. Each of these parts is, for convenience, now reprinted 1 Mr. F. Chandler, General Secretary of the Amalgainated Society of Carpenters and Joiners, and member of the Parliamentary Committee of the Trade Union Congress, Chairman of the Chorlton Board of Guardians ; Mr. G. Lansbury, member of the Central (Unemployed) Body for London, and of the Poplar Board of Guardians ; Prebendary Russell Wakefield, Chairman of the Central (Unemployed) Body for London, Rector of St. Marykbone ; Mrs. Sidney Webb. INTRODUCTION xvii verbatim in a separate volume.^ In the Blue-Book version the student will see every statement of fact, every figure, every piece of evidence, and every quotation authenticated by exact references to sources and authorities, to be found either among the Proceedings of the Commission itself or in other Parliamentary papers ; in the official Proceedings of Local Authorities, or in published works ; and sup- ported, moreover, by innumerable footnotes. But all this apparatus of verification — amounting in bulk to about one-third of the text — indispensable as it is in the official document, merely makes the Report hard reading for the public. The whole of these references have therefore been cut away from this popular edition, in which the text alone is given in pleasant typographical form. It remains only to be said that the numerous references to " our Investigators " are to the valuable Reports of the various ladies and gentlemen whom the Commission, with the sanction of the Lords Commissioners of the Treasury, appointed to investigate particular subjects. Among the most interesting of these Reports (which will, in due course, be published by the Commission) are those by Mr. A. D. Steel- Mai tland and Miss Rose Squire (Industrial and Sanitary Conditions) ; Mr. Cyril Jackson and Rev. J. C. Pringle (Relief Works) ; Mr. Cyril Jackson (Boy Labour) ; Mr. Thomas Jones and Miss Constance Williams (Outdoor Relief) ; Dr. J. C. Mac Vail (Medical Relief) ; Dr. Ethel Williams, Miss M. Longman and Miss M. Phillips (Condi- tion of the Children) ; Miss Harlock (Cases refused Outdoor Relief) ; Dr. Parsons (Able-bodied in Scottish Poorhouses) ; Mr. Kaye and Mr. Toynbee (Charities), etc. SIDNEY AND BEATRICE WEBB. ^ Part II. is published under the title of The Public Organisation o/the Labour Market (Longmans : 5s. net). The Poor Law is at the present time only to a small extent concerned with the man who is able-bodied. The various sections of the non-able-bodied — the children, the sick, the mentally defective, and the aged and infirm — make up to-day nine-tenths of the persons relieved by the Destitution Authorities. In Scotland, indeed, no other persons can lawfully receive Poor Law relief. In England and Wales, though persons in distress from want of em- ployment may be relieved under the Poor Law, and have, at times, loomed large in Poor Law statistics, this section now forms only a small fraction of the pauper population. In Ireland the position is essentially the same as in England. VOL. I 1 B CHAPTER I THE GENERAL MIXED WORKHOUSE OF TO-DAY The Poor Law Report of 1834 was concerned, almost exclusively, with the problem of Able-bodied Destitution ; that is to say, with the case of the labouring man unable, through unemployment or under-payment, to maintain himself and his family. The one positive recommendation with regard to the children and the aged that can be extracted from the Report is - the repeated demand that, where these classes are provided for in institutions, they must be, not in a single " mixed " institution, however perfect might be the nominal classification, but in entirely separate buildings, with distinct rules and arrangements, and under quite independent management. Nothing can be stronger than the condemnation in the Report of the General Mixed Workhouse, whether large or small, old or newly designed for its purpose. The Assistant Com- missioners had found, in the great majority of parishes, the Workhouse " occupied by sixty or eighty paupers, made up of a dozen or more neglected children (under the care, perhaps, of a pauper), about twenty or thirty able- bodied adult paupers of both sexes, and probably an equal number of aged and impotent persons, proper objects of relief. Amidst these the mother of bastard children and prostitutes live without shame. ... To these may often be added a solitary blind person, one or two idiots, and not infrequently are heard, from among the rest, the incessant ravings of some neglected lunatic. In such receptacles the sick poor are often immured." On account of the inevitable association of the difierent classes, even the largest and best designed General Mixed Workhouses 4 GENERAL MIXED WORKHOUSE OF TO-DAY were equally condemned. " Even in the larger Work- houses," continues the Report, " internal subdivisions do not afford the means of classification, where the inmates dine in the same rooms, or meet or see each other in the ordinary business of the place. In the largest houses, containing from 800 to 1000 inmates, where there is comparatively good order, and, in many respects, superior management, it is almost impossible to prevent the forma- tion and extension of vicious connections. Inmates who see each other, though prevented from communicating in the house, often become associates when they meet out of it. It is found almost impracticable to subject all the various classes within the same house to an appropriate treatment. One part of a class of adults often so closely resembles a part of another class, as to make any distinc- tion in treatment appear arbitrary and capricious to those who are placed in the inferior class, and to create dis- contents, which the existing authority is too feeble to suppress, and so much complexity as to render the object attainable only by great additional expense and remark- able skill." Hence, stated the Report, " at least four classes are necessary — the aged and really impotent, the children, the able-bodied females, the able-bodied males," for each of which distinct institutions were to be provided. " Each class," continues the Report, " might thus receive an appropriate treatment ; the old might enjoy their indulgences without torment from the boisterous ; the children be educated ; and the able-bodied subjected to such courses of labour and discipline as will repel the indolent and vicious." We regret to have to report that, notwithstanding the distinct and emphatic recommendations of the Report of 1834, to which it is commonly assumed that Parliament gave a general endorsement by the Poor Law Amendment Act of 1834, the General Mixed Workhouse has not been abolished. In the course of the past half-century, a certain number of specialised institutions, such as Poor Law Schools and Poor Law Infirmaries, to be hereafter de- scribed, have been established for the children and the sick of certain districts. But every one of the Unions of GENERAL MIXED WORKHOUSE OF TO-DAY 5 England, Wales and Ireland, and now a large number of parishes or combinations of parishes of Scotland, has its General Mixed Workhouse ; and the great majority of the non-able-bodied poor for whom institutional treatment is provided are still to be found intermingled with the able- bodied men and women in these institutions. Of the 50,000 children who are in Poor Law Institutions in England and Wales, there are still 15,000 living actually- inside General Mixed Workhouses. We found that in Scotland, where it is commonly assumed that the Poor Law children are either boarded-out or maintained upon Outdoor Relief, there were 1845 children in the General Mixed Workhouses, or not far short of as many in propor- tion to population as in England itself. In Ireland, out of 9000 children maintained in Poor Law Institutions, no fewer than 8000 are in the General Mixed Work- houses, where their condition is the worse in that they do not even go out to the public elementary day school, but are taught on the Workhouse premises. Nor is it otherwise with the sick and the aged. Of the uncounted host of inmates of Poor Law Institutions who are so sick or infirm as to need nursing or medical attendance — estimated to number in the United Kingdom at least 130,000 — more than two-thirds are in General Mixed Workhouses. Of the 140,000 persons over sixty in Poor Law Institutions, only a thousand or two in England and Scotland, and none at all in Ireland, are in the separate establishments recommended by the Report of 1834, where " the old might enjoy their indulgences without torment from the boisterous." Commingled with this mass of non-able- bodied or dependent poor there may be found, in all the Workhouses of England, Wales and Ireland, and in the Poorhouses of Scotland, a number of men and women in health and in the prime of life — termed " able-bodied " in England, Wales and Ireland, and "tests" or " turn-outs " in Scotland — who are scarcely capable, from physical or mental defects, of earning a continuous livelihood. In the mammoth establishments of London, Glasgow, Liverpool, Dublin and Belfast we found even a considerable number of really able-bodied and mentally competent men and 6 GENERAL MIXED WORKHOUSE OF TO-DAY women, who are " work - shy " or merely unemployed through misfortune — some of them being chronic *' ins and outs," or, as the Scotch say, "week-enders," who, whilst they add comparatively little to the official statistics of indoor pauperism, are a perpetual cause of demoralisa- tion of the other inmates. In fact, the General Mixed Workhouse, including all classes of destitute persons, far from having been abolished, forms to-day the basis of the whole system of Poor Relief in England and Wales ; it has, within the last century, spread over all Ireland ; and we even see it, during the past decade, growing up in its worst forms in Scotland, which had formerly been free from its baneful influence. (a) The Promiscuity of the General Mixed Workhouse We see no reason to differ from our predecessors, the Royal Commissioners of 1834, in their decisive condem- nation of the General Mixed Workhouse. We do not wish to suggest or imply that the Workhouses of to-day are places of cruelty ; or that their 250,000 inmates are subjected to any deliberate ill-treatment. These institu- tions are, in nearly all cases, clean and sanitary ; and the food, clothing and warmth are sufficient — sometimes more than sufficient — to maintain the inmates in physiological health. In some cases, indeed, the buildings recently erected in the Metropolis and elsewhere have been not incorrectly described, alike for the elaborateness of the architecture and the sumptuousness of the internal fittings, as "palaces" for paupers. In many other places, on the other hand, the old and straggling premises still in use, even in some of the largest Unions, are hideous in their bareness and squalor. But whether new or old, urban or rural, large or small, sumptuous or squalid, these establishments exhibit the same inherent defects. We do not ignore the zeal and devotion by means of which an exceptionally good Master and Matron, under an exceptionally enlightened committee, here and there, for a brief period, succeed in mitigating, or even in counteracting, the evil tendencies of a general mixed institution. But these evil tendencies, exactly as PEOMISCUITY 7 they were noted by the Commissioners of 1834, are always at work ; and sooner or later they have prevailed, in every Union of which we have investigated the history. After visiting personally Workhouses of all types, new and old, large and small, in town and country, in England and Wales, in Scotland and Ireland, we find that the descrip- tions of the Workhouses of 1834, so far as we have quoted them above, might be applied, word for word, to many of the Workhouses of to-day. The dominant note of these institutions of to-day, as it was of those of 1834, is their promiscuity. We have ourselves seen, in the larger Work- houses, the male and female inmates, not only habitually dining in the same room in each other's presence, but even working individually, men and women together, in laundries and kitchens ; and enjoying in the open yards and long corridors innumerable opportunities to make each other's acquaintance. It is, we find, in these large establishments a common occurrence for assignations to be made by the inmates of different sexes, as to spending together the "day out," or as to simultaneously taking their temporary discharge as "ins and outs," It has not surprised us to be informed that female inmates of these great establishments have been known to bear ofispring to male inmates and thus increase the burden on the Poor Eate. No less dis- tressing has it been to discover a continuous intercourse, which we think must be injurious, between young and old, innocent and hardened. In the female dormitories and day-rooms women of all ages, and of the most varied characters and conditions, necessarily associate together, without any kind of constraint on their mutual inter- course. There are no separate bedrooms ; there are not even separate cubicles. The young servant out of place, the prostitute recovering from disease, the feeble-minded woman of any age, the girl with her first baby, the un- married mother coming in to be confined of her third or fourth bastard, the senile, the paralytic, the epileptic, the respectable deserted wife, the widow to whom Outdoor Relief has been refused, are all herded indiscriminately together. We have found respectable old women annoyed, by day and by night, by the presence of noisy and dirty imbeciles. 8 GENERAL MIXED WORKHOUSE OK TO-DAY " Idiots who are physically offensive or mischievous, or so noisy as to create a disturbance by day and by night with their howls, are often found in Workhouses mixing with others both in the sick wards and in the body of the house." We have ourselves seen, in one large Workhouse, pregnant women who have come in to be confined, com- pelled to associate day and night and to work side by side with half-witted imbeciles and women so physically deformed as to be positively repulsive to look upon. In the smaller country Workhouses, though the promiscuity is numerically less extensive, and, in some respects, of less repulsive character, the very smallness of the numbers makes any segregation of classes even more impracticable than in the larger establishments. A large proportion of these Workhouses have, for instance, no separate sick ward for children, and, in spite of the ravages of measles, etc., not even a quarantine ward for the constant stream of newcomers. Accordingly, in the sick wards of the smaller Workhouses, with no constraint on mutual intercourse, we have more than once seen young children in bed with minor ailments, next to women of bad character under treatment for contagious disease, whilst other women, in the same ward, were in advanced stages of cancer, and senile decay. Our Children's Investigator reports, after visiting many Workhouses in town and country, "that children when detained in the Workhouse always come into contact with the ordinary inmates. Certainly, in a country Workhouse this seems impossible to avoid. Paupers are always employed to help with the rough scrubbing and cleaning, and though Matrons invariably try to send the more respectable women into the children's quarters, often the only women available are the mothers of illegitimate babies." In many Workhouses we have ourselves found the children having their meals in the same room and at the same times as the adult inmates of both sexes, of all ages, and of the most different conditions and characters. Even the imbeciles and the feeble-minded are to be found in the same dining-halls as the children. In some Workhouses, at any rate, the boys over eight years of age have actually to spend the long hours of the PROMISCUITY 9 night in tlie same dormitories as the adult men. In all the small Workhouses and in many of the larger ones, the infants are wholly attended to by, and are actually in charge of, aged, and often mentally defective, paupers ; the able-bodied mothers having, during the first year, daily access to their own babies for nursing, and, subse- quently, such opportunities for visiting the common nursery as the master may decide. In the better managed, and in the largest establishments the nursery is, it is true, in charge of a salaried nurse, but even here the handling of the babies is mostly left to pauper inmates. However desirable may be the intercourse between an infant and its own degraded mother, it is not to the advantage of the scores of infants in the nursery to be perpetually in close companionship, for the first three or four or five years of their lives, with a stream of mothers of various types that we have mentioned. Such a nursery imbedded in the midst of an institution containing, not merely hundreds, but thousands of paupers of the most diverse classes is im- pregnated through and through with the atmosphere of pauperism. (b) The Unspecialised Management of the General Mixed Workhouse Apart from this promiscuity — which, be it noted, increases with the size of the establishment — it is an inherent defect of the General Mixed Workhouse that it makes impossible the proper treatment of any one of the various classes of paupers agglomerated within its walls. It is, indeed, largely on the ground that it actually pre- vented the subjecting of each class to its " appropriate treatment " that the General Mixed Workhouse was con- demned by the Royal Commissioners of 1834. We have satisfied ourselves that this condemnation is still entirely justified. The very uniformity of regimen to which all the inmates are subjected makes it impracticable to deal properly with any one class. But a more insidious, and, as we think, equally disastrous incident of the mixed institution is what we 10 GENERAL MIXED WORKHOUSE OF TO-DAY venture to call the " mixed official." To place under the management of one man and his wife an institution which, whether large or small, combines the functions of rearing children from infancy to adolescence ; treating sickness in all its forms from phthisis to cancer, from maternity to senility ; controlling the feeble-minded, the imbeciles, the epileptics and even the certified lunatics; reforming the mothers of illegitimate children ; maintaining respectable deserted wives and widows, and setting to work the able- bodied of both sexes — not to mention the usual additional duty of harbouring vagrants — is to abandon all hope of getting expert training or specialised skill. To begin with, the mixture in a single institution, of both men and women — against which the Commissioners of 1834 ex- pressly protested — has, for obvious reasons, involved placing the management in the hands of husband and wife. This leads constantly to an inferior or even an unfit Master being appointed or retained, because of the qualities of the Matron his wife ; or an inferior or even unfit Matron being put up with, because of the excellence of her husband the Master. But over and above this elementary difficulty, the union of so many different classes in one establishment makes it impossible for any head to acquire the training that is needed for such manifold duties. Neither man nor woman can be simultaneously trained and technically expert in the rearing of children, the setting to work of adult labour, the superintendence of a hospital, the tasking of vagrants, the control of lunatics and the wardenship of an almshouse. Boards of Guardians are often blamed for entrusting the management of institu- tions containing hundreds or even thousands of inmates — children and sick, aged and imbeciles, sturdy rogues and dissolute women, respectable old men and widows — to a promoted porter or ex- labour master, and the wife whom he happens to have married. We do not see what other course they can take. If they pro- mote the schoolmaster or the nurse, these more refined natures may be unfitted to cope with the sturdy vagrant or the "in and out" prostitute. There is no conceivable training that would fit one man (and his UNSPECIALISED MANAGEMENT 11 wife) for the task. And the very mixture of functions — the impossibility of attaining technical excellence or, indeed, achieving any recognisable success, in any one of them — has, we have repeatedly noticed, a subtle deteriorating effect on the persons appointed. This is hard on the large class of excellent men and women, for the most part quite poorly remunerated, whom the General Mixed Workhouse has enlisted in its service. Here and there we meet exceptionally gifted natures, whose faith and love and moral refinement enable them, to some extent, to with- stand the deadening influence of the non-specialised insti- tution, and to persist in regarding each inmate as an individual soul. But to the common run of men and women who gain appointments as Master and Matron, there comes to be, amid all the differences of sex or age or character, or health, or strength, or defectiveness, but one category of inmate — the pauper; the person who ought not to be there ; the semi-delinquent who ought to be grateful for being, at the public expense, just kept alive ; whose condition, far from being improved, is sup- posed always to be kept less eligible than that of the lowest grade of independent labourer. The effect of having always to superintend and organise, not a hospital or a school, a lunatic asylum, or even a reformatory, in which there is some recognisable standard of technical success, but a hopeless mass of undifferentiated pauperism, with which there is nothing to be done, necessarily develops in the ordinary man or woman, during the years of fruit- less service, a particular type of character, manifesting itself in a certain trick of bearing, even a peculiar facial expression quickly recognisable by the experienced visitor. "We all know," remarks a professional journal, "the common uneducated type of man to be found in this oflice in so many places ; his mind stored, for the confounding of newly -elected Guardians, with rules, bylaws and regulations, his heart hardened by long contact with a system under which deceit is the only means by which relaxation of rules can be obtained." As some of the best among these Workhouse Ofiicers pathetically complained to us, the men and women whom we harness to the service 12 GENERAL MIXED WORKHOUSE OF TO-DAY of the General Mixed Workhouse almost invariably develop an all-embracing indifference — indifference to suffering which they cannot alleviate, to ignorance which they can- not enlighten, to virtue which they cannot encourage, to indolence which they cannot correct, to vice which they can- not punish. The one attribute common to all Workhouse inmates which can be, and is, appreciated by those in authority over them, is ready and unhesitating obedience, passing into servility. The faculties which the Master and Matron find developed in themselves are the trick of securing a machine-like order, and a suppleness of seem- ing compliance with the fancies of Guardians who are as devoid of specialised training as they are themselves. In too many cases, as has been well said, " Guardians and Master are satisfied if the floors are washed, the steps pipeclayed, and the regiments of books of entry in order for the inspector." (c) The Universal Condemnation of the General Mixed Workhouse So complete a condemnation of the General Mixed Workhouse will, to those who know that institution only by repute, or who have come to accept it as inevitable, appear exaggerated. Their first thought may be that we are expressing only a personal view, inspired by some un- reasonable ideal, and based only on a few bad examples that we happen to have visited. This is not the case. We have to report that there exists in all parts of the king- dom, among all classes, the greatest dislike and distrust of this tj^pical Poor Law Institution. The respectable poor, we are told, " have a horror of it," and they will not go " into the House at all unless they are compelled." The whole institution, reports our Medical Investigator, " is abhorred. . . . The Workhouse and everything within its walls is anathema excepting to the very dregs of the population." It is, said one of our witnesses, " the supreme dread of the poor." " Life in the Workhouse," sum up our Investigators, " does not build character up. It breaks down what little independence or alertness of UNIVERSAL CONDEMNATION 13 mind is left. ... It is too good for the bad and too bad for the good." This " evil reputation " of the General Mixed Work- house among the respectable poor is, reports our Medical Investigator, ''partly traditional or historical, and partly due to the curious and objectionable agglomeration of purposes which it now serves. It is a home for imbeciles, an almshouse for the destitute poor, a refuge for deserted children, a lying-in hospital for dissolute women, a winter resort for the ill-behaved casual labourer or summer beggar, a lodging for tramps and vagrants as well as a hospital for the sick." " Being gathered into one establishment," says the Vice - Chairman of the Manchester Board of Guardians, " all must be subject to the same regulations — framed to be deterrent to the lazily disposed, and to pre- vent preference of the workhouse to labour. The day- rooms and dormitories are necessarily shared by good and bad, and close association is inevitable. The cost of separation into small groups in a Workhouse is prohibi- tive of attempts to place like-minded inmates together. This aggregation of inmates is not at all unpleasant or irksome to the loafer, to the vicious, to the drunkard seeking the safety and rest of the Workhouse after a debauch, and to the careless idler, who is ever preying upon the labour of others. Their chief objection to the Workhouse is the curtailment of liberty and the absence of opportunity of self-indulgence. But to the reputable clean-minded inmate this association with the depraved is the bitterest and most humiliating experience of life." It is to be noted that this condemnation applies alike to the five or six hundred smaller Workhouses or Poorhouses of rural districts of the United Kingdom, as well as to the two or three hundred larger establishments. These latter have terrors of their own. " The mere size of the Great House " may, indeed, as has been suggested, be in itself " a strong deterrent to the honest poor. Accustomed to live in a single room, they are appalled at the size of the Workhouse, and as terrified to go into it as a child into the sea. It can seldom be possible . . . for any one man to grasp all the details of our largest Workhouses, and 14 GENERAL MIXED WORKHOUSE OF TO-DAY where he cannot do so there must be great danger of neglect and bad under -management." But the smallest rural Workhouses exhibit, in some respects, the greatest mixture. " A small country Workhouse with fifty or sixty inmates," testifies a well-known and experienced county administrator in the North of England, "is a shame to our Christian civilisation. There may be found collected in it perhaps ten old men and ten old women, drunken, idle blackguards, the outcasts of society ; and, compelled to live among them, perhaps five or six respect- able old people who, through absolutely no fault of their own, having worked hard all their inofiensive lives, have come to poverty. There will probably be three or four imbeciles of each sex, sometimes harmless and amusing, very often vicious and annoying to the inmates ; two or three single women waiting for their confinements — in many cases an annual visit ; three or four loafing * ins and outs,' able-bodied men ; three or four feeble persons ; and eight or ten illegitimate children, all practically living together, and too often under a master who is tyrannical in his treatment and careless of his duties. It is a life absolutely repugnant to the respectable poor. Surely the time has come when, for the sake of not only the aged poor, but of the sick, the imbeciles, and the children, a drastic reform should be made, which would, at all events, bring us to a level with Denmark and other European countries." It is in the wards of such small country Workhouses that the visitor may see — to use the words of an experienced lady Guardian of the Poor in a southern county — "all the inmates under lock and key, good char- acters and bad classed together, imbeciles and epileptics amongst them, all dressed in ill-fitting Workhouse clothes of old-fashioned clumsy make, all sitting on hard benches round the long tables or the walls of the ward, while the building with its bare stone floors, curtainless windows, and harshly clanging locks seemed more like a prison for criminals than a last home for aged men and women." Nor is this condemnation of the General Mixed Work- house any new-fangled complaint. From 1834 down to the present day there has been a stream of adverse comment UNIVERSAL CONDEMNATION 15 on an institution which is, we believe, unknown to any other country. We need not quote again the opinion of the Royal Commissioners of 1834. In 1862 the principal author of their Report, Nassau Senior himself, recorded his protest against the perpetuation of the General Mixed Workhouse which they had done their best to rid the country from, and with which, nevertheless, Boards of Guardians, at the instance of the Poor Law Board, were covering both England and Ireland. " We recommended," he said, " that in every Union there should be a separate school ; we said that the children who went to the Work- house were hardened if they were already vicious, and became contaminated if they were innocent. We recom- mended that in every Union there should be a building for the children and one for the able-bodied males, and another building for the able-bodied females ; and another for the sick. We supposed the use of four buildings in every Union — four distinct institutions — except this, that they need not be Workhouses. You might easily hire a house [apiece] for four distinct institutions separate from one another. We never contemplated having the children under the same roof with the adults." The feelings of surprise and dismay with which Nassau Senior watched the perpetuation of the General Mixed Workhouse were widely shared. " During the last ten years," said a learned lawyer in 1852, "I have visited many prisons and lunatic asylums not only in England, but in France and Germany. A single English Workhouse contains more that justly calls for condemnation in the principle on which it is established, than is found in the very worst prisons or public lunatic asylums that I have seen. The Workhouse as now organised is a reproach and disgrace peculiar to England, nothing corresponding to it is found throughout the whole Continent of Europe. In France, the medical patients of our Workhouses would be found in ' hopitaux ' ; the infirm aged poor would be in 'hospices'; and the blind, the idiot, the lunatic, the bastard child and the vagrant would similarly be placed in an appropriate but separate establishment. With us a common malebolge is provided for them all ; and in some 16 GENERAL MIXED WORKHOUSE OF TO-DAY parts of the country, the confusion is worse confounded by the effect of prohibitory orders, which, enforcing the appli- cation of the notable Workhouse Test, drive into the same common sink of so many kinds of vice and misfortune the poor man whose only crime is his poverty and whose want of work alone makes him chargeable. ... It is at once equally shocking to every principle of reason and every feeling of humanity that all these varied forms of wretchedness should be thus crowded together into one common abode ; that no attempt should be made by law ... to provide appropriate places for the relief of each." Continental writers of authority, at one time admirers of our Poor Law, became equally condemnatory of the General Mixed Workhouse. "The English Workhouse system," declared Rudolph von Gneist in 1871, "notwithstanding the elaborate Orders, remains undeniably at a stage of development which most Continental administrations have passed. The Workhouse purports at one and the same time to be : (i.) A place where able-bodied adults who cannot and will not find employment are set to work ; (ii.) an asylum for the aged, the blind, the deaf and dumb or otherwise incapacitated for labour; (iii.) a hospital for the sick poor ; (iv.) a school for orphans, foundlings and other poor children; (v.) a lying-in home for poor mothers ; (vi.) an asylum for those of unsound mind not being actually dangerous; (vii.) a resting-place for such vagabonds as it is not deemed possible or desirable to send to prison. The combination of such mutually inconsistent purposes renders the administration defective as regards each one of them ; subjects to shame and indignity whole classes of persons who never ought to be brought into such companionship ; and in particular makes the institution as a place for children absolutely ruinous." A quarter of a century later, a French critic made much the same complaint. " In the Workhouse as we have described it," wrote Monsieur fimile Chevalier, " we see many faults. The requirement of work from inmates, justified if it contributed towards the cost of maintenance, becomes, when it is so ludicrously unpro- ductive, nothing better than an unwarranted punishment. Yet the institution might possibly justify itself, if cot to UNIVERSAL CONDEMNATION 17 the economist, at any rate to the philanthropist, as capable of affording a temporary refuge for unmerited distress, but for the fact that in these establishments the very notion of relief gives way to that of penal treatment, whilst in the majority of cases they result in complete promiscuity between the idle and the worthy, between vice and mis- fortune." Nor have these weighty foreign condemnations of the very nature of the General Mixed Workhouse evoked any denial of the facts. The institution, admitted, in 1881, the Rev. T. W. Fowle, "contains those very classes whom one would least of all select to associate with each other ; both sexes, extreme ages, different degrees of imbecility and disease, those who are much to be pitied and those who are much to be blamed. All these are under the same roof, and under the government of the same officials, who may be as fit to deal with one class of inmates as they are unfit to deal with another. Hence, there comes from this aggregation of classes something that may be described as the Workhouse essence ; it is neither school, infirmary, penitentiary, prison, place of shelter or place of work, but something that comes of all these put together. Nor is it possible by any classification to prevent contact, and, it may be, moral contagion ; in the smaller houses classification is at all times difficult, and in no case does it hold good at meals, church and other occasions. And it may well be that the regular and peaceable (affiicted) inmates endure much preventible suffering from the operation of this cause." (d) Why the General Mixed Workhouse has continued to exist In face of so universal a condemnation of the General Mixed Workhouse — begun in the Report of 1834; con- tinued decade by decade by all sorts of critics, English and foreign ; admitted during a whole generation by the Local Government Board itself; and abundantly confirmed by our own investigations — the question naturally arises why was this institution re-established by the Poor Law Com- VOL. I c 18 GENERAL MIXED WORKHOUSE OF TO-DAY missioners of 1834-47 ; why was it continued by the Poor Law Board of 1847-71 ; and why has it endured down to the present day, in spite of the almost incessant endeavours of the Local Government Board, by urging successively the withdrawal of vagrants, the children, the sick, the able-bodied and the aged from its demoralising influence, to break it up altogether ? Our inquiries show that the explanation of the re-establishment of the General Mixed Workhouse by the Poor Law Commissioners of 1834-47, in flagrant defiance of the Report of 1834, and its persist- ence in spite of the constant efibrts of the Local Govern- ment Board to supersede it by specialised institutions, are both to be traced to the nature of the Local Authority concerned. The Poor Law Commissioners do not seem, on assuming office, to have intended to set aside, on this point, the clear and emphatic recommendations of the 1834 Report. They had no wish to re-establish the General Mixed Workhouse. There is evidence that they began, in the first Unions that they created, by trying to get organised a series of four or more separate institutions, specialised for different classes of poor. But Parliament had placed the care of all these classes of poor in each Union under a single Local Authority, and had charged that Authority, not with the treatment of any one of these classes, not with the education of the children or the prevention and cure of sickness, but generally with the relief of the destitution of all of them. The Poor Law Amendment Act of 1834 had substituted, in fact, by combining many parishes into one Union, a new Destitution Authority for the old Destitution Authority, with a some- what larger district. The Assistant Commissioners quickly discovered that it was quite as much as the new Destitution Authority could do to govern one institution in or near the market town around which, as a nucleus, the difi'erent parishes were grouped. The numbers of persons in the difi'erent classes in the rural Unions of that date were small. To the Boards of Guardians of 1835, as to their successors in many a subsequent decade, it seemed a wanton waste of money to maintain a series of separate small institutions, all having vacant places. Within a few WHY IT HAS CONTINUED TO EXIST 19 montlis we see the attempts given up, and all the classes of poor huddled into a single building. Presently we see the Assistant Commissioners themselves converted to the General Mixed Workhouse ; converting their official superiors to it as the only course practicable with the Local Authorities through which they had to work ; and propagating the idea to their Boards of Guardians with all the zeal of converts. " The very sight," argued the ablest of these Assistant Commissioners, " of a well-built efficient establishment would give confidence to the Board of Guardians, the sight and weekly assemblage of all servants of their Union would make them proud of their office ; the appointment of a Chaplain would give dignity to the whole arrangement, while the pauper would feel it was utterly impossible to contend against it. In visiting such a series of Unions, the Assistant Commissioner could with great facility perform his duty, whereas if he had eight establishments to search for in each Union it would be almost impracticable to attend to them. I would, more- over, beg to observe that in one establishment there would always be a proper governor, ready to receive and govern any able-bodied applicants, whereas in separate establish- ments this most important arrangement (the Able-bodied House) during harvesting, etc., would constantly be empty, and consequently would become inefficient in moments of emergency." The same Assistant Commissioner, in writing a fare- well letter to the Kentish Boards of Guardians at the end of 1835, urges them not only to stick to the dietary, but also to appoint a chaplain *' to your central house, which will shortly be the sole establishment in your Union. . . . As soon as this important object has been gained — as soon as you find that the whole of your indoor poor are concen- trated in one respectable establishment — under your own weekly superintendence — when you see yourselves sur- rounded by a band of resolute, sensible, well-educated men faithfully devoted to your service — you will then, I believe, fully appreciate the advantage which you, as well as your successors, will ever derive from possessing one strong, efficient building, instead of havicg, from false economy, 20 GENERAL MIXED WORKHOUSE OF TO-DAY frittered away your resources aniong your old existing houses." What is specially interesting at the present juncture is that it was the existence of a Destitution Authority, charged with the "relief" of all sorts and conditions of men, that has rendered nugatory, decade after decade, every attempt to undo the harm done in 1835. Once the General Mixed Workhouse is established, the ease and apparent economy of the arrangement becomes, in the hands of a Destitution Authority, an obstacle always defeating the efforts of the Central Authority to reverse its own action, and to go back to the policy of the 1834 Report. For the Poor Law Commissioners themselves very soon realised the false step that they had taken in merging all classes of paupers in the General Mixed Work- house. Their first remedy was to try to exclude the vagrants, and to provide, in London, for their treatment in specialised " asylums for the homeless poor." To this end orders were issued, joint boards established and even sites purchased. But the attempt failed. Nothing would induce the separate Boards of Guardians to relinquish their care, troublesome though it was, of all the classes of the destitute. The Poor Law Board had then to fall back on the imperfectly specialised Casual Ward of the General Mixed Workhouse. But to get any really specialised treatment of the vagrants out of a " Destitution Authority " — even to get carried out the explicit directions of the Local Government Board to that end — has proved quite impossible. Half a century of failure has recently driven the very experienced members of the Departmental Com- mittee on Vagrancy to recommend that this class of destitute persons should be wholly withdrawn from the supervision of the Local Authority dealing with the category of the destitute. Even more disastrous in its results was the merging of the children in the General Mixed Workhouse. As early as 1841 the Poor Law Commissioners had realised their mistake, and had begun the attempt to transfer the chil- dren to district schools. Here again it was the very nature of the Local Authority that stood in their way. A WHY IT HAS CONTINUED TO EXIST 21 Board of Guardians, elected to relieve the destitution of all the poor, refused to consent to cede the children to any other Authority, even to a joint Committee of Boards of Guardians. It needed a cholera epidemic among the Poor Law children at Tooting to enable the Poor Law Board to get even a dozen district schools established, and more than five hundred Unions persisted in keeping their chil- dren in their own Workhouses. Right down to the present day the Local Government Board, in spite of unwearied efforts, has failed to reduce the number of children actually living in General Mixed Workhouses below what is really the enormous number of 15,000. And there is no prospect of this number being lessened. There is indeed in some cases a tendency to reversion. In a Welsh Union that we visited, which, at the instance of the Local Government Board, actually provided a separate building for its chil- dren, we found this empty and disused, the number of children having fallen to eight. It seemed more economical and more convenient to the Destitution Authority to take these eight children into the General Mixed Workhouse to live with the forty other inmates, who were mostly either semi-imbeciles and feeble-minded, or senile or paralytic old men and women, with half-a-dozen tramps, men, women and children, coming in every night. It took thirty years to convince the Central Authority that it had made a mistake in merging the sick in the General Mixed Workhouse ; but, once convinced, its action was, in London at least, decisive. From 1866 onward we see first the Poor Law Board and then the Local Government Board exercising the strongest and most persistent pressure on the Boards of Guardians to get them to provide entirely separate institutions for the sick poor. At first the attempt was to get neighbouring Unions to combine, in " Sick Asylum Districts," to maintain a joint infirmary. This has proved practically a failure. The Boards of Guardians, feeling that it was their function to look after all classes of the poor, and dominated by their one business, as they conceived it, of relieving destitution, flatly refused to remove their sick from the General Mixed Workhouse in order to place them in the infirmary of a 22 GENERAL MIXED WORKHOUSE OF TO-DAY joint committee. In the Metropolis the Local Government Board had to take the drastic step of taking the infectious sick and the imbeciles out of the hands of the Boards of Guardians, and entrusting them to a sejDarate body, the Metropolitan Asylums Board, which has become virtually a Public Health Authority. Only in the Metropolis and in a score or so of large provincial towns has the persistent pressure of the Local Government Board now succeeded in inducing the Boards of Guardians to place the sick in separate Poor Law infirmaries ; and that only imperfectly. In a majority of the Unions the local Destitution Authority, in the teeth of medical advice, insists on retaining all sections of the sick — the tuberculous, the cancerous, the venereal, the maternity cases, the children, the senile, and even sometimes the infectious — in the General Mixed Workhouse. The next class which the Local Government Board strove to get out of the General Mixed Workhouse was that of the able-bodied. Again the Boards of Guardians resisted, seeing no advantage in paying for the establishment oi specialised institutions, even as "Test Workhouses" for the able-bodied. Presently, at Poplar in 1871, and again at Kensington in 1882, the Local Government Board took the opportunity of there being vacant accommodation to persuade the Board of Guardians to set aside a special building for the able-bodied of their own and of adjacent Unions. Similar experiments were started at Birmingham and Manchester. We shall point out, when we come to deal in Part II. with the able-bodied, how all these experi- ments, though strikingly successful in their purpose of diminishing able-bodied pauperism, were one and all brought to untimely ends in consequence of being en- trusted to a Destitution Authority unable to resist the constant temptation of using the vacant places for other classes of paupers. A similar tendency to reversion is seen in the various experiments that have been tried by indi- vidual Unions in segregating their own able-bodied for specialised treatment. Our study of their records shows that these experiments are always breaking down because the Destitution Authority cannot resist the temptation, WHY IT HAS CONTINUED TO EXIST 23 when its other wards get full, of first temporarily and then permanently relegating to their so-called able-bodied block detachments of such other classes of destitute persons as the men over sixty, the sane epileptics, and even the able- bodied of the other sex. To complete the survey of the efforts of the Central Authority to break up the General Mixed Workhouse, we have to record its action on behalf of the only class not hitherto mentioned, by its successive circulars, from 1900 onward, urging Boards of Guardians to provide specialised accommodation for the worthy aged. These attempts have met with little result, as the great majority of Boards of Guardians have felt, and sometimes expressly reported, that the structural arrangements of the General Mixed Workhouse did not permit of any such separate accom- modation as was suggested. In the whole of England and Wales fewer than a thousand old persons are as yet provided for in the separate Poor Law institutions on which the Report of 1834 insisted. We need not recount the parallel histories of Scotland and Ireland, where the success of the Central Authorities in inducing the local Destitution Authorities to make specialised institutional provision for the separate classes has been, on the whole, even less successful than in England and Wales. We are anxious to make clear that it is not to any inferiority of calibre, or any lack of good intention, in the members of the Boards of Guardians in England, Wales and Ireland, and the Parish Councils of Scotland, that we ascribe their almost invariable failure to free themselves from the dominion of the General Mixed Workhouse. It is, we think, inherent in the nature of the Destitution Authority, having to deal with all classes of persons merely because they are destitute, to make this character- istic of destitution their dominant idea. In this connec- tion, it is, we think, highly significant that, in the model Union of Bradford, in which — to use the words of its late Chairman — " the determination to break up the mass of pauperism into its component parts, and to deal separately with each of these parts," has " been the guidiug principle of the Guardians in recent years," we see how hard is the 24 GENERAL MIXED WORKHOUSE OF TO-DAY way and how imperfect is tlie success of any Destitution Authority that aims at providing really separate institu- tions, under distinct management, for each of the hetero- geneous series of classes committed to its care. The only class, even at Bradford, which has been completely separ- ated off from the rest is that of the children, for whom admirable " Scattered Homes " are provided. Yet even here the Destitution Authority cannot refrain from sending in other destitute persons. " I was sorry," reports our Children's Investigator, in speaking of the St. George's Children's Home at Bradford, " to see a defective girl, aged seventeen, helping in the housework. These defec- tives are very often to be found in the Children's Homes. They are too old for the schools, they cannot be sent out to service, and are sent to help in the Children's Homes, pending a decision about their destination which the Guardians are very slow to make. They are very much out of place amongst young children. I feel very strongly that they should be sent to proper Homes for Defectives." And it is the same with the other classes. Genuine philanthropic feeling has induced the Bradford Board of Guardians to build, a couple of miles away from the General Workhouse, a charming quadrangle of separate tenements for their most respectable aged. Yet, because it had presently to provide additional accommodation for destitute sane epileptics, and then a place for the destitute able-bodied men to be subjected to the Outdoor Labour Test, this Destitution Authority could not resist the temptation of housing its epileptics in the very quadrangle occupied by the old men and women ; of setting the able- bodied men to work on the same site ; and of placing all three classes — the most worthy aged, the sane epileptics and the Outdoor Labour Test men — under one and the same Superintendent. Meanwhile, within the walls of the old Workhouse, we find the blocks of the able-bodied and semi-able-bodied men and women closely hemmed in by new and elaborate hospital blocks for different groups of the sick, the whole within the same curtilage, entered by the same gate, and under the formal superintendence of the same Master and Matron. CONCLUSIONS 25 (e) Conclusions We have therefore to report : (1) That the General Mixed Workhouses of England, Wales and Ireland, and the Poorhouses of Scotland, whether urban or rural, new or old, large or small, sumptuous or squalid, all exhibit the same inherent defects, of which the chief are promiscuity and un- specialised management. (2) That these institutions have a depressing, degrad- ing and positively injurious effect on the character of all classes of their inmates, tending to unfit them for the life of respectable and independent citizenship. (3) That the institution of a General Mixed Work- house, whether large or small, was decisively condemned by the Poor Law Commissioners of 1834; that it has been repeatedly condemned since that date by a succession of competent critics ; that this condemnation has been confirmed by the evidence given before us, by the reports of our own Investigators, and by the individual inspections that we have been able personally to make in many difierent parts of the United Kingdom. (4) That the institution is everywhere abhorred by the respectable poor, and that, in our judgment, the continued incarceration within its walls of the non-able- bodied or dependent poor, who are admittedly incapable of earning an independent livelihood, cannot be justified. (5) That the continuance of the General Mixed Work- house as the main method of institutional treatment, alike by the Boards of Guardians of England, Wales and Ireland, and by the Parish Councils of Scotland, in spite of such long-continued and widespread condemna- tion, is to be attributed to the fact that these bodies are essentially Destitution Authorities, charged with the "relief" of persons of the most difi'erent ages, ailments and conditions, in respect only of their destitution. CHAPTER II THE OUTDOOR RELIEF OP TO-DAY The common alternative to maintenance in the General Mixed Workhouse, in England and Wales, Scotland and Ireland alike, is, for all classes of the non-able-bodied, a small allowance, usually weekly, of money, food, and, less frequently, clothing. This practice, which is as old as the Elizabethan Poor Laws, was not condemned, and was scarcely even criticised in the Report of 1834. In contrast with the emphatic condemnation of Outdoor Relief to the able-bodied, the authors of the Report of 1834, like the Poor Law Commissioners of 1835-47, seem, in fact, to have acquiesced, so far as the non-able-bodied classes were con- cerned, in a continuance of the then existing practice of staving off destitution by small money doles, which, in cases of permanent incapacity or old age, became weekly allowances almost mechanically continued during life. There were, however, two requirements made by the Report of 1834 in respect of the administration of relief to the non- able -bodied, as well as to the able-bodied. "Uniformity in the administration of relief," says the Report, "we deem essential, as a means, first, of reducing the perpetual shifting from parish to parish, and fraudu- lent removals to parishes where profuse management pre- vails, from parishes where the management is less profuse ; secondly, of preventing the discontents which arise among the paupers maintained in the less profuse management, from comparing it with the more profuse management of adjacent districts ; and thirdly, of bringing the manage- ment, which consist in details, more closely within the 26 THE OUTDOOR RELIEF OF TO-DAY 27 public control." And the uniformity of treatment on which the Report of 1834 laid so much stress was held to apply in a special degree to the administration of Outdoor Relief in respect of the character or past conduct of the applicants. " The natural tendency " of the reliev- ing Authority " to award to the deserving more than is necessary, or ... to distinguish the deserving by extra allowances" was denounced in that Report as an evil. " The whole evidence," it was declared, " shows the danger of such an attempt. It appears that such endeavours to constitute the distributors of relief into a tribunal for the reward of merit, out of the property of others, have not only failed in effecting the benevolent intentions of their promoters, but have become sources of fraud on the part of the distributors, and of discontent and violence on the part of the claimants." This system of granting doles and allowances to the non-able-bodied poor, accepted by the Royal Commission of 1834, has never been prohibited by the Local Govern- ment Board, and has accordingly continued, with its authority, down to the present day. The sum thus distributed is now very large, approaching, in the United Kingdom, no less than £4,000,000 sterling annually. It has, during the past fifteen years, greatly increased, and it is, at present, taking the whole United Kingdom, prob- ably greater than at any time since 1834. More than two-thirds of the whole of the paupers are, in fact, in receipt of Outdoor Relief. We were surprised to find that, as far as England and Wales are concerned, contrary to the usual impression, no Order has ever been issued regulating or controlling the very extensive provision thus made for the great mass of the non-able-bodied poor. So far as the orphans and deserted children, the aged and infirm, the sick and the mentally afflicted, and the widows with legitimate off- spring, are concerned — and these make up nine-tenths of the pauper host — the Boards of Guardians all over England and Wales have been permitted to exercise unchecked their power of awarding doles and allowances, under such conditions as seemed to them fit. 28 THE OUTDOOR RELIEF OF TO-DAY (a) Local Bylaws as to Outdoor Relief Under these circumstances many of the Boards of Guardians have, for their own guidance, framed Bylaws or Standing Orders as to Outdoor Relief, which afiford an interesting vision of their divergent ideals of administra- tion. The most frequent clause in the couple of hundred such Bylaws that we have seen is one which makes the grant of Outdoor Relief dependent on the character and conduct of the applicant. This is expressed sometimes as excluding those who are actually of " immoral habits," or " habitual drunkards and bad characters," or merely " known to be in the habit of frequenting public-houses." Some Boards exclude " common beggars" or "persons known to be addicted to begging " ; others disqualify any one, whatever his present conduct, who "has wasted his substance in drinking or gambling, or has led an idle or disorderly life " ; or those who cannot satisfy the Relief Committee that their destitution has not been caused by " their own vicious habits " or their own improvidence or intemperance in the past. Occasionally a particular form of extravagance is specially penalised by the refusal of Outdoor Relief. In a large number of Unions we find a rule prohibiting the grant of Outdoor Relief to the widows of men who had been provident enough to insure for their funeral expenses, if, in the opinion of the Board of Guardians, such funeral money had been "lavishly or improperly expended." The professed aim of these Boards of Guardians is to make the grant of Outdoor Relief not merely necessary relief, dependent exclusively upon the economic circumstances of the case, but (as some of them frankly avow) an indulgence " to persons of past and present good conduct, who require relief by reason of unmerited misfortune"; who " can show a thrifty past," or that "whilst in work they did all they could to make provision against time of sickness or want of employ- ment " ; or " whose destitution has arisen from no fault of their own." This conception of granting Outdoor Relief according to the past conduct of the applicant is most fully carried out by the Sheffield Board of Guardians, LOCAL BYLAWS AS TO OUTDOOR RELIEF 29 which deliberately aims in its Bylaws at a " classification of the recipients of relief with a view to the better treat- ment of those of good character." Thus, those whose past life (which must be combined, by the way, with twenty years' residence within the Sheifield Union) entitles them to the utmost indulgence (Class A), get 5s. per week per adult ; those who, though equally destitute and presumably costing as much to keep, fall short of this high standard by one or two or three degrees (Classes B, C and D) receive, to live upon, respectively, 4s., 3s., or only 2s. 6d. per week per adult. This determination to discriminate, in the actual amout of Outdoor Relief allowed, between the deserving and the undeserving — which we find everywhere influencing the stricter type of Guardian, and which one of the most strictly administered Unions thus explicitly avows — is, as we have seen, significantly at variance with the recommendations of the 1834 Report. It is perhaps with regard to wives apart from their husbands, and widows, that the Bylaws relating to Outdoor Relief display the most extraordinary of their diversities. The Langport Board of Guardians professes to refuse all Outdoor Relief to healthy able-bodied widows under any circumstances, however large may be their dependent families. Most Unions which have rules prohibit Outdoor Relief to widows, whatever their legiti- mate family, who have had an illegitimate child ; indeed, ** any person who may have given birth to an illegitimate child" is commonly excluded. Widows who have only " a small family," or, if an able-bodied widow " of the working class," not more than two children, are made ineligible in some Unions. Far more usual is it to require the widow with only one child to keep herself and child without relief at all, after the first six months — some say after the first three months, after the first two months, or even the first month — of her widowhood ; at least, say some Boards, if the child is a year old, eighteen months old, two years old, or of school age. Many Unions express the same idea by providing that children in excess of one or two should, in preference to any grant of Outdoor Relief — and in face of the present strong objection of the 30 THE OUTDOOR RELIEF OF TO-DAY Local Government Board to the presence of children in this institution — be taken into the Workhouse, the General Mixed Workhouse that we have described. On the other hand, some Unions expressly provide for Outdoor Relief to a widow with only one child, or without any dependent child at all, and even, subject to being con- sidered by the whole Board, to widows with illegitimate children born since their widowhood. No less diverse are the fates in different Unions of wives deserted by their husbands. Most Boards of Guardians profess to refuse Outdoor Relief to all such cases, owing to the diflSculty of preventing collusive desertions. Others withhold it only for six months, or for a year, or for three years, or even for five. On the other hand, some Unions explicitly provide that deserted wives shall be treated as if they were widows. One island Union does the same if the husband is "beyond the seas," whilst others give relief, notwithstanding their fear of collusive desertions, if there are several children. There are several Unions which, apparently without consideration of the elBfect on the children, make the Outdoor Relief to deserted wives con- ditional on the woman and children first going into the Workhouse — the General Mixed Workhouse that we have described — for such time as the Guardians think fit. If there is any validity in the assumptions of the Report of 1834 that an absence of uniformity in Poor Law adminis- tration produces discontent amongst paupers and a perpetual shifting from place to place in order to take advantage of the Guardians' laxity, the divergencies in policy in the cases of widows with children, or widows who have had an illegitimate child, or deserted wives or unmarried mothers, would appear to be just those in which these assumptions would be most likely to apply. Some Boards push their test of conduct beyond the applicant himself; and deny Outdoor Relief to applicants " residing with relatives of immoral, intemperate or improvident character, or of uncleanly habits." There are even Bylaws in many Unions — in spite of an express statutory provision that such women should be treated as widows — forbidding the grant of Outdoor Relief to LOCAL BYLAWS AS TO OUTDOOR RELIEF 31 "married women (with or without families) whose husbands, having been convicted of crime, are undergoing a term of imprisonment"; a common rule sometimes loosely expressed so as to apply to the dependents of all persons detained in prison, even if merely awaiting trial. But Boards of Guardians frequently have further By- laws or Standing Orders as to Outdoor Relief, which are based on other considerations than the character or conduct of the applicant. More than a dozen South- country Unions, of which we have seen the rules, choose arbitrarily to limit the grant of Outdoor Relief, without reference to the character or conduct of the applicant, to such persons as have completed two years' residence within the Union. In Worksop the deserted wife having one or more children, if of good character, and if, in the judg- ment of the Guardians, her desertion is from no fault of her own, will, if she has resided within the Union for ten years, be granted 4s. a week, and Is. 6d. for each child. If, however, she has resided there for any shorter period than ten years, she will only get 3s. a week, and Is. 6d. for each child. Many other Boards of Guardians profess the enlightened policy of insisting on a sanitary home ; refusing Outdoor Relief to any one, whatever his or her character or conduct, who is living in a cottage or a room " kept in a dirty or slovenly condition " ; or " in premises reported by the Medical Officer of Health to be unfit for occupation, either from overcrowding or from being kept in a filthy condition " ; or " reported by the Sanitary Officer as injurious to health " ; or " in the opinion of the Relief Committee detrimental to the moral or physical welfare of the inmates " ; or merely " premises in which it is undesirable, on account of its sanitation, condition or locality, that they should reside." This restriction on the home is sometimes widened in scope and sometimes particularised. Thus, Outdoor Relief may be refused to an applicant, however deserving, who has the misfortune to live, as so many of the poor do live, " amid insanitary or immoral surroundings." Applicants must not live in common lodging-houses, nor lodge on premises licensed 32 THE OUTDOOR RELIEF OF TO-DAY for the sale of drink ; nor even live in " furnished lodgings," nor rent " furnished rooms " ; at any rate, if these are such as the Guardians deem "unsuitable." On the other hand, too good a home is as fatal a disqualification in some Unions as too bad a home is in others. Outdoor Relief is, in some places, refused to persons, whatever their character and conduct, who live " in cottages rented above the average rent of the neighbourhood " ; or in a dwelling of " a higher rent than £3 (per annum ?) in a town or £2 in a rural district " ; or £5 rent rural and £6 urban " ; or " £6 rent rural and £7 urban " ; or " at the gross estimated rental of £10 or upwards " ; or who occupy ** a cottage and land (small holding) " of any kind ; or more than half an acre of land ; or any tenement " the rent of which is in the opinion of the Board unreasonably high." But the applicant for Outdoor Relief will, according to the particular part of England in which he or she lives, have also to fulfil other requirements. He or she must not be " living alone in a house " ; or, as it is more usually specified, must be "competent to take care of himself or herself," or be " residing with some person competent and willing to take charge of him or her," or have " friends or relatives to attend to them." But such relative or friend must not be a daughter, for Outdoor Relief will be refused to " any parent having a girl at home over thirteen years of age capable of earning her living " ; or " over fourteen years," or " above fifteen years," At the same time, appli- cants for Outdoor Relief must not live together or share houses with each other, for Outdoor Relief " shall not be granted to more than one family in the same house " ; nor must they even let off" part of a house in lodgings without great discrimination, as "no Outdoor Relief" will be given "to persons who let lodgings or rooms to more than a married couple with children or to more than one lodger " ; whilst " no woman on Outdoor Relief" is "allowed to take in a male lodger except by permission of the Relief Com- mittee"; nor may she have resident with her "any woman with an illegitimate child or children." We may add that in some Unions no Outdoor Relief is allowed to any person having a dog in his possession, or " keeping a LOCAL BYLAWS AS TO OUTDOOR RELIEF 33 dog or gun, or holding a licence for either " ; or having an allotment (" except by way of loan ") ; or, in one case, " keeping dogs, horses, donkeys, cows or poultry." The question of thrift seems to be a puzzling one to Boards of Guardians. As we have mentioned, many Unions require the applicant for Outdoor Relief to " have shown signs of thrift." Yet, as we have seen, the occupa- tion of a small holding, the holding of an allotment, the keeping of a cow or a donkey, or the possession of poultry, is, in some Unions, actually a cause of disqualification. So is the possession of a cottage, a Post Office annuity or a tiny investment of any sort, for "no Outdoor Relief" except as a loan, will be given to persons in receipt of money derived from property " ; or except " to the actually destitute." The only form of saving which Boards of Guardians seem willing to recognise and encourage in the concrete, and not merely by abstract advice, is that of subscription to a friendly society. In one Union accord- ing to its Rules, "no Outdoor Relief" will be given "to any applicant under forty-five" unless he is actually " drawing sick pay from a friendly society." Apart from the recent statutory direction that allowances from such a society not exceeding 5s. a week are to be altogether ex- cluded from the Guardians' consideration, various Unions arrange for subscribers to " Benefit Societies to receive special consideration." " A person who has been a member of a friendly society for at least ten years and has ceased to be a member through no fault of his own" — or the widow of such person — may even receive 6d. a week above the ordinary scale of Outdoor Relief. But even in this matter many Boards of Guardians limit their encouragement in various ways. Only one seems willing to exclude all "club pay ... in fixing the amount of relief." Others will not take into account "any sum exceeding 10s. per week received from a Benefit Society," or even anything in excess of the bare statutory sum of 5s. a week ; or only half of any such excessive savings. Various other Unions so far limit their Outdoor Relief to those who have provided themselves with sick pay, as to insist that the sick pay, together with the Outdoor Relief, must never exceed " the VOL. I D 34 THE OUTDOOR RELIEF OF TO-DAY usual rate of wages." There are even Unions which profess by their Bylaws to ignore the recent statute ; thus one will only leave wholly out of consideration such pay not exceeding 2s. 6d. a week, and will treat any greater provident insurance up to 5s. a week as if it were 2s. 6d., unless the applicant has a wife and family dependent on him. Some other Unions still retain Bylaws providing merely for the supplementing of the sick pay by such Outdoor Relief as may be needed for support. And the Runcorn Board of Ouardians still defiantly print, in their Year-book for 1906-7, the old-fashioned rule that "sick money received from a club by an applicant for relief shall be taken at the full value." Even more inconsistent one with another are the local Bylaws relating to the earning of wages. Some Boards of Guardians profess to prohibit it altogether, ordaining that "no person in receipt of permanent Outdoor Relief shall be permitted to work for wages," except, say some Boards of Guardians, widows to whom Outdoor Relief has been granted, who are expressly permitted to "work for wages." The prohibition is put in another form by Boards of Guardians which forbid Outdoor Relief " in aid of wages or other earnings." Sometimes it is only earning more than a specified maximum that is made a disqualification for Outdoor Relief — more than 2s. per head per week, at Barton-upon-Irwell ; more than 4s. per head per week at York and Halifax ; or more than half a crown per head per week after paying the rent, at King's Norton and Bolton. The Worksop Board of Guardians makes an express excep- tion for widows and deserted wives, who are thus permitted to earn money. On the other hand, not only is a woman allowed to earn money to supplement her Outdoor Relief, as at Hitchin and Worksop ; but various Boards of Guardians so far recognise the earning capacity of their recipients of Outdoor Relief as to lay down regular scales of relief diminishing in proportion to earnings. Thus the Prest- wicli Board of Guardians explicitly provides that " in case of relief given in aid of earnings . . . where the earnings amount to at least one-third of the sum named in the scale . . . the maximum amount of relief, including such earn- LOCAL BYLAWS AS TO OUTDOOR RELIEF 35 ings, shall not exceed the amount named in the following scale, viz., two persons, 6s. . . . six persons, 14s. per week." Another way of effecting the same result is to say that " the relief granted shall be on such a scale that, with the income coming into the house from other sources the amount shall not exceed 3s. per head." On the other hand the Leigh Board of Guardians ignores any income or other resources not exceeding one -third of the scale of Outdoor Relief. The earnings from letting lodgings are sometimes systematically computed and deducted from the amount of Outdoor Relief according to the scale in force ; thus at Cheltenham, a male lodger boarding in the house is reckoned as equivalent to 2s. a week profit, and a female lodger at Is. 6d. a week; whilst in the neighbouring town of Warwick a male lodger is regarded as worth 3s. per week. Where the applicant lives with relations, it is pro- vided in the Bylaws of some Boards of Guardians that the aggregate earnings and income from all sources of the whole family group shall be taken into account, whether or not the members are legally liable to maintain the applicant. Sometimes this is put in the form that Out- door Relief will be refused to a widow " able to do all the usual household duties " who has an unmarried son at home " earning full weekly wages." The climax is per- haps reached in those Unions in which Outdoor Relief, far from being restricted to the destitute, is explicitly con- fined, in the case of widows with children, to those who can prove that they are earning not less than three shillings a week. This analysis of local Bylaws reveals, we think, a hope- less confusion of policy on the crucial question of how far Outdoor Relief should be restricted to those who have been thrifty in the past, or who are still exerting them- selves to earn a partial livelihood. Some Boards of Guardians profess to abide by an entirely contrary inter- pretation of the Poor Law, and to confine Outdoor Relief to the actually destitute. "It is the duty of a Board of Guardians," says one Board, "to relieve actual destitution, that is to say to relieve the poor who are unable, without support from the rates, to provide themselves with the 36 THE OUTDOOR RELIEF OF TO-DAY absolute necessities of life, and who have no relations who can be required by law to maintain them ; but not to administer charity in the sense of alleviating the lot of those who are poor, but not actually destitute." " Under the Poor Law," says another Board, ** destitution, not poverty, gives the only claim to relief from the Poor Rates." "Society," says another Board, "owes relief to those only who, by force of circumstances, are rendered unable to provide for the necessaries of life ; to distribute relief in any other case is to create mendicity, to encourage idleness and to produce vice. The function of the Guardians is to relieve destitution actually existing, and not to expend the money of the ratepayers in prevent- ing a person from becoming destitute. Public relief is designed to meet destitution irrespective of the particular person, or of his good or bad character." But whatever may be otherwise prescribed, an examina- tion of the scales of Outdoor Relief embodied in these Bylaws makes it clear that these doles and allowances are practically always professedly fixed on the understanding that the applicants have earnings, or other sources of in- come, without which they must inevitably starve. Indeed, there are only two or three Unions in England in which we have found the case of persons having absolutely no means expressly differentiated in the Bylaws from that of persons working for wages or having other sources of income. The lowest scale that we have come across is that of Hertford, which grants for each adult only Is. a week and 5 lbs. of flour, or its equivalent in bread. More usual is it to find the scale allowing 2s. 6d. per week for an adult (as at Bedminster, Prestwich, Nantwich, Epping, etc.) ; or 3s. (as at Cheltenham, North Bierley, Hardingstone, etc.) ; or 3s. 6d. (as at Warwick) ; though in a very few Unions it is put at as much as 4s. (as at Newport), and even 5s. (as at Loughborough and Bradford). For each child residing at home one Union still gives only 6d. and 5 lbs. of flour, others Is. and a loaf, occasionally Is. and two loaves, and in some cases Is. 6d. or 2s. — in most Unions, we understand, without anything additional being allowed for the mother, if she is an able-bodied widow — as com- LOCAL BYLAWS AS TO OUTDOOR RELIEF 37 pared with the 2s. per week for each child which the Guardians of Bradford and Sheffield think necessary in addition to a sum for the mother herself. The scale is put in more complicated form at Derby beginning with man, wife and one child at 5s., and rising to man, wife and ten children at 12s. 6d., or widow and ten children 13s. 8d., being about half what would be allowed at Bradford. One Union has a "summer scale" and a "winter scale," both very low, allowing a married couple with one child 5s. a week in summer and 7s. a week in winter ; with Is. addi- tional for each further child. It will be evident that, even allowing for differences in the cost of living, the lowest of these widely divergent scales of relief, can be described only — to quote the words of the Clerk of one of the most important Unions — as ** starvation out-relief" (b) TJie Practice as to Outdoor Relief The " Babel of principles " as to Outdoor Relief to the non-able-bodied, revealed in the foregoing analysis of the Bylaws formulated by the different Boards of Guardians, is in flagrant disregard of the policy of National Uniformity recommended in the Report of 1834. Moreover, we can- not take even these Bylaws as measuring the diversity that prevails. So far as we have been able to ascertain, only two-fifths of the Unions have any rules at all, the remainder professing to deal with each case " on its merits." Even where Bylaws or Standing Orders as to relief still appear in print, they have in many cases become obsolete, or are in practice more frequently transgressed than adhered to. Our special Investigators into Outdoor Relief report that " Many Boards have drawn up scales of relief for their own guidance. These are printed, hung up and often disre- garded ! * Each case on its merits ' is the formula used to conceal much caprice, prejudice and favouritism. The result is injustice. There is neither the superficial equality of treatment which adherence to a rigid scale gives, nor the deeper equality of treatment according to ascertained need. There is little or no attempt at discovering the whole posi- tion of a case and meeting it in a thoughtful fashion. 38 THE OUTDOOR RELIEF OF TO-DAY Guardians prefer to give small sums to many persons to thoroughly helping a few. For the last fifty years the deterrent and repressive aspects of the Poor Law have been urged upon them. They have disagreed and rebelled, but instead of attempting a thorough-going remedial policy, they have halted halfway and settled down to slipshod inquiry and the soothing dole. They are not relieving destitution, but supplementing small and precarious in- comes." It was in view of these facts that we paid special attention to the actual practice in different parts of the Kingdom, with regard to the grant of Outdoor Relief; alike in our oral examination of witnesses, in our personal visits to see Boards of Guardians and Relief Committees at their work, and in the appointment of special Investigators. We find certain characteristics almost universal, alike in those Boards of Guardians which have formal scales of relief, and those which " treat each case on its merits." The dole given is practically never adequate to the requirements of healthy subsistence. The sums awarded are almost mechanically doled out, according as the Relieving Officer reports the applicant to come into one or other wide category, as widow, sick husband, aged person, etc., without any real consideration of the sum that it would require properly to maintain each house- hold; and without any accurate ascertainment of the other resources. *' They do not confess that they have a scale," says one of the Inspectors ; " but the frequency with which Is. or Is. 6d. per week will be given for each dependent child, and 3s. for each adult, makes the so- called ' treating the case on its merits,' really amount to the same thing." "The Guardians," reports an ex- perienced Clerk, " get into their heads that 2s. 6d. or 3s. a week is the proper sum, and they give it to a great number." What weighs with them is that, if they give some such dole, '* they have got rid of the case." " As a matter of fact," reports one Local Government Board Inspector, " these half-crowns, eighteenpences and shillings are given because the facts are not ascertained." AVhat we have ourselves seen of the practice of Boards of Guardians in different parts of the country completely PKACTICE AS TO OUTDOOR RELIEF 39 confirms this testimony. "There are," noticed one of our Committees, "no relief rules or fixed scales, yet all the evils of rules and scales of relief are in existence. It is a rule to give 2s. 6d. to an aged person ; sometimes 6d. less, but rarely ever more that 2s. 6d. One case was that of a widow, sixty-seven years of age, living alone; the rent was 2s. 6d. (a week) ; they granted only 2s. (a week) ; there was no other known income." Many specific cases of wholly inadequate relief came before the notice of our Investigators. "This inadequacy," they report, " strikes us as being particularly injurious in the case of widows who have young children dependent upon them " ; to whom, as we have mentioned, only Is. or Is. 6d. a week is usually allowed for the entire main- tenance of each dependent child. So important does this allegation appear to us — affecting, as it did, the conditions of life of no fewer than 170,000 children in England and Wales whom the State is maintaining on Outdoor Relief — that we appointed special Investigators to inquire into the conditions under which these children were living. The result of this Inquiry was to prove conclusively that, "in the vast majority of cases," the amount allowed by the Guardians is not adequate. " The children," sums up our principal Children's Investigator, " are under-nourished, many of them poorly dressed, and many barefooted. . . . The decent mother's one desire is to keep herself and her children out of the workhouse. She will, if allowed, try to do this on an impossibly inadequate sum, until both she and her children become mentally and physically deteriorated. ... It must be remembered," adds this medical expert, "that semi -starvation is not a painful process, and its victims do not recognise what is happening. . . . We give relief without knowing whether the recipients can manage on it ; we go on giving it without knowing how they are managing on it." Along with this fact that the Outdoor Relief given is practically never adequate for healthy subsistence, goes the other fact, which we find almost invariable, namely, that Outdoor Relief is professedly not intended by the Guardians for those who are really destitute but for those 46 1:HE outdoor relief of TO-DAY who can, in some way or another, see their way to a few shillings a week. There has grown up, we are informed, a regular practice of giving Outdoor Relief in order to supplement the assumed other sources of income, whether petty earnings, charitable gifts or contributions from relations — to such an extent, indeed, that applicants often fictitiously magnify these resources in order to induce the Guardians to grant the dole of Outdoor Relief ; and Guardians will even refuse to grant Outdoor Reliei where the applicant, however worthy, really has no other means of livelihood at all. We have already seen to what an extent the Bylaws of the different Unions recognise the receipt of sick pay from a friendly society, and even sometimes require it as a qualification for Outdoor Relief. The occasional allusions in the Bylaws to such sources of income as letting lodgings, cultivating gardens or allotments, or keeping a dog " for the purposes of his business," and even working for wages, thus become intelligible. So plain did it become to us that women, in particular, were habitually granted Outdoor Relief in aid of their wages or other earnings that we thought it necessary to appoint special Investigators into this practice all over England and Scotland. These Investi- gators found many thousands of women who were regularly in receipt of Outdoor Relief, working as char- women, laundrywomen and domestic servants (outdoor) ; in dressmaking, tailoring and all the " needle " trades ; in shoemaking and weaving, confectionery and boxmaking ; in factories and workshops as well as in their own homes ; holding permanent situations as well as temporary engagements ; for weekly, daily and hourly wages as well as at piecework rates. Even the aged persons who are granted Outdoor Relief are habitually assumed to have some other means of support. Those who have absolutely no resources must, nearly everywhere, go to the Workhouse — to the General Mixed Workhouse that we have described. It is, indeed, clear that of the three to four million pounds a year annually given in Outdoor Relief, the greater part is given, not in relief of destitu- tion, strictly defined, but in aid of poverty. PRACTICE AS TO OUTDOOR RELIEF 41 We do not at this point discuss the debatable question of whether or not this almost universal system of granting Outdoor Relief in supplement of earnings, charitable gifts or the contributions of relations has injurious results upon either the market rate of wages or the flow of charity. We thought it important, however, to ascertain what steps were taken by the Boards of Guardians to satisfy themselves, before granting their manifestly inadequate doles of Outdoor Relief, as to the actual existence of the other resources which they tacitly assumed to exist, and as to whether the amount of such resources, joined with the Outdoor Relief, was sufficient, and no more than sufficient, for the proper maintenance of the household. We regret to say that, excluding a very few exceptionally administered Unions, we found nothing worthy of the name of an ascertainment of even the existence, let alone the amount, of any such resources. " In a great many instances," testifies the Clerk of a great urban Union, " Guardians guess at the amount that is coming in, and think that because there are charities in the neighbour- hood these people must be getting some of it, whereas in some cases I fancy they do not get quite as much as the Guardians imagine they do." The Guardians, in fact, as an Inspector assured us, "leave a good deal to the imagination in cases of that sort." The Guardians, said another witness, give such inadequate relief " in the hope that there are (other resources) ; I do not think they give it from definite information at all." This testimony is borne out by what we have ourselves seen of the way in which Boards of Guardians deal with the cases. " There was hardly any evidence," notes one of our Committees, " that anything more than the statements of the appli- cants was used in deciding their cases. Very little verifi- cation except a visit to the home." " Inquiries as to resources," notes another Committee, " are practically not made at all. . . . Widows with children receive varying amounts ; it seems quite a matter of chance how much." The lack of an ascertainment of resources does not always result in too little being given. We are convinced, not only by the testimony of competent witnesses, but also 42 THE OUTDOOR RELIEF OF TO-DAY from our own observation, tliat Outdoor Relief is some- times granted in cases in which the home could be quite well maintained without it. "It is far from infrequent," one official witness assured us, " to find that the Outdoor Relief paupers are in possession of considerable sums of money, or have other means, which they had not divulged to the Relieving Officer." Owing to the persistent refusal of the Guardians to allow proper investigation, says the Superintendent Relieving Officer of a large London Union, " we are done every day we rise." " Altogether seventeen cases were heard," notes one of our Committees, " and the applicants seen. The majority of these cases were widows and children, the relief being on an unusually adequate scale. Thus a widow with three children dependent, and earning 14s. a week and some food, was given 7s. a week relief, bringing her total weekly income up to 21s. and food. In another case a widow with four dependent children, and one boy earning 15s. a week, with a total income to the family of 25s., received 7s. a week, bringing their total income up to 32s. a week for six persons." We may cite in confirmation some recorded cases. "A widow living with her single daughter . . . aged thirty-nine, who was working at the shoeworks and earning an average weekly wage of 18s. 3d. Two sons gave their mother Is. each Aveekly, which made the income 20s. 3d. weekly for two persons. Guardians granted 3s. 6d. and 6d. grocery in addition. The Relieving Officer . . . reported each time the case came before the committee that *it was not a case of destitution.'" A Local Government Board Inspector " stated that on the morning he was present relief was granted where the united earnings of the family amounted to 34s. per week. Two glaring cases were brought to our notice in which Outdoor Relief to the extent of 3s. and 5s. a week respectively was granted to two families, of which the total earnings were, in the one case 40s. 9d., and in the other 51s. 6d. per week. It is possibly connected with this general lack of ascertainment of the applicant's resources, combined with the absence of any guiding principle, that we find an amazing diversity in the treatment of similar cases, not PRACTICE AS TO OUTDOOR RELIEF 43 only between Union and Union, but even within the same Union. We have ourselves noticed this divergence be- tween committee and committee of one and the same Board of Guardians, uncontrolled by any superior authority. Nor is this by any means exceptional. " I have found," sums up one of the Local Government Board Inspectors, " diflferent committees of the same Board dealing quite differently with similar classes of cases, which is obviously wrong." In a town where this habitually takes place, " it is known," testifies a competent witness, " that paupers shift from other districts of the town, where the maximum is not always given, to the more favoured locality and get the maximum." Indeed, apart from divergence of practice between different Relief Committees of the same Union, we have ourselves noticed — what is in fact notorious — that the same Relief Committee of the same Board of Guardians will deal differently with similar cases (and even with the same case) at successive meetings, according to the accident of which of the Guardians happen to be present. ** It is often a matter," say our Investigators, " of persuading a Guardian to take up the case. If the appeal succeeds, at the next meeting of the Relief Com- mittee, the Guardian will present the claims of ' My Mrs. Smith ' much as an outside charity worker will. When such personal relations are established there may be as much or as little fraud in the one case as in the other, for in neither is inquiry always thorough." " It was evident," noticed one of the Committees, " that the amount actually given in each case varied according to whether such applicant had or had not a personal advocate among the Guardians. Thus in one case personally advocated by a Guardian, an old man and his wife, living with their married daughter, and paying no rent, received 6s. a week. In another case, not vouched for by any Guardian, a woman aged fifty-eight, and disabled by debility, paid rent Is. 9d. a week, and had no relatives able to assist her, yet she only received 3s. 6d., leaving her Is. 9d. a week to live on after paying her rent." Such cases of inequality of treatment, owing to the accidental or deliberate absence or presence of particular members of 44 THE OUTDOOR RELIEF OF TO-DAY the committee are, we are informed, frequent ; and can, we are assured, with an Authority constituted as at present, scarcely be avoided. We now come to what appears to us the worst feature of the Outdoor Relief of to-day. With insignificant ex- ceptions. Boards of Guardians give these doles and allow- ances without requiring in return for them even the most elementary conditions. They are bound by statute to require that the children of school age should be in attendance at school, and this alone is what the average Relieving Officer sees to. As we have mentioned, many of the Bylaws require the recipients of Outdoor Relief to live in houses that are maintained in a sanitary state, and in homes kept reasonably clean. But whether or not the Union has Bylaws to this effect, it is plain that, in the vast majority of cases, no such condition is enforced. We draw here a distinction between the completely rural Union and that of the great town or urban district. In the former, though the conditions are not ideal, the lowest depths are rarely sounded. So far as the towns are con- cerned we have ourselves visited the homes of recipients of Outdoor Relief in Union after Union, only to find their condition, in the majority of cases, distinctly unsatis- factory, and in many instances simply deplorable. We have found innumerable cases of gross insanitation and overcrowding, and not a few of indecent occupation. We have seen homes thus maintained out of the public funds in a state of indescribable filth and neglect; the abodes of habitual intemperance and disorderly living ; and this — as it grieves us above all to say — even in families in which the Boards of Guardians are giving Outdoor Relief to enable children to be reared. One of our Committees, after visiting the homes of the Out- door paupers in a large urban Union, reported " that the Guardians in distributing Out-relief pay no atten- tion to the sanitary conditions in which the applicants live ; that bedridden cases are not properly looked after ; that there seems to be serious overcrowding; and that Out-relief administered on these lines . . . must not only lower the standard of public health and hinder the work PEACTICE AS TO OUTDOOR RELIEF 45 of the Sanitary Authorities, but must also be really injurious to the recipients." Another Committee " visited some thirty to forty Out-relief cases. For the most part they are living in houses which reflect most serious discredit on the Sanitary Authority, and on the great companies which have attracted to the district a large population. The overcrowding is of such a kind that ordinary decency is impossible ; both sanitary accommo- dation and water supply are most inadequate." A third Committee, visiting the Outdoor Relief cases in one of the principal cities of England, " went on to a wretched street ; many of the houses stood forsaken, with broken windows and doors, dirty, forlorn and tumbling to pieces. We knocked at one which was inhabited. The door was opened by a big, hulking man, the son-in-law of the recipient of Outdoor Relief. She was blind, and lay on a dirty bed in the front parlour ; she looked neglected, and the room was very dirty, the walls dilapidated. Almost the entire space was occupied by the blind woman's bed and that of her daughter, who lay, I thought, not sober, certainly very dishevelled, though it was mid-day. I wondered how much of the Out-relief went to the blind bedridden mother, and how much to the daughter and her big husband." Another Committee, attending the meeting of the Relief Committee in a great town, reports that " Drunkenness seemed to be considered a venial fault. In one case a widow with children had been receiving relief for two years, although the Guardians had several times been informed that she was drinking. She subsequently became a prostitute, neglected her children, was prosecuted and imprisoned at the instance of the N.S.P.C.C. Her children were taken charge of by the Guardians, and it was on her release from gaol that the case came up ... as to what should be done with the children. We could not help feeling that the lax grant of Out-relief probably con- tributed to the moral ruin of this woman's life." So much were we impressed by what we had ourselves seen that we requested the Local Government Board to ask their Inspectors for general reports upon the character of the homes in their districts into which Outdoor Relief was 46 THE OUTDOOR RELIEF OF TO-DAY being given. Tliese reports unfortunately bear out our own impressions. " The outdoor poor relieved in all large cities," reports one of these Inspectors, " may be broadly classified in three divisions : first, a minority of really respectable and decent folk," whose homes " are generally kept clean and often comfortable " ; next, " the bulk of the recipients of out-relief who have sunk into pauperism from various causes or combination of causes, some self-created, such as drink, vice and thriftlessness. Old age, sickness, general inefiiciency and lack of industrial training account for many cases. The homes of this class vary considerably according to individual character and circumstances. . . . Taken as a whole, their condition is not very much worse than their neighbours who are not chargeable, and some- times it is better." But there is, as he adds, a third class to whom Boards of Guardians persist in giving Outdoor Relief without requiring any improvement. "Too fre- quently they represent the most demoralised and diseased of the population. They include sane epileptics, imbeciles and cripples of the lowest class. Their homes are nearly always to be found in the poorest quarters where popu- lation is densest. Cleanliness and ventilation are not considered of any account. The furniture is always of the most dilapidated kind. The beds generally consist of dirty palliasses or mattresses with very scanty c(Jvering. The atmosphere is offensive, even fetid, and the clothing of the individuals, old and young, is ragged and filthy. Bankrupt in pocket and character, this class look to the rates to support them, and are never backward in making application. The children are neglected, furnish the com- plaints of the N.S.P.C.C. inspectors, and fill the homes of the Guardians. The men are drunkards, gamblers, work- shy boys and often criminals. The women are too often immoral as well as unclean and neglectful. Souteneurs may be included in this class. ... It is impossible with the present powers to deal satisfactorily with the various subsections of (this class). . . . The Guardians feel forced to give relief to bad cases because of the children, or for fear of some allegation of want of consideration to destitute ruffians or drunkards." We wish carefully to guard against PKACTICE AS TO OUTDOOR RELIEF 47 it being supposed that this description applies to the bulk, or even to the majority, of the cases on Outdoor Relief. There are among them, even in the large towns, numbers of worthy and decent people of sober and respectable lives. But it is necessary to realise that, under the present administration of Outdoor Relief, there are many recipients who are of the kind described in the foregoing graphic report. And this report, authoritative in itself, is con- firmed by those of the other Inspectors. " I found," writes one of them after visiting the Outdoor Relief cases, " far too much intemperance, and sometimes even drunkenness, in cases to which relief was being granted. It was most observable in the overcrowded quarters and slums. Closely allied to it, and as a rule the fruits of it, were filth, both of person and surroundings ; and sadder even was the neglect and resultant cruelty to children, who were ill-fed and ill-clad. . . . Though the living-room might be fairly clean, the rest of the house was a mass of filth, the bedding dirty, a heap of ill-smelling rags for bed clothes, and the atmosphere vile and vicious. In some instances even the living-room was a disgrace to humanity." We must add that another Inspector reports that " a not inconsiderable proportion of Guardians" take the view, first, that the disposal " of the relief granted by them is a matter for which not they, but the recipients, are responsible ; and, secondly, that, however small the relief given to a person with little or no other apparent means of subsistence, it is no one's business to inquire further if the applicant is satisfied." "The first of these views," continues the Inspector, " which I have heard expressed even by a Chairman of a Board of Guardians, is almost an incitement to a careless parent to. waste on drink money which should be devoted to the nourishment and clothing of the children ; while the second may mean a bargain between a parsi- monious Board of Guardians and liberty- or licence-loving paupers for the lowest terms on which they will keep out of the workhouse." The same testimony is given, with a special emphasis derived from his professional experience, by our Medical Investigator. " The worst kind of public policy," sums up Dr. M'Vail, "is that under which an 48 THE OUTDOOR RELIEF OF TO-DAY Authority representing a community confers personal benefits without any accompanying requirement of good order or obedience. I heard of a Relieving OfiScer in an urban Union who, reporting on an application, recom- mended that relief be refused because the applicant was a lazy loafer, continually to be found at public-house corners, and any money he received would be spent in drink. A Guardian listening to this report indignantly demanded to be told : What right has any one to interfere with how a man spends his money ? The wrong policy is crystallised in the Guardian's query. It is surely obvious that if indi- viduals or their dependents are to be selected for mainten- ance in whole or in part by local rates or Imperial taxes, they should in their maintenance be duly controlled by the Authority which supports them. The principle is so elementary as hardly to require setting forth, but under the Poor Law it is abrogated every day of the year and every hour of the day. . . . Persons suflfering from the most serious transmissible maladies are afforded relief without prevention of opportunities to inoculate the healthy or contaminate the next generation. . . . Phthisis cases are maintained in crowded unventilated houses where there is unrestrained facility to convey the disease to their own offspring. Diabetes cases live on the rates and eat what they please. Infirm men and women supported by the Poor Law are allowed to dwell in conditions of the utmost personal and domestic uncleanli- ness. Widows get money for the upkeep of their family without any advice or requirement as to the spending of it, or as to the healthy rearing of their children. ... It is not worth while entering on any reform of the Poor Law unless this policy is changed. Beneficiaries must be compelled to obedience alike in their own and in the public interest." The gravest part of this indictment appeared to us to be the allegation that thousands of children, whose maintenance was being paid for out of public funds, were being brought up in homes such as have been described. We therefore specially directed the attention of the Investigators, whom we appointed to report on the PRACTICE AS TO OUTDOOR RELIEF 49 conditions in which the children on Outdoor Relief were being brought up, to the moral environment in which they found these children to be living. The result was a complete confirmation of the testimony already adduced. The report of our Investigators, with great wealth of statistical detail, divides the mothers of the 170,000 Outdoor Relief children into four classes : the first good ; the second mediocre ; the third including " the slovenly and slipshod, women of weak intentions and often of weak health, not able to make the most of their resources " ; and the fourth " the really bad mothers — people guilty of wilful neglect ; sometimes drunkards or people of immoral character . . . unfit to have charge of children." The percentages of the different classes were found to vary greatly. In the rural districts, whilst the third or unsatis- factory class is large (19 per cent), the fourth or unfit is small (6 per cent). In the towns, conditions are, as a rule, much worse. We may honourably except Bradford, where Outdoor Relief is administered with great discrimina- tion, but even here a few mothers of the fourth class were found in receipt of relief. In other towns the results of the investigation were simply appalling. In one great urban Union, in which every Outdoor Relief child was actually seen and inquired into — to say nothing of those living with " unsatisfactory " mothers — the number living with "really bad mothers — people guilty of wilful neglect; sometimes drunkards or people of immoral character " ; all "unfit to have charge of children" — amounted to 18 per cent of the whole number of children on Outdoor Relief. In another great Union, similarly completely investigated, this terrible percentage rose to as much as 22. To sum up, our Investigators estimate that the number of Poor Law children on January 1, 1908, in the very unsatisfactory homes of the third class, in England and Wales, is more than 30,000. The number of those in the fourth class, where the home is demon- strably wholly unfit for children, is no fewer than 20,000. We can add nothing to the force of these terrible figures. VOL. I 50 THE OUTDOOR RELIEF OF TO-DAY (c) The Cause of the Failure of the Present Administration of Outdoor Relief It becomes now our duty to state what, in our opinion, is the cause of the disastrous social failure of the present administration of Outdoor Relief. In order that any policy of domiciliary treatment of persons in need of support may be pursued without the gravest social and economic peril, the authority charged with its administra- tion must be so constituted as to ensure the fulfilment of three fundamental conditions. There must be, in each case dealt with, an accurate ascertainment, first, of the particular needs of the applicant ; and second, of the economic, sanitary and other circumstances of the house- hold. There must be, further, in each case, an impartial judgment, upon uniform principles, whether, on the ascertained facts, relief or treatment in the home is necessary and desirable, and if so, to what extent. Finally, if the relief is not to become, in many cases, demoralising to the recipient, and injurious to the com- munity as a whole, there must be imposed and enforced conditions as to the manner in which the publicly sub- sidised household shall be maintained, appropriate to the needs of each case. In our opinion, the Local Authority to which this important duty has been confided in the case of the Poor Law, namely, the Board of Guardians in England, Wales and Ireland, and the Parish Council in Scotland, with its stafi" of Relieving Officers, is, by its very nature, inherently incompetent to fulfil the require- ments that we have postulated. (i.) Tlie Destitution Officer We must begin with the Relieving Officer, who has to deal with all applicants for relief, whether men or women, children or aged, sick or well, in respect of the one characteristic of destitution. This "Destitution Officer," as he may be called, is, we are told, '* very largely the pivot on which the Poor Law works." And this is specially so in respect of Outdoor Relief. With regard THE DESTITUTION OFFICER 51 to institutional relief, the Relieving Officer is but the portal ; once the pauper has entered any Poor Law institution, the Relieving Officer has no further concern with the case. With regard to Outdoor Relief, on the other hand, this officer is, from first to last, all-important. It is to him that all applications have to be made. It is he who has to decide, in the first instance, whether the applicant is eligible for relief at all ; and in many cases his refusal is conclusive. He alone decides whether the applicant stands in need of immediate succour, and he administers what he judges to be necessary. It is he who visits the applicant's home, in order to form a judgment as to all the circumstances of the case. If there is ill-health, real or simulated, it is the Relieving Officer who decides whether or not to give the applicant access to the Poor Law Medical Officer; and indeed, whether the case is sufficiently grave to send into the Workhouse, or whether it should be treated at home. It is he who decides, on his own responsibility, whether a poor person is sufficiently obviously of unsound mind to be forcibly conveyed, pending judicial determination, to the Workhouse or infirmary ; and when, as some guide for this purpose, the "family history" is inquired into, it is upon the same officer that this difficult and delicate duty falls. It is on his report that all cases come before the Guardians. It is, in the vast majority of instances, his information alone beyond the applicant's own state- ment, that is supplied to the Guardians ; whether that information relates to the earnings or other resources of the applicant, to the ability of his relations to assist him, to his past character and present conduct, to the sanitary state of the house and street, to the cleanliness and decency of the home, to the number and conditions of the family, to the state of health and ability to work of the applicant, and even to the infectious or contagious nature of a disease such as phthisis, from which the applicant or some member of his family may be sufiering, and to the likelihood of recovery under the conditions of the home. It is on the report of this Destitution Officer that the Guardians have to rely in such momentous 52 THE OUTDOOR RELIEF OF TO-DAY issues of fact as to whether the character of a particular mother is or is not such as to warrant her being entrusted with the rearing of her children ; or whether a particular tradesman is or is not a suitable person to whom to bind a boy apprentice. The Relieving Officer is even required to discover and state what is the cause of the destitution into which the applicant has fallen. But all this array of duties, varied as it is, amounts only to the ascertainment of different classes of facts. When the case comes before the Board of Guardians, the Destitution Officer has to decide on a policy — has, that is to say, to give to the Guardians his responsible and authori- tative advice as to the kind of relief, the amount of relief, and the conditions of the relief that, according to the law of the land, the directions of the Local Govern- ment Board, and the best economic doctrine, the case ought to receive. We have been puzzled, indeed, to discover what exactly is assumed to be the right relation in this respect between the Relieviug Officer and the Guardians before whom he brings his cases. From the authoritative evidence of the Inspectors of the Local Government Board, experienced Clerks to Boards of Guardians and Poor Law experts, it appears that Relief Committees ought to be guided by specific recommenda- tions from the Relieving Officer in each case, and that contrary action on the part of the Guardians calls, as a rule, for official criticism, if not for censure. " The Guardians," complains an Inspector with regard to some of his Unions, " will override the 'plain facts of a Relieving Officer's statement, and deal with a case contrary to his advice." " I rather fear," regretfully admits the Clerk of a great Midland Union, " that . . . the reports of our Reliev- ing Officers are not always acted upon." It is " where the administration is bad " that " the Relieving Officer is set aside," suggests Mr. C. S. Loch, to which an Inspector replies, " That is so." This being the view taken by their official superiors, it is not surprising to find that the Destitution Officers themselves place a high estimate on their right to pass judgment on the cases, as well as to ascertain the facts. " Relieving Officers," asserts one of THE DESTITUTION OFFICER 53 them, " should be held responsible for the strict and proper administration (of the Poor Law), and should not be interfered with in any shape or form, and, if possible, should be given greater powers. From the time of appli- cation the Relieving OjBicer should see the case straight through, viz. kind and amount of relief to be given, recovery of maintenance from relatives, settlement and removal of paupers," etc. , The function of the Destitution Officer is, however, not exhausted when he has ascertained the facts, and given to the Guardians his judgment upon them. He has also to carry out the course of relief decided on, alike in its responsible and in its mechanical aspects. " When the proceedings of the Guardians are ended," says an In- spector, " the real work of the Relieving Officer commences. He has to pay the new relief which has been granted, as well as the old cases ; and he has to be ready to receive fresh applications as well as fulfil other duties and respon- sibilities which differ in different Unions. ... To begin with, he has his own books to keep. He has to remove pauper lunatics to the Workhouse or Asylum. He is nearly always Collector to the Guardians ; in other words, the official who finds out what relatives of paupers are liable and able to contribute to the maintenance, and collects these contributions. For this he is paid a percentage. A good Collector must carry on a large correspondence, and the office, if properly filled, is a very necessary and important one." It is, moreover, the duty of the Relieving Officer to watch carefully all the cases relieved, and to take upon himself the responsibility of reporting to the Guardians any facts which, in his judg- ment, ought to cause the relief to be stopped or varied. If any pauper gets drunk, or begins to lead an immoral life, the Relieving Officer must take the initiative. He will himself stop the Outdoor Relief, in bad cases, and inform the Guardians at their next meeting. Nor is the work over when all the persons actually in receipt of relief have been dealt with. It is on the Relieving Officer, not upon the Board of Guardians, that rests the legal, as well as the moral, responsibility, in cases in 54 THE OUTDOOR RELIEF OF TO-DAY which Outdoor Relief has been refused, and the applicants have not entered the Workhouse, for keeping the family continuously under observation, so as to be prepared to grant instant succour on " sudden or urgent necessity," in the event of any member of the family falling dangerously out of health in consequence of destitution. We shall refer again to this responsibility at a later stage of our report. The combination in a single Destitution Officer of such heterogeneous functions is, in our judgment, fatal to the establishment of an efficient service. Struck by the im- perfect qualification of the Relieving Officers for their varied and responsible duties, we asked what had been prescribed in the matter by the Local Government Board, only to find that no qualification whatever was required. Nor could the Inspectors or the Clerks to Boards of Guardians suggest to us any qualification or training that could advantageously be insisted on for the office as it at present exists. " There is no standard," explained to us one of the Insj)ectors, " there is no college of Out-relief, there is no Faculty." "You might impose an age limit," suggested another Inspector, " you might do some good by that ; you might impose a certain amount of reading, writing and general information as a qualification, but I do not know that that would help you very much. It is very difficult to suggest a qualification which would ensure your having the men you want for the Poor Law work." Even such examinations as those now required in the case of Sanitary Inspectors and Factory Inspectors could not, we were informed, be exacted from Relieving Officers, because " you cannot define a Relieving Officer's work." '* You want the Sanitary Inspector to do certain definite work, but the Relieving Officer has no definite work. An Inspector of Factories and an Inspector of Nuisances . . . have certain definite duties to perform, for the performance of which you can ascertain their competency to a great extent by examination ; but with regard to Relieving Officers you cannot do that." And this we agree is sub- stantially the case, not because this Destitution Officer's duties are indefinite, but because they are not limited to THE DESTITUTION OFFICER 55 one specialism, or even to two specialisms. It does not appear to us that one and the same officer can be qualified to obtain accurate and sufficient information on (1) the financial resources and circumstances of the household and its relatives; (2) the sanitary environment, personal health and prima facie need for treatment or removal of the various members of the family ; and (3) the educational requirements of the children, and the 'prima facie fituess for their nurture of the home and the parents. These three sets of leading facts seem to us to require, in each case, a certain measure of specialised training, which cannot be expected to be found combined in one investigator at between 30s. and £3 a week. The same is true with regard to improving the sanitation of the home, to seeing that the Medical Officer's orders are obeyed, and to giving the necessary advice in matters of personal hygiene, for lack of which, at present, the Outdoor Relief for the infant fails to keep it alive, and that given to the phthisical father too often results in the contamination of the family. Similarly, neither the financial officer nor the health visitor can supervise the children's schooling, test the home influence, and see that proper apprenticeship or corre- sponding training is in due course provided. And if this is true of investigation and execution, still more is it true of the responsible task of recommendiug what financial assistance, if any, the economic circumstances of the house- hold warrant, and by whom the burden should be borne ; or what kind of education and what general regimen each child or each sick person requires. It w^ill be unnecessary to point out, to those who are conversant with English Local Government, how adversely the absence of any prescribed qualification acts upon the selection of persons for any salaried post. A Board of Guardians, having no definite test of fitness to apply to candidates for a vacant Relieving Officership, is apt, at best, to take refuge in the known probity of an entirely inex- perienced neighbour or a minor subordinate ; and, at worst, to fall a prey to mere favouritism and jobbery, or even (as in some notorious recent cases) a squalid corruption. We are glad to find that the first of these alternatives is that 56 THE OUTDOOR RELIEF OF TO-DAY which the majority of Boards of Guardians have chosen. The 1700 or 1800 Relieving Officers as a class appear to us to be upright and honourable men, hard-worked and poorly remunerated, regular and diligent in the performance of what they conceive to be their duties. But not in- frequently, as we regret to have to report, the impractic- ability of any professional training and the absence of any prescribed qualification have resulted, in some Unions, in the office being filled, not by the men best fitted for it, but by those who most desire it and have friends at court. " Relieving Officers," says Sir William Chance, ** are often appointed for every other reason except that of a knowledge of their duties." "Many have qualified for the work," report our own Investigators into Outdoor Relief, "as soldiers in the South African War, as Scripture-readers, or as gate- porters." "You will sometimes see a man appointed as a Relieving Officer," testifies a Local Government Board Inspector, " simply because he has failed in everything else ... he may have failed as a farmer ; he may have failed as a contractor ; he may have failed as a road surveyor ; he may have failed in any sort of line of business to which he has devoted himself ; but if he be well known and have a quantity of friends they will find something for him." But the difficulty of securing the appointment of suit- able persons is not the only way in which the mixture of duties injuriously afi'ects this Destitution Officer's service. It is one of the minor tragedies of the present arrangement that, as some of the best Relieving Officers have complained to us, the very heterogeneity of their functions, involving the absence of expert technique and the lack of any definite standard of professional efficiency, has a deteriorating effect on their character. Like the Workhouse Master and Matron, and for the same reason, this "Mixed Officer" almost inevitably comes to despair of the preventive and curative side of his task. " Any leaning towards thorough investigation," says our Investigator, " and plan-full relief which he may have had at his appointment, the Guardians will have steadily discouraged. The result is routine. . . . The average officer has no policy, he works by rule of thumb." Dealing indiscriminately, as this Destitution THE DESTITUTION OFFICER 57 Officer must, without specialist training, with the vagrants and the unemployed, the widows and the unmarried mothers, the aged and the infants, the sick and the children, he is driven to ignore the special features of each class — and it is on these special features that its successful treatment depends — in the one common attribute of destitution. The one thing that is clearly expected of these Destitution Officers by their official superiors is to stave off this destitution from becoming pauperism. It is for a diminution in the number of unemployed men on the Outdoor Labour Test, in the number of deserted wives relieved, or in the number of medical orders granted, that the " model " Board of Guardians and the zealous Local Government Board Inspector will praise the officer. " Their work," say our Investigators, " is such as to breed suspicion of their fellow-men, and the more efficient the officer the more he comes to pride himself on his acuteness in ferret- ing out impostors." They are, we fear — to use the words of one witness before us — " expected to make it disagree- able for applicants to apply." " The general feeling," says another witness, " is that Relieving Officers are more in the nature of watch-dogs " than anything else. The result is that even the kind and humane officer, excluded by lack of professional training from successful curative or pre- ventive treatment of any one of the different classes with which he has to deal, feels it almost his duty to become, as a Medical Officer of Health complained to us, " a sort of detective who keeps out the improper cases." In some Unions, as a clergyman testified, " you do decidedly get men whose manner becomes, after years of work of that kind, harsh, and what you termed deterrent, which is fearfully painful to the deserving poor." "It seems," said another witness, " as if the Relieving Officer was too often tempted to be a bully. The result is to make the refined among the poor frightened, the weaker ones sly and cringing, the bad or strong - minded insolent and defiant." For the Relieving Officers, as another witness rather despairingly put it to us, " are desperately tried by deceit and trickery on the one hand, by overwork and by the necessity of not giving if it can be helped." 58 THE OUTDOOR RELIEF OF TO-DAY So the poor " press and fawn and lie " ; and there grows on the unfortunate Relieving Officer the invidious habit of feeling it his duty to " resist and deprecate, and disbelieve." "Thus," says a Local Government Board Inspector, " the best Relieving Officer is the one who keeps fewest paupers," just as " the best AVorkhouse Master is the one whose establishment is least loved by the able- bodied loafer." To sum up, it is to the combination of heterogeneous functions in one and the same person that we ascribe the failure of the Relieving Officers to prevent the disastrous social failure in the administration of Outdoor Relief that we have described. It is not, as is sometimes supposed, a question of inadequacy in the number and organisation of the staff. It would, in our judgment, be of no avail to reduce the size of the districts and multiply the number of the officers, even up to such a point that every one of them had only to deal with hundreds, instead of thousands of families. It would not cure the evil to raise, as is sometimes vainly done, one of them in each Union to the post of Superintendent Relieving Officer, and to set apart others as Cross Visitors, so as strictly to check the work. AVhat has been found impracticable is not to get a sufficient number of these officers, nor yet to get them to work con- scientiously and zealously, but to secure, in any one of them, the manifold training that would be necessary for the really successful performance of their present duties. To fit a man to carry out adequately even the subordinate duties of a Relieving Officer in all their different aspects would require an impossible combination of the training and attitude of an accountant and an inquiry agent, a debt collector and an Assessor of Income Tax, a Sani- tary Inspector and a Health Visitor, a School ]\Ianager and a School Attendance Officer. To fulfil completely the higher moral and legal responsibilities of the office in all its ramifications — to qualify, that is to say, a Super- intendent Relieving Officer to determine the policy to be pursued in regard to the due measure of financial assist- ance to be given, the contributions to be exacted from relatives, the healtJi measures to be adopted, the conduct THE DESTITUTION OFFICER 59 to be insisted on, and the education to be prescribed, for the children, the unmarried mothers, the widows, the phthisical members of the family, the chronic invalids and the acutely sick — would demand the training and intel- lectual habits of a Medical Officer of Health, a Director of Education and a County Court Judge. (ii.) Tlie Many -Headed Tribunal It is, however, to the Boards of Guardians, not to their Destitution Officers, that Parliament has entrusted the ultimate decision as to the grant of Outdoor Relief. We have therefore inquired how it is that these Boards have been so unsatisfactory in their decisions on the evidence presented to them. It was suggested to us by some witnesses that their failure to deal wisely with the problem of Outdoor Relief was to be attributed, in the main, to the character of their membership, and especially to a certain falling-off in social status which is alleged to have taken place since the abolition, by the Act of 1894, of the property qualification and the ex officio membership of the Justices of the Peace. Putting aside the question as to exactly what changes in social status may have taken place in different Unions, we have satisfied ourselves that, broadly speaking, the disastrous social failure of the Outdoor Relief administration neither began in 1894, nor has been increased or appreciably afi'ected by the changes of that year. Moreover, though difi'erent Boards of Guardians tend to err in different directions — some granting Outdoor Relief where it ought to be refused, others refusing it where it ought to be given — we cannot say that, in our experience, we have found the so-called " strict " Boards appreciably different from the " lax " Boards, in such fundamental matters as the complete ascertainment of facts, the specialised treatment of the different classes, the enforcement on the recipients of properly considered conditions of life, and, above all, impartial uniformity as between committee and committee, between meeting and meeting, and even between case and case. The cause of so general and so prolonged a failure, 60 THE OUTDOOR RELIEF OF TO-DAY common to all parts of the country, and to all periods of the past three-quarters of a century, must, we suggest, lie deeper than any personal characteristics of particular Guardians, or even of particular Boards. We discover the cause of the failure of the Outdoor Relief administration in the very nature of the Local Authority itself. There is, first of all, the inherent difficulty that a "Destitution Authority" finds in pro- viding itself with the varied technical advice necessary to the proper domiciliary treatment of so many difi'erent classes of persons. Just as the Destitution Authority, as we have seen, inevitably tends to have one General Mixed Workhouse, so it tends to content itself, for all classes alike, with the unspecialised counsel of the one "mixed ofiicial" known as the Relieving Officer. When it becomes conscious of the inadequacy of its staff, the only reform it can conceive is to multiply the number of these Destitution Officers, or to set one above the others as Superintendent, or to have one to check the others as Cross Visitor. It is significant that we have not discovered a single Board of Guardians that has sought to equip itself with a differentiated out -relief staff, in which one officer reported on personal hygiene and the sanitation of the home, another on the educational requirements and progress of the children, whilst a third specialised on the investigation of the financial resources and on the recovery of contributions from relatives. But apart from this lack of specialised officers, which is as inimical to successful Outdoor Relief as it is to successful institutional treatment, the present tribunal for hearing and deciding applications for Outdoor Relief has what, in our judgment, is the fatal defect of being a board — a board, by the way, of as many as twenty, forty, or even 100 members. The Board of Guardians was established mainly for the purpose of administering the Workhouse. But the work of adjudicating upon individual applications for Outdoor Relief differs fundamentally from that of managing institutions. When a committee manages a school or a hospital, it does not decide what shall happen to each particular pupil or inmate. AVe recognise at THE MANY-HEADED TRIBUNAI 61 once how fatal to efficiency it would be if the managing committee undertook to decide what should be taught to each particular child or gave orders about the treat- ment of an individual patient. In the administration of institutions, the resolutions of the committee, which are merely general decisions as to policy, do not become instantly and irrevocably operative in individual lives. In arriving at these decisions the suggestions and criticisms, the experience, and even the idiosyncrasies of a number of different persons are all of use. The analogous work in the sphere of Outdoor Eelief is the formulation, and from time to time the alteration, of the general rules according to which the relief should be given. This is essentially the work of a representative body. Most unfortunately, the application of this well- established distinction between the functions of a repre- sentative body and those of its executive are obscured in the case of the Poor Law by a strong popular sentiment against officialism, and a general impression that the direct interference of the Guardians interposes a human element between the destitute and the soulless letter of the regula- tions. The Guardians themselves, jealous of the officers and their powers, and keenly alive to the electoral advan- tages of being able to oblige individuals and to obtain a reputation for sympathy with the poor in whole neigh- bourhoods, are naturally altogether on the side of popular sentiment in the matter. Even the educated classes are apt to be under the impression that the Poor Law of 1834 earned the execration of all benevolent men by its sacrifice of human rights to inhuman official theory. It is, there- fore, necessary to point out that the restriction of a representative body to its proper function by no means dehumanises that function, any more than the fact that the jurymen in a criminal case are allowed neither to make the law nor to devise punishments according to their own fancy, withdraws from the prisoner the protection of that human element without which legal institutions would be impractical. It is not suggested that the Desti- tution Authority should not investigate grievances, or should be denied that access to the relieved without which 62 THE OUTDOOR RELIEF OF TO-DAY it would remain in ignorance, not only of the grievances actually complained of, but of the far more important short- comings of which neither the paupers nor the officers are conscious. Apart from grievances, the main work of the Destitution Authority, that of drawing up the regulations and deciding general questions of policy, must depend for its effectiveness on continuous contact with and observa- tion of its effect on the destitute, as well as on the community at large. There is, besides, the work of choosing the officers and, when necessary, dismissing them. In the exercise of duties thus scientifically limited there would be far more scope than at present for the exercise of that intelligent public-spirited humanity which at present is literally crowded out of the meetings of the Destitution Authority by the intrusion of individual applicants for relief, appealing to the short-sighted good- nature, to the desire for electoral popularity, and to the inevitable tendency of the ward representative to be regarded by his constituents, and finally by himself, as a patron saint at whose intercession the Authority must either grant the prayer or slight the intercessor. We have ourselves repeatedly noticed the members of Relief Committees and Boards of Guardians, whilst the cases were being heard, paying very different degrees of atten- tion to the evidence that was being given before them ; swayed very differently by considerations other than those given in evidence ; and governed by quite different views of social expediency. The joint decision of so composite a tribunal on individual cases can never be a good one. All this is intensified if the Board or Committee is selected by popular vote of the districts in which it has to administer Outdoor Relief. Moreover, the composition of the Board or the Relief Committee, whether elected or nominated, necessarily varies from meeting to meeting, and even from hour to hour. In some cases, to quote the descrip- tion given by one of our committees, " the Guardians wander from one (Relief) Committee to the other at pleasure," and "administer relief to their own constitu- ents." When the Board does not divide into committees, the effect is much the same. " Each Guardian's atten- THE MANY-HEADED TRIBUNAL 63 tion," says a witness, "is attracted only by cases from his own parish," and too frequently "it is turned, during the rest of the time occupied with the relief lists, to other matters, to the loss of silence or orderly procedure." Under such conditions it is not surprising to learn, on the testimony of a Guardian in a large urban Union, that " Outdoor Relief granted on one occasion may on the next be reversed, without there being any change in the cir- cumstances, but owing to diiferent Guardians being present. This matter ought not to depend on the views held by individual Guardians, but upon a general policy of the whole, otherwise preferential treatment is obtained by some and in other cases the reverse." " I find in my own experience," testifies the President of the Metro- politan Relieving Ofiicers' Association, " that cases are dealt with differently according to the absence or presence of certain Guardians. Say my Relief Committee consists of eight persons. If Mary Jones comes one week, with certain Guardians present, she will perhaps get 3s. 6d. in grocery; but if she comes the following week before another batch of Guardians, she will perhaps get 5s." ** At present," says an Inspector, the Guardian " considers every case in his ward as ' my case,' and speaks and acts as if he was the specially appointed almoner of the ward that he represents. . . . When the case comes on, the Guardian rises and pleads the cause of his client. . . . I have observed," continues this Inspector, "that when Guardians have stated their cases, and have indeed acted first as counsel, and then as judge and jury for their client, they too often consider they have done their duty, and leave the room." All this may be very human; but it is so in the sense in which to err is human ; and the notion that such humanity is good either for the destitute or for the community at large must be thoroughly shaken off" in reforming our system. This fatal defect of "many-headedness," combined with that of mutability of membership, has, we need hardly say, no relation to the manner in which the board or committee is constituted. It is not a question of the name of the body, or of the method of its election or 64 THE OUTDOOR RELIEF OF TO-DAY appointment, or the number of its members, or of the size of the area for which it acts, or even of the character and capacity of its membership. The business to be done is, by its very nature, unfit for decision by the votes of a board or committee, whether elected or appointed. There is in it absolutely no room for sentiment about an indi- vidual case, personal acquaintance or neighbourliness. It is, in fact, "one of the weak points" of the present "system of relief," says an Inspector, "that it gives opportunity for favouritism, or that preferential treatment which a spirit of neighbourly friendship is sure to en- gender." To let in any such considerations — still more to allow the decision to depend on the accidental presence or absence of particular members — is to deprive the com- munity as a whole of its power of control, and to risk non-compliance with the general rules which, by its elected representatives, the community has deliberately laid down. Far from the plan of decision of individual cases by an elected Board being essentially democratic, the chance whim or the accidental non-attendance of one member becomes the means of thwarting the popular will. This is none the less the case because the interference has been caused by a member who has been himself elected. When, however, the intervention is that of an ex officio or nominated member, the arbitrary and undemocratic char- acter of this assumption of power by an individual member becomes glaringly apparent. The work of deciding whether or not a given case comes within rules is, in fact, essentially of a judicial character. As such, the only way to obtain effective democratic control, and the only way to secure a uniform impartiality, is to entrust the detailed application of the popularly -formulated rules to one re- sponsible person, adequately trained for and profession- ally engaged in the task of hearing and weighing evidence, who can be definitely instructed to apply evenly to case after case the principles laid down by the elected repre- sentatives of the people. THE SCOTCH INSPECTOR OF POOR 65 (d) The Scotch Inspector of Poor We have been able to include in one common descrip- tion, and to subject to one common criticism, the adminis- tration of Outdoor Relief in all parts of the United Kingdom, whilst paying attention more particularly to England and Wales, because the systems and the practice of Ireland and Scotland are, in our judgment, both in methods and results, not essentially different. The resemblance of the Scotch Poor Law to that of England is obscured by differences of terminology. But from the evidence given to us, and from what we have ourselves seen, we have to report that the " aliment " granted by the Parish Councils of Scotland, though commonly less adversely criticised, is open to nearly the same animad- versions as the Outdoor Relief given by Boards of Guardians in England. It is at any rate as completely unconditional. It is given with as little real ascertainment of the economic facts of the case. It is administered, not by a body elected to do what is required in the public interest for any particular class of persons, but by what we have called a Destitution Authority, concerned only to relieve the destitution of all. It is very frequently, if not quite so universally, inadequate for any healthy sub- sistence. In one respect, however, the working of the system in Scotland appears to us to be more in accordance with the recommendations of the 1834 Report and less open to criticism than that of England, namely, in being given with greater uniformity. We have been impressed with the much greater approach in Scotland to identity of treatment of similar cases in the same parish, and of similar cases in different parishes. We attribute this greater evenness and impartiality of administration to two important differences between the Scotch and English organisations. In Scotland, and not in England or Ireland, there is an appeal from the decision of the Destitution Authority, on some points to the Sheriff, and on others to the Central Authority. Whilst the number of such appeals to the Local Government Board for Scot- land is not large, we believe that the effect of the right VOL. I • F 66 THE OUTDOOR RELIEF OF TO-DAY of appeal in securing general uniformity of treatment is wholly advantageous. But tlie most important respect in which the Scotch organisation differs from the English is, in our judgment, the existence in each parish of an Inspector of Poor, who occupies a position far superior to that of the English Relieving Officer. Like him, indeed, he is what we have termed a Destitution Officer. He is under the disadvantage of having to deal with all sorts and conditions of men, merely in respect of their destitu- tion; and cannot, therefore, specialise in the appropriate treatment of any one class. But unlike the English Relieving Officer he is himself effectively in communica- tion with the Central Authority, and, indeed, usually acts as Clerk to his Parish Council. This right of direct com- munication with the Local Government Board for Scotland puts the Scotch Inspector of Poor in a position to prevent the deviations from uniformity which, in England and Ireland, so often proceed from the favouritism or neigh- bourly sentimentality of individual Guardians. In some of the largest towns, indeed, where the Inspector of Poor is a salaried officer of position and attainments, the Parish Council, whilst retaining fully in its own hands the direction of policy and the formulation of the rules as to relief, in practice largely leaves to the Inspector of Poor the adjudication upon individual cases, with the result, as we believe, of a much nearer approach to an accurate, impartial and even-handed execution of the will of the elected representatives than any English or Irish Board of Guardians can count on. (e) The Suggested Abolition of Outdoor Relief In face of the unsatisfactory results, and, in some cases, the disastrous social failure of the Outdoor Relief adminis- tration, some English Boards of Guardians have attempted to pursue the policy of practically abolishing Outdoor Relief altogether — not merely, as was recommended in the Report of 1834, to the able-bodied, but also, as was suggested by most of the Local Government Board's Inspectors of 1871-80. to the non-able-bodied. This SUGGESTED ABOLITION 67 prohibition of Outdoor Belief to tlie non-able-bodied has never been embodied in any authoritative document of the Local Government Board ; but it has been, from time to time, practically effected in one Union or another, by the simple expedient of offering, to all applicants for relief, nothing but maintenance in the Workhouse — the General Mixed Workhouse that we have described. We need not recount the well-known experience in this respect of such Unions as Atcham and St. Neots, Brixworth and Brad- field, St. George's-in-the-East, Stepney and Whitechapel. As has been forcibly represented to us, and demonstrated by repeated statistics, this policy undoubtedly reduces the number of persons maintained at the expense of the Poor Rate. The universal " offer of the House," whilst bring- ing rapidly to an end the swollen lists of outdoor poor, does not appreciably or permanently increase the number of the indoor poor. To a very large proportion of the non-able-bodied poor, the General Mixed Workhouse is, in fact, so deterrent that, rather than enter its portals, they will try every possible alternative, and even put up with almost any privation and suffering, to the physical and mental deterioration of their children and themselves. It would, however, be unfair to those Boards of Guardians who have adopted this policy, and to those advocates who have suggested it to us, to imply that they are indifferent to this privation and suffering. They assert, on the contrary, that experience shows, *' in the most incontest- able manner, that the effective restriction of Outdoor Relief always improves the condition of the poor," and that there is no foundation whatever for the belief that its refusal inflicts any hardship. The fact that the applicants refuse the offer of maintenance in the Workhouse is held to show that they are able, when pressed, to fall back upon other resources ; and to prove that they were not really so destitute as they represented themselves to be. In the Unions in which this policy has been adopted, it is asserted that the "hard cases" that occur have been dealt with partly by contributions from relations able to assist, and partly by voluntary charities of one sort or another. On the other hand, it has been represented to us 68 THE OUTDOOR RELIEF OF TO-DAY that the poHcy of refusing Outdoor Relief, whilst in some cases unnecessarily breaking up the home, and forcing women, children and the aged into the demoralising atmo- sphere of the General Mixed Workhouse, has, in others, resulted in failure to relieve destitution virtually equivalent to a local abrogation of the Poor Law, leading to misery, to degeneration, and sometimes even to premature death from want and exposure. We thought it necessary, in order to clear up this conflict of testimony, to supplement the very elaborate investigations that we set on foot as to the efi'ect of Outdoor Relief, by the appointment of a special Investigator to make a detailed inquiry in six relatively " strictly " administered Unions in town and country — including some in which the Workhouse policy has been pursued for many years with apparent success — in order to ascertain what subsequently happened to families to whom Outdoor Relief had been refused, and who had not accepted the alternative off"er of the Work- house. Such an inquiry, involving personal investigation some time after the cases had been before the Board of Guardians, was beset with difficulties. Our Investigator was able, however, to trace out and report upon altogether forty-nine families in two Metropolitan Unions, one large provincial town, and three rural Unions. The results of this investigation, unfortunately, do not bear out the assertions that the refusal of Outdoor Relief is unattended with hardship to the poor, and that it is, if not actually beneficial, at any rate without injury to them. Our Investigator — herself an experienced Poor Law Guardian — sums up her conclusions as follows : — 1. In no case was the support by relatives increased through the refusal of Out Relief. In practically all the cases they were BO poor themselves that they were not in a position to give systematic assistance. If such additional help had been given it would have been at the cost of the physical efficiency of the younger generation. 2. In no case has any charitable agency effectively dealt with the destitution. Occasionally I found that spasmodic gifts were made, but with one exception, no effort was attempted definitely to place the family upon a sound economic footing. 3. There was no evidence to show that the applicants them- SUGGESTED ABOLITION 69 selves had been stimulated by the refusal of relief to greater personal efforts. On the contrary, the denial of assistance appeared to have discouraged and disheartened many whose energy might have been roused by wise guidance accompanied by sufl&cient temporary aid to enable them to maintain physical efficiency. 4. Two of the cases (out of forty-nine) found work. In one of these the man went back to his old employment straight from prison, and in the other the man got some irregular and possibly only temporary employment. 5. In more than half the cases the refusal of Out Eelief led to a gradual dispersal of the household furniture and wearing apparel, often not even excepting the most necessary clothing. There were also unmistakable signs of a marked physical deteriora- tion of the members of the families, owing to lack of food, warmth and proper clothing. If eventually the applicants are forced to enter the Workhouse, they will do so with health gone, home gone, and spirit and courage shattered. This deterioration is, from the national standpoint, probably most serious in the case of the children. The homes which were being broken up were of two classes : firstly, respectable homes which have been in the past thoroughly comfortable; secondly, homes which possibly have never reached a high standard of comfort. These conclusions are of grave import. Moreover, it must be remembered that the effects of a policy of " offer- ing the House " are not confined to the families to whom Outdoor Relief is actually refused. The policy of the Board of Guardians soon becomes known to the poor, and if nothing is to be obtained except an order of admission to the General Mixed Workhouse, even the destitute do not care to apply for relief " They had very few cases of the refusal of Out Relief," said one Clerk. " The people in the district knew the policy of the Board and did not apply for relief unless they thought they had a strong case." " The applicants know the policy of the Board and rarely apply for relief," reports our Investigator, '* in the circumstances when the only thing given would be an order for the House." ** Great hardships are undoubtedly borne in many cases by poor persons," reports one of the Diocesan Committees, whose assistance we have sought, " because of their extreme unwillingness to enter the Workhouse. It is alleged that in some cases * the House * is offered by the Relieving Officers where they know it 70 THE OUTDOOR RELIEF OF TO-DAY will not be acceptable, in order to avoid giving Outdoor Relief, and thus to keep down the expenditure of the Guardians." " A sickly man will not go in," reports another Diocesan Committee, "because he is helpless when he comes out ; the mother will not appeal because she may be separated from her children. . . . Many would starve first." The result is that, as one official witness candidly put it, " the very poor are sometimes very badly looked after . . . when they are ill." The same witness adduced case after case in which grave injury had been caused, in some cases leading to death, owing to the lack of prompt Poor Law relief; the sufferers in most cases neglecting or refusing to apply to the Relieving Officer, because they did not want to enter the Workhouse ; and the Relieving Officer not becoming aware of their need. It is, in fact, not regarded as any part of the duty of this Destitution Officer to search out destitution as a School Attendance Officer searches out cases of non-attendance at school, or as a Sanitary Inspector searches out nuisances. As a general rule, the Relieving Officer neither discovers, nor is informed of, any case of want otherwise than through the application of the sufferer. If — deterred by the known policy of the Board of Guardians — the poor do not apply for relief, they may, and sometimes do, sink gradually lower and lower in semi-starvation and misery until they are found actually dying, and are then removed to the Workhouse or infirmary in such a state that they survive their admission only a few hours or days. It is clear that, in a few cases, they die of starvation. We may believe that, in particular instances, in small Unions, where persons of influence and means make a point of privately relieving every " hard case," the strict refusal of Outdoor Relief, to the non-able-bodied as well as to the able-bodied, may not actually increase the misery of the poor, or lead to death from starvation. But viewed from a national standpoint, and having regard particularly to the children and to persons in the early stage of disease, we cannot say that the policy of refusing Outdoor Relief, even as described by tliose who believe in it, appears to us to be, in practice, any more satisfactory than the laxer SUGGESTED ABOLITION 71 policy that we have described. It appears to us, in fact, to fail at least equally in the two fundamental require- ments of ensuring appropriate treatment to those in need of it, and of enforcing suitable conditions of life upon those of irregular habits or improper surroundings. And the policy of refusing Outdoor Relief has the added draw- back that — as is vividly shown by the Parliamentary Returns of deaths from starvation in the Metropolis — the cases do not usually come to the notice of any public officer until they have become hopeless. " I was much struck," reports our Investigator, " with the hopeless con- dition of some of the cases at the stage at which I visited them. With these, an earlier common-sense treatment would have prevented the development of destitution (and in some cases of degradation also) to its present acute form. . . . To effectively suppi'ess pauperism, cases of destitution should he dealt with at an earlier stage." And the earlier treatment must be, not deterrent, but curative. "There are many cases," continues our In- vestigator, " which cannot suitably be met either by the grant of a Workhouse order or by " — the only alternative which most Boards of Guardians seem able to conceive, namely, a money dole of — " Out-relief. Some require curative treatment, others merely sound advice. No case which has ever touched the Poor Laiv should be left to drift unaided." We may cite as an example of the being "left to drift unaided" the case of one family, which was refused Outdoor Relief by an able and strict Board of Guardians, and in which, as our Investigator observes, " there were possibilities of development which were not taken. James, a lad of fourteen when his parents first applied to the Board, was alloiued to remain untrained, and now, at the age of twenty-four, is selling flowers in the streets instead of being employed at a good trade. The Relieving: Officer calls the attention of the Guardians to the daughter Margaret, a girl of nineteen (a cripple), and sug- gests that she be taught some occupation by which she can earn her living, but nothing is done ; and we now find her sometimes in the Workhouse and sometimes living with her mother, entirely untrained and incapable of supporting 72 THE OUTDOOR RELIEF OF TO-DAY herself. In all probability she will be a source of expense to the State as long as she lives, and her happiness in life will be curtailed by her limitations. Yet when she first became chargeable she was only a child of eleven." (f) The Substitution of Charity for Outdoor Relief It is sometimes suggested that, if all Outdoor Relief were refused, voluntary charity of one sort or another would come forward to deal with the cases that would not really be better in the Workhouse. Without dis- cussing the probability of this happening in country and town, all over the Kingdom — for we have found no evidence whatever on which to base so optimistic an assumption — we were struck with the allegations that were made as to such voluntary charities as already exist. It was asserted that the work of these charitable agencies, whether individual or corporate, was open to the same criticisms as those made against the Poor Law Guardians' administration of Outdoor Relief. We therefore thought it necessary to have a special inquiry made into the results of the charities and charitable endowments in a dozen different towns and villages. o The outcome of this investigation was very largely to confi.rm these allegations. It was found that, in place after place, the charitable gifts — whether of individuals or of the churches, of benevolent associations or of endowed trusts — are distributed without any complete ascertainment of the recipient's resources, and with even less inquiry and protection against overlapping than is practised by the Relieving Officer. There was evidence that many of the grocery tickets are sold at the public-house, and that, in one case, they had even been taken in payment at the local theatre. " Charity givers," said a witness who had for thirty-eight years been a Local Government Board Auditor, " are more imposed UjDon than the Guardians, and the cases would not be sifted, and the gifts would go by favour." " I do not consider," says a rural clergyman, " it would be practicable to substitute charity for Out-relief. There could not be quite the same efficient investigation SUBSTITUTION OF CHARITY 73 by the trustees ... as there is by Poor Law Guardians." So experienced a Poor Law Official as Mr. A. F. VulHamy informed us that he considered " it would be very mis- chievous indeed to substitute charity for Out -relief; because . . . the administrators of charities have seldom " the necessary training, "and would be apt to relieve, in the majority of cases, without system or proper investiga- tion." " Of the two " (charity and Poor Law Relief), testifies the Secretary of a provincial Charity Organisation Society, " I consider here that the Poor Law relief has the less demoralising effect, because there is careful inquiry by an excellent Relieving Officer, and a certain amount of supervision which acts as a deterrent." " In a few cases," says another witness, " it was very beneficial, but as a rule it was rather the contrary, because so many ladies, young ladies especially, would take a district and deluge it with charity, get very tired of it, and then say : ' Well, you must now go to the Poor Law,' which they would not have done in the first place." The Taunton Union is adduced by an Inspector as an example of '* rigid and good administration," by means of the strict limitation of Outdoor Relief. The Relieving Officers are vigilant and efficient, if not, as some say, " hard and somewhat brutal with the people." On the other hand, the town is over- run with charities, administered by trustees. Here there is canvassing of individual trustees, and " the usual wire- pulling. . . . The applicants are not seen by the trustees at their quarterly meeting when pensions and grants are awarded. There is no officer corresponding to a Relieving Officer or a Charity Organisation Society agent to investi- gate the circumstances of the applicants." With regard to the no less important point of the recovery of the cost of relief, when the recipient or some of his relatives are in a position to repay it, the evidence goes to show that voluntary charitable agencies are far more remiss than the public authority. In fact, our Investigators report that they " rarely came across a case in which relations had been approached with a view to enlisting their assistance." There is the very minimum of attempt, except in the case of almshouses, to enforce among 74 THE OUTDOOR RELIEF OF TO-DAY the recipients better conditions of living ; often, indeed, there is practically no discrimination according to character. In the practice of one society " for relieving the sick poor," which distributes above £800 annually, we are told that "poverty rather than character would appear to constitute a claim. ... A lady who had been a visitor for the Society for three or four years said she had never rejected a case. . . . No attempt is made to co-operate with other societies in the weekly allowance cases, and there is a great deal of overlapping. ... In a large number of cases the assistance is given in supplementation of Poor Law relief. For instance, out of twenty-five cases taken at random, it was found that ten were receiving Outdoor Relief." This over- lapping with the Poor Law, and with other charitable agencies, was found to be almost universal. Our Investi- gators report that *'in the case of . . . almshouse and pension charities," not under revised schemes, "the bene- ficiaries are very commonly chosen from among persons receiving Outdoor Relief, and in the case of the Dole Charities it is only in the rarest instances that any attempt is made to discriminate between those who are and are not in receipt of Poor Law relief." In one town, they state, " when lists ... of the recipients of the charities were submitted by us to the Relieving Oflicers, over sixty cases of people receiving Out-relief were at once, much to their surprise, recognised by them." As if to complete the parallel with the laxest Poor Law, there is even a practice, " especially in country districts," of giving " charity to agricultural labourers and others in supple- mentation of the ordinary wages current in the district, and not at times of exceptional need or distress." Above all, there is practically nothing in the nature of providing for each case exactly the treatment appropriate to its needs. " The work," reports our Investigators, " of pro- viding assistance suitable to the varying circumstances of each case demands an amount of knowledge and interest in charitable work, and an expenditure of time and trouble which can rarely be found under the conditions of charit- able administration. . . . It is . . . much easier to find a body of trustees who will make good appointments of SUBSTITUTION OF CHARITY 75 almspeople and pensioners than one which will satisfac- torily perform the difficult work of from time to time giving appropriate assistance in cases of special need and distress." It is interesting to find one small community in which organised charity has taken the place of the Poor Law. There are three small parishes in Herefordshire, adjoining each other, Letton, Bredwardine and Staunton-on-Wye, with an aggregate population of fewer than 200 families, which enjoy an honestly and, on the whole, ably directed charitable endowment producing (for almshouses, medical attendance and doles alone, besides boarding and day schools) over £1000 a year. Indeed, in these villages the trustees of Jarvis's Charity act instead of the local Board of Guardians. They relieve all temporary distress, distri- bute winter coals and blankets, educate and clothe and apprentice the children, provide gratuitous nursing and free medical attendance by their own doctor, pay for serious cases in the nearest hospitals, give regular weekly allowances to the aged, and accommodate those who need it in almshouses. The result is that there are practically no paupers in these villages, the total Out-relief expendi- ture for them all being under 12s. a week. The Poor Law has, in fact, been superseded by organised charity. The result is significant. " There can be no doubt," say our Investigators, " that the Charity is doing the work of the Poor Law, only on easie7^ terms, and people get help from the Charity ivho would he refiLsed by the Guardians. For instance, no steps are taken to see that children do their duty by their parents and contribute to their support when able. On looking through his books, one of the Relieving Officers for the Weobley Union found that out of 107 cases he had on hand, in thirteen he had secured payments from children. As regards the Jarvis Charity, there was not a single case in which the trustees had com- municated with the children." It is interesting to note that the wages current in these villages are distinctly low for the county in which they are situated, and that " the cottages . . . are very poor." Practically no other chari- table agencies exist, so that there is no overlapping. 76 THE OUTDOOR RELIEF OF TO-DAY and none of that competitive philanthropy so much deplored in large towns. There are friendly societies, but it is doubtful whether their membership is up to the average, as *' many young men who ought to be members . . . neglect to join . . . with the idea that the Jar vis Charity will be available should sickness overtake them." In short, in these three villages in which a relatively well- administered charity is " doing the work of the Guardians," and the Poor Law is practically non-existent, we have exactly the same complaints as those made against a lax Poor Law. It "does away with thrift"; it "creates a great tendency to laziness and dependence " ; " it is difficult to get work done in the parish ; men prefer to loaf about, and there is plenty of drinking going on " ; it makes " the people careless, lazy and unthrifty " ; " there is no demand at all for small holdings or land for allotments, while there is a growing demand in all the adjoining parishes " ; yet " you could not find a more discontented lot of people in any parish in England." It is interesting to observe that the failure of the various voluntary agencies adminis- tering charitable doles and allowances — whether individuals or societies, churches or endowed trusts — to avoid short- comings and defects exactly similar to those of the Poor Law, is to be attributed to the same imperfections in the dispensing authority. We have examined the constitutions and rules of dozens of charitable agencies up and down the country, including Charity Organisation Societies and Guilds of Help ; and we have not discovered one in which there is any requirement of specialist training in the "helpers," " visitors " or other workers, by whom the service is performed. The persons engaged, whether as paid officers or as volunteers, to inquire into the cases, to recommend the policy, and to carry out the course of treatment decided on, have, in fact, no more specialist training in their com- plicated task — either in the ascertainment of economic circumstances, or in personal hygiene and sanitation, or in the educational requirements and progress of the children — than the Relieving Officers themselves. Indeed, they have usually less competence than the Relieving Officers, as they have not the advantage of being continu- SUBSTITUTION OF CHARITY 77 ously employed on investigation and relief. They are, in fact, for the most part, merely amateur "Destitution Officers," without the professional experience which serves, at any rate, to enable the Relieving Officers to protect the community from imposture. Moreover, the voluntary committees before whom the cases are brought are as " many-headed " in their composition and at least as shifting in their membership as are the Boards of Guardians. And whilst there is only one Poor Law authority in each Union, there are often, besides uncounted individual donors, dozens of separate charitable agencies — in large towns hundreds, and in the Metropolis nearly two thousand — each spending " its income without any relation at all to the spending of its neighbours," guiding its policy solely with a view to its own individual interest, neither knowing or caring, as a rule, what is done by any other agency, and almost inevitably creating extensive overlapping with its consequent waste and demoralisation. It is therefore not surprising that a majority of the witnesses to whom we put the question, regarded the substitution of charitable agencies for Poor Law relief as neither practicable nor advantageous. (g) Conclusions We have therefore to report : 1. That the abolition of Outdoor Relief to the non- able-bodied is, in our judgment, wholly impracticable, and, even if it were possible, it would be contrary to the public interest. There are, and, in our opinion, there always will be, a large number of persons to whom public assistance must be given, who can, with most advantage to the community, continue to live at home ; for instance, widows with children whose homes deserve to be maintained intact, sick persons for whom domiciliary treatment is profession- ally recommended, the worthy aged having relatives with whom they can reside, and such of the permanently in- capacitated (the crippled, the blind, etc.) as can safely be left with their friends. Nor can the community rely on voluntary charity providing for these cases. In many 78 THE OUTDOOR RELIEF OF TO-DAY places such charity does not exist, and in many others there is no warrant for assuming that it would ever be adequate to the need. Moreover, our investigations show that voluntary charity, in so far as it exists in the form of doles and allowances to persons in their homes, has all the disastrous characteristics of a laxly administered Poor Law. 2. That so long as the alternative is admission to the General Mixed Workhouse, the policy of systematic refusal or restriction of Outdoor Relief to the non-able-bodied, pursued by a few Boards of Guardians in England, cannot be recommended for general adoption. We are unable to resist the evidence that this policy of " offering the House " even to the non-able-bodied results, in not a few cases, in unnecessarily destroying the home and breaking up the family, in separating child from mother, and in exposing young and innocent persons to the demoralising atmo- sphere of the General Mixed Workhouse. Such a policy, moreover, by deterring the poor from applying for relief, leads, in far too many cases, to semi-starvation and physi- cal and mental degeneration, from which the women and children especially suffer, and, in a small number of cases, even to death from want and exposure. The proposal made to us by some witnesses, that, in order to obviate this latter danger, the Destitution Authority should be granted powers of compulsory removal, appears to us — in view of the character of the General Mixed Workhouse in which these poor people would be incarcerated — wholly out of the question. 3. That the present system of administering Outdoor Relief to the non -able-bodied in England, Wales and Ireland, and, to a lesser degree, also in Scotland, is open to the gravest criticism. The large sum of nearly four millions sterling which is now expended in this way annually — a burden on the community that is steadily increasing — is being dispensed, without central inspection or control, in doles and allowances, awarded upon no uniform principle, and differing widely from place to place. This lack of common principle is observable even in the Bylaws or Standing Orders by which the best-administered CONCLUSIONS 79 Unions in England profess to guide their action. But in the actual practice the diversity between one place and another, in large districts between one Relief Committee and another, and sometimes even between one meeting and the next, according to the accident of which members attend — a diversity applying alike to the persons to whom Outdoor Relief will be given, to its amount and to its conditions — is still more extreme. It can, in fact, be described only as a total absence of principle. 4. That amid all this diversity of principle and practice, we find certain evil characteristics practically universal. Except in an insignificant number of well-administered districts in England and Scotland, the doles and allow- ances given are manifestly inadequate for healthy subsist- ence. They are given, not in relief of destitution, strictly so-called, but in supplement of other resources that are assumed to exist. In many cases, such other resources — whether earnings, charitable gifts or the contributions of relations — do exist, but are insufiicient. In some cases, on the other hand, the total income of the household is such as not to warrant any relief from the Poor Rate. But no Destitution Authority that we have seen succeeds in ascertaining what other sources of income exist or whether any such exist ; and the majority of them do not seriously attempt to do so. The result is that there are a great many cases in which, whilst Out-relief is given on the assumption that other resources will be forthcoming, none such are found ; so that the dole of Poor Law relief — upon which thousands of old people, sick people and even widows with young children are steadily degenerating — is a starvation pittance. 5. That an equally grave defect in the Outdoor Relief of to-day, at any rate from the standpoint of the nation, is the unconditional character of the grant. With a few honourable exceptions, no attempt is made by the Destitu- tion Authority even to ascertain how the household is actually being maintained upon the Outdoor Relief that is granted, still less to efiiect any necessary improvement in the home. The result, as we have grave reason to believe, is that a large part of the sura of nearly four millions 80 THE OUTDOOR RELIEF OF TO-DAY sterling is a subsidy to insanitary, to disorderly or even to vicious habits of life. The saddest feature of all is that no small proportion of the 234,000 children whom, in the United Kingdom, the Destitution Authority elects to bring up upon Outdoor Relief — in the course of a year prob- ably as many as 600,000 different children — are to-day, without any interference by these Authorities, chronically underfed, insufficiently clothed, badly housed, and, in literally thousands of cases, actually being brought up at the public expense in drunken and dissolute homes. 6. That we do not ascribe the disastrous social failure of the Outdoor Relief of to-day to any personal short- comings of the individual members of Boards of Guardians in England, Wales and Ireland, or of Parish Councils in Scotland. We have found no evidence that the corrupt and criminal practices which have unhappily occurred in certain places are at all frequent or widespread. Nor have we reason to suppose that the evil influences of electoral or social pressure have been otherwise than ex- ceptional. We have, indeed, been impressed by the vast amount of zealous and devoted service, unremunerated and unrecognised, that is being rendered in all parts of the Poor Law administration of the United Kingdom, by men and women of humanity and experience. We ascribe the defects and shortcomings of the present administra- tion of Outdoor Relief to the very nature of the Local Authority to which this duty is entrusted. 7. That we attribute the almost universal failure of the Boards of Guardians in England, Wales and Ireland, and of the Parish Councils in Scotland, in the matter of Outdoor Relief, in all districts, and in every decade, partly to an illegitimate combination, in one and the same body, of duties which can be rightly done by a board or committee, and those which can be efficiently dis- charged only by specialised ofiicers continuously engaged in the task. The " many-headed " body is exactly what is required, whether for Outdoor Relief or for the manage- ment of institutions, for arriving at decisions of general policy ; for prescribing the rules that are to be followed in determining particular cases ; and for examining griev- CONCLUSIONS 81 ances and preventing the abuse of their powers by the officers. But if the administration is to be democratic in its nature — if, that is to say, the will of the people is to prevail — it is absolutely necessary that the application to individual cases of the rules laid down by the board or committee, should be determined evenly, impartially and exactly according to the instructions, by a salaried officer, appointed for the express purpose. We recognise this at once in the management of a school, a hospital or an asylum, where the most democratic committee finds the best guarantee for the execution of its will in ordering its salaried officials to apply the rules that it lays down. But in the dispensing of Outdoor Relief the same " many- headed " body that makes the rules, has also attempted to apply them to individual cases ; and in doing so inevit- ably brings in personal favouritism, accident and the emotion of the moment, to thwart the will of the com- munity as a whole. The relative success of the Outdoor Relief administration of some of the best governed parishes of Scotland, is due, we think, to the fact that, whilst the Parish Council makes the rules, their applica- tion to individual cases is not left to the chance member- ship of a particular meeting, but is in practice largely entrusted, as a judicial function, to the Inspector of Poor. 8. That it is, however, not merely that " many-headed- ness" of the existing tribunal that is the cause of the failure of the Outdoor Relief administration of to-day. We ascribe that failure quite as much to the fact that the duty is entrusted to a Destitution Authority, served by subordinates who are essentially Destitution Officers. To entrust, to one and the same authority, the care of the infants and the aged, the children and the able-bodied adults, the sick and the healthy, maids and widows, is inevitably to concentrate attention, not on the different methods of curative or reformatory treatment that they severally require, but on their one common attribute of destitution, and the one common remedy of "relief," indiscriminate and unconditional. And just as this Destitution Authority tends always, in institutional organisation, to the General Mixed Workhouse, with its VOL. I G 82 THE OUTDOOR RELIEF OF TO-DAY promiscuity and unspecialised management, instead of to the appropriate series of specialised nurseries, schools, hospitals and asylums for the aged that are needed, so it tends also, with its general " mixed official," the Reliev- ing Officer, to provide, alike for widows and deserted wives, the sick and the aged, infants and school children, one indiscriminate unconditional dole of money or food, instead of the specialised domiciliary treatment, according to the cause or character of their distress, that each class requires. CHAPTER 111 BIRTH AND INFANCY We find the care of maternity, and of the infants under school age, undertaken in England and Wales, Scotland and Ire] and alike, by two Local Authorities, both spend- ing public funds upon this service, without co-ordination, and almost without communication with each other. Everywhere the Destitution Authority is providing main- tenance and medical treatment for expectant mothers, and for mothers with infants, applying for relief in respect of their destitution. Besides this, and apart from this, the Local Health Authority is, in a rapidly increasing number of areas, affording medical advice, and sometimes food to necessitous mothers and infants in the poorer dis- tricts. These rival Local Authorities are influenced by diametrically opposite conceptions of what is the public duty in the matter. Boards of Guardians, priding them- selves on " good administration," restrict their relief of expectant mothers and of mothers with infants, by deter- rent devices, with the object of reducing to a minimum the volume of " pauperism." The more " enlightened " of the Public Health Authorities, on the other hand, are perpetually striving to extend their ministrations to every necessitous mother and infant within their areas, with the object of diminishing infantile mortality. What is remarkable is that both policies are, at the present time, simultaneously receiving the encouragement of the Local Government Board. The result is that the Public Health Service, though in this department of very recent growth, and still only imperfectly sanctioned by Parliament, 83 84 BIRTH AND INFANCY is creeping over the whole country ; and will, in the near future, if not checked, practically supersede much of the work of the Poor Law. Meanwhile, the partial and uneven duplication of the service, together with the frag- mentary and entirely unco-ordinated provision made by voluntary agencies, is undermining parental responsibility, and causing wasteful expenditure, whilst failing to prevent excessive infantile mortality. (a) Tlie Provision for Birth and Infancy made by the Destitution Authonty The Report of 1834 gave practically no directions as to the provision to be made for infants, who were assumed to follow the father (or, in his absence, the mother). If the father of a legitimate child was able-bodied, or if the child was illegitimate, the infant, however young or sickly, was to be relieved only by admission with its parents to the Workhouse, where no special arrangements were made for it. The legitimate infants of fathers who were not able-bodied, and those of widows whether able-bodied or not, would, it was assumed, continue to be maintained on Outdoor Relief, without any direct responsibility for the infant's welfare being undertaken by the Local Authority. What would be the best course for the infant does not seem to have been considered. These two methods of provision are still in use. The expectant mother, or the mother with her infants, may receive either a Medical (including midwifery) Order, with or without other Outdoor Relief ; or may be provided with maintenance and medical treatment in a Poor Law Institution. (i.) Domiciliary Treatment of Expectant Mothers and Mothers with Infants We find to-day an extraordinary diversity of policy between one district of England and Wales and another with regard to Domiciliary Treatment of mothers — a diversity which bears no relation to the character of the district, to the needs of the mothers or to the rate of DOMICILIARY TREATMENT 85 mortality among the infants. This diversity is even prescribed and insisted on by the Local Government Board for England and Wales; though for what reason and with what object we have been unable to discover. In those parts of England and Wales (comprising two- thirds of all the Unions, scattered quite indiscriminately up and down the country) which are under the Outdoor Relief Regulation Order, expectant mothers and mothers with infants may be lawfully treated in their own homes, whether they are married or single, whether their husbands are able-bodied or not, and whether or not they have already had illegitimate children. In other parts of England and Wales, comprising about one-fifth of the Unions, where the Outdoor Relief Prohibitory Order is alone in force, expectant mothers and mothers with infants cannot lawfully receive Domiciliary Treatment, whatever their character or circumstances, if they have able-bodied husbands, or if (being unmarried) they are themselves able-bodied. In yet other parts of England and Wales where the Outdoor liabour Test Order or the Workhouse Modified Test Order is in force along with the Outdoor Relief Prohibitory Order, the expectant mothers or the mothers with infants, having able-bodied husbands, may lawfully receive Domiciliary Treatment, but only if the husbands fulfil the conditions of work in the Labour Yard or residence in the Workhouse. But the diversity of usage with regard to Domiciliary Treatment thus prescribed for mothers and infants by the Local Government Board for England and Wales, according to the geographical situation of their homes — whatever may be its reason — is thrown into the shade by the still more extraordinary diversity of policy among the Boards of Guardians that we have already described. We need refer here only to the fact that whereas many Unions in England refuse Outdoor Relief altogether to expectant mothers who are unmarried, and to the mothers of ille- gitimate children, other Unions grant it frequently in such cases. Sometimes, as at Norwich, the Board of Guardians will withhold it until the infant is at least three months old ; on the other hand, the Board of Guardians of the 86 BIRTH AND INFANCY little urban Union of St. Thomas, Exeter, not only grants Outdoor Relief to the mothers of illegitimate children, but even provides expressly in its standing rules, without objection by the Local Government Board, for the expect- ant mothers of such children, at a regular scale of Is. 6d. per week prior to the birth and 3s. 6d. per week for four weeks afterwards. Quite as important, however, to the community, as the diversity of treatment of expectant mothers and of mothers with infants, is the almost invariable inadequacy of the provision made under Domiciliary Treatment for the proper nourishment of the child. An expectant mother, if granted Outdoor Relief at all, is seldom given more than 2s. or 3s. per week, no consideration being given to the special needs of her condition. " It is unfortunate," says a Medical Officer of Health, "that in Poor Law administration (so far as I know) no particular instructions are issued to Relieving Officers to grant special food to women who are about to become mothers." In due course the Midwifery Order, if granted, provides the attendance of the District Medical Officer, or (in a few districts) of a salaried midwife ; but it is seldom accompanied by any nursing; and the doctor does not by any means always recommend the grant of "medical extras." When the infant is born, the Outdoor Relief granted is, as we have described, usually only 2s. or 3s. per week — often, indeed, only Is. or Is. 6d. a week for the child, and nothing for the mother ! Only in one or two Unions, such as Brad- ford, is care taken to see that the Domiciliary Treatment, if decided on, is accompanied by really adequate provision for subsistence. Combined with this inadequacy is the wholly uncon- ditional character of the treatment afforded. We cannot discover that, when a Board of Guardians decides thus to maintain on Outdoor Relief a destitute expectant mother or a mother with infants, it ever occurs to any one to accompany the money with any sort of instructions as to prenatal conduct and health ; or with any sort of direc- tions as to how the child should be reared. In view of the fact that the mothers are, in the great majority of DOMICILIARY TREATMENT 87 cases, extraordinarily ignorant on these points, it does not seem to us economical that so large an expenditure should annually be incurred from the Poor Rate in order to pro- vide for the birth of infants, without any precautions being taken to prevent these infants from dying within a few days or weeks of birth. Nor do we find the Destitu- tion Authorities in any part of the Kingdom taking any heed whatsoever of the conditions under which the 50,000 infants under five years of age, whom they have always on their books as Outdoor paupers, are being reared. The mothers may nurse their infants themselves, or may use the most insanitary bottles ; they may feed their infants properly, or give them potatoes and red herrings ; they may lock them up in a deserted room all day (since the Guardians make it necessary for the mothers to go out to work), or they may leave them (with dummy teats or " comforters ") with the most careless neighbours ; they may overlay them in bed ; they may even insure their little lives with one of the Industrial Insurance Companies, and so use some of the Guardians' Outdoor Relief money thus hideously to speculate in death — all without the slightest instruction, without any warning or prohibi- tion, and without even any attention by the Destitution Authority, out of whose funds these infants are being maintained. Under these circumstances we cannot but regard it as unfortunate that the Local Government Boards for England and Wales, Scotland and Ireland respectively, should never have procured any statistics as to the mortality among the 5000 infants under one year whom the Destitution Authorities are now maintaining on Outdoor Relief. Some Boards of Guardians, as we have seen, solve the problem by refusing Outdoor Relief, and even a Midwifery Order, to expectant mothers, or to the mothers of infants, unless under excej)tional circumstances, or with deterrent restrictions. We are indebted to Mr. Theodore Dodd for pressing on our attention the fact that the rate of infantile mortality appears to be specially high in some Unions in which Outdoor Relief is practically always refused ; and that no attempt is made by the Boards of Guardians 88 BIRTH AND INFANCY actively to prevent such grave results of the destitution in their districts which it is their statutory duty to relieve. Mr. Dodd's statistical data are admittedly very imperfect, but the general purport of his evidence receives confirma- tion in other quarters. " A distressing element of the work," we read in the Annual Eeport of the Medical Officer of Health for Kensington, " is the poverty which, during the lying-in period, reduces many a mother to a state of destitution, rendering it impossible for her properly; to nourish her infant in the natural way. ... I think," adds the Health Visitor, " I must have seen quite j&fty mothers who, I have every reason to believe, were in a state of dire need, with their babies of a few days old lying beside them. . . . Appeals to the Eelieving Officer for Out-Eelief in such cases, unless the District Medical Officer is in attendance, result in the ' offer of the House,' of which the mothers of families are unwilling to avail themselves." With regard to the very common restriction of Mid- wifery Orders, many of our medical witnesses attributed serious consequences, in the low standard of health of working women, in the excessive infant mortality, and in various defects in the children who survive, to the fre- quent lack, in poor families, of qualified attendance at childbirth. " In many emergencies," we were told by a great Medical authority, "there is no time to obtain a Medical Order from the Relieving Officer ; and by the time medical help is secured the opportunity for successful treatment may have passed." We were, for instance, con- fidently informed that a fourth or one-third of those blind from childhood — a large proportion of whom become permanent paupers — are blinded shortly after birth by ophthalmia neonatorum, which can usually be prevented by simple medical care. Under these circumstances we have been surprised to find that — apparently without objection by the Local Government Board — many English Boards of Guardians have rules restricting the grant of Midwifery Orders — not, as might be supposed, to mothers in their first confinements — but to the experienced mothers only who have already had three children, or four children, or sometimes even to those only who have had five children, who have all lived. Our Medical DOMICILIARY TREATMENT 89 Investigator happened himself to see the working of this restriction. Apphcation was made to the Relieving Officer for an Order for the doctor to attend a labourer's wile in her fifth confinement. But it turned out that only two of the four children previously born were still alive, and the Eelieving Officer declined to grant the Order, but promised to mention the matter to the Guardians, though without much expectation, as I understood, that they would break through their rule. Necessarily under the Poor Law, the point of view in these cases is solely the financial cir- cumstances of the applicant, not the future health of the pro- spective mother. Manifestly for her health the most important confinement is not the fifth, but the first. If not properly guided in it, illness may result which will lead to permanent ill-health. But a labourer, it is held, should be able to pay for the doctor for the first confinement, and so it is only when the family has in- creased to four that relief is given. We feel compelled, at this point, very seriously to draw attention to a diversity of treatment of these cases in Scotland, which results in no little preventable suffering and mortality, if it does not also have consequences gravely affecting domestic morality. Under the Scotch Poor Law, as it has been interpreted by the Law Courts, an expectant mother, or a mother with infants, who is the wife of an able-bodied man, may not, however dire her necessity, lawfully be granted by the Destitution Authority, whether in the Poorhouse or in her own home, either medical or midwifery attendance, or food or other necessaries, so long as she is living with her husband. In fact, the grant of any relief whatever to such a woman, even to save her or her infant from immediate death, and even with the sanction or consent of the Parish Council or the Local Government Board, would be an illegal payment, liable to be surcharged at audit. On the other hand, the expectant mother, or the mother with infants, who is unmarried, or whose husband has deserted her, may, if destitute, not only be granted adequate medical attendance and main- tenance, whatever her past or present conduct or character, but can actually claim it as of legal right, whatever the Parish Council may decide in the matter, and can enforce this claim by summary appeal to the Sheriff. 90 BIRTH AND INFANCY We think that this extraordinary law should be at once amended, so as to give the necessitous married woman and the legitimate child at least as good a position as the un- married or deserted mother, and the illeo^itimate child. At present, the Scottish Poor Law — we could scarcely have believed it if it had not been testified to us by the Legal Member of the Local Government Board for Scot- land — deliberately puts a premium on irregular sexual intercourse, on permanent unions without marriage, and on the desertion of wives and children by their husbands and fathers. The grave results of this law are, we are in- formed, familiar to those acquainted with the lives of the poor in the great cities of Scotland. One of the least of these is the simulation of wife-desertion which is frequently practised, with the wife's connivance, by respectable hus- bands who find themselves unable to pay the expenses incidental to another birth. But there are more serious evils. We cannot help connecting the continuance in Scotland of a high rate of illegitimacy, the prevalence of irregular unions, and the increasing frequency of wife- desertion, with the state of mind that has permitted this disqualification of the married woman living with her husband to remain on the statute-book, and even to find defenders. We are aware that the more humane Parish Councils seek to evade this extraordinary provision of the Scotch Poor Law, by directing their Medical Ofiicers, when wives or legitimate children are patently starving, to find some excuse for certifying the husband or father as non-able- bodied, however able-bodied he may m fact be. We are not satisfied that this " subterfuge " as it was described — we prefer to say this demoralising evasion of an immoral law — is sufficiently universally practised by Parish Council Officers, or is sufficiently widely known among respectable working-class families, destitute through lack of employ- ment, to check the preventable suff"ering and mortality entailed by the law itself. " In point of fact," admitted the Medical Member of the Local Government Board for Scotland, " many cases of serious hardship do arise." It has been urged that the community has no reason to DOMICILIARY TREATMENT 91 regret the large and unnecessary infantile mortality, which evidently results from the restriction of Domiciliary Treat- ment in England and from the refusal of all relief in Scot- land to the dependents of able-bodied men, and from the ignorance and the suffering of the poorest class of mothers. It is suggested that this preventable mortality is but one aspect of the " survival of the fittest," by which the com- munity is actually strengthened and the race improved. We prefer to say nothing as to the demoralisation of character which, in our judgment, attends upon any such deliberate condemnation of thousands of human beings to death or any such reasoned acquiescence in their prevent- able deaths, in order that the survivors may somehow be benefited. What will appeal more to those who take this view is the unmistakable evidence that there is no scientific justification for the assumption that the pre- ventable deaths of infants either result in the survival of the fittest — whatever definition may be given of that term — or tend to the improvement of the race. The competition for the means of subsistence does not take place among the infants themselves. There is no evidence that the babies who perish in the first year of life, owing, not to their own physical or mental characteristics, but to the ignorance or the poverty of their mothers, are in any way mentally or morally inferior to those who survive ; or even that they are physically inferior to the infants of other families who survive only by reason of elaborate and continuous care. We have to remember that, according to the best scientific evidence, *' between 80 per cent and 90 per cent of the babies born in this country are born healthy. The greater part of the disease and mortality among infants is not due to ante- natal conditions ; it is due entirely to the fact that a large number of babies cannot obtain food," and this virtual starvation of the infants is quite independent of their own physical fitness or strength. We cannot even assume, merely because the mothers are poor, that these children come of stocks in any way inferior to the average. What is, however, more important to those who have to con- sider (and perhaps to bear the expense of) the future 92 BIRTH AND INFANCY maintenance of all the children is that the premature deaths of these infants imply a disastrous weakening of those who just escape death. "The infantile mortality question," says a high medical ex- pert, " is one, therefore, of extreme importance ... in regard to the physique of the nation. While thousands perish outright, hundreds of thousands who worry through are injured in the hard struggle for existence, and grow up weaklings, physical and mental degenerates. A high infantile mortality rate, therefore, denotes a far higher infantile deterioration rate, and this unwelcome fact must not be lost sight of." Sir John Simon, Chief Medical Officer to the Local Government Board, pointed out a generation ago that — "A high infantile mortality almost necessarily connotes a prevalence of those causes and conditions which in the long run determine a degeneration of the race." " The more we investigated," significantly declares a scientific expert on the disease of children, " the more we were struck with another factor, which we regard as even more serious, and that is the condition of the infants that do not die. The statistics of infantile mortality at the present time afford a very important index of the serious conditions that affect infant hfe. This mortality is not by any means the worst result of the conditions as they are found in this country. By far the most serious matter, affecting the commonwealth in every possible way at the present time, is the condition of the babies who do not die, but who are reared in a condition of hopeless malnutrition. Let us consider, for instance, one disease — rickets. Its effects on the nervous system are of the most far-reaching character. Of the ' convulsions ' which cause the death of babies at about twelve months of age, rickets is practically the sole cause. At a later stage of life the manifesta- tions of the injuries caused by this disease are seen in epilepsy and in insanity. The lunatic asylums are largely occupied at the present time by cases of insanity arising from injuries of the nervous system by rickets. Adenoid growths, one of the common troubles of childhood, are practically caused entirely by deformed structure due to rickets. If you go to the chest hospitals and select the patients who are under treatment for pulmonary tuberculosis, you will find the majority of them are suffering from deforn^ities of the chest due to rickets. The pulmonary disease is simply a secondary result of the injuries to the chest, and of the injuries to the tissues arising from rickets. All sorts of deformities which go to make up the number of cripples that we are acquainted with are caused by the same disease. And in addition to specific DOMICILIARY TREATMENT 93 disease and deformities, rickets is responsible for a general and permanent enfeeblement of mind and body," In short, we do not feel sure, in view of the scientific evidence that has been adduced, whether, in a final analysis, the excessive infantile death-rate caused by maternal poverty and ignorance, is not really intimately connected with the annual recruiting of able-bodied destitu- tion and the " Unemployed." Has not Dr. A. K. Chalmers said : " The dead baby is next of kin to the diseased baby, who in time becomes the anaemic, ill-fed and educationally backward child, from whom is derived, later in life, the unskilled * casual ' who is at the bottom of so many of our problems " ? (ii.) The Worknouse as Maternity Hosintal But a large and increasing part of the Poor Law provision for child-bearing women takes the form of Indoor Relief. Few persons realise the extent to which, in England and Wales, Scotland and Ireland alike, the Workhouses or Poorhouses are being used as Maternity Hospitals. In Glasgow the number of births in the Poor Law Institutions of the city has doubled in five years. The Workhouses in the smaller rural Unions of England, Wales, and Ireland, and the Combination Poorhouses of Scotland, have perhaps only half a dozen confinements each in a year. In the town Workhouses they are numbered by dozens or by scores. And in such populous Parishes or Unions as Liverpool, West Derby, Belfast, and Glasgow, a baby is born in the Workhouse nearly every day. We regret that the Local Government Board was unable to furnish us with any statistics as to this subject. From such statistics as are available we gather that the annual number of births in the Poor Law institutions of the United Kingdom probably exceeds 15,000. In the thirty-four lying-in wards of the Poor Law institutions of the Metropolis, nearly 3000 births occur annually. In the Irish Workhouses the number actually reported was, in 1906-7, 2012. From exact returns obtained by one of 94 BIRTH AND INFANCY our members from 450 out of the 645 Unions in England and Wales, we estimate that of the 11,000 children thus born in the Workhouses of England and Wales, about 30 per cent were described as legitimate and 70 per cent as illegitimate, the latter amounting to about 18 per cent of all the illegitimate births. It is interesting to notice from the statistics that a large, and, as we have some reason to believe, an increas- ing proportion of these mothers, do not appear to be, in the ordinary sense of the term, destitute persons. They are usually not in receipt of Poor Relief of any kind prior to their lying-in ; and they voluntarily take their dis- charge, with the infant, within a few weeks of its birth. In the Workhouses from which exact statistics were obtained, more than half the mothers in 1907 discharged themselves within a month — one-eighth of them, indeed, within a fortnight. In comparatively few cases are these women noted as being readmitted to the Workhouse during the ensuing twelve months. In fact, they resorted to the Workhouse simply in order to be delivered. The women who thus resort to the Workhouse in their hour of need are, we find, of all nationalities, all grades of character and conduct, and all degrees of intelli- gence. In the Metropolis especially there are many domestic servants, laundresses, and the humbler members of such nomadic professions as that of the theatre and music-hall. " Poor girls refused the shelter of their own homes in time of trouble ; syphilitic patients ; women who have been knocked about, neglected, and ill-treated up to the last minute ; cases actually in labour when admitted; in fine, all sorts and conditions of poor women who have nowhere else to go, find their way to the Poor Law maternity wards, where," optimistically observes an Inspector, " they receive the most skilful and tender care for themselves and their little ones." Some of these are " Ins and Outs " of a peculiar type, recurring at something like twelve months' intervals. An examination made by one of our members showed that in many cases the same woman's name will be found occurring several times at varying intervals in the maternity ward register. In one WOKKHOUSE AS MATERNITY HOSPITAL 95 case a name was pointed out as that of a person who had been in for three confinements, it having been verified that the woman in question had been in for three other con- finements in the neighbouring Union, thus having been delivered of six illegitimate children at the public expense. We were surprised to find that there is no system of classifying those who come in for confinement, a defect which, from the evidence of Matrons and Midwives, as well as of Poor Law Guardians, leads to the moral deterioration of many of those women who might other- wise have been induced to lead respectable lives. This is true of the Workhouses and Poorhouses of England and Wales, Scotland and Ireland alike. " In a large number of Workhouses," reports the Vice-Pegal Commission on Poor Law Reform in Ireland, " can be found in the same ward young girls awaiting the birth of their first baby, unmarried mothers with an infant or a child under two years of age, and unmarried mothers with two or more illegitimate children. These girls and women are also employed throughout the Workhouse as scrubbers, attend- ants, and laundresses, and continually have opportunities for conversation with one another and with other female inmates. The result is that in most cases girls lose a sense of shame and become more and more degraded." "No- where," declared to us the Lady Inspector for the Local Government Board for England and Wales, '* is classifica- tion more needed than in the maternity wards. The unavoidable and close intercourse between the young girl, who often enters upon motherhood comparatively innocent, and the older woman who is lost to all sense of shame and who returns again and again to the maternity wards for the birth of her illegitimate children, constitutes a grave danger. Too often the older woman invites the friendless girl to share her home on leaving, and so leads her on to further ruin." "We believe," declares the Vice-Regal Commission, with regard to Ireland, " that in the enormous majority of cases a Workhouse life debases such girls, who get used to their companions and surroundings ; and they leave and return to the Workhouse as necessity compels or as their own blunted feeling inclines them." And the demoralisation 96 BIRTH AND INFANCY becomes, we might almost say, a matter of inheritan(;e. " We have frequently found in the Workhouse," declares the same Commission, "an illegitimate baby, its mother and its grandmother ; and in one case we were shown in the same Workhouse a baby, its mother, its grandmother and its great-grandmother, or four illegitimate generations in the female line." We find that it is generally assumed that the women admitted to the Workhouse for lying-in are either feeble- minded girls, persistently immoral women, or wives deserted by their husbands. Whatever may have been the case in past years, this is no longer a correct descrip- tion of the patients in what have become, in effect, Maternity Hospitals. Out of all the women who gave birth to children in the Poor Law institutions of England and Wales during 1907, it appears that about 30 per cent were married women. In the Poor Law institutions of London and some other towns the proportion of married women rises to 40, and even to 50 per cent. It has in some districts become common, we are informed, for the waves of unemployed but respectable working-class men to resort to the Workhouse for their lying-in, in order to escape the ordeal of another confinement with no money coming in. The majority of these mothers, as we have mentioned, whether married or unmarried, stay only a short time in the Workhouse — sometimes as little as ten days — and no arrangements seem to be made for usefully occupying those who remain longer in a convalescent ward, or for affording any of them any kind of instruction in the management of their own health, or in the rearing of their infants. " In their time after working hours they are compulsorily idle." Expectant mothers are not even allowed to prepare for the coming event by making any clothes for the infant ; still less are they instructed how to do so. "It is," we were informed, " against the Work- house rules " for expectant mothers to make the baby clothes, which "are made in the sewing -room by the older women." "No instruction or help of any kind," observes a lady Guardian, " is given to young mothers. WORKHOUSE AS MATERNITY HOSPITAL 97 There is no one to give it." We have observed in our own inspections of Workhouses that even the part taken by the mothers in the management and upbringing of their children is decided more from the point of view of what is convenient to the institution, than from the idea of developing any sense of responsibility in the mother. The nursery is usually in charge of a paid attendant, not a trained nurse, but a woman of some experience in the care of children, who is aided by " grannies " or old pauper women who nurse the babies, and younger pauper women who do the scrubbing and charing. These are not usually mothers of children in the nursery. The matron finds that the children of such mothers cry after them, and it delays the work, and she prefers to employ the mothers elsewhere. If mother and infant remain in the institution for nine months or a year the separation between them becomes complete. This being the organisation of the Workhouse, those mothers who come in for a temporary period, to whom some real training in responsibility, etc., would be valuable in their future liffe, have necessarily to fall in with the existing arrangements. When they leave the Workhouse with their babies, they pass officially quite out of the ken of the Destitution Authority, which takes no heed of how they are going to live, or whether, under the circumstances, the baby born at so much expense to the Poor Rate is likely to live or die. The unmarried mother who takes out her infant finds on her no sort of pressure to take the trouble to keep it in health, or even to keep it alive. There is not even any notification of the cases to the Local Health Authority, which is often simultaneously going to great expense in endeavouring to watch over all the infants in the district. " We have all births reported to the Health Department," said one Medical Officer of Health, " and it is the business of the Women Inspectors to visit and advise the mothers as to the feeding and rearing of infants. The infants who are particularly likely to die are the illegitimates. The mothers of these infants are to a large extent confined in the Workhouse Hospitals ; and it is difficult for us to get the addresses of these children when they leave the VOL. I H 98 BIRTH AND INFANCY Workhouse Hospitals, in order that they may be super- vised." The result is, so far as can be gathered from those who come in contact with the facts, that the illegitimate babies whom their mothers take out with them after their two or three weeks' stay in the Work- house lying-in ward only rarely survive. Many of them are dead within a few weeks. Here as elsewhere, in fact, we see the costly provision made by the Destitution Authorities so organised as to break down any sense of personal obligation on the part of the recipient, and so narrowly restricted as to avoid any stimulus or incentive to parental responsibility. The only remedy for this grave social neglect that has been suggested to us on behalf of the Destitution Authorities is that they should have power to detain the mothers in the Workhouse for a certain period after childbirth. We have been unable to ascertain how far this compulsory detention is advocated for the purpose of educating the mothers ; how far for that of deterring them from " coming on the rates " ; how far for that of punishing them for having caused expense ; and how far for that of prevent- ing them from further breeding. Whatever may be the value of compulsory detention as a remedy, it is, we think, clear that no such power can properly be granted to a Destitution Authority. In no case is the General Mixed Workhouse a place in which persons ought to be com- pulsorily immured. If the object of the detention is educa- tion, all our evidence goes to prove that the Destitution Authority, from its very nature, cannot be an efficient teaching body. If the object be deterrence or punish- ment, we cannot imagine any justification for its infliction v/ithout judicial trial and sentence for some definite offence. But we apprehend that the suggestion is really intended to apply only to those unmarried mothers who are so feeble-minded or so mentally or morally defective as to be unable to take proper care of themselves in the competitive world. We doubt whether, in practice, it will be found possible, with any sort of responsible medical and judicial discrimination, to bring any large proportion of women into this category. We agree with the Royal WOEKHOUSE AS MATERNITY HOSPITAL 99 Commission on the Care and Control of the Feeble-minded that all such cases, whether few or many, ought to be wholly removed from contact with the Destitution Authority ; and that they should be dealt with accord- ing to their condition, whether by detention under proper certificate or not, by the Authority responsible for all grades of the mentally defective. But the aspect of the Poor Law maternity hospital with which this chapter is primarily concerned is that relating to the infant. Early in our evidence our atten- tion was drawn by Dr. Fuller, Medical Inspector of the Local Government Board for Poor Law Purposes, to the apparently excessive infantile mortality prevailing in Poor Law institutions. In the course of an inquiry into the care of infants made some years ago, he had obtained incomplete returns from 546 workhouses, which showed that out of an average total of 3719 infants under two years of age always in the nurseries and lying-in wards, there had been an average number of deaths per annum during five years of 1315, or more than one- third of the average infant population annually. This very alarming proportion of deaths among a constantly changing stream of infants is, however, not statistically comparable with any standard death - rate ; and the Local Government Board does not seem to have followed up the subject by more exact inquiry. We were, therefore, interested in the mortality statistics of the 8483 infants who w^ere born during 1907 in the Workhouses of the 450 Unions responding to the inquiry made by one of our members. Out of these 8483 infants, no fewer than 1050 actually died on the premises before attaining one year. The Registrar-General, as is well known, gives, for the whole population, the number of babies, out of every 1000 born, who die before the expiration of certain days, weeks and months of the first year of life. Similarly, there has been worked out for these 8483 babies born in 450 of the Poor Law institutions in England and Wales during 1907, taking only the deaths actually occurring in the institu- tions, the proportion dying within corresponding periods of their first year — making the assumption, for the purpose 100 BIRTH AND INFANCY of comparison of death-rates, that those who left the Workhouse within the year had a death-rate equal to those remaining in the institution. We append the result in the following table : — Number of Infants, out of every 1000 Born in the Poor Law Institutions of 450 Unions in 1907, who Died within those Institutions within the Periods specified ; together with Corresponding Statistics for the whole of the Births in England and Wales and in London respectively FOR 1906 TABLE I. Infantile Deaths out of every 1000 Born In Workhouses outside In London Workhouses. Experience of Experience of uuu. England and London for Age at Death. Wales, 1906 (Legitimate and 1906 (Legiti- mate and Legitimate. Illegitimate. Legitimate. Illegitimate. Illegitimate). Illegitimate). Days. 18-9 7-9 13-0 11-4 n-8 — 1 23-7 32-2 28-0 23-5 13-2 — Weeks. 1 2 8-6 13-5 6-2 11-2 6-1 — 51-2 53-6 47-2 46-1 31-1 37-6 15-0 - 13-9 11-7 11-6 6-2 _ 3 Months. 6-4 10-7 26-6 9-0 4-6 — 72-6 78-2 85-5 66-7 41-9 37-0 1 45-2 55-1 23-8 67-2 14-3 13-4 2 27-6 30-8 33-3 49-0 11-4 11-2 3 31-0 27-6 42-4 .f)4-0 10-2 10-1 4 33-1 16-5 22-6 30-3 8-7 8-6 5 12-7 12-3 5-9 23-3 8-1 8-6 6 10-) 11-9 18-2 31-6 7-4 7-7 7 13-7 7-9 18-4 20-2 6-8 7-3 8 7-1 8-9 12-3 20-4 6-6 6-7 9 28-9 6-4 31-4 16-7 6-1 7-0 10 18-5 4-6 6-3 12-6 5-6 6-1 12 Number of 11-3 8-4 19-5 — 5-4 6-2 311-7 268-6 319-6 392-0 132-5 1299 1 Infants at [ 1479 4421 1002 1581 risk J WOEKHOUSE AS MATERNITY HOSPITAL 101 TABLE II. Summary of Table I. Ages at Death. Workhouses outside London. London Workhouses. England and Wales. London. Legitimate. Illegitimate. Legitimate. Illegitimate. Under 1 month 1 to 3 months 3 to 6 „ 6 to 9 „ 9 to 12 ,, 72-6 72-8 76-8 30-8 58-7 78-2 85-9 56-4 28-7 19-4 85-5 57-1 70-9 48-9 57-2 66-7 116-2 107-6 72-2 29-3 41-9 25-7 27-0 20-8 17-1 37-0 24-6 27-3 21-7 19-3 311-7 268-6 319-6 392-0 132-5 129-9 Number of in- fants on whose experience from birth the above rates are based 1479 4421 1002 1581 This result appears to us somewhat startling. The infantile mortality in the population as a whole, exposed to all dangers of inadequate medical attendance and nursing, lack of sufficient food, warmth and care, and parental ignorance and neglect, is admittedly excessive. The corresponding mortality among the infants in the Poor Law institutions, where all these dangers may be supposed to be absent, is between tivo and three times as great. Out of every 1000 babies born in the population at large, 25 die within a week and 132 are dead by the end of the first year. For every 1000 children born in the Poor Law institutions, 40 to 45 die within a week, and, assuming the mortality among those who are dis- charged to be the same as those remaining, no fewer than 268 or 392 will be found to have died by the end of the year, the number varying according to whether we take the experience of the Poor Law institutions for legitimates or for illegitimates, in the Metropolis, or elsewhere. Corresponding statistics were obtained from the Poor- 102 BIRTH AND INFANCY houses of eight great urban parishes in Scotland. In these institutions the births were only 391, but of these no fewer than 56 died on the premises before attaining the age of one year. Making exact allowance for the varying periods at which the other infants left the Poorhouse in the same way as has been done for England and Wales, these figures indicate that if none of the infants had been discharged, more than half of them would have been found dead before the expiration of one year. The infantile mortality for these eight large Scottish Poorhouses appears, in fact, to be much worse than that of the English Workhouses. For Ireland, statistics were obtained only for one large Workhouse, and in this case the results were as bad as those of the Scottish Poorhouses. It is interesting to observe that these heavy infantile death-rates in the Poor Law institutions do not seem to bear any exact relation to legitimacy or illegitimacy. Taking particular ages or particular districts, the death- rate among illegitimate infants is sometimes below and sometimes above that for legitimate children. Thus, for the Poor Law institutions of London taken together, the death-rate is, for the whole year, much higher among the illegitimate than among the legitimate. For the institu- tions outside London, on the other hand, the death-rate for the year is actually lower among the illegitimates than among the legitimates. The variations in this respect as between the different ages, whether in London or else- where, are apparently quite without connection with legitimacy. It would seem as if the protection and food enjoyed by the infants in the workhouse, legitimate and illegitimate alike, removed the presumption against the survival of illegitimate infants. Equally interesting is it to notice that the excess of infantile mortality in the Poor Law institutions is actually greater at the ages between one and six months, than during the first month of life. Whatever allowance should be made for the fact that the Poor Law institutions receive many cases in which the mother has been exposed to adverse conditions, it is impossible to avoid the conclusion that the arrangements of the workhouse nurseries — to WORKHOUSE AS MATERNITY HOSPITAL 103 which Dr. Fuller so pointedly drew our attention— need serious examination. This inference seems to receive some confirmation from the fact that the excessive infantile mortality in the Poor Law institutions is not universal ; and that some have apparently a much higher death-rate than others. We do not wish to attribute too much importance to the statistics of particular institutions for so short a period as one year ; but it cannot be right that there should be Workhouses in which 40 per cent of the babies die within the year. When we find that out of the 493 infants born in ten Workhouses (having each not fewer than twenty births in the year) there were only fourteen deaths in the year, or 3 per cent, whereas out qf the 333 infants born in ten other Workhouses (having each not fewer than twenty births in the year) there were as many as 114 deaths, or 33 per cent, we think it is high time for systematic inquiry. For these startling infantile death-rates, whether in all the Poor Law institutions, or in the worst of them, do not appear to result from epidemics, in the ordinary sense of the word. We do not find the deaths occurring in bunches, or even in excess in summer as compared with winter. It has been suggested to us, by persons ex- perienced in the peculiar dangers of institutions for infants of tender years, that the high death-rates — especially the excessive death-rates after the first few weeks of life, right up to the age of three or four — may be due to some unnoticed adverse influence steadily increasing in its deleterious effect the longer the child is exposed to it. In the scarlet fever wards of isolation hospitals, it has been suggested that the mere aggregation of cases may possibly produce, unless there are the most elaborate measures for dis- infection, a dangerous "intensification" of the disease. In the Workhouse nursery there is practically no periodical disinfec- tion. The walls, the floors, the furniture must all become, year after year, more and more impregnated with whatever mephitic atmosphere prevails. The very cots in which the infants lie have been previously tenanted by an incalculable succession of infants in all states of health and morbidity. It may well be that human infants, like chickens, cannot 104 BIRTH AND INFANCY long be aggregated together, even in the most carefully devised surroundings, without being injuriously affected. A grave question arises on these statistics whether the policy of restricting outdoor medical relief to expectant mothers, refusing Midwifery Orders, and offering only " the House " for lying-in, ought any longer to be allowed. If the effect of compelling the mothers to come into the Workhouse for their confinements is that twice or three times as many of their babies will die, as if they had been delivered in their own homes, we do not think that the community will, or should, permit such a policy to continue. We have not had time to give the matter the statistical investigation that it imperatively demands. But one of our members obtained, for the purposes of comparison, exact statistics of all the babies born during the same year (1907) under the care of the Plaistow Maternity Charity, an organisation for providing gratuitous midwifery attend- ance at birth, and for the first fortnight afterwards, in the mothers own home, in one of the most poverty-stricken districts of West Ham. Statistics were thus obtained for no fewer than 3005 infants, all of them born in households having incomes of no more than twenty-one shillings a week. Of these, there died within the first fortnight only 47, or 15*33 per 1000 births. In the four large voluntary maternity hospitals in the Metropolis, of which we have statistics, the infantile mortality taken together was, for the first fortnight, 30 per 1000 births. This, too, was nearl}^ the infantile death-rate for the first fortnight among the whole population (viz. 31'!). In the Poor Law institutions of the Metropolis the corresponding death-rate was, among legitimate children, 47 '2, and among illegitimate children, 46 '1 per 1000 births. In the Poor Law institutions outside the Metropolis, the corresponding death-rate was, among legitimate cliildien, 51*2, and among illegitimate children, 53 'G per 1000 births. The three thousand infants attended to in their homes, poor and wretched as were these homes, by the competent nurses of the Plaistow Maternity Charity, had, therefore, a death-rate, during the first fortnight after birth, considerably less than that in the most successful WORKHOUSE AS INFANT NURSERY 105 of the voluntary hospitals, and less than a third of that in the Poor Law institutions. (iii.) The Workhouse as Infant Nursery Some of the mothers who have come into the Work- house to be delivered do not immediately take their discharge, but remain in the institution with their infants. Other infants of tender years are always being brought into the Workhouse by their destitute parents, or as orphans or foundlings. One way or another the Destitution Authorities accordingly find themselves having to provide in their institutions for a steadily growing number of children under school age — an infant population under five years old that amounts, in the United Kingdom, to about 15,000. For this gigantic " State Nursery " there is practically no other place at present than the General Mixed Workhouse. We regret to report that these Workhouse nurseries are, in a large number of cases — alike in structural arrangements, equipment, organisation and stafiing — wholly un suited to the healthy rearing of infants. It is in vain that the Local Government Board has for more than a decade laid it down that : " In every Workhouse where there are several children, too young to attend school, a separate nursery, dry, spacious, light and well ventilated, should be provided. ... In no case should the care of young childreu be entrusted to infirm or weak- minded inmates. . . . Unless young children are placed under responsible supervision they cannot be said to be properly taken care of." The Boards of Guardians have not obeyed. We have visited many Workhouse nurseries in the different parts of the kingdom, and we have found hardly any that can possibly be regarded as satisfactory places in which children should be reared. The mere fact that the infants are almost universally handled by pauper inmates, many of them more or less mentally defective, makes it impossible for a Workhouse nursery to be a proper place. The infants, deposed one lady Guardian, " are left to the paupers to look after them," and this has 106 BIRTH AND INFANCY a bad effect, both on the infants and on the mothers. " / have frequently seen,'^ declared to us another competent witness, " a classed imbecile in charge of a baby." The whole nursery, says a lady Guardian, has often been found "under the charge of a person actually certified as of unsound mind, the bottles sour, the babies wet, cold and dirty." There are, of course, occasionally fatal results. The Royal Commission on the Care and Control of the Feeble-Minded draws attention " to an episode in con- nection with one feeble-minded woman who was set to wash a baby ; she did so in boiling water and it died." This state of things is not unknown to the Local Govern- ment Board. We are supplied by Dr. Fuller, the Medical Inspector for Poor Law Purposes, with a copy of a Report that he made to the Board in 1897, showing that: It is not an uncommon thing to find suckUng mothers acting as ward-attendants, which means they rarely, if ever, get into the open air for exercise, and their infants rarely or never go out of the sick wards, except in the arms of a convalescent, into the airing courts. ... In sixty-four Workhouses, imbeciles or weak-minded women are entrusted with the care of infants, as helps to the able- bodied or infirm women who are placed in charge by the matron, without the constant supervision of a responsible officer. In 370 Workhouses the inmates (a very large proportion of whom are aged or infirm women) have the charge of infants without any officer other than the Matron to supervise' them. In 113 Work- houses, able-bodied or aged and infirm inmates are entrusted with the charge of the infants, with the occasional supervision of either the Assistant Matron, trained nurse, assistant nurse, industrial trainer, portress or labour mistress, in addition to the Matron, who visits twice a day. We recognise that some improvement has since taken place. But, as we have ourselves seen, pauper inmates, many of them feeble-minded, are still almost everywhere utilised for handling the babies ; and the Workhouse nurseries, so far as paid officers are concerned, are still so inadequately staffed as to make pauper help indispensable. The sanitary arrangements are nearly always so primitive, and so far below the standard of the best day nurseries of the present time, that a very large amount of personal WOKKHOUSE AS INFANT NURSERY 107 service is necessary, if the nursery and the babies are to be kept in a proper state of cleanliness and purity. As things are, the visitor to a Workhouse nursery finds it too often a place of intolerable stench, offensive to all the senses, under quite insufficient supervision, in which it would be a miracle if the babies continued in health. A further evil, to which practically no attention seems to have been paid, is the extent to which these Workhouse nurseries are continually being decimated by the admission of infants bringing with them incipient measles or whooping-cough ; "and that, just at an age," to quote the words of Dr. Downes, the Senior Medical Officer for Poor Law Purposes, " when the common infections are most fatal." We were surprised to find, in Workhouse after Workhouse, practically no arrangements for quarantining the new-comers, or otherwise preventing " the great danger of the introduction of infection among them." In all but a few quite exceptional Workhouses, the constant stream of entering infants, of all ages between a few weeks and five years, many of them coming straight from the most filthy and insanitary homes — some of them, indeed, the dependents of " ins-and-outs " — passes instantly into the midst of the nursery population. The very least that ought to be provided, to use the words of the Senior Medical Inspector for Poor Law Purposes, is " a sort of duplication of their nursery, so that the new-comers could be kept apart from the main body of the children." But, as the Lady Inspector of the Local Government Board for England and Wales observed to us, the Workhouses of the great towns, " always more or less crowded, do not admit of probation nurseries. ... The present mixture of all the children under three years of age, those who are more or less permanent and the ' ins-and-outs,' varying in age from the infant of three weeks old to the children between two and three who can run about, appears, speaking generally, to be an insuperable difficulty." What exactly is the result of this extraordinary exposure to infection, in the prevalence of measles and whooping- cough in the Workhouse nurseries, is unfortunately not recorded. " In some cases," euphemistically observes 108 BIRTH AND INFANCY the Senior Medical Inspector for Poor Law Purposes, " epidemics of measles and whooping-cough have been very troublesome." We have already mentioned the excessive mortality which Dr. Fuller found generally to prevail in England and Wales among the Workhouse children under two. We have reason to believe that the mortality between two and five years is also excessive ; and we regret that the Local Grovernment Board has obtained no statistics on the subject. We can add nothing to the gravity of the authoritative indictment of the Boards of Guardians, as managers of infant nurseries, with which Dr. Fuller and Miss Stansfeld — witnesses whose official position gives weight to their testimony — have thus supplied to us. But we may mention, as illustrative of the total incapacity of the Destitution Authorities to provide for even the most elementary requirements of an infants' nursery, three incidents that we have ourselves witnessed. In one large Workhouse our Committee noticed that the children From perhaps about eighteen months to perhaps two and a half years of age had a sickly appearance. These children were having their dinner, which consisted of large platefuls of potatoes and minced heef, a somewhat improper diet for children of that age, and one which may partly account for their pasty looks. The attendants did not know the ages of the children ; the children are not weighed from time to time and a record kept. In another extensive Workhouse nursery our Com- mittee found The babies of one to two years of age preparing for their afternoon sleep. They were seated in rows on wooden benches in front of a wooden table. On the taUc was a lony narrow cushion, and when the hahics were sufficiently exhausted, they fell forward upon this to sleep! The position seemed most unconifortuble and likely to be injurious. AVe were told tliat the system was an invention of the Matron, and had been in use for a long time. Finally, in the great palatial establishments of London and other large towns, we were shocked to discover that the infants in the nursery seldom or never got into the WOEKHOUSE AS INFANT NURSERY 109 open air. We found the nursery frequently in the third or fourth storey of a gigantic block, often without balconies, whence the only means of access, even to the Workhouse yard, was a lengthy flight of stone steps, down which it was impossible to wheel a baby carriage of any kind. There was no staff of nurses adequate to carrying fifty or sixty infants out for an airing. In some of these Work- houses it was frankly admitted that the babies never left their own quarters (and the stench that we have described), and never got into the open air, during the whole period of their residence in the workhouse nursery. (iv.) The Cause of the Failure of the Destitution Authority We do not attribute this failure to any personal short- cominojs of the members of the Boards of Guardians and Parish Councils ; still less to any lack of humanity among them. The fact that these bodies, almost alone among Local Authorities, include women in their membership, is a confirmation of this inference. In our visits up and down the country, we have been much impressed by the high social standing, the sympathetic character and the superior intelligence of the great majority of the women members of the Boards of Guardians. It is they, almost alone among our unofficial witnesses, who have brought to our notice many details of the extraordinarily defective pro- vision now made for women and children. But the atten- tion of the Boards of Guardians has never been directed to the evils that we have mentioned as problems to be solved by approjoriate treatment. To them there is in the Work- house no " Maternity Hospital," no " Rescue Home," no " Infant Asylum." What they believe themselves to be doing — what they are charged to do — is merely to " give relief"; and relief which, as a Destitution Authority, they are authoritatively told must neither be insufficient to support life, nor more than will just suffice for that pur- pose, to the good as to the bad — relief which may begin only when "destitution" sets in, and must suddenly cease when " destitution " ends. So long as the task set to a no BIETH AND INFANCY Local Authority in this service of Birth and Infancy is merely the " Relief of Destitution," no body of men and women is likely to do better than the present Board of Guardians or (in Scotland) the Parish Council. If they were removed from popular control they might — however carefully selected — easily do worse. Nor is there any reason to assume that an enlargement of the area for which the Destitution Authority acts would cause any improve- ment in this particular service. On the contrary, our own opinion is that the provision actually made for Birth and Infancy at the present time in the smaller Unions of England and Wales is both less demoralising to the mothers, and less fatal to the infants, than the promis- cuous lying-in wards and the crowded nurseries of the palatial Poor Law Infirmaries and mammoth Workhouses of the Boards of Guardians administering districts of a population of more than a quarter of a million. We cannot escape the conclusion that a Destitution Authority, whatever its area, whatever its method of appointment, and whatever the character of its membership, is, by the very nature of its task, unsuited and positively disabled for making whatever provision for Maternity and Infancy is, in the interests of the community as a whole, deemed desirable. (b) Voluntary Agencies for providing for Birth and Infancy We are supported in our condemnation of the use of the Workhouse as a Maternity Hospital or as an Infant Asylum by the emphatic conclusions of the recent Vice- Regal Commission on Poor Law Reform in Ireland, which paid special attention to this subject. That Commission recommended that the General Mixed Workhouse should absolutely cease to be used, either for the reception of expectant mothers, or for lying-in, or as a nursery for infants of any age. It was proposed, in accordance with an overwhelming concurrence of testimony, that girls on their first lapse should be placed, both before and after their confinement, in suitable voluntary institutions devot- ing themselves to this service : — VOLUNTARY AGENCIES 111 " In this way," it was suggested, " there would be a hope that the life of the girl would not be wrecked owing to her fall, but that she might, as far as practicable, be restored to the possibility of living a good and useful life. When the time for the girl's confinement arrives, we contemplate that she should be sent to the nearest district or other hospital, from which she would return with her baby to the special institution after the usual period for remaining in a lying-in hospital. We would rely upon kind and prudent treatment of the girls individually, and to the placing of each of them, as far as possible, in suitable situations after they had spent a year or thereabouts nursing their babies, and after spending such additional time, if any, as the managers of the institution might think necessary for the strengthening of their character. As soon as a girl-mother could be provided with a situation, and the sooner the better, we think, after the nursing period, we suggest that her child should be boarded-out, unless it should be kept for medical reasons in the institution a little longer. We would make such institutions open, as regards adults, only to girls after their first fall." In view of this authoritative recommendation, and of suggestions made to us on similar lines as regards Great Britain, we deemed it necessary to inquire how far volun- tary agencies were available and suitable for undertaking this important work. We were, unfortunately, unable in the time allowed to us to make anything like a complete survey, but one of our members has placed at our disposal the results of inquiries into the provision that is actually being made for Maternity and Infancy by voluntary agencies in two important areas of England, the Metropolis and the West Riding of Yorkshire, which together com- prise nearly a quarter of the whole population of England and Wales ; and in one or two other areas. These volun- tary agencies may be classified, roughly, into — (1) Rescue Homes ; (2) Maternity Hospitals ; (3^ Domiciliary, Midwifery and Nursing Agencies ; (4) Day Nurseries ; and (5) Infant Asylums. (i.) Rescue Homes The Rescue Homes usually receive unmarried ex- pectant mothers for a few months before confinement, and 112 BIKTH AND INFANCY for a few weeks afterwards, nearly always sending the woman to a Maternity Hospital for lying-in. Such Insti- tutions exist at present only in a few towns, and on a comparatively small scale relative to the total number of cases requiring attention. The information obtained with regard to twenty-four Rescue Homes in the Metropolis, half-a-dozen in the West Riding, and half-a-dozen else- where, shows that they are supported by voluntary contri- butions, and to a small extent by payments made by the patients or their friends. In nearly every case they are managed by small committees, often connected with a religious denomination. They nearly all limit themselves to girls with their first illegitimate child, and they can usually admit only ten or twenty cases a year each, hardly any among them having accommodation for as many as fifty at a time. The length of the girl's stay varies from three months to one year, during which she is trained in domestic service, and at the end of which a suitable situa- tion is found for her. Foster-mothers are found for their infants, the mother being required to pay, from the time she gets a situation, 5s. per week for the support of her child. The idea that the girl must necessarily be ashamed of her child is fast disappearing, and she is encouraged to work for it and to take a pride in its well-being, instead of placing it in an institution such as the Foundling Hospital, where the primary condition of admission is that the mother must be willing to cede all claims over her child and never see it again. The most extensive of these agencies is, perhaps, that administered in connection with the Salvation Army, with Rescue Homes in various parts of the country. We have been much impressed by what we have learnt from various sources of the invigorating and restorative effect of the treatment of the large number of girl-mothers annually dealt with in these Homes, and by the practical wisdom and administrative skill displayed in all the details of their management. We think that the methods adopted in these Homes merit careful study by those who may be responsible for dealing with the problem at the expense of public funds. KESCUE HOMES 113 We are impressed — as was the Vice-Regal Commission on Poor Law Reform in Ireland — with the admirable social work done by the various Rescue Homes, and by their far greater success in reclaiming the best class of unmarried mothers, and enabling them to make a fresh start in life, than can be claimed by any Poor Law Insti- tution. We regret that more use is not made of these Homes by the Boards of Guardians. We suggest, however, that they require official inspection and supervision, especi- ally from the standpoint of the welfare of the infant. At present they concentrate their attention almost entirely upon the mother, and her future welfare. Comparatively little thought is given to what happens to the babies ; and no information is available as to the rate of mortality among them. In view of the supreme interest of the community in the coming generation, the arrangements made for the rearing of these infants ought clearly to be under special supervision by the Public Health Authority. (ii.) Maternity Hospitals Special Maternity Hospitals seldom exist, we believe, except in London (which has less than a dozen), Dublin (three, including one large one), Edinburgh and Glasgow, though there are sometimes maternity wards in the general hospitals. Such Maternity Hospitals date from the middle of the eighteenth century. They do not appear to be a popular form of charity, and they exhibit a much smaller growth than other institutions for the treat- ment of the sick — perhaps because they have suffered in the past from a high rate of mortality among the mothers. This drawback, we gather, has now been over- come. Nevertheless, so far as we have been able to estimate, only 5 or 6 per cent of the births in London, and only an insignificant percentage elsewhere, take place in voluntary institutions. Only in Dublin does the pro- portion rise to a high figure ; and there it appears to reach 20 per cent. Nor are these institutions always accessible to poor women. Most of the Maternity Hospitals VOL. I I 114 BIRTH AND INFANCY in London admit only women who obtain "letters" from one of the hospital governors or subscribers. This ''letter" system doubtless facilitates the work of the hospital ; it regulates the number of patients ; and ab- solves the hospital authorities from the difficulties of selecting cases; but, on the other hand, it reduces a woman's chance of admission to a question of luck, and it frequently means that only those directly in touch with district visitors and clergy, who are given letters for use in their parish, can hope to obtain the benefits of the hospital. Such a system may become very demoralising, for by making people dependent on the favour or goodwill of the rich, it is apt to create a worse form of pauperism, with more disastrous results upon character, than any to be found in a public institution. It is impossible, more- over, to avoid the conclusion that these hospitals are run more for the sake of affording opportunities for the instruc- tion of doctors and midvvives than with any considera- tion of what is best for the mothers and infants. Under the present arrangements a woman is received only when actually in labour, and is usually retained only for fourteen days (occasionally 'only for eight days, rarely for three weeks). At the end of that time she has to return to her home, or to find a lodging ; weak, quite unfit for the work of trying to make both ends meet, with an infant on her hands, and very little knowledge of how to look after it. The Maternity Hospitals, indeed, usually disclaim all responsibility, and refuse to make any domiciliary provi- sion, for either mothers or infants, after they leave the wards. To some small extent this care and educational training before and after confinement is, as we have seen, supplied by the Rescue Homes. From the Public Health standpoint, however, it is clearly objectionable that any of the cases should disappear from ken, without instruc- tion how to rear the baby, and without the stimulus to maternal responsibility that is given by the consciousness of being kept under observation. As it is, we are in the dark as to the rate of infantile mortality among the babies for whose birth the Maternity Hospitals are incurring so much expense. Tliese hospitals, indeed, like the Rescue MATERNITY HOSPITALS 115 Homes, seem to pay comparatively little attention to the infants. Though the infant death -rate inside the best of the institutions is now far less than it used to be, and far less than that for the first fortnight in the lying-in wards of the Workhouses, there are some Maternity Hos- pitals which appear to lose three or four times as many babies in the fortnight as others. Here, too, there is clearly urgent need for supervision and inspection by the Local Health Authority. (iii.) Domiciliary Midioifery Agencies There appear to be at least a score of large "out-patient" midwifery charities in the Metropolis, and there are others in connection with the general hospitals of the provincial towns, besides some smaller agencies in connection with missions and settlements. The most important of these are the out-patients' departments of the Maternity Hos- pitals, and of the General Hospitals having medical schools. The large number of medical students and midwives in training in London, Edinburgh, Dublin and the dozen other centres of medical education, each of whom has to attend a certain number of midwifery cases as a condition of obtaining a qualification to practise, renders the problem of public provision, as it does that of provident medical insurance, essentially different in these towns from that elsewhere. It was given in evidence that one hospital alone in this way provides medical attendance for 4000 confinements annually. The total number of confine- ments in the United Kingdom thus gratuitously attended to by voluntary agencies in the patients' own homes must, in the aggregate, run into many tens of thousands. The work is, however, confined to London and a score or two of other large towns. It is limited to the attendance of the doctor or midwife at birth, occasional subsequent visits by the midwife, and sometimes daily visits by the nurse during ten days. No provision is made for the mother's instruction, or for subsequent care. We can do no more than call attention to the extent of the domiciliary midwifery provision thus thrown, so to 116 BIRTH AND INFANCY speak, gratuitously at the heads of the poor, practically without inquiry as to character or need, without any sort of co-ordination with other agencies, without connection with the provision for necessitous mothers both before and after child-birth, and without the cases being brought under the supervision of the Local Health Authorities. (iv.) Day Nurseries For the children under the lower limit of school age — which may be three, four, or five years — of mothers who are unable to look after them during the day, practically the only organised provision is that of Day Nurseries, or creches. In view of the fact that the Outdoor Relief afforded to mothers of young children is practically never adequate to allow them to forego earning money, and that many Boards of Guardians, as we have seen, actually incite the mothers to go out to work, it (is im- portant to inquire what becomes of the young children whilst the mothers are away. We found that in very few places was any systematic provision made for the care of these infants, or others in like case. Neither the Desti- tution Authority, which was assuming to maintain so many of these infants, nor the Local Health Authority, in its crusade against infantile mortality, has done any- thing in the matter. Voluntary charity has done very little. We were supplied by one of our members with reports as to the charitable Day Nurseries of the Metro- polis, the West Riding of Yorkshire, and a few other places. These institutions are far more prevalent in London than elsewhere ; and even in London they appear to number only seventy or eighty, accommodating between twelve and sixty infants ; or, for all London's million families, not more than 2000. They are managed by philanthropic committees on voluntary contributions, but they make a charge to the mothers (usually 3d. or 4d. per day), which about covers the cost of the infant's food. These institutions, which are at present under no sort of public supervision or official inspection, are scattered most irregularly over the Metropolis. A few of them have DAY NURSERIES 117 excellent buildings, good sanitary arrangements, competent staffs, and well -contrived provision for all the infants' requirements. Most of them were found to be faulty in some of these respects ; and more than a third was dis- tinctly open to grave criticism. These showed an utter lack of knowledge of the most elementary principles of the hygiene of child-life. Many of them were overcrowded, ill-ventilated, dark, dirty, and foul-smelling. The babies were in charge of totally inexperienced women. The milk and the bottles were often wholly unsuitable. We do not wish to offer any opinion upon the vexed question of how far Day Nurseries are desirable. But it is clear that, wherever the Destitution Authority incites the mother to go out to work and leave her babies, or where it gives Outdoor Relief so inadequate as to compel the mother to go out to work, it becomes responsible for seeing that the little children whom it is thus maintaining as Outdoor Paupers are properly provided for. We can- not regard it as satisfactory that no attention should, at present, be paid to this matter ; and we cannot help attributing some of the very high infantile mortality among Outdoor Paupers to the neglect of the Destitution Authorities to consider what effect their policy is having on the children. It is plain that any Day Nurseries that exist, in which there ought to be no large aggregation of children, need to be under the supervision and inspection of the Public Health Authority. (v.) Infant Asylums We cannot pass over without mention the fact that there exist extensive voluntary institutions providing maintenance for infants, which might be made use of by Local Authorities unable satisfactorily to provide for their younger children. Some of these institutions admit babies from the very earliest age, and appear to surmount very satisfactorily the difficulties in nursery administra- tion experienced by the Destitution Authorities. These institutions are proud of their success, and many of them would welcome a voluntary inspection, which could not 118 BIRTH AND INFANCY fail to be of use in suggesting methods of improvement. It would be an additional advantage of a supervision of these institutions by the Public Health Authority that their rates of mortality and their valuable experience would become available for comparison. (vi.) The Insufficiency of the. Voluntary Agencies We are much impressed, as we have already mentioned, with the value of voluntary agencies in dealing with the problems of birth and infancy, especially with that pre- sented by the young unmarried mother with her first child. We think that suitable agencies of this kind might, with great advantage, be far more extensively utilised by the local authorities for particular cases than has yet been done. " The mothers of illegitimate children," emphati- cally declares the Vice-Regal Commission with regard to Ireland, " should never, it is suggested, be in future admitted or retained in any Workhouse or institution where they would have freedom of ingress or egress, and where they could associate with other classes. Unmarried mothers should, in our opinion, be provided for in special institutions under religious or philanthropic management, their infants being kept with them until tvea7ied." Any philanthropic institutions thus made use of should be placed on the list of "Certified Schools and Homes" at present issued by the Local Government Boards for England and Ireland, and the Local Government Board for Scotland should frame a similar list. It would, of course, be necessary for every such institution to be periodically inspected by duly qualified officers of the Local Government Board ; and it should be a condition of such certification, and of the receipt of any patients, or of any payments, from any Local Authority, that the institution should come also under the regular inspection of the Local Health Authority. But whatever may be the case in Ireland, there is in Great Britain no provision by Voluntary Agencies — whether Rescue Homes, Maternity Hospitals, Domiciliary Midwifery Charities, Day Nurseries or Infant Asylums — INSUFFICIENCY OF VOLUNTARY AGENCIES 119 at all adequate to the need. This deficiency shows itself alike in amount of accommodation and in its geographical distribution, in the quality of the service and in its limited duration. As we have seen, none of the five forms of voluntary provision that we have described comes any- where near being able to cover all the cases. What is done is limited to London and a comparatively small number of large towns. The efficiency of the service rendered is extremely unequal, and much of it would have to be very drastically reformed before it could be utilised by a Public Authority. Finally, all these Voluntary Agencies — the Rescue Homes being in this respect least open to criticism — share with the Destitution Authorities the drawback that they deal with these cases only during a narrowly limited period of time. Their patients come to them out of the unknown, and after the briefest of treat- ment, disappear again into the unknown, having received temporary physical advantage but the very minimum of mental or moral improvement. To be of any real value to the community, the temporary physical improvement aff'orded by these Voluntary Agencies to their patients must be set in a framework of more continuous preventive and educational activity, brought to bear on the character and intelligence of these persons both before and after the acute crisis of their distress. We are, therefore, unable to share, so far at any rate as Great Britain is concerned, in the optimistic assumption of the Vice- Regal Commission on Poor Law Reform in Ireland that Voluntary Agencies are in a position adequately to deal with the problems of Birth and Infancy. Whatever use of them by the Local Authority may prove possible, it is clear that they will need stimulating and supervising by public officers, and, in nearly every district, they will require to be supplemented by public provision at the expense of the rates, both in the form of institutions for specific classes of cases left wholly or partly undealt with by the philanthropist, and in that of more extended, more systematic and more continuous domiciliary treat- ment than is aff'orded by any Voluntary Agency. 120 BIRTH AND INFANCY (c) The Supervision of Birth and Infancy hy the Local Health Authority The continuance of a high rate of infantile mortality, in spite of a steadily falling mortality among persons of other ages has, within the last two decades, forced itself upon the attention of the Local Authorities. Whilst the general rate of mortality has fallen in the United King- dom during the past forty years by at least one-sixth, the proportion of deaths under one year per thousand births has, until lately, remained almost undiminished. The result has been a great outburst of sanitary activity in new directions. " The question of how we are to prevent so large an infantile mortality," says a recent report, " is now engaging the attention of every Medical Officer of Health throughout Great Britain, and more or less of every Sanitary Authority, and the great factors . . . which they are to combat are ignorance, carelessness, and neglect of the hygienic laws. It, therefore, becomes necessary to instruct the people in these matters." At first, " the efforts of Health Committees " were " directed chiefly towards reducing the deaths among infants from epidemic diarrhoea." But ''statistics have clearly shown that the practice of feeding infants with artificial food is chiefly responsible for the terrible wastage of life at present going on." Thus the Local Health Authorities have found their work taking the novel forms of giving advice to mothers how to treat their babies — advice which it was difficult to distinguish from that given by the private practitioner or the District Medical Officer ; and in some places of actually supplying the mothers with suitable food for their babies — food that might otherwise have been sought as Outdoor Relief from the Destitution Authority. (i.) Provision of Midwifery We must first notice a small, and, we think, undesigned responsibility assumed by the Local Health Authority in some places, in connection with the provision of medical attendance on women in child-birth, who are destitute of PROVISION OF MIDWIFERY 121 the means of providing it for themselves. Under the Mid wives' Act of 1902, and the rules framed by the Central Mid wives' Board, the 12,000 practising mid wives in England and Wales are legally required instantly to call in a qualified medical practitioner in cases of difficulty or danger. No provision was made for the remuneration of the doctor thus imperatively summoned ; and, in a large proportion of the cases, the patient is quite unable to pay him. Under these circumstances, the Local Government Board has permitted the payment to be made, sometimes by the Destitution Authorities, sometimes by the Local Health Authorities. In some places the Boards of Guardians have demurred to making any payment in such cases to a private practitioner, considering that the duty should fall exclusively on the District Medical Officers. In some places the Boards of Guardians make the payment, provided that the doctor — summoned perhaps in the night — has first obtained a note from the Relieving Officer authorising his attendance, or provided that it is proved that application was first made, and made in vain, to the District Medical Officer, or provided that the case is, after inquiry, considered by the Guardians to be destitute. In some places (as at Manchester and Liverpool) the Town or District Council is, with the approval of the Local Government Board, making the payments under the general terms of Sec. 133 of the Public Health Act. There is nothing to prevent both Local Authorities paying for the same service. For instance, both the Manchester Town Council and the Manchester and Chorlton Boards of Guardians have actually resolved to make such payments under certain conditions. On the other hand, in other places, the doctor fails to get his fee from either Local Authority. (ii.) Provision of Hygienic or Medical Advice Whilst the provision of midwifery by the Public Health Authorities is, at present, occasional only, the provision of hygienic or medical advice for infantile ail- ments has already become an organised service. The 122 BIHTH AND INFANCY most remarkable feature of this development has been its educational aspect. The Local Health Authority found the bulk of the poor mothers — those in receipt of Outdoor Relief no less than the others — totally unaware how to rear their babies in health. They were both unable and unwilling to pay for the private practitioner's advice, at any rate so long as the babies were not actually ill, and the Destitution Authority provided no instruction even for the mothers whom it was relieving. It was argued by the Local Authorities that : " No education in school is likely to have much practical result in lessening the vast amount of preventable mortality and sickness among young infants. Very few of the mothers in the working classes have either the time or the ability to understand books or leaflets on the management of children. What is required is that they should have actual practical instruction from some properly trained and tactful visitor soon after the child's birth, who would be able to show them that it would save them trouble in the long run if they spent a little pains in preparing for their child's food, in the event of their not being able to nurse it themselves." The result has been the creation of a remarkable organisation, partly paid and partly voluntary, by which the Medical Officer of Health attempts to keep under observation during the whole of the first year of life, all the babies born in the poorer families, including those who are on the Outdoor pauper roll of the Destitution Authority, and those among them who are actually under the attendance of the District Medical Officer. This organisation has already gone very far. It may be said that Parliament has sanctioned the new development by expressly legalising the appointment of paid Health Visitors by the Metropolitan Borough Councils ; and by passing the Notification of Births Act of 1907, the avowed object of which was "to give Sanitary Authorities the opportunity of effecting improvements in Infant and Domestic Hygiene by means of Health Visitors." Accordingly, at the present time, in the poorer districts of many towns of Great Britain, every house at which a birth occurs, or at which a child under two years has died (even those at which the District HYGIENIC OR MEDICAL ADVICE 123 Medical Officer is in attendance) is visited by an officer from the Medical Officer of Health's Department — in some places by a lady volunteer, in others by a semi-philan- thropic paid agent, in others again by a trained professional Health Visitor, qualified by a sanitary certificate or a nurse's experience. Including the organised volunteers, there are already more Health Visitors than there are Relieving Officers in England and Wales. At Hudders- field and elsewhere some of these Health Visitors are even qualified medical practitioners. They interview the mother and inspect the baby ; they advise how it should be fed, washed, clothed, and generally treated ; they criticise what is being done wrong or unskilfully ; they keep a sharp eye for the presence of disease to be reported to the Medical Officer of Health ; they suggest hygienic improve- ments in the household ; if the baby is ailing they are often able to suggest the cause and remedy ; and, finally, if the case looks serious, they urge the obtaining of further professional advice either by the calling in of a doctor for payment, or by application to the Relieving Officer for the attendance of the District Medical Officer. The adoption of this system of domiciliary "health visiting," as applied to the 2 "45 per cent of the jjopulation which is under one year of age, has apparently resulted in a great improve- ment in its health ; although the proportion of those visited to the total population has not yet risen to a sufficient height to have any marked statistical result on the whole. Three features stand out in this expansion of the work of the Local Health Authority, all of them in significant contrast with that of the Destitution Authority. The first is its humanising and educational character. The poverty- stricken mother, tempted to regard the newly-born infant only as an additional burden, finds herself reminded of the importance of the child's life, finds its welfare a matter of interest to the visitor, and finds herself gradually acquiring a higher standard of child-rearing. The second significant feature of the work is the extensive use made of volunteers in an altogether new relation to the official machinery. Such volunteers, numbering in towns like Huddersfield 124 BIRTH AND INFANCY several scores, visit the poor in a friendly, unofficial way, and yet serve systematically as the eyes and ears of the Local Authority, working always under the supervision, guidance and control of the responsible salaried officer, and his representative Health Committee. The third feature is the stimulus given by the action of the Local Authority to parental responsibility, personal self-control and regu- larity, and self-help. The Destitution Authority, grudg- ingly giving its dole of Outdoor Relief to the destitute mother, leaves her not only without instruction how to make the best use of it, but also free to neglect her infant, to endanger its life by irregular hours, and even to let it starve quietly to death if she chooses. What the Local Health Authority does is to persist in inquiring after the health of that baby ; to send its Health Visitors to see its condition ; to make the mother feel that she is being helped ; to induce her to take some pride in the infant's thriving ; and to show her how she can make it thrive. We have been much impressed by the evidence afforded to us of the beneficial results of this kind of State action in positively increasing self-respect, a sense of personal responsibility and maternal care. (iii.) Provision of Milk In a dozen towns (St. Helens since 1899 ; also Liver- pool, Battersea, Finsbury, Lambeth, Woolwich, Glasgow, Leicester) the Health Authority has gone a step further. It provides a municipal milTi depot, or rather a " milk dispensary," at which babies requiring artificial feeding are supplied with pure milk (and hygienic feeding teats) on payment of a small sum. At Liverpool this has developed into an elaborate organisation with branch depots in various parts of the city, supplying " humanised sterilised milk" of seven different grades, for infants of various ages (in addition to the babies brought to the depots) to many hundred families by direct delivery. But the special interest of the '' milk dispensary " to the sanitarian is the personal supervision which it enables the Medical Officer of Health to exercise over these ailing PROVISION OF MILK 125 babies. At Finsbury tbe supply of the milk is made con- ditional on the babies being brought regularly for inspec- tion, accurate weighing, and hygienic advice. Those who cannot be brought are visited in their homes. At Glasgow a qualified medical practitioner (lady) visits every home as a matter of course. Practically, though not avowedly, the Medical Officer of Health becomes the Medical atten- dant of each of these infants ; to whom, indeed, he not infrequently supplies the milk gratuitously rather than let them die or compel the destitute parents to "go through the rigmarole " of obtaining Poor Law relief for them. " During the hotter portion of the year," reports the Medical Officer of Health for Norwich, " and to a lesser extent since, with the sanction of the Health Com- mittee, I have distributed (through the lady health visitor) a considerable quantity of dried milk powder to neces- sitous mothers and, on the whole, have been well satisfied with the results." "It is clear," says Dr. Newman, now Chief Medical Officer to the Board of Education, " that such a specialised milk supply does not meet the whole problem of infant mortality. . . . Nevertheless it is true that a properly equipped and controlled Infants' Milk Depot is part of the solution at the present time and under present conditions, and is a practical step in the right direction." Here, too, as with the advice given to the mothers by the Health Visitors, the most prominent features of the work are the education of the persons aided, and the stimulus to their sense of responsibility. When the baby has to be regularly brought to be inspected and weighed, the mother's interest in its physical condition is not allowed to slacken ; there is praise and approval if the baby goes on well ; there is blame and warning if it sickens. The connection between irregular hours, dirt, carelessness about the food and other forms of neglect, and the ups and downs of the baby's physical development are brought home to the most ignorant and apathetic of mothers. In marked contrast with the practice of the Poor Law, the actual gift of material relief is made only an incident — for the most part only an occasional incident 126 BIRTH AND INFANCY — in the process of education and inspection. The self- respect, the power of will, the sense of personal responsi- bility, instead of being weakened, as it is under Outdoor Relief, is, with a Milk Dispensary, actually strengthened. (d) The Need, for a Unified Service dealing ivith Birth and Infancy The rapid upgrowth of the organised supervision of Birth and Infancy undertaken by the Public Health Authorities, and the confusion and overlapping with the work of the Destitution Authorities to which this is giving rise, compel a consideration of the question whether the whole of the public provision for Birth and Infancy — whatever that provision may be — ought not to be placed in the hands of a single Local Authority. If, on the one hand, the Local Health Authorities have trespassed on the domain of the Destitution Authorities in paying mid- wifery fees, and in supplying medical advice and milk to necessitous mothers, the Destitution Authorities are administerino^ certain other services with regard to Birth and Infancy which form indispensable parts of the Public Health machinery. Our attention has been called, by the Boards of Guardians themselves, to the fact that, owing to historical accidents, it is upon them and not upon the Local Health Authorities that has been cast the adminis- tration of the registration of births and deaths, of vaccina- tion, and (outside the Metropolis) of the inspection of " baby-farms." Throughout England and Wales it is the Board of Guardians which chooses and nominates the Registrars of Births and Deaths ; and the Local Health Authority has absolutely no official contact either with these officers or with the indispensable registration which they conduct. The result is that the system of registra- tion itself is less effective from the Public Health stand- point than it might easily be made ; and the Medical Officer of Health has no means of getting the instan- taneous information as to every birth and every death within his district that should be automatically at his disposal. It is equally anomalous that the machinery for NEED FOR A UNIFIED SERVICE 127 vaccination, a compulsory and universal provision against an infectious disease, should be entirely in the hands, not of the Local Health Authority, but of the Destitution Authority. We have found no one to defend this arrange- ment. All our witnesses recommend the immediate and complete transfer of both these duties of the Destitution Authority to the Local Health Authority, especially if that Authority acts for an area of adequate extent. It has been represented to us as no less anomalous that the administration of the Infant Life Protection Acts should, in England and Wales outside the Metropolis, be entrusted to the Destitution Authority. This service is at present very imperfectly performed by the Boards of Guardians, several of which strenuously opposed the Infant Life Pro- tection Bill in 1902; and it is by most of them wholly neglected. The transfer of the three services of the regis- tration of births and deaths, vaccination, and the adminis- tration of the Infant Life Protection Act — now the Children's Act, 1908 — from the Destitution Authorities to the Local Health Authorities, which is necessary in the interest both of economy and efficiency, would, in our opinion, by concentrating in the department of the Medical Officer of Health all the available knowledge as to the local facts, make it inevitable that the whole responsibility for whatever public provision is made for Birth and Infancy should be concentrated in the Local Health Authority. This suggestion receives support from another con- sideration. What is needed, for a treatment of Birth and Infancy from the standpoint of the community, is con- tinuous observation of the household both before and after birth. The Destitution Authority, by the very nature of its work, has, and can have, no such continuity of know- ledge. The expectant mother, or the mother with infants, only comes within its ken when " destitution " sets in, and disappears the very moment that " destitution " ceases. The Local Health Authority, on the other hand, is — by its ubiquitous machinery of Health Visitors, and house to house visitation — continuously observing the circumstances of the household, irrespective of temporary destitution. 128 BIETH AND INFANCY By its staff of Saoitary Inspectors, it knows the character of the street, and even of the house, in which the expectant mother is living, and is therefore in a position to gauge the probable risk to mother and infant in domiciliary confinement. Above all, the Local Health Authority is primarily concerned with the prevention of disease and death, and has, for its responsible adviser, not a clerk or solicitor but a medical expert. Thus, if the Local Health Authority were responsible for the whole of the public provision for Birth and Infancy, it would decide the ques- tion of whether institutional treatment should be afforded to a confinement, upon grounds of the risk to health and life, and the chance of survival of mother and infant. Under the Destitution Authority, the decision is made, irrespective of considerations of health, or even of the character of the mother, according to the dominant policy of the Guardians asjainst or in favour of " Outdoor Relief." As a matter of fact there is much evidence that, for the normal case, it is in many respects better, as well as less costly, to provide midwifery attendance in the home, than to require the mother to enter a Maternity Hospital. As we have seen, the statistics of infantile mortality in the lying - in wards of Workhouses and Maternity Hospitals alike, compared with those of domiciliary confinements where adequate food and attendance are provided, are such as to make us pause before we establish any more Maternity Hospitals at the public expense. But there are other reasons, founded jn the results upon personal character, and the integrity of the home, which make in- stitutional treatment undesirable. For a poor mother to leave her home and family means often the abandonment of her children to most inadequate care, and an additional temptation to her husband to seek amusement elsewhere. Though her confinement in a crowded, poverty-stricken home may cause much inconvenience, she feels that she can still watch over her children, direct the elder ones what to do for the household, and (as it has been graphi- cally put) " keep the purse under her pillow." We have been much impressed by the experience in this respect of the Plaistow Maternity Charity, to which we have already NEED FOR A UNIFIED SERVICE 129 referred, a voluntary organisation for supplying midwifery attendance gratuitously to the homes of a very poor part of the West Ham Union. Here a great feature is made of the hygienic advice and instruction given to the mother. Those responsible for its organisation are firm in the belief that domiciliary treatment of confinement cases is the only sound one, for they consider that the nurse may leave behind her lessons of health which will long be remem- bered. This, however, is at present very imperfectly undertaken, owing to the absence of any co-operation with the Local Health Authority. The nurse only attends a case for ten days at the most, and it may require many months of simple instruction before a woman has the desire or knowledge for fighting against the overwhelming odds of a ** slum " existence sufficiently well to obey even the simplest laws of health. It is here that the continuous supervision and friendly counsel of the Health Visitors — continued as we have described, quite irrespective of whether or not the mother continues to be destitute — becomes of so much value. No such machinery is, or can be, at the disposal of a Local Authority concerned with the mere relief of destitution. There are, however, a number of maternity cases which — whether on medical or social grounds — cannot properly be treated in the home. It is a powerful argument for entrusting the whole service to the Local Health Author- ity that such an Authority has, in its qualified staff, the means of discovering these cases in advance; and of arranging for their admission, not at the moment of labour, but in due time. It is clear that the Maternity Hospitals supported from public funds must be either supervised or administered by the Local Health Authority, which is already charged with the duty of dealing with puerperal fever. By its ability to exercise the necessary medical supervision, such an Authority would be able to do what the Destitution Authority never feels itself able to^do, namely, make full use of philanthropic or charitable institutions undertaking the reclamation of girl-mothers. Above all, the Local Health Authority would be in a position, with regard to each case, to deal with it by the VOL. I K 130 BIRTH AND INFANCY desirable combination of domiciliary and institutional treatment — to watch the patient at home, to arrange for admission to the appropriate institution just for the crisis, to continue the treatment at home, and to follow this up by the instructional care which goes far to strengthen and enforce personal responsibility. Whilst the good mother would be stimulated and encouraged, the bad mother would be kept under observation and, if necessary, prosecuted for letting her baby die. It has been strongly represented to us that the special supervision of the Local Health Authority should not be confined to the first year of life, but should be continued until, at whatever age may be fixed, the children pass under the supervision of the Local Education Authority. " There is no doubt," testified the Clerk of the Glasgow School Board, " that the absence of public provision for chil- dren under five, so far as the poorest classes are concerned, is a crying evil. The evils of slum life in relation to these children cannot be minimised. Probably the evil in- fluences of the slums upon them afi"ect their whole lives and make the whole question of education right up to four- teen more difficult." "Young children in poor districts," said an important London witness, "who do not attend school are often locked up in one room for hours without attention, while the mothers are out at work. Either they are in danger from a fire in an open grate, or there is no fire and they suffer terribly from cold. When not locked in a room they are left to run about alone in the streets. In either case it frequently happens that no attempt is made to keep them clean, this being done only when they go to school. Under such conditions it is hopeless to expect children to acquire good and clean habits." The Destitu- tion Authority, as we have seen — even with regard to the considerable proportion of these children which it is main- taining on Outdoor Relief — exercises no supervision over such cases. It is, we think, clear that it is the Local Health Authority that should be charged with the respon- sibility for the whole of the public provision that is made for the child under school age, whether this takes the form of supervision, from the standpoint of Public Health, of NEED FOR A UNIFIED SERVICE 131 infants at large, or the maintenance of infants discovered to be in a state of destitution. We are supported in this assumption of the proved necessity for a systematic super- vision of infants up to school age by the recent authori- tative Report of the Consultative Committee of the Board of Education. "The first three years of a child's life," states that Committee, " are the most critical of all, and . . . if the State acknowledges the duty of providing care and training for certain children after the age of three there is even greater reason for extending that care to children below that age. As to the permanent efiect of proper care during the first three years of life the Committee entirely agree. . . . They would like ... to record their conviction that the improved treatment of such children depends almost entirely upon the improved conditions of their homes, and this opinion strengthens them in urging that in making provision for children over three nothing should be done which might arrest the development of the idea that the best place for all children under five is a good home." This unification in the hands of the Local Health Authorities of whatever public provision is made with regard to Birth and Infancy seems to us as desirable in the interest of economical expenditure of the public funds, as it is in the interest of efiiciency of service. We do not agree that the assumption by the Local Health Authority of the work now done by the Destitution Authority in providing medical attendance and maintenance for sick or destitute mothers and infants, would involve any extension of gratuitous service. It has been found, in practice, easier for the Local Health Authority to obtain repayment of the cost of the milk that it now supplies to necessitous mothers and infants, than for the Destitution Authority to recover the cost of the " relief" doled out in the homes, or of the fortnight's sojourn in the maternity ward of the General Mixed Workhouse. The greater willingness of the poor to pay for the food thus obtained from the Local Health Authority arises from the fact that it is tendered in a spirit of helpfulness to persons discovered to be in need of it, with no accompaniment of humiliation, and 132 BIRTH AND INFANCY conditional only on their making a right use of it ; instead of being, like Poor Relief, grudgingly granted, without consideration or counsel, to such applicants as brave the deterrent tests, and submit to the humiliation of pauper- ism and the stigma of civil disability. But apart from this effect on the recipient, encouraging in him responsive effort, there is, in all the range of operations of the Local Health Authority, an even greater safeguard to the rates in the fact that this Authority prevents destitution, and is not confined to merely treating it when it arises. In all these cases prevention is far more economical, as well as more efficient, than cure. The Destitution Authority has not, and never can have, any cognisance of the fact that an expectant mother, or mother with infants, is, owing to the neglect of her husband properly to maintain her, getting into such a state of weakness that she will shortly become chargeable to the rates. The Local Health Authority, by its machinery of Health Visitors and Sani- tary Inspectors, can discover the approach of destitution, and by moral pressure, and, if need be, by legal prosecu- tion, can enforce on husband or parent the responsibility for maintenance before actual destitution or chargeability arises. We see the superior economy of this preventive activity of the Local Health Authority in the work which it has already accomplished. The great improvements in town sanitation of the past half-century, which have so enormously diminished among adults both the death-rate and the loss by preventable sickness, have been effected quite as much by enforcing on owners and occupiers their obligation to keep their own dwellings in a sanitary con- dition, on traders their obligation to sell only wholesome food, and on employers their obligation to provide healthy workshops, as by expensive street improvements effected at the cost of the rates. It is only in default of private action that the Local Health Authority does the work itself; and then it is often enabled to recover the cost from the individual in default. This principle it is that we seek to extend from the sanitation of the environment to the personal hygiene of the mother and infant. At present, as we shall show in our chapter on " Charge and NEED FOR A UNIFIED SERVICE 133 Recovery by Local Authorities," the law and practice of recovering the cost of maintenance from the persons bene- fited, especially in the present sphere of the Destitution Authority, is in a state of utter confusion and futility. In that chapter, and more definitely in the chapter giving our " Scheme of Reform," we shall point out how these financial responsibilities of husbands and parents may be really enforced. (e) Conclusions We have, therefore, to report : — 1. That the Boards of Guardians of England, Wales, and Ireland, and the Parish Councils of Scotland, have proved themselves to be, by their tery nature as Destitu- tion Authorities, wholly unsuited to cope with the grave threefold problem as to Birth and Infancy with which the nation is confronted. Alike in the prevention of the continued procreation of the feeble-minded, in the rescue of girl-mothers from a life of sexual immorality, and in the reduction of infantile mortality in respectable but necessitous families, the Destitution Authorities, in spite of their great expenditure, are to-day efi'ecting no useful results. With regard to the first two of these problems, at any rate, the activities of the Boards of Guardians and Parish Councils are, in our judgment, actually intensifying the evil. If the State had desired to maximise both feeble-minded procreation and birth out of wedlock, there could not have been suggested a more apt device than the provision, throughout the country, of General Mixed Workhouses, organised as they now are to serve as un- conditional Maternity Hospitals. Whilst thus encouraging irregular sexual unions and the procreation of the feeble- minded, the Destitution Authorities are doing little to arrest the appalling preventable mortality that prevails among the infants of the poor. The respectable married woman, however necessitous she may be, can, with diffi- culty, take advantage of the free food, shelter, and medical attendance provided at great expense by the Destitution Authority for maternity cases. In Scotland she is — if living with her own husband, he being in good health — 134 BIRTH AND INFANCY absolutely debarred from relief by law. In England and Wales she is, as far as possible, deterred. 2. That in view of the fact that the Destitution Authorities of the United Kingdom have constantly on their hands more than 65,000 infants under five years of age, and that there is grave reason for believing the mortality among them to be excessive, alike among the 50,000 who are maintained on Outdoor Relief and among the 15,000 in Poor Law Institutions, careful statistical inquiry ought immediately to be made, in order to dis- cover where the mortality is greatest, and how this loss of life can be prevented. 3. That, in accordance with the recommendations of the Royal Commission on the Care and Control of the Feeble-minded, those unmarried mothers who come on the rates for their confinements, and are definitely proved to be mentally defective, should be dealt with exclusively by the Local Authority for the Mentally Defective. 4. That, whatever provision is made from public funds for maternity, whether in the way of supervision, or in domiciliary midwifery, or by means of Maternity Hos- pitals, should be exclusively in the hands of the Local Health Authority. 5. That, in accordance with the recommendations of the Vice -Regal Commission on Poor Law Reform in Ireland, the fullest possible use should be made, under the inspection and supervision of the Local Health Authorities, of such Voluntary Agencies as Rescue and Maternity Homes, Midwifery Charities, and Day Nurseries. 6. That the system, which has already proved so successful, of combining the efibrts of both salaried and voluntary Health Visitors with the work of the Medical Officer of Health and his stafi", should be everywhere adopted and developed so as to extend to all infants under school age. 7. That the Local Health Authority should, in all its provision for birth and infancy, continue to proceed on its accustomed principles of : — (a) The provision, free of charge, of hygienic information and advice to all who will accept it ; CONCLUSIONS 135 (6) The strict enforcement of the obligation im- posed upon individuals to maintain in health those who are legally dependent on them ; and (c) Where individual default has taken place in this respect, the immediate provision of the neces- saries for health, and the systematic recovery from those responsible, if they are able to pay, of repay- ment according to their means. CHAPTER IV CHILDREN UNDER RIVAL AUTHORITIES The authors of the Report of 1834 found only one Local Authority dealing with poor children, namely, that acting under the Elizabethan Poor Law. In 1909 we find the work shared among three distinct Local Authorities ex- pending rates and taxes — the Destitution Authority, the Education Authority, and, in England and Wales, also the Police Authority. Each of these Local Authorities acts under its own set of Statutes, and is, in England and Wales, subject to the control of a different Government Department — the Poor Law and other Divisions of the Local Government Board, the Board of Education, and the Home Office. Of these three Local Authorities dealing with poor children, the Education Authority (which now often provides maintenance as well as instruction) has become, within the last few decades, by far the most extensive in its operations, now spending at least £25,000,000 annually. The total expenditure of the Destitution Authority on all its 237,000 children between five and sixteen, including instruction as well as mainten- ance, may be estimated at nearly two millions sterling annually. The Police Authorities, the County and Borough Councils, which have sometimes established industrial schools of their own, take rank with the Voluntary Com- mittees which, alongside of them, administer other schools of this kind at a cost of £600,000 a year, met partly by substantial grants in aid from the Home Office. All the three kinds of Local Authorities provide, in a certain proportion of cases, both maintenance and instruction ; all three deal with children who, whatever else they may 136 CHILDEEN UNDER RIVAL AUTHORITIES 137 be, are certainly destitute ; and, as a matter of fact, it is not uncommon to find the different children of one and the same family being treated by two, or even by all three, separate Local Authorities simultaneously. (a) Children under the Destitution Authority We need not again recur to the fact that the authors of the Report of 1834 recommended that, for the destitute children of school age, there should be provided entirely separate residential institutions under schoolmasters ; and that this recommendation applied, not merely to orphan or deserted children, but also to the families of all the able- bodied persons who were in any way relieved from the rates. The only children aided from the rates whom the authors of the 1834 Report would have left with their parents were those of sick or infirm persons, for whom alone Outdoor Relief was contemplated. This recommendation was ignored by the Poor Law Commissioners of 1835, who relegated to the General Mixed Workhouse the children of all those who received institutional relief; and left in the homes, on small weekly allowances without any education at all, the children of the constantly increasing number of parents — widows, the sick, the aged and the infirm, men on Outdoor Labour Test, etc. — who where excluded from the operation of the Outdoor Relief Prohibitory Order. From 1841 onward, as we have already described, the Central Authority in England and Wales has been per- sistently striving to induce the Boards of Guardians to reverse the policy with regard to the children of school age which it unfortunately pressed on them in 1835, It has done its best to get the Guardians to provide efficient education for the children ; to establish separate schools for them ; to obtain trained and qualified teachers for them at adequate salaries ; to get the children of school age out of the General Mixed Workhouse into which they have been driven ; and to diminish the number of children who, on Outdoor Relief, were left without either adequate education or proper supervision. Unfortunately, the Destitution Authorities have, nearly 138 CHILDREN UNDER RIVAL AUTHORITIES everywhere, shown themselves very slow and reluctant to adopt the new policy. At the present day, out of the 186,000 children between five and sixteen maintained by the Poor Law Authorities in England and Wales alone, there are 130,000 on Outdoor Relief, and about 3000 in the ordinary wards of the General Mixed Workhouse, apart from several thousands more who are in the sick wards of General Mixed Workhouses, and several thou- sands in addition who are in separate infirmaries, usually without separate wards for children. We have already described the treatment meted out by the Destitution Authorities of England and Wales to the 130,000 children of school age, whom they elect to main- tain on Outdoor Relief. After the elaborate report of our Special Investigators into the conditions of these children, as well as from what we have ourselves witnessed, we are unable to resist the conclusion that the great bulk of these children are growing up underfed, wrongly clothed, and housed under insanitary conditions. They are demon- strably being stunted in their growth and physical de- velopment, falling, as they grow up, year by year, farther behind the average in height and weight. What is even more deplorable is that, with regard to at least ten or twenty thousand of them, it is, as we have seen, only too probable that they are being subjected to the influences of parentage and homes of dissolute or immoral character. The condition of the children on aliment in the large towns of Scotland is, in these respects, quite as bad as that of the Outdoor Relief children in England and Wales. " The out-relief children," emphatically sums up our Children's Investigator, " are definitely and seriously sufi'ering from the circum- stances of their lives." With regard to the 3000 children between five and sixteen (not including the 7000 others who are in the sick wards or infirmaries) who are still living in the General Mixed Workhouses of England and Wales, we need do no more, after our description of the evil promiscuity of that institution, than emphasise the universal condemnation of such a method of providing for the rearing of the young. "The retention of children in Workhouses," reports our UNDER THE DESTITUTION AUTHORITY 139 own Children's Investigator, " is always unsatisfactory. Even where they have special attendants they are never completely separated from the ordinary inmates. ... In York certainly the children were dull and inert ; they stood about like moulting crows, and did not seem able to employ themselves with any enthusiasm or vigour. The arrangements for their tendance and training are never as good as in an establishment wholly given up to them; the separation from the ordinary inmates of the Workhouse was very incomplete in each case I saw." Despairing of being able to induce the Destitution Authorities to send the children away to proper residential schools, the Local Government Board for England and Wales has, during recent years, contented itself with pressing the smaller Unions to let the children in the Workhouses attend the public elementary day schools. This is doubtless an advance on the old school within the Workhouse walls ; but we cannot too emphatically express our disagreement with those who accept this as any excuse for retaining children in the Workhouse at all. The day school accounts for only about one-third of the child's waking life. The Local Government Board Inspectors themselves point out that it leaves the children, in practice, exposed to the contamination of " communication with the adult inmates whose influence is often hideously depraving." " It is a serious drawback," says the Inspector, " that every Saturday and Sunday, to say nothing of summer and winter holidays, have, for the most part, to be spent in the Workhouse, where they either live under rigid discipHne and get no freedom, or else if left to themselves are likely to come under the evil influence of adult inmates. The Workhouse is at best a dreary place for children to spend their lives in, and I should Hke to see them quite cut off from it." " The most unpleasant feature of this system," says another Inspector, " is that in some of the small rural Unions there are so few children that the Guardians cannot reasonably be expected to pay additional officers to look after them. There are but few Unions where there is no paid officer in charge of the children, but there are many where there is only a female officer, and where a pauper inmate is placed with the boys and sleeps in their bedroom. The male pauper selected for this purpose is generally the best man available, but too often he is not the sort of character which it is good for the boys to associate with." 140 CHILDREN UNDER RIVAL AUTHORITIES We paid special attention to this point of the provision for children on our visits to Workhouses, large and small, in town and country, in England, Wales, Scotland and Ireland. We saw hardly any Workhouse or Poorhouse in which the accommodation for children was at all satisfac- tory. We unhesitatingly agree with the Inspector of the Local Government Board who gave it to us as his opinion that " no serious argument in defence of the Workhouse system is possible. The person who would urge that the atmosphere and associations of a Workhouse are a fit up- bringing for a child merely proves his incapacity to express an intelligent opinion upon the matter." From what we saw of the Poorhouses of Scotland, great or small, we came to the conclusion that the residence of children in those institutions was no more to be justified than it was in the Workhouses of England and Wales. It does not seem to be realised in Scotland to what a large extent the Poorhouse is used for children. Disregardino^ the infants under five, with whom we have already dealt, there were in the Scottish Poorhouses on March 31st, 1906, no fewer than 1095 boys and girls between five and six- teen ; or actually one-third of the corresponding number in England and Wales, which has seven times the popula- tion. Nor does this represent the whole story. The number of children found in the Poorhouses on any one day is less than half the total that passes through these institutions in the course of the year ; so that we may infer that at least 3000 boys and girls of school age came under the evil influences of the Scottish Poorhouse during last year. We do not think that it is generally known in Scotland that the General Mixed Poorhouse harbours at least twice as many children of school age, in proportion to population, as the General Mixed Workhouse does in England and Wales. As to Ireland, we have been able to obtain only im- perfect statistics. But we gather that, of children between five and sixteen years of age, there are over 6000 in Poor Law Institutions. We infer that there must be, in the General Mixed Workhouses of Ireland, something like 5000 boys and girls of school UNDER THE DESTITUTION AUTHORITY 141 age, who are mostly being educated within the Work- house walls. Turning now to the specialised treatment provided by the Destitution Authorities of the United Kingdom for about 60,000 out of the total of 237,000 children between five and sixteen whom they maintain, we are confronted with six different methods of provision varying greatly in the amount and quality of what is done, and therefore in the cost. The expense, in fact, shows the most extra- ordinary variation — some children being maintained on eighteenpence or half-a-crown a week, whilst others run up to as much as twenty-five shillings a week. Without at present attempting to estimate the comparative advantages of these six methods, we proceed first to describe them in the order of their apparent cheapness, taking first that which is apparently the least costly. (i.) Boarding-Out within the Union Of the method of providing for children known as Boarding-Out, there are, in England and Wales, two varieties existing under very difierent conditions. Under an Order of 1889 Boards of Guardians may board out children " within the Union," which means, in practice, no more than paying a small sum weekly to a foster parent residing within the same Union, who undertakes to main- tain the child. " In point of fact the cases boarded-out within the Union are cases with regard to which the Guardians would ordinarily give Outdoor Relief, and . . . did give ordinary Outdoor Relief prior to the . . . Order being sent out." It is a system " which extends auto- matically," stated the Senior Boarding-Out Inspector : — For many persons who might maintain children related to them, but for whom they are not legally responsible, will not do so if they see that their neighbours receive parish pay for children under similar circumstances. Also, though there are now about 107 committees within the Unions for which they act, there is no official inspector to report on, and help their work ; while the rest of the children are only under the supervision of the relieving and medical officers, who cannot make the thorough inspection of the 142 CHILDREN UNDER RIVAL AUTHORITIES homes and bodily condition of the children which a woman can. It is, therefore, probable that many of the homes are accepted in ignorance of what the treatment of the children really is, and that many of the foster-parents would decline to receive them at the low rates of payment often given if of&cial investigation were made into the nature of that treatment and their expenditure of those payments. We regret to report that we have been unable to find any official information as to the condition of the 6806 children thus dealt with in England and Wales, children who, though placed out at sums varying from eighteen- pence to five shillings per week, to persons not their parents, are not under the inspection of any ofiicer of the Local Government Board, and usually, indeed, have in a majority of Unions not even the protection of a Boarding- Out Committee. Because the foster-parents happen to live within the geographical boundaries of the Union to which the children belong, the theory of the Local Govern- ment Board is that the inspection and supervision of the Guardians themselves, the Relieving Officer and the Dis- trict Medical Officer will suffice to ensure that the children are being properly cared for, much as if they were children on Outdoor Relief. As we have seen, the Guardians, in the majority of cases, give no supervision at all, and there is evidence that the prescribed inspection of the children by the District Medical Officer is seldom adequately carried out; and it is remarkable that where a Boarding -Out Committee exists, the official regulations enable such medical inspection to be entirely dispensed with. The only responsible person is, in that case, the Relieving Officer. This " Destitution Officer" does not think it his duty minutely to inspect the children ; and even if he were a desirable person with whom to bring the child in contact, he can hardly be expected to be expert in ascer- taining and enforcing the physical and mental requirements of healthy child life. The children are, in fact, often under no supervision at all. In one Union our Committee heard of " Thirty-one children boarded-out within the Union at a cost of from Is. 6d. to 2s. 6d. per child. There is no list of boarded-out children except the entry in the Application BOARDING-OUT WITHIN THE UNION 143 and Report Book ; in fact it is really Out-relief. There is no superintendence and inspection except such as the Relieving Officers give." One of the Local Government Inspectors informed us that he had himself become aware of several cases of neglect, and even of cruelty to these totally uninspected children ; and he suggested to us the desirability of "an absolutely independent inquiry . . . to see how they do fare, and whether they are well treated or badly treated. All the people who take them want to make money out of them. The worse they treat them the more money they make." Such an inquiry we found our- selves without time to undertake. But our Special Investi- gator into Children inquired into the condition of the children boarded out within the Union in six different districts of England and Wales. The results of this sample inquiry are, in our judgment, very disquieting : — " It is clear," sums up our Investigator, " from the accounts of these six Unions, that effective supervision of boarded-out children and their homes is not obtained under the ordinary Poor Law administration. . . . Supervision of homes and children by Guardians and Relieving Officers was never found to be satis- factory. Relieving Officers have too much the standard of the ordinary Out-rehef family; also a man cannot investigate the sleeping accommodation, beds, and clothes of girls in any effective fashion. He cannot discuss with the foster-mother the girl's health and temperament in the way a wise woman can do." In view of these statements, and of the very grave facts that are constantly being discovered by the lady Inspectors of the Local Government Board among the other boarded- out children who are inspected in England and Wales, we cannot but regard the total absence of official information with regard to these 6806 children as unsatisfactory. This is the more important in that it is only this section of boarded-out children that, in England and Wales, shows any sign of increasing in numbers. Without waiting for any systematic reform of the Poor Law, they ought, in our opinion, to be at once made the subject of a special inquiry, and placed for the future under the same official inspection as the children boarded out beyond the Union. This, we may observe, would need no legislation, and could be instituted next week by a stroke of the pen. 144 CHILDREN UNDER RIVAL AUTHORITIES (ii.) Boarding-Out in Scotland and ''Boarding-Out without the Union " in England and Wales But the system of boarding-out "within the Union" in England and Wales is but an anomalous offshoot of the general plan of placing out the children, far from Poor Law associations, with carefully chosen foster-parents who should care for them as for their own offspring. We need not recount the well-known story of the immemorial practice of the Scotch Kirk - Sessions in boarding-out orphan and deserted children, which became, after 1845, the regular system of the Scotch Poor Law. Nor need we describe the adoption after 1862 of a similar system for Ireland, and after 1870 also for England and Wales. To those who had become conscious of the terrible promiscuity and evil associations of the General Mixed Workhouse, or of the machine-like routine of the great " barrack schools," the plan of boarding-out the children in the cottages of foster-parents in the country promised the best substitute for the home life which the orphan or deserted child had irrevocably lost. " The testimony " of many witnesses, as the Departmental Committee on Poor Law Schools reported in 1896, "is emphatically in favour of the boarding-out of pauper children as the best system, and that which secures to them the healthiest and most natural life, and gives them the best chance of . . . becoming absorbed into the respectable working population." Accordingly, there are at present over 10,000 children "boarded out ' in the United Kingdom (apart from the anomalous " boarding- out within the Union " already referred to), namely, about 6000 in Scotland, 2100 in Ireland, and 1800 in England and Wales ; out of the total of about 305,000 infants and children under sixteen whom the Destitution Authorities are maintaining. The provision for children in Scotland by means of boarding-out, though commonly assumed to be the prin- cipal, if not the only method there adopted, is made use of only for orphan, deserted, or " separated " children, and is applied, in fact, only to one-sixth of the pauper children. But it is estimated that of the orphan and deserted children BOARDING-OUT 145 over 80 per cent are now boarded out. Of the 7552 infants under five in receipt of Poor Relief on March 31, 1906, 315 were boarded out ; of the 32,075 children between five and sixteen, 5700 were boarded out. There are, it must be remembered, in Scotland no Poor Law schools. Cottage Homes, or Scattered Homes, and little use is made of institutions under voluntary management. We have to report that the plan of boarding-out, as applied in Scotland to the orphan and deserted children, appears to be endorsed by Scottish public opinion. It has, however, been observed to us that these thousands of children are entrusted for money to stranger foster-parents — sometimes four or five to one person, and a score or two to a single Highland village — without any sort of independent official supervision or inspection. The work of selecting the foster-parents, and bringing the children, is left to the Destitution Officer of the Destitu- tion Authority from whose district — often far distant — the children come. Our Investigator reports that — When a child is once boarded-out the supervision exercised over it is not very close. The Inspector of Poor for the parish in which the children are placed has no legal responsibility, and sees little of the children, unless, as in Lanark, he gives part of his time to visiting them just as he visits his own. The formal inspection by the parish to which the children belong is always the same, and consists of two visits a year by an inspector, once alone and once accompanied by two members of the Parish Council. These visits have little value in advice to or control over the foster-parent, but they may afford opportunities for gaining information as to the condition of the child. Parish Councils seem to rely a good deal on the informal supervision of neighbours, ministers, and schoolmasters for bringing abuses to fight, but people are not usually inchned to give information against their neighbours, especially in a small place where every one knows every one else, and a good deal of neglect and injudicious treatment, if not actual cruelty, might easily go on without any one feeling it his business to bring such matters to the notice of those in authority. Such cases, we were informed, have been known to occur. It appears to us, moreover, somewhat remarkable that there is no systematic medical supervision of the boarded-out children. VOL. I L 146 CHILDREN UNDER RIVAL AUTHORITIES " There is," notes our Investigator, " no medical inspection of these children at all. The foster-parents are expected to take them to the doctor when necessary, and have a right to his attend- ance for them, but they are themselves the only judges of the necessity. One child, boarded in Saltcoats, was attending an eye hospital in Glasgow, on the advice of the inspector given at one of his half-yearly visits. There was a boy of ten in Lanark who had a tubercular knee, and ought to have been kept in bed. Indeed, when the doctor visited him he was there, but at other times he was found hopping about the room. Another girl (one of those belonging to Lanark itself) was feverish and obviously ill. When she was medically examined at school, she was sent home with a message that she was to be put to bed. She was found sub- sequently playing in the street, and though again advised to do 80, her guardian did not put her to bed, apparently through sheer carelessness, and did not send for the doctor. It was afterwards found that this child had been in hospital for some time, and dis- charged because she had phthisis, and such cases were not treated there. She was under no kind of medical supervision." We note that the practice of Scotland is to include as " boarded out " children who would not, according to the English terminology, be so described. A certain propor- tion of the children said to be " boarded out " are merely placed in institutions under voluntary management, some of which are of large size. Thus the Edinburgh Parish Council has always a score or two of children in a large Roman Catholic orphanage, and fifty or sixty in other voluntary institutions, which w^ould, in England and Wales, be inspected by the Local Government Board, and *' certified " as suitable for the reception of the children. Various other Parish Councils in Scotland dispose of children in this way, the total number amounting, apparently, to about 750, without, so far as we have been able to gather, any systematic inspection of these private institutions being conducted, either by the Local Government Board for Scotland, or by the Parish Councils concerned. AVe cannot approve of considerable sums of public money — amounting, as we understand, to thousands of pounds annually — being thus paid to private, and often denominational institutions, without ofiicial inspection or public representation on the governing bodies. There is also another practice disguised under the BOARDING-OUT 147 term " boarding-out." One of the General Superin- tendents under the Local Government Board for Scotland speaks " most emphatically of the success of the system . . . when the children are really boarded out," but he goes on to say that, " In some cases the children have been left with relations — a grandmother, elder sister or brother, or aunt — who have probably offered to take the children at a reduced aliment, say Is. 6d. a week each. In these cases I have not found the children so well accommodated and cared for." The proportion of children dealt with in this way, even in the poor "slums "of the great cities, appears to be sometimes considerable. In Aberdeen, for instance, where there were, on July 1, 1907, altogether 1557 pauper children, 1297 were simply on Outdoor Relief, and no fewer than 75 were living in the General Mixed Workhouse ; 185 were nominally " boarded- out," being nearly 12 per cent of the whole. But we found that of these 9 were in various private institutions, 29 were living with relations on a low aliment, and only 147 were really boarded out with strangers, and these by no means all outside the city itself. Of the whole 6710 children reported as " boarded out " in Scotland on May 15, 1907, whilst about 750 were in institutions, 1929 were boarded with relations, and only about 4000 with stranger foster-parents. We hesitate to express an independent opinion on the Scottish plan of boarding- out. But we cannot escape the feeling that so extensive a system of "farming-out" the children of the poor, great as may be its advantages in the best cases, ought not to continue without systematic medical inspection once a quarter, and regular visitation of all the cases at least once a year by trained lady inspectors under the Local Government Board for Scotland. Very different are the conditions under which the Destitution Authorities in England and Wales have been permitted to board out their children beyond the limits of their own districts. There must be a Voluntary Com- mittee of local residents, individually and collectively approved by the Local Government Board, each of whom 148 CHILDREN UNDER RIVAL AUTHORITIES must engage in writing to undertake the responsibility of choosing the foster - parents, supervising the homes, visiting them at least every six weeks, making the payments for the children's maintenance, and reporting periodically on the children's condition. The master of the local Public Elementary School must report quarterly on each child on an official schedule. A definite contract must be made with a local medical practitioner for the attendance of the children in sickness. And over and above this local supervision, which is strictly insisted on, the Local Government Board maintains three trained and specialised lady inspectors who do nothing else but travel up and down the country examining the homes, the health, the food and clothing, and the physical and mental con- dition of these 1800 children. On the other hand — in sharpest contrast with the arrangements which content the Local Government Board for Scotland — the Relieving Officers, whether of the Union from which the child goes, or of that in which the foster-parent lives, have absolutely nothing to do with the case. The Board of Guardians into whose district the child comes knows nothing of it. And what is the more remarkable, the Board of Guardians which pays for the child, and is responsible for its welfare, is strongly discouraged, if not even actually forbidden, to send any of its officers or to depute any of its members to visit the child's new home or personally inspect its con- dition. Any such visitation or inspection would, it has been officially stated, be objectionable, "as keeping up associations of pauperism which it is one of the objects of the boarding-out system to remove," and expenses incurred for this purpose would, it has been intimated in at least one Union, be liable to be disallowed and surcharged by the District Auditor. The vigilant and incessant supervision of the three lady inspectors of boarding-out in England and Wales — not extended, we must repeat, to the 6000 children " boarded out within the Union " — has, we gather, resulted in these carefully watched children being, on the whole, kindly treated. Many of them, it is clear, receive the great advantage of a first-rate working-class home. BOARDING-OUT 149 " Boarding-out," states our own Children's Investigator, ** when properly supervised, and with an active and wise Boarding-out Committee, is, I believe, the ideal system both for boys and girls, but especially for girls." But we have some doubt whether the system can, under present circumstances, be greatly extended in scope. We do not think, for instance, that it can be used for children who have mothers of their own, not being such as deserve to be completely and permanently deprived of their offspring. Nor is it applicable to the not inconsiderable number of children who, from mental or physical peculiarities, have to be dealt with by persons skilled in the treatment of the abnormal child. Thus the percentage of children who can be made eligible for boarding-out cannot, we think, appreciably exceed the present class to which the Board- ing-out Order applies, which probably comprises only about one-tenth of the total number of Poor Law children. Further, the number of foster-parents who are both able and willing to receive boarded-out children and who possess suitable homes is, in England even more than in Scotland, plainly very limited. We have regretfully to admit that, good as it is as far as it goes, " boarding- out can only touch the fringe of the problem of the training and upbringing of pauper children." Moreover, amid all the advantages of the foster- parent's home, we have felt uncomfortable, in such personal inspections as we have been able to make, in Scotland, Ireland and England alike, as to whether sufficient care was being taken to see that these boarded- out children were in all cases being fed, clothed, educated and medically attended in such a way as to make them into healthy and productive citizens. The official inspec- tion in England, and local public opinion in Scotland, may, in cases of open abuses, protect them (in all but a few exceptional cases) against wilful cruelty or gross neglect. But it ought frankly to be recognised that the standard of efficiency of the average mother in the rearing of children is a low one, often not consistent with the continued health and adequate training even of her own children, to which she brings the incalculable compensating 150 CHILDREN UNDEK RIVAL AUTHORITIES advantage of instinctive care. It cannot be said that the present occasional inspections protect the boarded -out children against a foster-parent's low standard of know- ledge of how to bring up a child, or against a foster- parent's lack of means. Practically nothing can be done by the Local Government Board Inspectors to ensure that the children get continuously sufficient food of the proper kind, QT the right sort of clothing, or even adequate sleep. The amount usually paid for their maintenance — 3s., 4s., and occasionally 5s. a week, with 10s. a quarter for clothes — is, with the usual limited knowledge as to how best to lay out this sum, insufficient for adequate food and clothing of a growing child and ordinary remuneration for the very real labour of attending to it. We do not feel any assurance that the boarded - out children, if properly weighed and measured, would be found to be much more nearly equal to the average weight and height for their years than the children on Outdoor Relief. Unfortunately the boarded-out children are, as a rule, not medically inspected, or even periodically weighed and measured at all ; and we have it in evidence that this lack of medical inspection results in many minor ailments remaining untreated. " I believe," sums up our Medical Investigator, with regard to these boarded-out children, " the main reason for present defects to be that the children are regarded as belonging to the Poor Law system of the country, are under charge of the Poor Law Authority, and that their whole management is pervaded by the Poor Law spirit. They are a burden on the rates ; no more should be done for them than the absolute minimum demanded by necessity. It is the duty of the Guardians to keep down expenditure, and to see that pauper children shall not be better cared for than the children of the poorest labourer. Proposals as to better treatment, better feeding, and better control hardly belong to the sphere of Poor Law work." And, seeing that the very object of the system is to free the child from any connec- tion with the Poor Law, so that neither the members nor the officers of the Board of Guardians responsible for the child's maintenance and welfare can properly be allowed BOARDING-OUT 151 to visit or inspect it, lest this should keep up '* associations of pauperism," we fail to see why the Destitution Authority- should continue to have anything at all to do with the boarded-out child. Such a child might, it would seem, just as well be entrusted to the care of the Local Education Authority — '"' an authority," to use the significant words of our Medical Investigator, "whose special duty would be the proper guidance and control of these children . . . so as to fit them for a useful life, and to remove as far as practicable the evil effects of their mental and physical heritage " — an authority which is now to have systematic arrangements for medical inspection by doctors having special knowledge of children's physical needs, and which has its own staff of School Attendance Officers, and its own voluntary bodies of School Managers or Children's Care Committees, free from any of the " associations of pauperism." (iii.) Certified Schools and Institutions Closely connected with the system of boarding-out the children with foster-parents, is that of placing them in schools and homes under the management of voluntary philanthropic committees, to which, in England and Wales, the Destitution Authority pays a sum, approved by the Local Government Board, of from 3s. to 10s. 9d. per child per week. Other institutions, not certified, are made use of by special permission of the Local Government Board in each case. This method of providing for the children is now resorted to by about half the Boards of Guardians in England and Wales, who place out in this way over 11,000 children, mostly of school age; 8171 being sent to the 269 certified homes and schools, and about 3000 to uncertified institutions. About a score of Unions have each more than a hundred boys and girls so disposed of. In a large number of cases these are children of Roman Catholic parentage, for whose reception about fifty -five Roman Catholic certified schools, homes and orphanages are maintained, having altogether about 5000 Poor Law inmates. There are a score of certified institutions for the 152 CHILDREN UNDER RIVAL AUTHORITIES blind, deaf and dumb, crippled or idiotic, with about 700 inmates. There are three certified training ships, having about 250 Poor Law boys. The other 191 certified institutions, containing about 2200 Poor Law children (or, on an average, twelve apiece), include a great variety of " homes " and " schools " and " orphanages," mostly small in scope ; frequently undenominational, but some- times definitely Anglican, and occasionally Wesleyan or Jewish in character ; established, as a rule, by little groups of philanthropists ; almost invariably unincorporated, unendowed, and supported partly by voluntary contribu- tions ; and administered by Voluntary Committees, largely composed of benevolent ladies. "They are," somewhat optimistically deposed the Chief Inspector of the Local Grovernment Board, "perhaps the best illustration of charity working in co-operation with the Poor Law. Good people start these homes ; we certify them ; the Guardians pay for the children going there ; and we inspect them." The striking feature about this method of providing for over 11,000 of the "Children of the State" is the lack of official knowledge of what is happening to them. Of the 3000 in the uncertified institutions — which include other training ships, sanatoria of various kinds, schools for epileptics, blind asylums and farm colonies — we have found no information at aU. But even of the officially certified institutions little is apparently known. Some of them are large, ably administered and apparently very successful. Others are small and obscure places, with indefinite variations according to the personality and means of the persons who happen, for the time being, to be taking an interest in them. Some that we happened to visit seemed to leave nothing to be desired. Others were much less satisfactory. The first question that is naturally asked with regard to children of school age is what are the arrangements for their education ; but there are no official Reports published as to either the educa- tional attainments or the physical condition of these eleven or twelve thousand children, most of whom are of school age, and nearly all the others are supposed to be still CERTIFIED SCHOOLS AND INSTITUTIONS 153 under educational training of one sort or another. The Local Government Board presumably obtains, at the out- set, all the necessary evidence before certifying that an institution is in all respects fit to receive Poor Law- children ; but we gather that it relies on a visit by one of its General Inspectors, who " satisfies himself that the children are properly fed and clothed, and that the cubical and superficial space is sufiicient " for the number for which the place is then certified. We understand that no Report is obtained from any educational expert as to the sufficiency and suitability of the education provided — in fact, we have been unable to discover that the Poor Law Division of the Local Government Board even knows which of these places are themselves schools, and which of them merely board and lodge the children. Down to 1871 they were not inspected. Those which are certified are now subject to an annual visit by the General Poor Law Inspector in whose district they happen to be situated, but no reports of these visits are published or were supplied to us ; it is no part of the duty of the Inspector to estimate the efficiency of the children's education ; and we have been unable to ascertain whether the inspection extends nowadays to more than it did in 1888, when it was offici- ally stated to relate to no more than seeing that the children had enough food and clothing, and were not overcrowded. Representations appear from time to time to have been made as to the desirability of some inspection being made of the educational work by qualified inspectors. In 1883 a London Board of Guardians inquired, with some anxiety, whether there was any Government inspection at all of the education in these certified schools for which the Boards of Guardians were paying large sums. In conse- quence of this inquiry arrangements were made, in the course of the next few years, for getting twenty-three out of the fifty-five Roman Catholic institutions — but no others — regularly inspected by the Inspectors of Poor Law Schools. In 1904 the duty of inspecting the education in these twenty-three schools (and in these only) w^as trans- ferred to the Board of Education, who have communicated to us an interesting report on the results of the recent 154 CHILDREN UNDER RIVAL AUTHORITIES visits to them of His Majesty's Inspectors of Schools. So far as we can ascertain, the education given in the other Roman Catholic schools, some of which have over a hundred boys or girls, and that given in the schools and homes belonging to other denominations, or to no denomination — apart from a score of institutions which happen to receive grants also from the Board of Education as being public elementary schools — is, to this day,- not subject to any inspection whatever. We gather that in many of the smaller " homes " no schooling at all is provided, and it is assumed by the Local Government Board that in these cases the children of school age are sent out to the local public elementary school. We find that it is not generally known to the Boards of Guardians concerned, any more than it is to the Poor Law Division of the Local Government Board, which institutions provide schooling and which are merely homes ; and there is no arrangement for ensuring that the Managers of the institutions of the latter kind cause the children entrusted to them to attend school at all, still less that they attend regularly and continuously up to the age for legal exemption. It has been suggested that it may be assumed that the Local Education Authority should see to this matter ; but there is, we find, no arrangement for informing the Local Education Authority when Poor Law children are sent into its district ; it has no power to inspect residential institutions which are not public ele- mentary schools ; and we do not feel sure that children in residential institutions are always included in any syste- matic scheduling of children that may be undertaken by the School Attendance Ofiicers. Moreover, we fear that the annual visit of the General Poor Law Inspector to the certified institutions does not necessarily ensure, even in respect to the matters which he attends to, that every one of these 8171 children that have been sent to these institutions will be seen by him. The Inspector is not supplied with any list of names of the Poor Law children who ought to be presented to him in each institution, and does not even know how many ought to be seen by him. There is accordingly nothing to pre- CERTIFIED SCHOOLS AND INSTITUTIONS 155 vent some of the Poor Law children from being withheld from his inspection, either because they were not in a fit state, or because they had been sent out to work, or because they were in excess of the maximum number for which the institution was certified, or because they had been, without the knowledge of anybody concerned, illegally boarded out. We feel bound to call attention to this remarkable laxness, because — though we have no further information on the subject — it has been given in evidence, by an officer of the Local Government Board, that cases have been acci- dentally discovered in which children, entrusted by a Board of Guardians to a home duly certified by the Local Govern- ment Board, were found to have been illegally boarded out in cottages with foster-parents, for payments less in amount than those which the certified home was receiving. And it must be remembered that these children have no other protection than that which official inspection afi'ords. " The Guardians," reports one of our Committees, " practi- cally wash their hands of them entirely." Some Boards do visit a few of the institutions they make use of, but such visits are officially discouraged ; and in at least one Union they have been discontinued on a threat from the District Auditor that he would disallow and surcharge the expenses. It has been held, in fact, that it is the duty of the Guardians to rely on the certificate of the Local Government Board. We cannot feel that it is either right or convenient that the power of placing children of school age in these voluntary institutions — which thus receive about £200,000 a year from public funds — should continue to be exercised by Destitution Authorities, who cannot be expected, any more than the Poor Law Division of the Local Government Board, to be qualified to form any skilled judgment as to the efficiency of the training given at the public expense. (iv. ) Scattered Homes In view of the fact that it w^as impracticable to board out more than a fraction of the children who had to be 156 CHILDEEN UNDER RIVAL AUTHORITIES maintained from the poor rates, the Sheffield Board of Guardians in 1893 started what has since been termed the system of " Scattered Homes." The Guardians set themselves the problem of how to procure for children, unsuited for boarding-out, the best available condi- tions for health and education, with such supervision as would pre- vent abuses. They began by renting houses — such as are generally occupied by families of the working-class — in which they placed from fifteen to eighteen children with a motherly woman as house- keeper. They aimed to retain, as much as possible, the original character of the house, taking pains, however, that the drainage should be good and the air-space sufficient for children. At the same time, they estabhshed an administrative centre for the recep- tion of all children who might be thrown on the rates of their Union, which centre, unconnected with any other Poor Law insti- tution, was designed to lodge each child during the few weeks necessary for the observation of its health and character, until it could be sent, without any Workhouse memory, and with fair security of success, to one of the houses. All the houses are under the supervision of a superintendent and his wife, who keep the necessary accounts, report to the Guardians on the state of the homes, form a necessary link between the various homes, and generally secure that order which is essential in the expenditure of pubhc funds under the control of the Local Government Board. This system, which " has the advantage over all the others [except boarding-out] that there is less capital expendi- ture," costs only a few shillings a week more for mainten- ance than boarding-out itself ; and has now been adopted by about sixty Unions, for nearly 5000 of their children, practically all of them being of school age. There are many persons of knowledge and experience who regard this system as, on the whole, the best yet devised for the normal child whom the community has to maintain. It has distinct advantages over boarding-out, in that it is applicable to children whose parents are them- selves in the Workhouse ; the food, clothing, and housing are always adequate ; the foster-parent is more carefully selected and is a salaried officer ; regular medical inspection is provided for ; and there is continuous skilled supervision of the home. It is claimed that it is superior to the system of Poor Law Schools and Cottage Homes, presently to be described, in that, whilst being much less costly, the SCATTERED HOMES 157 children are less " institutionalised," and mix naturally with other children at school and at play. But, in our opinion, it is a drawback that the children in the Scattered Homes are still in contact with the Poor Law. They usually pass through the Workhouse or some other Poor Law institution before admission to the Scattered Homes, or on discharge from them ; they are officially visited by officers of the Poor Law, and by the Poor Law Guardians, instead of, like other children, by the officers of the Local Education Authority and members of the Children's Care Committee ; and they are classified as being in the category of the destitute, rather than according to their several talents and requirements. As we have mentioned, "de- fectives are very often to be found in the Children's Homes," merely because they are destitute like the rest. " In one of these Homes," deposed the father of the system at Sheffield, "we had a girl of feeble mind, now about fifteen. . . . She grew worse as her womanhood developed. . . . She corrupted the other girls in the Home. . . . There are two or three other girls in our Home who look to me to be going in the same way." Moreover, it is impossible not to admit that, as compared with the most modern of the Poor Law Schools or Cottage Homes, the children^ in the. Scattered Homes do not, under the admin- istration of the Destitution Authority, get such good opportunities for manual instruction, for learning swimming, for domestic economy, and generally for industrial training, as can be afibrded in the more highly organised institu- tions. All this, however, merely comes to the fact that the children in the Scattered Homes are the wards, not of the Local Education Authority, but of the Destitution Authority, which cannot be got to think of much beyond their board and lodging. They suff"er, in fact, from not being specially provided for by the Local Education Authority, which, if the Scattered Homes were within its jurisdiction, might well arrange for the children to share, over and above the ordinary schooling, ending at thirteen or fourteen, in the necessary industrial training and domestic economy instruction which the wisest parent wishes to secure for his family, and which the most 158 CHILDREN UNDER RIVAL AUTHORITIES advanced among Local Education Authorities are already beginning to provide. (v.) The Boarding School of the Destitution Authority All the systems for the specialised treatment of Poor Law children that we have so far described have arisen since 1870, and depend on the ubiquitous provision of public elementary schools by the Local Education Authori- ties. Prior to 1870 the only method of withdrawing Poor Law children from the General Mixed Workhouse or the unconditional Outdoor Relief that we have described, was to establish the separate boarding schools recommended in the Report of 1834. As we have mentioned, this policy, though rejected by the Poor Law Commissioners of 1835, became, from 1841 onwards, the favourite policy of the Central Authority, and in the course of the next forty years several dozens of such schools came into existence in England and Wales and two in Ireland. Some of these, serving combinations of Unions, were of huge size, accom- modating over 1000 children. We need not describe the change in opinion that has taken place during the last twenty years, and the conse- quent arrest of this policy, leading to the breaking up of two of the largest of the " barrack schools," and to the adoption, for all new boarding schools, of the plan of building the children's residences in detached blocks, which sometimes take the form of the separate villas known as " Cottage Homes," grouped into " Village Communities." Of these boarding schools of the Destitution Authority, of the old type or the new, there are, we gather, at present about 100, containing just over 20,000 children, all between three and fourteen years of age. Whether this plan of providing for the children who have to be maintained by the community is or is not superior to that of placing them in Scattered Homes or in Certified Institutions, or of boarding them out with foster-parents, is a matter of great controversy. The last official examinations of the problem are those made by the Departmental Committee on Poor Law Schools of 1896. the conclusions of which were POOE. LAW SCHOOLS 159 generally adverse to these boarding schools, and the suggestively critical report on the industrial training that they afforded to girls, by Miss Stansfield in 1899. On the other hand, such scanty evidence as we have received on the subject has been, on the whole, in their favour ; and it seems as if great improvements had taken place in the last decade, alike in the organisation of the institutions and in the education provided. The issue between those who advocate and those who oppose the extension of these boarding schools for Poor Law children seems to have been obscured by a constant intermingling of two separate considerations ; whether boarding schools furnish an advantageous method of bringing up some or any of the " Children of the State " ; and whether schools of any sort are, or are likely to be, from an educational standpoint, economically and success- fully administered by a Destitution Authority. The advantages of corporate life among equals and the incal- culable mental and physical education of organised games have caused the boarding school to be preferred for their own children by the majority of parents who are in a position to choose what they think best for them. On the other hand, no middle or upper class parent would dream, if he could avoid it, of immuring his child in a boarding school for the whole twelve months of the year. We regret the almost universal practice of the Destitution Authority of making no provision to enable the children whom it places in its boarding schools to spend a month or two in every year, by way of holidays, in the home of everyday life ; either boarded out with suitable relations or friends, or provided for in country cottages. It is to this lack of holidays out of school, to this absence of experience of home life, to this extraordinary immuring of the child continuously for seven or ten years in an institu- tion, that nearly all the cogent objections to the " barrack schools " are to be attributed. One solid objection to the boarding school as a system of providing for poor children is its great expense, com- pared with the actual cost of maintenance of the child in a working-class home. The various Poor Law schools and 160 CHILDREN UNDER RIVAL AUTHORITIES Cottage Homes established during recent years show that it costs from £100 to as much as £250, in capital outlay, to accommodate one Poor Law child, and from £30 to £55 per annum for its maintenance. To deal at this cost with all the 237,000 Poor Law children of school age up and down the kingdom appears to us out of the question. And whilst part of the expenditure on this or that costly new institution may have been an unnecessary extrava- gance, it is clear that, alike in capital outlay and annual maintenance, the cost of the boarding school must always greatly exceed the five or six shillings a week for food and clothing, and the four or five pounds a year in the public elementary school, which is all that is spent on the average child, even in the most prosperous sections of the wage- earning class. The boarding school run " on the cheap " has no good points. We are far from suggesting the dis- continuance of the existing residential schools, but we think that these boarding schools, by whatever Authority administered, should be specialised for particular classes, and reserved for those children who cannot be successfully provided for in their parents' homes on adequate allowances, or in Scattered Homes, or in suitable certified schools or homes, or by boarding- out. We are, however, of opinion that such boarding schools cannot, from the educational standpoint, be economically and efficiently administered by a Destitution Authority. We may pay an ungrudging tribute of admiration and respect to the managers and staffs of the Poor Law schools, and to the officers of the Local Government Board who have been concerned, for the success with which they have, in the main, overcome the difficulties formerly experienced by these schools in maintaining the children in health and vigour ; and in protecting them from the " blight " which in former times too often devastated the young lives whom the community was in this way rearing. Indeed, the majority of the Boards of Guardians, having such schools, have certainly not spared expense. We have frequently noticed, in personally inspecting the Poor Law Schools and Cottage Homes, that these institutions — like the Poor Law Infirmaries — tend to be needlessly elaborate and extrava- POOR LAW SCHOOLS 161 gant in buildings, ornament and arrangements, without really securing the highest technical efficiency. Neither the Destitution Authority, nor any of its officers, nor yet the Poor Law Division of the Local Government Board which sanctions the plans, has any continuous experience or expert technical knowledge of what a modern educa- tional building requires to be. Even the largest Destitu- tion Authority only builds a school once in half a century, whereas the Local Education Authority for the same area may be building one a year, or even (as in London) one a quarter. The Destitution Authority is, in fact, for any such building, almost necessarily at the mercy of an archi- tect casually selected for the job by persons having no experience of educational buildings. In the same way, we have found that the Destitution Authority, even if willing to spend largely on buildings, seldom realises adequately the importance of obtaining a sufficiently large and suffi- ciently highly qualified teaching staffi The salaries to the headmasters of the large Poor Law Schools, like those of the assistants, are habitually "very appreciably lower" than those paid by the Local Educational Authorities around them for work of equal magnitude and difficulty ; whilst the holidays in the Poor Law service are shorter, and the teachers are usually expected to perform much of the work "which properly belongs to paid attendants." It is, in fact, almost impossible for a Destitution Authority to free itself from the feeling that the teaching of pauper children, — still more the responsible duty with regard to his pupils that falls to the headmaster of a boarding school — is a matter on which it would be unreasonable to spend as much as upon the same duties with regard to other children. Yet it is plainly work of at least equal difficulty and importance. Nor is it easy for a Destitution Authority, even if it seeks to do so, to get the best teachers. The Poor Law Schools do not form part of the educational service of the country ; and the teachers in that service cannot pass into that of the Boards of Guardians without encountering pecuniary loss. The separateness of the service prevents the Boards of Guardians attracting the best of the certificated teachers ; and stands in the way of VOL. I M 162 CHILDREN UNDER RIVAL AUTHORITIES their getting the utmost out of such teachers as they do attract into their service. It gives rise, the Board of Education Inspectors report : — To a special difficulty in dealing with weak teachers in Poor Law schools. Guardians have no choice of schools, and are, there- fore, unable to move worthy but weak teachers from places foi which they are unsuitable to places where, by means of stronger support and guidance, they may become passably efficient. Their only alternatives are to dismiss a weak teacher, or to let him stay on in a place for which he is unfit ; and being human, they usually choose the latter course. Even if the legal difficulties were removed which at present impede free circulation of teachers between the educational and the Poor Law services, there would still remain the drawback, in the latter, of professional isolation and aloofness. " Poor Law teachers," as the Inspectors of the Board of Education report, are : — A class apart from teachers of Public Elementary Schools, and each Poor Law school is a water-tight compartment. The teachers miss the stimulus to self-improvement, and the interchange of ideas on their work, which do so much to refresh their fellow-teachers outside, and to extend their views ; nor do they share in the friendly rivalry which grows up when many people are working under one large Authority. Nor is the influence of the Destitution Authority any better upon the curriculum of the Poor Law School than it is upon the teaching staff. " The average Guardian," it has been said, " has but little oppor- tunity of seeing other schools at work, and his consequent inex- perience of what is good in education and what is merely fustian has been the origin of the ' show work,' which is still so prominent in the Poor Law schools. ... As a result of the visits of inexpert managers, there is to be noticed in many Poor Law schools a desire to make a display, whether it be by means of a ' showy ' piece of needlework or drawing, or by 'pretty' groupings and posings in physical exercises or recitations by a few ' show ' infants. It is not unlikely that teachers have discovered that the average Guardian is impressed more by these trifles than by soUd work, of which it is not easy to make an attractive display." This backwardness in "book-learning" is sometimes supposed to be compensated for by the superior industrial POOR LAW SCHOOLS 163 training. Boys and girls in the Poor Law schools spend a large part of their time — in some cases, it is reported, at an earlier age than is legally allowed under the Educa- tion Acts — in industrial and domestic work, from which they doubtless derive some training. But we doubt the educational value of much that, in these schools, is called industrial training. What is most evident is the desire to utilise the elder boys and girls in digging and scrubbing and turning the handles of the machines used in the laundry, 'partly out of a vague feeling that the children have got to be "taught to work," but principally with the object of reducing the expenses of the establishment. Even where boys are supposed to be taught a trade, such as shoemaking or tailoring, the work is of little value as industrial training. The latest report shows that: — The work that is done in the shops is generally of a utiUtarian character, and consists of making and mending for the institution. As its aim is so different, it is unfair to compare it with the handi- craft instruction of the PubMc Elementary School. It is felt by many of the Board of Education Inspectors, with much reason, that it would be possible, without serious interference with the present system, to make industrial instruction more intelhgent and educative; but no effective reform can be expected in this department unless the training of the boys themselves on educa- tional lines, and in ways that will develop their intelligence and skill, and give them a thorough technical training is given preced- ence over the merely industrial work of the Institution. This is now organised mainly with a view to saving the poor-rate, hy causing the young lads in the institution to do as much as possible of the various jobs needed in its daily working. The girls are employed in the kitchen, the scullery and the washhouse, but in many of the schools it cannot be said that they are taught cookery or laundrywork. " We found," say the Board of Education Inspectors, "that, while all the girls did a certain amount of washing and ironing, their work was incomplete ; that is to say, they would iron collars they had not learnt to starch, and wash articles they never learned to iron, exactly in the same way in which they peeled potatoes that they could not cook. They assisted as 'hands' in the work of a large laundry ; but for that very reason, they failed to acquire any practical knowledge of the complete art of washing clothes." 164 CHILDREN UNDER RIVAL AUTHORITIES Indeed, " many Boards of Managers " of Poor Law schools, made up, as these are, exclusively of members of the Destitution Authorities, " have so little experience of the value of improved methods" of industrial training, " that expenditure on such methods often seems to them to be to the loss rather than to the gain of the ratepayers." Hence, alike with regard to buildings and equipment, to teaching staff and to curriculum, " it is difficult to avoid the conclusion," to which the Inspectors are driven, " that the educational part of the work, which is now done by Guardians, would, in the majority of cases, be much more efficiently performed by the local bodies, whose primary function is to deal with schools, and which are, or might be, composed of persons who are interested in and conversant with educational matters." In view of the enormous importance of "giving an efficient education (both general and technical) to girls and boys who are in the public care, very often up to sixteen years of age, and of the many difficult problems involved in planning and working a good system of education for children of such varying ages and capacities, it seems deplorable that the experience and knowledge which have been and are constantly being acquired in these very matters by the members and officials of Local Education Authorities should not in some way be brought to bear upon the problem." There remains, however, a further drawback to the Poor Law school. However well the members of a par- ticular Board of Guardians might happen to be qualified for the task of educational administration, however wisely they might select the school architect, their headmaster, their specialist teachers and their industrial trainers, and however educational might be the curriculum upon which they decided, they would still be baffled, in their desire to build up a really successful school, by the extra- ordinarily inept selection of the children for which they had necessarily to provide. In visiting some of the best administered Poor Law schools, we have been struck by seeing, side by side in the same class, doing the same lessons, under the same teacher, 9- bright child of " scholar- POOR LAW SCHOOLS 165 ship " capacity, a child of criminal type, the anaemic child of defective circulation and dull wits, and the ordinary normal child. All these children of the same age are being taught together, not by reason of anything in them- selves, but merely because their parents happen to be destitute and to have their legal settlements in one and the same Union. The attempt to remedy this mixture of capacities by sorting the children into classes of equal attainments leads to groupings even more injurious to educational efficiency. There may be seen " in infant classes . . . elder children, admitted in a state of almost absolute ignorance. Thus it is not uncommon to find children of ten and eleven learning to read and write by the side of children of five and six. Such big children sit in small desks with evident discomfort, they are depressed at finding themselves among much younger children, and they apparently learn little under the circum- stances. The situation becomes absolutely grotesque when the infant classes turn out for organised games, and well- grown boys of eleven years old are required to play infantile games. Thus we found such boys playing ' Who killed Cock Robin?' with the infants, and a boy of thirteen reading aloud from a primer (already read twice) ' What Dottie did,' before a class of children half his age." In one Union no fewer than fifty - one mentally defective children were found intermingled with the other children in a very costly Poor Law school, to their mutual detri- ment. None of the fifty - one appeared to the skilled investigator to be beyond the reach of special training, but they were getting none. Finally, there is, in this association of the school with the Destitution Authority, the insuperable objection that the child never does get absolutely free from the evil influence of pauperism. Because they are built by Destitution Authorities, these schools are, in too many instances, actually within the curtilage of, or closely adjacent to, the Workhouse. In nearly all Unions the children are taken to the Workhouse first, and spend some time there, before going to the separate school or Cottage Homes. When they leave the school they are 166 CHILDREN UNDER RIVAL AUTHORITIES usually taken to the Workhouse, or at any rate to the porter's lodge, before passing out into the world. Whilst at the school, they see constant comings and goings of children to and from the Workhouse, frequent comings and goings of Poor Law officials, and occasional visits of Poor Law Guardians. "These arrangements," as one of our committees noted, after inspecting one of the best administered of the Poor Law Schools, " to a large extent defeat the object of removing children from the evil associations of Workhouse life." It was in recognition of these inevitable consequences of the connection of these schools with the Poor Law Authorities that the Departmental Committee of 1896 was emphatic in declar- ing that "all children should be cut off absolutely from the first from all association with Workhouses and their officials, and that no child of three years old or upwards should, under any circumstances, be allowed to enter a Workhouse." It was for this reason that it recommended that all " children over three years of age should be immediately handed over," to an authority other than that of the Boards of Guardians, " which should have the absolute care of them so long as they remain chargeable to the State." The experience of the last twelve years, and the latest reports of the Educational work in the Boarding Schools of the Destitution Authorities in England and Ireland alike, appear to us, for all the improvement that they reveal, only to confirm the validity of this decisive judgment. (vi.) The Receiving Home The undesirability of admitting and discharging children through the Workhouse has led some Boards of Guardians, during the past decade, to establish Receiving Homes or Probationary Schools. This course was, after the Report of the Departmental Committee on Poor Law Schools, suggested by the Local Government Board, who thought it "most undesirable that children should be . . , detained in the Workhouse, and also very desirable that those who ordinarily continued in receipt of relief for very RECEIVING HOME 167 short periods should be kept separate from the children of the more permanent class in the District or Separate School." Twenty -four Unions in the Metropolis, and several in other parts of England and Wales, have now provided such Receiving Homes for children at an expense, for the Metropolitan Unions alone, of about £200,000. In respect of these Receiving Homes, England is in advance of either Scotland or Ireland, where every child who comes under the complete care of the Destitution Authority has to enter the General Mixed Workhouse or Poorhouse, and reside there for a longer or shorter period, before it can be boarded-out. But even the best of the English Receiving Homes for children suflfer from their connection with the Poor Law. We note that, where the Boards of Guardians have, on the incitement of the Local Government Board, incurred the expense involved in establishing these separate Homes, in order to free the children, as far as possible, from association with the Workhouse, the mere fact that it is the Destitution Authority which has undertaken this task has gone far to nullify all that has been done. Thus, more than one Board of Guardians has insisted on establishing its Receiving Home as near to the Workhouse as possible, sometimes actually within the curtilage of the Workhouse, entered by the Workhouse gate, and guarded by the Workhouse porter's lodge, through which every tramp and pauper passes. Moreover, even when the Receiving Home is quite away from the Workhouse premises, the children are — by an arrangement for which there seems to us no rational excuse whatever — actually sent to the Workhouse, or the Workhouse lodge, whenever they have to be reunited with their parents, on these taking their discharge from the Workhouse. The usual practice is for children to go from the Workhouse to the Receiving Home in charge of the porter or one of his messengers — often an elderly pauper — or a paid officer who assists in that part of the Home. From the Receiving Home children go to the schools in charge of one of the Receiving Home attendants, either the Matron, one of the nurses, or even the cook. If they are discharged with 168 CHILDREN UNDER RIVAL AUTHORITIES their parents they usually return to the Workhouse to be clothed in their own garments again, and then discharged. In such cases they are taken by a Receiving Home Officer to the Workhouse ; or an officer may come from there with the notice of discharge and take the child back with him. The business of discharge is very rapid. A message or messenger comes from the Workhouse, and within a few minutes the child has been found and despatched in return. They seem even to be taken when half-way through their meals. We strike here one aspect of the most baffling problem of child life with which the Destitution Authority finds itself forced to deal — the problem of what to do with the child of parents unwilling or unable to aflPord it a proper home. (vii.) Children of Unfit Parents This problem, so far as the Destitution Authority is concerned, takes three main forms — the children of " Ins- and-outs," the children of vagrants, and the children in the Workhouse of parents who have deserted them or definitely proved their unfitness to have the control of them. (a) The " Ins-and-Outs " We deal first with the children of the so-called " Ins- and-Outs." There are, among the Workhouse inmates in England and Wales, Scotland and Ireland alike, especially in the large towns, a certain number who are not permanent residents, but who are perpetually claiming their discharge, going away for a few days or weeks or months, and then returning to the shelter of the institu- tion. There is even, in Scotland and Ireland, as well as in England, the habitual "week-ender," who makes a practice of entering the Workhouse or Poorhouse for a few days' rest whenever he finds himself absolutely penniless or exhausted by debauch or inanition. These "Ins-and-Outs," or — to use an American term — these "revolvers," are sometimes able-bodied men or women, ''INS-AND-OUTS" 169 sometimes feeble-minded or half-witted, or more or less incapacitated or crippled. What is important is that they very often have dependent children, whom, as the law at present stands, they have the right to take with them when they leave the Workhouse, and of whom, in fact, they are required to assume the custody on being discharged, whether or not they wish to do so, or have any means of providing a home or even a night's lodging for them. " Children of this class give great trouble to the Guardians everywhere. They are sometimes dis- charged and readmitted several times in the year ; they often bring back disease, dirt, and bad habits, and though permanently belonging to the pauper class, are unable to receive the regular instruction and discipline in either the district or the separate school." Such children are, indeed, the despair of those in charge of Poor Law schools. As was graphically said by Miss Florence Davenport Hill, they " come and go like buckets on a dredging machine," passing in and out of " all sorts of horrible places and scenes of vice," and periodically mixing "with the children in the school and . . . turning their moral filth on them." To protect the more permanent children from this contamination and this perpetual interruption of their studies, some Boards of Guardians turn their Receiving Homes into regular " schools for Ins-and-Outs," Thus the Kensington and Chelsea Guardians have a "school for 'permanent' children at Banstead, but the * Ins-and-Outs ' are kept and taught at Marlesford Lodge, Hammersmith, until the Managers are satisfied that their parents will remain in the Workhouse permanently or, at any rate, for some considerable time. The children are then drafted to Banstead. In this way Banstead Cottage Homes are to a great extent immune from the trouble and interruption caused by 'Ins-and-Outs.' The same system has been adopted at Olive Mount, Liverpool." One of our colleagues has extracted the following tables from the Admission Books to show the extent to which the Receiving Homes are made use of for the children of " Ins-and-Outs." 170 CHILDREN UNDER RIVAL AUTHORITIES Name of Receiviug Home. Number for which it is certified. Number of Families who are Ins-and-Outs. Greatest number of times any family has been admitted within five years. Average number of times, etc. Camber well ?60 35 76 33 Paddington St. George's, Hanover 35 12 20 10 Square . St, Marylebone . Shored itch. 70 ? 77 25 21 15 36 35 111 10 14 42 Stepney Wandsworth 108 103 12 63 15 70 7 29 Whitechapel 69 60 43 10 The returns of the Kensington and Chelsea School District Receiving Home (certified for 137) show that, with 680 to 820 admissions yearly, the following per- centages of re-admissions, the large majority of which are " Ins-and-Outs." Kensington. Chelsea. Per cent. Per cent. 1903-4 28 15 1904-5 38 12 1905-6 31 13 1906-7 30 20 1907-8 39 14 Out of twenty special cases of whicli details have been obtained, twelve families have been in and out ten or more times. One child has been admitted thirty-nine times in eleven years ; another twenty-three times in six years. The Wandsworth Union has a large number of dis- solute persons in the Workhouse with children in the Intermediate Schools. The parents never go out without taking the children and seem to hold the threat of doing so as u rod over the heads of the Guardians. Any quarrel or strictness of discipline at the Workhouse, or even a refusal on the part of the Matron at the Receiviug "INS-AND-OUTS" 171 Home to let the childreu receive presents of" sweets from their parents in the Workhouse, is followed by a demand for a discharge and the children in the Home must be sent for at once. One mother frequently had her child brought out of his bed to go out into the cold winter night. It must be remembered that children who are discharged are sent out in their own clothes unless these are hopelessly ragged or too small. There is also the fact that parents of this class have some feeling against the children going to the District Schools, which are further away ; and whenever the children are transferred to the schools the parents discharge themselves at once. One boy, who had been re-admitted twenty-five times in ten years, had been sent more than once to the Banstead Schools, but had never stayed there long. Whenever he knew that he was to go there he used to write to his mother in the Workhouse, and she would apply for her discharge and go out with him. This plan of using the Eeceiving Home as an Inter- mediate School protects the Poor Law school from what a Board of Education Inspector calls the "aggravating influx and exodus," which, in other Unions, goes far to render nugatory the expensive provision of schooling, especially in the junior classes. But it affords this pro- tection at the cost of largely depriving the Receiving Home of the character of a strictly temporary probationary ward, and even to some extent unfitting it for this use. It does nothing to protect the children from being dragged in and out, as it suits their parents' whim or convenience. The man or woman may take the children to a succession of Casual Wards or the lowest common lodging-houses ; there may be no prospect whatever of an honest livelihood or a decent home ; the parents may go out with the intention of using the children, half- clad and blue with cold, as a means of begging from the soft- hearted ; or they may go out simply to enjoy a day's liberty from workhouse restrictions, and find the children only encumbrances, to be neglected and half- starved. One family of childreu at Wandsworth used to be taken to the Common in rain or shine and left there without 172 CHILDREN UNDER RIVAL AUTHORITIES food for the day. Another family of children used to go out with their father and follow him from one public- house to another till evening, when he would hand them his Workhouse admission order and send them back with it. As the Porter would not admit them without their father they would wait about until late and then find a policeman, who would take them to the gates and have them admitted. The father would return later when the public-houses were closed. All this misuse of liberty is, to the Destitution Authorities, a matter with which they have and can have no concern. As Destitution Authori- ties their jurisdiction ends absolutely as soon as a person ceases to be chargeable to the poor rate. They have neither the legal power nor the official machinery for following the children from the Workhouse or the Poor Law school to the lodgings to which they are taken, and for seeing that they are provided with a home, food and clothing, and a continuous education. The Local Educa- tion Authorities, on the other hand, do not become aware of the children's existence unless and until they are dis- covered by the School Attendance Officers in their periodical schedulings of their districts. Between these two Authorities — the one dealing with children only as destitute persons, the other responsible only for the education of children resident within a given district — the unfortunate boys and girls who are dragged back- wards and forwards by parents of the "in-and-out" class practically escape supervision. They pass the whole period of school age alternately being cleansed and "fed-up" in this or that Poor Law institution, or starving on scraps and blows amid filth and vice in their periodical excursions in the outer world, exactly as suits the caprice or the convenience of their reckless and irresponsible parents. The class of " in-and-out " children is a large and, we fear, an increasing one. (h) The Children of Vagrants The children of the Vagrant are, even more than the children of the " in-and-out," excluded from the benefits CHILDREN OF VAGRANTS 173 provided and the protection given by the Local Health and Education Authorities to the children who are known to be resident in one locality. Dragged along the roads by day and spending night after night either in the common lodging-house or the Casual Ward, they may never, in practice, come within the ken either of the School Attendance Officer or of the Sanitary Inspector. For such vagrant children — who number at any one time in the United Kingdom at least several hundreds, and probably several thousands — the Destitution Authority does nothing except provide a night's lodging and food in the Casual Ward in England and Wales, in the Work- house in Ireland, and (whatever may be the strict law on the subject) in the Poorhouse or '' Casual Sick House " in Scotland. Yet the Destitution Authority is the only organ of the State with which these unfortunate children come in contact. For their attitude of official indifference to the fate of the children of the " ins-and-outs," and the children of the Vagrants, the Boards of Guardians can plead that the policy of opening and shutting the door of the Workhouse and Casual Ward simultaneously upon parent and child alike — unconcerned as to what happens to the child — is strictly in accordance with the principles on which the 1834 Report proceeded. Throughout that Report it was laid down that the able-bodied man, if married, and the able-bodied woman, if unmarried, should be considered as alone responsible for maintaining their offspring. Unless the able-bodied parents consented to enter the Workhouse, no child of theirs was to be admitted ; and whenever they decided to leave its shelter, their de- pendants were to go out with them. The only way by which they could get Poor Relief for their children, without entering the Workhouse themselves, was to desert the children, a proceeding which, whilst it threw the children on the rates, exposed the parents to criminal prosecution. Omitting, for a moment, the effect upon the child of this policy of 1834, we may note that its advantage to the ratepayer depends upon continuously maintaining the deterrent character of the Workhouse to 174 CHILDREN UNDER RIVAL AUTHORITIES the particular class concerned. Now, in spite of all the horror which the General Mixed Workhouse excites among the respectable poor, this institution, as it exists in England and Wales, Scotland and Ireland alike, is found, in fact, to offer distinct attractions, as a place of temporary residence, to the dissolute and worthless men and women who comprise the growing class of " ins -and -outs" or "week-enders." When such persons have children, this periodical use of the Workhouse becomes even more advantageous to them. At some ages, and at certain seasons of the year, children are necessarily a burden on their parents ; at other ages, especially at particular seasons, they may be made sources of actual profit. For the Destitution Authority to follow in this respect the policy of 1834 — to maintain the whole family in the Workhouse whenever the parents think fit to come in, and to let the whole family go out whenever the parents see any advantage in going out — is, at the cost of the rates, to offer the maximum of subsidy to a particularly disreputable and injurious perversion of parental rights. Passing from the effect of the present policy on parental responsibility to its results on the children concerned, it is plain that the existing arrangements are about as bad as they can possibly be. Imagination fails to picture the evils of the life of the child of the "in-and-out" or habitual Vagrant, during the periods when it is outside the Workhouse or the Casual Ward. It is the smallest part of the injury thus done to no trifling proportion of the coming generation of citizens that such children, as we have already mentioned, usually get practically no schooling. These children might be properly brought up if their parents remained in the Workhouse ; they might conceivably be passably brought up if their parents were refused all relief whatsoever. But the present arrangement of letting them pass alternately in and out of the Workhouse or Casual AVard combines all possible disadvantages to the unhappy children thus dragged in and out, and to the other children whom they are perpetually contaminating. THE ABANDONED CHILD 175 (c) Tlie Abandoned Child The third class of children belonging to unfit parents are those who are left on the hands of the Destitution Authorities, either because the parents have simply deserted them or because the surviving parent is in prison, in a lunatic asylum, or in an inebriates' home. In respect to the class of deserted children we have again to draw attention to the demoralising provision of the Scotch Poor Law which makes it impossible for an able-bodied man, however destitute, to get food or shelter for his children without deserting them. We have been informed that child desertion, especially in Scotland, is becoming steadily more frequent. It is not uncommon for parents who have thus voluntarily or perforce abandoned their children subsequently to appear and claim them as soon as they attain an age at which they can be made to earn money. (d) The Assumption of Parentage To meet this threefold problem of the unfit parent — the child of the Vagrant, the child of the In-and-Out, and the deserted child — the only expedient afforded to the Destitution Authority has been to give it power itself to "adopt" any child that it found in the Work- house by reason of parental neglect. By Acts of 1889 and 1899 the Boards of Guardians in England and Wales are authorised to assume, up to the age of eighteen, com- plete rights and responsibilities of parentage in respect of orphan or deserted children, in respect of the children of parents in confinement, and, in certain cases, also in respect of the children of parents of vicious life or habits. This expedient of adoption gets over the difficulty presented by the deterioration of the child, at the cost of depriving the parents of their parental rights and responsibilities, and at the expense of placing the child wholly on the rates. Some Unions have already made considerable use of this power of adoption, there being now, in England and Wales alone, no fewer than 15,000 176 CHILDREN UNDER RIVAL AUTHORITIES children so taken away from parental control. It has, how- ever, so far been used most largely with regard to children who are orphans or whom their parents have deserted. It has been represented to us that, by the Acts of 1889 and 1899, Parliament has laid down the principle that, whenever there is reason to believe that a child is being habitually and seriously injured in body or mind by the evil or disorderly life of its parents, it is desirable, quite apart from any punishment meted out to the guilty parents, that the community, in the interests of the child, should itself assume full parental duties and responsibilities with regard to it. It has been forcibly pointed out to us that all the considerations that lead to the adoption of the deserted child, or the prisoner's child, or the cruelly treated child, apply equally to the child of the habitual Vagrant or " In-and-Out." The recent Departmental Committee on Vagrancy did not hesitate to recommend that the present power of adoption should be explicitly extended to the children now found in the Casual Ward. The Local Government Board itself has suggested its application to the children of habitual " Ins- and-Outs." Other witnesses pressed us, in the children's interest, to extend the advantages of adoption to larger and larger circles. The extension of the law to Scotland has been demanded. The Vice-Regal Commission on Poor Law Reform in Ireland has made still larger proposals of the same nature. These authoritative proposals for the increased use or legal extension of the power of adoption open up serious considerations. To many persons it is a matter for grave concern that the community should thus relieve parents of all financial and other responsibility for their offspring. And the further question arises whether, if there is to be any such assumption of parentage by the com- munity, the power and obligation should not be entrusted to an Authority charged with the education and care of children, rather than to a mere Destitution Authority. We think it is clear that, in view of the paramount importance of protecting the children from deterioration, the policy of the Assumption of Parentage must be continued, and that it must be extended to all cases in ASSUMPTION OF PARENTAGE 177 which leaving the child under the control of its natural parents can be plainly shown to lead to its grave physical or mental injury. From the standpoint of the ratepayer, there is even more reason for this power of taking the children away from their parents, when these are " Ins- and-Outs " or Vagrants, than when the children have been deliberately deserted. For it has been given in evidence that a large proportion of the parents who now come in and out of the Workhouses and Casual Wards w^ould, if they ran the risk of having their children permanently taken from them, hesitate thus wantonly to throw themselves and their families periodically on the rates — partly because these parents often retain a real affection for their children, and partly because they find them profitable. But we see grave objection, not merely with regard to any extension, but also with regard even to a continuance, of the present power of adoption, alike in its procedure and in the Authority to which it is entrusted. At present the parent may be deprived of his child without notice, by a mere resolution of the Board of Guardians, arrived at on the mere opinion of such members as happen to attend, without necessarily hearing any evidence, and without any kind of judicial decision. Moreover, if the child is adopted, the parent is, in practice, wholly relieved of the cost of maintenance, and, apart from particular criminal acts, he is not made liable to prosecution and punishment for the fact of having so conducted himself as to make it necessary to take his child from him. Whenever it is deemed necessary in the public interest that the community should deprive the parents of their control over a child, and that the full responsibilities of parentage should be per- manently assumed by a Local Authority, the case ought to be properly dealt with, however contemptible and unworthy the parents, by a judicial authority, and that authority should, in our judgment, be empowered at the same time to make such an order for a contribution towards the cost of maintenance, and to inflict on the parents such a punishment as the circumstances may require. And when adoption by the community is decreed, a Destitution Authority is, in our judgment, the very last VOL. I N 178 CHILDREN UNDER RIVAL AUTHORITIES to which the responsibilities of parentage should be trans- ferred. The object clearly is to free the new " Child of the State " from evil associations and bring it up as a healthy, independent citizen. It stands to reason that sucb a child should be kept as scrupulously clear of association with the Workhouse as with the gaol ; that it should never see the Destitution Officer or be brought into any kind of contact with pauperism. What the community undertakes is to watch over the child's life up to the age of eighteen ; and the Destitution Authority has normally no jurisdiction except over persons actually in receipt of relief, and no machinery, other than the Relieving Officer, for con- tinuously watching over the life of the young person. It is, in our opinion, plain that all such rights and duties in connection with the adoption of children ought to be entrusted to the Local Education Authority, which is specially charged with dealing with children, which has its own officers looking after children, which is experienced in children's requirements, and which would find no difficulty in including all necessary provisions for the adopted child among those which it already makes for the other children in its special residential schools. Moreover, if the full responsibility for the well-being of the children, including the power of adoption in default, were entrusted to the Local Education Authority, it would, in our opinion, probably become less frequently necessary to make use of so extreme a measure. At present the Destitution Authority must either do all or nothing. When a child is discharged from any of the institutions of that Authority, it has no further control over it, and ceases, in fact, to be cognisant of its existence. If, however, the child were discharged from one of the residential institutions of the Education Authority, that Authority, with its School Attendance Officers, could follow that child to his home, even after the destitution of the parents had ceased. The Education Authority, in fact, is rapidly developing, in the most advanced districts, in its highly differentiated series of schools and scholarships, its continuation classes, its technical institutes, its medical inspection, its attendance officers, its systematic house-to-house visitation and ASSUMPTION OF PARENTAGE 179 scheduling, and its local managers and Children's Care Committees, all the machinery for following up all the children coming in any way within its ken, even those of migratory or worthless parents, and for bringing a duly graduated pressure to bear on all the parents, so as to induce them continuously to fulfil their parental responsi- bilities. By this constant supervision of the children of unfit parents, before and after the crisis of destitution, it would be possible, in many cases, to prevent, at an early stage, any such flagrant neglect or ill-treatment of children by careless or vicious parents, as might otherwise be continued to the point of making necessary the extreme measure of public adoption. (b) Children under the Police Authority The first rival to the Destitution Authority in its work of maintaining the children of poor persons was not the Local Education Authority, but the Home Oftice, acting through the magistrates and the police. Under a series of statutes extending from 1854, and now consolidated in the Children's Act of 1908, there grew up, before there existed any Local Education Authority, a number of so-called Industrial and Reformatory Schools, to which poor children might be sent by the magistrates, quite irrespective of the Poor Law, and in which they were maintained at the expense, partly of such contributions as could be extracted from their parents, partly of voluntary contributions or the County Rate, but mainly of a substantial Government Grant administered by the Home Office. The Reforma- tory schools began as alternatives to the prison, and were designed for juvenile ofienders. The Industrial Schools were the direct heirs of the Ragged Schools founded in the first half of the nineteenth century. But the inclusion in the Ragged Schools and in Industrial Schools of children whose destitution, among other circumstances, placed them in danger of growing up to be criminals, caused them to infringe on the sphere of the Poor Law. At first the schools were sharply divided into Reformatory Schools, to which young criminals alone were sent, and Industrial 180 CHILDREN UNDER RIVAL AUTHORITIES Schools, to which perfectly innocent but neglected children were sent. Gradually, however, this line of demarcation has become obscured ; and in the latest classification, though the original names are maintained, these schools are divided principally according to the age of admission and discharge. Thus, the 30,000 boys and girls now under detention in these schools belong to many diiferent categories, the majority of them falling distinctly within the sphere of the Poor Law. These Industrial and Reformatory Schools have in common the characteristic of being mainly places of compulsory detention, to which children, though not necessarily criminals, are committed by judicial authority. But "voluntary cases" are now also received, amounting in 1906 to one-tenth of the whole. The 211 separate schools are now managed either by voluntary committees or by County or Borough Councils, at a total expense of over £600,000 annually, of which amount about five- twelfths are contributed by the Government and more than five-twelfths from local rates, whilst one-twelfth only is derived from voluntary subscriptions, and one-twentieth is extracted from the parents of the children. They are controlled, not by the Board of Education nor by the Local Government Board, but by the Home Office, which certifies them, inspects them, and controls their Grant-in- Aid. We have not had time to inspect many of these schools, although they constitute no small proportion of the public provision for destitute children ; and although, of the 30,000 children whom they maintain, a large proportion would otherwise have to be maintained in Poor Law insti- tutions. They even contain a number of pauper children, sent to them by the Destitution Authorities. We received a certain amount of evidence about them, and we made special inquiries of the London County Council, from whom we have received three valuable statements on the subject. What has most particularly struck us is the overlapping and confusion which results from the division of authority. The Industrial Schools have so essentially the same object and task as the Boarding Schools of the Destitution x4uthorities and the Certified Schools made UNDER POLICE AUTHORITY 181 use of by these Authorities, and they deal to so large au extent with the same classes of children, that we see no reason for any separation or distinction between them. The Destitution Authority themselves make no such dis- tinction, sending boys, for instance, indiscriminately to those training ships which the Local Governmeut Board has "certified" as schools or homes, and those which the Home Office has " certified " as Industrial Schools. Indeed, in half a dozen cases, at least (including one out of the seven English training ships), the same institution is certified both by the Home Office and the Local Government Board ; receives, in respect of identical children, grants from the former and payments by the Boards of Guardians under the authority of the latter ; and is presumably visited by the Inspectors of both departments, who do not communi- cate to each other their several reports. In Scotland, where the device of " certifying " is unknown to the Local Government Board, we gather that suitable children (who are usually returned among those " boarded out ") are sent by the Destitution Authorities indiscriminately, and the weekly payments made at the same normal rates, to the Industrial Schools to which the Government is paying grants, and to other institutions unconnected w-ith the Home Office, the Government Grants being paid in respect of pauper and non-pauper children alike. What stands out is the extraordinary lack of co-ordi- nation, or even of mutual consciousness of each other's existence, between the operations of the Destitution Authority and of the Authorities administering the Industrial and Reformatory Schools Acts. Both Authori- ties are admittedly dealing to a large extent with children of the same class. " The fact of children being sent to one kind (of school) or to the other is," we are informed, *' largely accidental " ; depending, as we gather, when no ofience against the criminal law has been committed, chiefly on which Authority gets hold of the case first. It was expressly stated that : " There is at present no co-opera- tion between the Council," acting under the Industrial and Reformatory Schools Acts, " and Boards of Guardians." " There is no record," we are informed, " as to whether 182 CHILDREN UNDER RIVAL AUTHORITIES any of the families from which children are sent to Indus- trial Schools are in receipt of Poor Law relief. No inquiry is made . . . upon this point, and the fact of such relief being granted would not disqualify a child for admission to an Industrial School." " The parents of many of the children " in the Industrial Schools of the London County Council " are . . . persons who frequent Workhouses and Casual Wards." No fewer than 113 cases were brought to our notice in which, within a single year, in London alone, the same family had been relieved out of the same fund of rates and taxes, by one or more children being sent to Industrial Schools, whilst other children, together with the parents, were being maintained (often as " Ins- and-Outs ") in one or other Poor Law institution. Many parents who have already been relieved by having some of their children placed in Industrial Schools are subsequently relieved under the Poor Law, by admission to the Casual Ward or Workhouse, and even, occasionally, by Outdoor Relief. It not infrequently happens that different children of the same family will be simultaneously maintained in Industrial or Reformatory Schools and in Poor Law Schools. We have even come across a case in which the mother was in receipt of Outdoor Relief in respect of some children, another child was in a Poor Law School, and another in an Industrial School ; and we may here add, though it anticipates a future section of this Report, that some of the children are being fed at school during the winter under the auspices of the Local Education authority. There is one development of the Industrial School which comes very near indeed to the work of the Destitu- tion Authority. In a score of towns in England and Scotland there have been established Day Industrial Schools. *' The first idea of a preventive institution," we are informed, "seems indeed to have been a day feeding school which, planted in the thick of the slums, was to fight at close quarters against parental neglect and the evil association of which the children were the victims." At the Day Industrial School the child attends from 6 A.M. or 8 A.M. in the morning till 6 p.m. at night, having provided for him not only instruction, but also UNDER POLICE AUTHORITY 183 properly supervised recreation and three meals of plain wholesome food. The children may be committed by the magistrate, or ordered to attend by the Local Education Authority, or merely admitted on the application of their parents. In every case the law has required a payment of at least Is. to be made by or on behalf of the parents, whilst the Government Grant is limited to Is. per week. For these and other reasons the Day Industrial Schools have not made much progress, and in half a dozen towns they have even been discontinued. Such schools, how- ever, especially under the wider powers given by the Children's Act, 1908, appear to us to have a very distinct use for the large class of parents — usually widowed mothers — who can earn a livelihood only by being absent from home for the whole day, and who are quite unable pro- perly to look after their children. We have already described in what an enormous proportion of cases the children whom the Destitution Authorities are maintaining on Outdoor Relief are demonstrably suffering in body and mind, and growing up to be themselves weaklings, paupers and criminals, from the inability or neglect of the parents, to whom the Destitution Authorities are entrusting the scanty dole of Outdoor Relief for the children, to give them the necessary amount of care and attention. It is, we think, a most unfortunate consequence of the separa- tion of the provision for the children who come under the Poor Law from that made for other children in the same locality, that only in two towns does it seem to have occurred to the Destitution Authority to make use of the Day Industrial Schools as a means of providing for the children on Outdoor Relief At Liverpool the Board of Guardians pays 9d. a week to the Local Education Authority for each child admitted with their approval, the cases being " the children of poor widows whose means are insufficient to provide the children with adequate food, or of women who have been deserted by their husbands, both of which classes have to earn what living they can in employment which very frequently requires them to leave home early in the morning." In Glasgow, too, the Parish Council arranges with the Local Education Authority for 184 CHILDREN UNDER RIVAL AUTHORITIES a number of children of widows on Outdoor Relief to be sent to one or other of the four Day Industrial Schools which the Joint Delinquency Board, a municipal authority, maintains ; and the Parish Council pays Is. a week for each child so sent. It has been suggested to us that such " Day Feeding Schools," to use the old phrase, are appar- ently exactly what is needed for the children of those widowed mothers who cannot be trusted to expend wisely on their children the full amount necessary for their main- tenance, and yet who are not morally bad enough, or mentally defective enough, to warrant their children being completely taken out of their control. If the children attend the Day Industrial School from morning to night, it is possible absolutely to ensure their being properly fed, clothed, taught and supervised, without running the risk of subsidising the mother in careless or irregular habits of life. The mother, in fact, may be set free to earn her own living, and, if possible, provide the rent, without Out- door Relief in any ordinary form, and without the family home being broken up. Such a "Day Feeding School" has, we believe, once or twice been started by English Boards of Guardians, only to be abandoned. The Day Industrial School stands, in a score of towns, ready to hand, offering exactly what is needed. Yet so strong is the influence of the separate existence of the Destitution Authority, and so intense is its jealousy of any other Authority, that only in two towns have any children been sent to what apparently seems to the Board of Guardians the institution of a rival Authority. In Edinburgh, the Parish Council, rather than send the children whom their widowed mothers could not look after in the middle of the day to the Day Industrial School which the Edinburgh School Board maintains, where they would be properly supervised, has preferred to start a feeding scheme of its own, distributing to such Outdoor Relief children as desired them, tickets entitling them to cheap meals in eating-houses, where (as we ourselves noticed) the condi- tions as to the serving of the meals, and the manners of the children — entirely without supervision — are anything but civilising. Everywhere else the children of the UNDER POLICE AUTHORITY 185 widowed mother on Outdoor Relief are left, so far as the Destitution Authority is concerned, in the condition that we have described. It has, however, come to be regarded as an anomaly that children should be dealt with by a Police Authority ; and the maintenance of the Industrial Schools of Borough or County Councils in England and Wales has now, on the pressing advice of the Home Office itself — possibly' even to a stretching of the law — been transferred to the Education Committees of those Councils. This transfer has been emphasised by the modifications in the law effected by the Children's Act of 1908. The provision for the children now in these schools has accordingly become part of the work of the Local Education Authority, which we have now to describe. (c) Children under the Education Authority The principal public body in England and Wales dealing with children of school age is, of course, the Local Education Authority. Beginning originally as the School Board, a mere supplementary organisation, established only where required, to supply elementary schooling only for those poor children for whom their parents and the various churches and voluntary agencies had failed to provide, it has become definitely the Local Education Authority, necessarily existing in every district of England and Wales, empowered or required, not merely to supply deficiencies, but to see that all the children of the locality, whatever their social grade, have provided for them all the education, whatever its kind or degree, which is, in the public interest, deemed necessary. Thus, in place of the " common school," of uniform type, provided in sufficient numbers as required, we have the Local Education Authority systematically laying itself out to equip its area with the varied array of different kinds of schools that the multifarious needs and idiosyncrasies of its children demand — elementary schools and secondary schools ; day schools and boarding schools ; schools for the precocious and schools for the mentally defective ; 186 CHILDREN UNDER RIVAL AUTHORITIES schools for the blind, the deaf and dumb, and the crippled ; trade schools and domestic economy schools ; schools for the children who are well, and schools for the children who are suffering from anasmia or incipient tuberculosis, favus or ringworm. In Scotland the School Boards are at least keeping pace in development with the Local Educa- tion Authorities of England and Wales. Only in Ireland are there yet no Local Authorities for Education. (i.) Medical Inspection and Treatment But the Local Education Authorities do not stop at the provision of schooling. Many of the children attending the public elementary schools were found to be suffering from lack of medical attendance and treatment ; they had upon them untreated cuts and sores ; they had adenoid growths I'equiring surgical removal ; their glands and tonsils were swollen and inflamed ; they had incipient curvature needing remedial drill ; their eyesight was often defective, some- times rapidly degenerating for lack of proper spectacles ; they had discharges from the ears, and inflamed eyelids, and skin diseases of various kinds — to say nothing of such gravely contagious conditions as ringworm and favus, and " dirty heads." In the large towns of Scotland the condi- tion of the children in these respects was found to be, if anything, even worse than in England. These tens of thousands of children were, from one cause or another, plainly destitute of the medical attendance that was neces- sary for them. According to law it was the duty of their parents to provide this needed medical attendance, and, in case of inability to pay for it, to apply to the Relieving Officer for a medical order. It was the duty of the Board of Guardians to grant that medical order whenever neces- sary, and to prosecute the parents under the Prevention of Cruelty to Children Act if they failed to apply. It is difficult at the present day to understand how the Desti- tution Authorities, even from their own standpoint of keeping down pauperism, can ever have reconciled them- selves to allowing so great a mass of destitution (with respect to medical attendance) to remain unrelieved. So MEDICAL INSPECTION AND TREATMENT 187 far as we can ascertain, they do not seem either to have taken any steps to furnish the medical treatment of which these children were clearly destitute ; nor yet, in the majority of cases, to have acted upon their statutory duty of proceeding against the parents who were thus guilty of neglect of their children. We find them even complaining of the action of the School Boards in pressing that every child detained at home through illness should be seen by a doctor. Thus the Chairman of the Atcham Board of Guardians — so widely known for its strict administration — complained in 1890 of the steps taken by the Local Education Authorities. "The action of School Boards," he writes, "is telling upon the question of Medical Relief, as some School Boards insist upon medical certificates being obtained when the reason for non-attendance of the child at school is alleged to be sickness ; and thus many poor people, who would be able to provide for slight ailments by warmth, care and attention, are driven to the District Medical OflScer for the sole purpose of obtaining this certificate, and thus becoming pauperised. This might be avoided by the School Boards engaging a medical man to visit, examine and certify for these purposes, if not satisfied with their existing oflicers. It appears to be necessary for the Guardians to watch this most closely so as to prevent Medical Relief being abused. It is desirable to study what steps can be taken for this end." In Scot- land, where the services of the Poor Law doctor are seldom, if ever, granted to persons not already on the pauper roll, even less is done than in England. The Parish Councils have, of course, the excuse that the Scottish Poor Law does not permit the grant even of medical relief to the dependents of able-bodied men, however destitute the men and how- ever ill their dependents might be. But the law does not prevent the Scottish Parish Councils from providing medical treatment for the children of widows or for those of disabled men ; and we do not find that any better pro- vision has been made for the relief of the glaring destitu- tion of these children than for those of the able-bodied men. What is even worse, we do not find that the Destitu- 188 CHILDREN UNDER RIVAL AUTHORITIES tion Authorities have even troubled, in this respect, to look after the children whom they were themselves main- taining. The Reports of our own Children's Investigator, as to the physical condition of these Outdoor Relief children in London, at Liverpool, and elsewhere bring to light innumerable cases of untreated sores and eczema, untreated erysipelas and swollen glands, untreated ring- worm and impetigo, untreated heart disease and phthisis. " There was," she reports, " one exaggerated instance. . . . The children," whom the Board of Guardians were main- taining on Outdoor Relief, " were in so filthy and neglected a state that the School Nurse herself interviewed the mother. Later the mother was formally warned" — not by any one sent by the Guardians — but by " the National Society for Prevention of Cruelty to Children, whose Inspector visited her and examined the children." The state of things is the same in the large towns of Scotland. In the elaborate investigations that have been made into the condition of the school children in Edinburgh, Glasgow and Dundee, the fact is brought to light that a large proportion of the children who are found to be suffering from lack of medical attendance, with all sorts of untreated ailments, are children whom the Parish Councils are main- taining on Outdoor Relief. Owing to this widespread failure of the Destitution Authorities in England and Scotland alike to relieve the destitution of children in the matter of medical attendance, and to the equal failure of voluntary agencies, we find the duty gradually undertaken — even to the stretching of their legal powers — by one of two other authorities. In the smaller Boroughs we see the Local Health Authority permitting the Medical Officer of Health to accede to the express or implied invitation of the Local Education Authority to institute a medical examination of all the children in the public elementary schools ; sometimes on the plea of detecting infectious disease, sometimes frankly to discover physical defects rendering the children unfit to profit by the instruction. In town after town we see the Medical Officer of Health advising on the children's diseases, as well as on defective eyesight and hearing, MEDICAL INSPECTION AND TREATMENT 189 sometimes systematically weighing and testing all the children. We see the Town Council's Health Visitors following the children back to their homes, and giving advice to the parents how to treat the defects discovered. Occasionally a special nurse is engaged by the Town or District Council, to visit the homes, in order to offer her services gratuitously for actual treatment of the cases as well as to advise the mothers how to remedy the trouble and prevent its recurrence. In this way the Local Health Authority has, in many towns, undertaken a proportion of the Medical Relief of poor children, which the Destitu- tion Authority, dominated by its desire at all hazards to restrict its work, had failed to provide. In London and the larger Boroughs we see the work which the Destitution Authorities refused or neglected to do undertaken by the Local Education Authorities them- selves. School Medical Officers and School Nurses have been appointed, whose business it is to examine all the children ; to discover all physical defects ; to test eyesight and hearing, and advise what steps should be taken as to treatment ; to instruct the mothers how to remedy the evils ; to supply gratuitously or at a nominal charge the spectacles required by the child's defective eye- sight ; and, in not a few cases, even systematically to provide the treatment required. " In Liverpool . . . over 50,000 dressings have been done in the course of 1904. In Birmingham there have been in four schools over 20,000 dressings in twelve months. ... At Reading a nurse is employed ... to attend to the heads of verminous children where the parents fail to do so." In 1907, by statute and by order of the Board of Educa- tion, these duties were not only sanctioned, but were even made obligatory on all Local Education Authorities, with regard to all the children in attendance at public element- ary schools. Nor are the Local Education Authorities to stop at mere inspection. "It is important," declares the Board of Education, " that Local Education Authorities should keep in view the desirability of ultimately for- mulating and submitting to the Board for their approval, under Section 13 (1) (b) of the Act, schemes for the 190 CHILDREN UNDER RIVAL AUTHORITIES amelioration of the evils revealed by medical irispection, including, in centres where it appears desirable, the estab- lishment of school surgeries or clinics, such as exist in some cities of Europe, for further medical examination, or the specialised treatment of ringworm, dental caries, or diseases of the eye, the ear or the skin. It is clear that to point out the presence of uncleanliness, defect or disease does not absolve an authority from the consequent duty of so applying its statutory powers as to secure their ameliora- tion, and to prevent, as far as possible, their future recur- rence or development." Accordingly, a "school clinic" has already been established by the Bradford Education Committee. This deliberate invasion of the sphere of the Destitution Authority by the Local Education Authority, so far as concerns the medical attendance of the 20 per cent of the population who are of school age, has been unfavourably commented on. It has been represented that, should the action taken by some Local Education Authorities become universal — as seems now to be required by the Board of Education as a condition for its Grants — there can be, in respect of the medical attendance of this large section of the population, no destitution left to be relieved by the Destitution Authorities. On the other hand, it is urged that the medical inspection, and consequent medical treat- ment, of school children is not only financially advan- tageous to the Local Education Authorities by securing a higher average attendance, but also vital both to national health and national wealth production, and has been, by the virtual abdication of the Destitution Authorities, too long delayed. Nor can we altogether blame the Boards of Guardians and Parish Councils for this abdication. They have never been told to search out destitution in the matter of medical attendance. They have been called upon only to provide such medical relief as was actually applied for. They have been praised for deterring people from applying for medical orders by means of inquisitorial inquiries, giving such orders " on loan " and recovering the cost, and even making it a condition that the head of the family should enter the workhouse when his child was MEDICAL INSPECTION AND TREATMENT 191 ill. lu Scotland, as we have seen, the Poor Law does not permit even the visit of the Parish Doctor to the sick child of any able-bodied man. We are of opinion that it is, on the whole, advan- tageous that the medical attendance of poor children of school age should not be undertaken by the Destitution Authority. If that Authority does the work, it does it as " Medical Relief" ; such relief, as we have seen, is afforded grudgingly ; granted only to those who apply to the Relieving Officer ; almost necessarily made to depend, not on the gravity of the illness of the child, but on the status of the parent ; withdrawn as soon as the parents wish to be without it ; and, when given, given wholly uncondi- tionally and usually without even the necessary hygienic advice. On the other hand, the medical examination and treatment of school children by the Local Education Authority (or by the Local Health Authority at its instance) is never of the nature of relief, but rather of hygienic discipline. It is systematically applied without any implication of pauperism to all children who are found to need it, without waiting for application to be made. It is continued so long as is found necessary, whether or not the parents actively desire it. And it always takes the form, to a very large extent, of hygienic advice, obedience to which is strongly pressed both on the child and on the parent. This medical inspection, it has been given in evidence before us, has actually a tendency to increase parental responsibility. When, for instance, under the London County Council, the School Nurse visits a school to put in force the cleansing scheme, "she examines every child, noting all that have verminous heads. The parents are notified by a white card, on which is also printed directions for cleansing. ... At the end of a week, if not cleansed, the child is made to sit separately from the rest of the class, and the School Attendance Officer serves a more urgent warning 'red card ' at the home. The Nurse, too, often visits to offer advice ; and then, if in another week the child is still unclean, it is excluded, after having been seen by the Medical Officer ; and the parent is prosecuted for not 192 CHILDREN UNDER RIVAL AUTHORITIES sending the child in a fit state to school." Under the influence of such a system, the obligations of the parents in this one matter of cleanliness have, in the course of the last few years, been so greatly increased that the pro- portion of verminous children has, through the exertions of the mothers, steadily diminished. The expenditure incurred from public funds, far from being " relief" to the parents, has been actually the means of compelling the less responsible among them to devote more time and money to their children's welfare. (ii.) School Feeding We come now to the most remarkable, and, it must be admitted, the most controversial, of the invasions by the Local Education Authority of the sphere of the Destitution Authority. During the past two or three decades, in London and more than 100 other towns, in England, Wales, Scotland and Ireland alike, there has grown up a system by which, under the auspices and with the active assistance of the Local Education Authorities, many thou- sands of destitute children are provided with food. In some towns a larger number of children are now, each winter, fed in the schools of the Local Education Authority, than are maintained as paupers by the Destitution Authority. The statistics for the Metropolis are specially remarkable. Between the ages of five and fourteen the various Boards of Guardians in London relieve on any one day some 14,000 children as indoor paupers and some 10,000 children as outdoor paupers. But in March 1908 the London County Council was organising the simultaneous feeding of no fewer than 49,000 children between these ages, or more than twice as many as those relieved by all the Metropolitan Boards of Guardians put together. The cost of this new service of school feeding has hitherto been largely provided from voluntary donations ; though the organisation, most of the paid service, nearly all the plant, and even some of the fuel, have long been provided from the Education Rate. During the year 1906, however, Parliament not only SCHOOL FEEDING 193 directed the formation by the Local Education Authorities of England and Wales of " School Canteen Committees " definitely to undertake this service, but also empowered them, subject to the approval of the Board of Education, to supply the necessary food at the cost of the Education Kate. In the very first winter under the Act, though London still relied on voluntary donations, no fewer than fifty such Authorities — nearly one-sixth of the whole — obtained the necessary sanction to feed their necessitous school children out of the Education Rate. The number has already grown to more than seventy. We cannot but anticipate that this action will become general throughout the towns of England and Wales. The nation is thus superseding the Destitution Authorities, so far as the provision for destitute children of school age is concerned, not merely in such specialised services as schooling and doctoring, but actually also in the simplest and most primitive of all needs, that of food. This paradoxical situation compels us to consider the reality of the alleged child destitution which the Local Education Authorities are relieving, the character of the relief given, and the advantages and disadvantages of so important a super- session, so far as regards the children of school age, of the Destitution Authority by the Local Education Authority. We have made no inquiries of our own as to the number of children who were, in the winter of 1907-8, so far destitute as to be provided with meals under the auspices of the Local Education Authorities ; though it is clear that the total for the kingdom must have risen, at its maximum, to over 100,000, and that this number must be largely exceeded during the winter of 1908-9. Nor have we taken any systematic evidence as to the reality or the cause of the destitution in these cases. The subject had been so recently investigated by no fewer than four successive Commissions or Committees, within five years, that we thought ourselves justified in utilising their evidence as our own, and in accepting their statement of the facts. We received, however, some important indepen- dent testimony on the subject, which was generally in support of that already given. Moreover, the general VOL. I 194 CHILDREN UNDER RIVAL AUTHORITIES conclusions of the four official inquiries as to the nature and extent of child destitution have since been confirmed and illustrated by an elaborate investigation, undertaken by the Sub - Committee on Underfed Children of the London County Council, into the actual family circum- stances of a large sample of the 49,000 children whom it was feeding as necessitous in March 1908 — the sample being carefully chosen so as to be accurately typical of the whole number. This latest inquiry, which was carried out by paid investigators who had been specially trained for such work, appears to us conclusive as to the facts. Taking what seems to be the low " Poverty Line " of a family income, after the rent was paid, at the rate of 3s. per week per adult unit, or a little over 5d. per day, the Investigators found that by no means all the necessitous children had been reported by the teachers ; that of the whole 3334 children whom they investigated, 78-88 per cent were genuinely necessitous " in the sense of lacking sufficient food, and 21*12 (per cent) non-necessitous; and that school meals will be required by the former until ejQfective Care Committees are able to check the diseases attendant on partial employment, bad housing, and other evils." Such information as has been supplied to us of the proceedings in Liverpool, Manchester, Leeds, Black- burn, West Ham, Swansea, and other places, indicates that the lines on which action has been taken do not differ essentially from those followed in London. We find it, therefore, difficult to resist the conclusion that, estimat- ing the total of children fed by Local Education Authorities throughout the kingdom to be 100,000, at least three- fourths of these were genuinely "destitute," that is, in want of food, and lacking means to obtain it, whilst it is probable, on the analogy of the London cases, that some thousands more who were equally destitute v:ere never reported by the teac'hers. And this calculation omits altogether the child destitution, doubtless much less in proportion, of the large number of towns in which no similar action has yet been taken by the Local Education Authorities. The first attempt to cope with this evil of child SCHOOL FEEDING 195 destitution was made by voluntary philanthropic agencies. As the hunger among the school children became known to the benevolent public, there grew up, at intervals during the last forty years, a whole series of charitable agencies for giving, sometimes during spells of severe weather, sometimes throughout the whole winter quarter, and occasionally throughout the whole year, free meals, or meals at nominal charges below cost, to the hungry chil- dren of the poorer districts. We do not find that these agencies acted, in any one case, in co-operation with the Destitution Authorities, and they do not appear to have even sought to discriminate between the hungry children already nominally provided for by Outdoor Relief, and those who were not being so relieved. It is impossible to withhold our admiration from the many thousands of humane and benevolent persons who have thus come forward, often at great sacrifice of money and personal service, to relieve the destitution of the children. But this unco-ordinated and irregular distribution of gratuitous or cheap food by irresponsible agencies had many obvious disadvantages. The relief given was in nearly all cases quite inadequate for the really destitute children, seldom amounting for each child to more than two or three meals a week. It was usually spasmodic and temporary, money being collected freely when a cold snap, or a dramatic cessa- tion of employment, brought home to the hearts of the charit- able the perennial destitution that existed. The relief was usually afforded in the least advantageous manner. Sometimes doles of soup, bread, and pudding were shovelled out to crowds of hungry children without any attempt being made to secure the ordinary decencies of civilised meals. Sometimes dinner tickets were distributed, which had to be presented at eating-houses of a cheap type, where the children were fed without responsible super- vision ; and where, moreover, the tickets could sometimes be exchanged for cigarettes or sweets. It was rare that any adequate investigation was made into the home cir- cumstances of the children who looked anaemic and hungry. Finally, from beginning to end of these attempts to meet the need by charitable agencies there was, we may say, no 196 CHILDREN UNDER RIVAL AUTHORITIES thought of anything but unconditional relief : there was no suggestion of obtaining, in return for the food, any- greater exertions by the parents for the benefit of their children, or of securing from the children any improvement in manners or greater regularity of life, or of enforcing by the prosecution of negligent and drunken parents any greater fulfilment of their parental responsibilities. After all that was done by charitable agencies, there remained, in certain schools, in certain districts, and at certain seasons, an amount of child destitution which public opinion eventually found to be intolerable. The existence of this enormous mass of child destitution in the schools was very slowly, and, we may add, very reluctantly, perceived by the Local Education Authorities ; and still more slowly and reluctantly were any steps ofiicially taken by them for its relief. Established to pro- vide schooling only, the School Boards were naturally averse from assuming responsibility for the home circum- stances of their pupils. They were under no legal or even moral obligation to see that their pupils were properly cared for out of school. What forced them to realise the existence of child destitution was the manifest absurdity of wasting costly education on hungry or starving children. When active physical exercises, which could not be shirked by the child, were added to mere sedentary listening to the teacher's lesson, which did not need to be learnt, this absurdity approximated to cruelty. To the keen educa- tionalist, as to the practical teacher, it became apparent that the semi-starvation, from which in " slum " districts whole schools were suffering, was producing two types of abnormality, both disastrous alike to the future welfare of the community and to the present efficiency of the school. These results of child destitution are graphically described by the medical expert who examined the children in the schools of the Liverpool Education Authority : — " Starvation acting on a nervous temperament," reported Dr. Arkle as to the children whom he examined, " seems to produce a sort of acute precocious cleverness. Over and over again, I noted such cases of children, without an ounce of superfluous flesh upon them, with skins harsh and rough, a rapid pulse, and nerves ever SCHOOL FEEDING 197 on the strain, and yet with an expression of the most lively intelli- gence. But it is the eager intelligence of the hunting animal, with every faculty strained to the uttermost so as to miss no oppor- tunity of obtaining food. I fear it is from this class that the ranks of pilferers and sneak thieves come, and their cleverness is not of any real intellectual value. On the other hand, with chil- dren of a more lymphatic temperament, starvation seems to produce creatures much more like automata. I do not know how many children I examined among the poorer sort who were in a sort of dreamy condition, and would only respond to some very definite stimulus. They seemed to be in a condition of semi-torpor, unable to concentrate their attention on anything, and taking no notice of their surroundings, if left alone. To give an example of what I mean, if I told one of these children to open its mouth, it would take no notice until the request became a command, which some- times had to be accompanied by a shght shake to draw the child's attention. Then the mouth would be slowly opened widely, but no effort would be made to close it again until the child was told to do so. As an experiment, I left one child with its mouth wide open the whole time I examined it, and it never once shut it. Now that shows a condition something like what one gets with a pigeon that has had its higher brain centres removed, and is a very sad thing to see in a human being. I believe both these types of children are suffering from what I would call starvation of the nervous system, in one case causing irritation, and in the other torpor. And further, these cases were always associated with the clearest signs of bodily starvation, stunted growth, emaciation, rough and cold skin, and the mouth full of viscid saliva due to hunger. With such children I generally had to make them swallow two or three times before the mouth was clear enough to examine the throat. ... I do not think I need say any more to show that the extent of the degeneration revealed by this investi- gation has reached a very alarming stage. . . . What is the use of educating children whose bodies and minds are absolutely unable to benefit by it. In my opinion, the children must first be taught how to live, and helped to get food to enable them to do it." The question arises why the Destitution Authorities had not already relieved the obvious destitution — not of education or of medical attendance, but actually of food — of this appalling number of children found to be positively sufifering from hunger. The first answer is that, in quite a large number of cases — we suspect, in all, many thousands — the Destitution Authorities were actually providing simultaneously by Outdoor Relief for the very children 198 CHILDREN UNDER RIVAL AUTHORITIES whom the Local Education Authorities found themselves driven to feed, because the Outdoor Relief allowed to the family was positively insufficient for its support. In the Metropolis it was found in 1907-8 that 3*29 per cent of 49,000 children fed were at the time in receipt of Outdoor ReHef, whilst no fewer than 13 '46 per cent had recently been in receipt of such relief, though it had been brought to an end before the date of the investigation. Thus, it would appear that of the 10,000 children of school age on any one day maintained by the Metropolitan Boards of Guardians on Outdoor Relief, something like 1600, or one in every six, were actually being fed, in the winter of 1907-8, by the Local Education Authority; whilst of the 30,000 separate children who got Outdoor Relief during some part of the year, no fewer than 7000, or one in every four or five, also got fed in that winter at school. The second answer of the Destitution Authorities is, apparently, to say that no application for relief had been made to them by the parents of the children. On this we have to point out that the Poor Laws do not require application to be made before relief is granted. It is the statutory duty of the Destitution Authority to relieve all the known destitution within its district, whether applica- tion be made or not. The Destitution Authority could hardly plead that it was unaware of the existence of hungry children unable to get food. The fact that children at school were actually sufiering from want of food was known to every Board of Guardians or Parish Council in the principal towns of the United Kingdom. Moreover, in the case of children, the Destitution Authorities have been, since 1868, under a special statutory obligation to proceed against parents who fail to supply their children with food — an obligation which was specially brought to the notice of the House of Lords Committee on Poor Relief in 1888 : — " There is," said the late Rev. W. B. Waugh, speaking for the National Society for the Prevention of Cruelty to Children, " an Act of Parliament, 31 & 32 Vict. c. 122, sec. 37, which requires that every Board of Guardians shall (the word ' shall ' is used) institute prosecutions and pay the costs where they have reason to believe that children are not sufficiently fed. . . . The Guardians SCHOOL FEEDING 199 do not act upon it to any great extent. . . . There are cases in which they are habitually doing it, chiefly where ladies are upon the Board, but in a very small number of cases, indeed, through- out the country. ... It is a matter of fact that the Eelieving QjBBcers know cases of children starving to death, and take no action, ... I will take a case at Swindon. Last week we sent to prison two persons who had seven children in their custody, all of whom were looked after by the Eelieving Officer to this extent. In January last he visited and reproved the woman, and I think he called the house very filthy in March, but no action was taken. The children were all dying. . . . They were children who might have been looked after by the officers of the Poor Law — children who ought to have been looked after under that section." Since this remarkable testimony, tlie law has been so far altered, owing to the neglect of the Boards of Guardians, as to allow other persons as well as these Boards to institute prosecutions in these cases ; and we gather that the Destitution Authorities have thereupon practically ceased to institute any proceedings whatever. It is, however, under the Prevention of Cruelty to Children Act, 1904 (now re-enacted in the Children's Act, 1908), still open to them to do so in all cases that come to their knowledge. The Local Government Board for Ireland specially drew the attention of the Irish Boards of Guardians to this fact in sending them the Act of 1904. We have it in evidence, from one of the English Local Government Board's In- spectors, that : " The laws of the land are perfectly adequate for bringing every man, who neglects his children by starving them, to the Police Court. ... If the law was stringently administered . . . you would stop the starving of children to a great extent." The Boards of Guardians have "a power of prosecuting" and also "a power of relieving." The Destitution Authorities, we were informed by another witness, have " ample authority " to punish parents who neglect their children, but " they think it is not advisable to do so." It has been urged on behalf of the Boards of Guardians that, in the early stages of the movement for the feeding of hungry children, no effort was made by the Poor Law Division of the Local Government Board to put them in a position to carry out their statutory obligations. Where 200 CHILDREN UNDER RIVAL AUTHORITIES the Outdoor Relief Prohibitory Order was in force, the Destitution Authority could lawfully relieve the children of able-bodied men only by receiving both father and child in the AVorkhouse. In other Unions, where the Outdoor Relief Regulation Order was in force, it had long been customary for the Board and its Inspectors to press Boards of Guardians to adopt the same policy of refusing Outdoor Relief to able-bodied men and their dependents. Not until 1905 did the Poor Law Division of the Local Government Board reverse that classic policy. In that year an Order was issued empowering Boards of Guardians, on the application of the Local Education Authority or its officers, to grant relief to the child of an able-bodied man without requiring him to enter the Workhouse, or to perform the Outdoor Labour Test. But all such relief was, if the father was deemed guilty of neglect, to be given only " on loan," and might be so given in all cases ; proceedings were (except in any special case to be re- ported to and sanctioned by the Local Government Board) always to be taken for the recovery of the amount from the parents ; and whether or not the amount was so recovered, the parent became legally a pauper and was consequently disfranchised. For some reason that we fail to understand, this Order was expressly stated not to apply to the children of widows, or to children residing with other relatives than their father, or to children who were blind or deaf and dumb, or to children whose fathers were for any reason absent from them. This belated attempt of the Local Government Board to spur the Destitution Authorities on to perform theii* statutory duty was a complete failure. In very few Unions was there any action at all taken under it. The express exclusion from its scope, without explanation, of the children of widows and deserted wives, and of absentee fathers, seemed, to many of the Authorities concerned, to render it almost useless. We do not find that the Local Government Board explained that the only reason for omitting these classes from the Order was that the Board of Guardians had already, without any Order, unlimited power to grant Outdoor Relief at their discretion for the SCHOOL FEEDING 201 support of all destitute children, except such as resided with fathers who were able-bodied. Nor was it explained that it was open for the Local Education Authorities, or for any one else conversant with the facts, quite irre- spective of the Order, to send in lists of destitute children, every one of which would then have to be dealt with by the Destitution Authority. Amid all the misunderstand- ing and confusion, the Order quickly became a dead letter. "The labour given to the officials," one of the Local Government Board Inspectors informs us, "and the expense to the Guardians, appear to be out of all pro- portion to the benefit conferred." At Manchester, Leeds and Bradford, where most seems to have been attempted under it, the action quickly broke down. The Local Education Authorities and the Boards of Guardians found it impossible to agree on any systematic scheme. When children were reported as underfed the Boards of Guardians struck four-fifths of them off", not because they disputed the children's need of additional food, into which they did not inquire, but because they chose to assume, on the information supplied to them by the Believing Officers, that the parents could have provided food for their children if they had chosen to do so. But the Guardians took no steps whatever to enforce on these parents their legal responsibilities, and the children re- mained unfed. For the small minority of children whose parents the Guardians admitted to be destitute, they issued tickets which could be exchanged, at eating-houses of a cheap type and at other shops, for any food desired, this plan having all the unsatisfactory features of private charity. The fathers of many of the children who had received such tickets indignantly refused to allow them to continue to receive them, when they understood that it involved, not only the striking ofi" of their names from the electoral roll, but also the subsequent refunding of the value of the tickets under circumstances of public indignity. The numbers fell ofi" to a nominal figure. Meanwhile, on the assumption that the Guardians were meeting the need, private donations declined ; and a large number of children remained hungry. 202 CHILDREN UNDER RIVAL AUTHORITIES The result of this long-continued abdication of duty by the Destitution Authority has been, in England and Wales, after calamitous delay, the assumption by the Local Education Authority of the obligation of seeing that hungry children are fed. There was no power to provide food out of the Education Rate, but we see the Local Education Authorities, in town after town, gradually driven to put themselves at the head of the movement, to do their utmost to spread out the charitable gifts so as to cover evenly the whole ground, to lend the aid of the school organisation, and to provide premises, equipment, staff and even fuel. At last Parliament felt itself com- pelled to intervene. A Bill to enable Local Education Authorities to undertake the feeding of necessitous chil- dren was read a second time, and referred to a Select Committee. This Committee recommended " that the Local Education Authority ought to undertake the ad- ministration rather than the Board of Guardians," up to the limit of a rate of Jd. in the £ ; and a measure to that effect became law in 1906. In the winter of 1907-8, and still more in that of 1908-9, most of the Local Education Authorities of the great towns in England and Wales were, as we have mentioned, feeding children out of the Education Rate. (d) The Failure of the Destitution Authority to Relieve Child Destitution We do not attribute the failure of the Destitution Authorities to prevent child destitution, to prosecute the negligent parents or to feed the hungry children — any more than we do their failure properly to supervise the host of children on Outdoor Relief — to any defects of the unit of area of Poor Law administration, or to any short- comings in the persons who constitute Boards of Guardians. We have, indeed, been much impressed by the humanity, zeal and self-sacrificing industry displayed by the members of these Authorities — especially the women members — in all their dealings with the children. The failure is certainly as great in the large Unions, wielding practically FAILURE OF DESTITUTION AUTHORITY 203 the whole powers of populous Urban communities, as it is in the smaller ones. Thus, no alteration in the member- ship, no change in the constitution, no enlargement of the area of the Destitution Authority would remedy the defects that now stand revealed. The failure of the Boards of Guardians in the great centres of population in England, Wales and Ireland, and of the Parish Councils in those of Scotland, to relieve so much of the child destitution, is rooted in the very fact that they are Destitution Authorities, with a long-established tradition of " relieving " such persons only as voluntarily come forward and prove themselves " destitute." What is re- quired is some social machinery, of sufficient scope, to bring automatically to light, irrespective of the parents' application, or even of that of the children, whatever child destitution exists. We see such machinery actually at work, so far as regards all the children of school age, in the organisation of the Local Education Authority. From its fifth or sixth to its fourteenth or fifteenth birth- day, every poor child resident in the district is daily under the notice of the officers of this Authority. A stafi" of School Attendance Officers is occupied in searching out all children who ought to be on the school rolls. Once on the roll, if a child stays away, the School Attend- ance Officer visits its home as a matter of course. In school the child is hour by hour under the observation of the teacher. The amount of its energy is being per- petually tested, mentally or physically. The systematic medical inspections now commanded will reveal the less obvious causes of malnutrition, for experience has shown " that it is very difficult to trace the source from which the unhealthy condition of the children arises, and that it might be due to congenital causes, late hours, insanitary surroundings, uncleanliness, or work out of school hours." It is clear that the Destitution Authority could not pos- sibly duplicate this official machinery for keeping con- stantly and automatically under observation the entire child population. The evil to be remedied is not the destitution of a day or of a mouth, but the continuous carelessness and ignorance bred of chronic poverty. This 204 CHILDREN UNDER RIVAL AUTHORITIES fact was abuodantly demonstrated in the four official inquiries the reports of which we have quoted, as well as in evidence that we have ourselves received. Though money and food were often necessary, it was not school dinners that would remedy the evils from which the children were suffering : — The general features, we were informed, prevailing in the homes of these neglected or underfed school children are strikingly alike. . . . There is an absolute lack of organisation in the family life. It seems to be entirely absent under conditions where careful and minute organisation of the family resources is more essential than anything else. Existence drags along anyhow ; the hours of work, leisure and sleep are equally uncertain and irregular. . . . The underfeeding of the children is but a part of a more important feature of the life in this district. The children's health is affected by many different evils, overcrowding, want of sleep, dirt, and general irregularity of life. An Authority, dealing with the child, or with the family, merely at the crisis of destitution, having no excuse for intervening before or after this crisis, can never cope with the conditions here revealed. What is required is the steady and continuous guidance of a friend, able to suggest in what directions effective help can be obtained where help is really needed, which will gradually remedy parental ignorance or neglect. In many cases friendly advice and warning will suffice. Such an organisation for systematic friendly visiting can, we think, only be supplied by voluntary effort, working as part of the machinery of the Local Education Authority, and enabled in ways that we shall subsequently describe to bring to bear the material aid that the children, in some cases, are found actually to require. These Children's Care Committees, under one title or another, are now becoming part of the machinery of the Local Education Authority. They were, for instance, required by the Act of 1906, and their establishment has been expressly called for by the Board of Education. It is obvious that Committees of this sort, equipped with the personal knowledge of each child derived from the School Attendance Officers, the Teachers, the School Nurse, and the medical inspection, and sending their members as FAILURE OF DESTITUTION AUTHORITY 205 friendly visitors to the homes of the parents, are far better able to effect the improvements required than any machinery that the Destitution Authority can devise. Where the parents prove recalcitrant to moral suasion, the Local Education Authorities, besides their full power to prosecute the parents under the Children's Act, 1908, have at hand, in the Day Industrial Schools that we have de- scribed, which they have in some towns already established, a method of ensuring the proper sustenance of the children, without relieving those parents who can maintain their offspring from the burden of providing for them. These Day Industrial Schools, originally established for the purpose of dealing with the neglect of parents to take the trouble to send their children regularly to school, have proved very successful in enforcing this particular parental responsibility. The parent, far from escaping scot-free, is ordered to make such weekly contribution to the cost of feeding his child as his means will allow ; and experience shows that, far from dealing laxly with such parents, the Local Education Authorities have been quite strict in their enforcement of this parental obligation. This use of the Day Industrial School has had a wonderful effect in stopping the particular form of parental neglect which shows itself in the child's truancy. It has been suggested that the Local Education Authority has in the power of committing children to these schools an instrument which, whilst ensuring the proper feeding of the child, and not relieving the careless or neglectful parent of its cost, is likely to be equally efficacious in bringing to an end a large amount of wanton parental neglect to provide meals. (e) The Supersession of the Destitution Authority hy the Local Education Authority The legislation of 1906-7, authorising the Local Education Authorities to give medical treatment and food to children found at school destitute of these requisites, sets the seal, in our opinion, on the necessity for completing, so far as children of school age are con- 206 CHILDREN UNDER RIVAL AUTHORITIES cerned, the supersession of tlie Destitution Authority by the Local Education Authority. It is, we think, clear that wherever the Local Education Authority performs what is now its statutory duty, and provides, or gets provided, not only schooling, but also medical inspection and treatment, and food for all who are in need of it, tlie Destitution Authority, in respect of the 20 per cent of the population who are between the ages of five and fourteen, becomes superfluous. Where both Authorities are actively at work there will be perpetual friction, overlapping and waste. Moreover, the rapidly developing machinery of medical inspection at school, and the visits to the homes of School Attendance Officers, School Nurses and members of Children's Care Committees, seem to furnish, for the first time, an efi'ective instrument for keeping under practically continuous supervision the 160,000 children of school age for whom Outdoor Relief is being granted, and the 35,000 more who, in different parts of the United Kingdom, are boarded out or placed in residential homes. With such continuous supervision by the Local Education Authority, we believe that by far the best way for the community to provide for a destitute child is, so to speak, " to board it out with its own mother," upon an allowance adequate for its full maintenance, provided that the mother is not mentally or morally unfit to be entrusted with its care. For undertaking the complete custodial care of children of school age who are without parents, or who have been compulsorily withdrawn from their unfit parents, the Local Education Authority off"ers manifest advantages over an Authority limited to the relief of destitution. Here the Local Education Authority has ready to hand, not only the device of Boarding-out already employed by that Authority under the supervision of Special Committees of philanthropic workers for some of the defective children, but also its residential schools, at present used only in the form of schools for special classes of children. If, for other sections of children, the plan of Scattered Homes commends itself, the Local Education Authority can most conveniently place these Homes in proximity to the day schools which the children should attend, and can allocate the children SUPERSESSION BY EDUCATION AUTHORITY 207 among them in such, a way as to provide each of them with accommodation in the type of school that its faculties make most appropriate. In so far as *' Certified Schools and Homes" are made use of for particular kinds of children, the Local Education Authority, unlike the Destitution Authorities, will have at its command qualified inspectors, accustomed to deal with the managers of voluntary institutions, and able to satisfy themselves of the value of the care and the instruction given. Com- pared with the Local Education Authority in this respect, the Destitution Authority, even at its best, stands at a grave disadvantage. It either has to divorce the children from all the official machinery which it directs — the Guardians and the Relieving Officers striving, so to speak, to hide themselves from the children's view, in order to free them from all associations with the Poor Law — or else it smears their young lives over with the stigma of pauperism, and brands them as a special caste. What the Destitution Authority does in this dilemma is to impale itself alternately on each of the horns ; never succeeding in wholly dissociating the children from the Workhouse or its precincts, and yet failing to maintain over them the watchful supervision that all systems require. Finally, even if it overcomes all these drawbacks, the Destitution Authority, as an Authority for children of school age, has, in the matter of education, an impossible task. The children with whom it has to deal are arbitrarily selected from the general child population by circumstances wholly irrelevant to their classification in the school, namely, by the destitution of the parents — the result being that old children and young, bright children and the mentally defective, criminal children and scholarship children, children who have been regularly under instruction and those who have been wandering untaught, are all dumped down in the same building, in the same classes, before the same teachers. In short, for the grouping of children in schools, as for the grouping of the sick in hospitals, the category of the destitute is a mischievous irrelevancy. 208yCHILDREN UNDER RIVAL AUTHORITIES (f) Conclusions We have therefore to report : — 1. That the Destitution Authorities of England and Wales, Scotland and Ireland, have proved themselves — in spite of the devoted personal service of many of their members — inherently unfitted, by the very nature of their functions, to have the charge of the 237,000 children of school age for whom the State, in the United Kingdom, assumes the responsibility of whole or partial maintenance. 2. That, as a result of this inherent unfitness of a Destitution Authority for the rearing of children, it has been demonstrated to us by our own expert investigators, and confirmed by other evidence, that certainly a majority of all the Outdoor Relief children — probably 100,000 boys and girls — are to-day suS'ering, definitely and seriously, in health and character from the circumstances of their lives — these circumstances being, in great part, the inade- quate and unconditional character of the Outdoor Relief upon which they are supposed to be maintained, and the lack of care and supervision exercised by the Destitution Authorities, and of inspection by the three Local Govern- ment Boards, to prevent the too frequent neglect and ill- treatment of these wards of the State. 3. That, in spite of almost universal condemnation, and notwithstanding a whole generation of eff'ort on the part of the three Local Government Boards to get the children otherwise maintained, there are, in Great Britain, three or four thousand, and in Ireland as many more, children of school age being brought up in the demoralising atmosphere of the General Mixed Workhouse ; and we have found no evidence of any efi"ective desire or intention on the part of the Destitution Authorities to take steps to bring to an end this discredited method of providing for children. 4. That the system of "boarding-out" the children with foster-parents, or placing them in certified institu- tions — a system which, under careful and continuous supervision, and confined to a minority of suitable cases, has much to recommend it — is at present seriously pre- judiced by the fact that the Destitution Authorities and CONCLUSIONS 209 their officers are, by the very nature of their functions, unqualified to maintain an efficient inspection of the homes and institutions which they select for their children, let alone any continuous supervision of their welfare. In some cases it has even been deemed advisable to dis- courage or prohibit such visiting of the homes or institu- tions in order to avoid the connection of the children with the Destitution Authority which is supposed to look after them. 5. That the children in Poor Law Schools and Cottage Homes — the conditions of which have, for the most part, greatly improved — are, in many instances, maintained at an unnecessary cost ; an excessive expenditure sometimes directly attributable to the inexperience of a Destitution Authority in school management, and one which still leaves the children suffering, even in well -administered institutions, from : (a) The difficulty of getting the best teachers in Poor Law Schools ; (b) The impracticability of affording these " institutionalised " boys and girls proper experience of life in a small home ; and (c) The educationally defective grouping together of children merely by the common attribute of their parents' destitution, instead of allocating them severally to the particular types of school (e.g. mentally -defective schools, crippled schools, higher- grade schools, technical schools, etc.) that their individual characteristics require. 6. That, owing to their lack of any appropriate machinery for the purpose, the Destitution Authorities fail to-day even to discover a large amount of the destitu- tion that exists among children in the great towns ; and this not merely in the matter of medical treatment urgently required, but even in the matter of actual inadequacy of food, so that the powers entrusted to the Boards of Guardians for the prosecution of cruel or neglectful parents are hardly ever put in force, and many thousands of children are, for lack of the necessaries of life, growing up stunted, debilitated and diseased VOL. I p 210 CHILDREN UNDER RIVAL AUTHORITIES 7. That, as a consequence of tliis failure of the Destitu- tion Authorities to prevent or to relieve child destitution, Parliament has been led, after many official investigations, to entrust to the Local Education Authorities the duty of providing meals for the children found at school unfed, at any rate on those days of the week and those weeks of the year when the elementary schools are open ; with the result that these Authorities are in England and Wales, during the present winter, feeding more than 100,000 children, and probably nearly as many children of school age as are being relieved, otherwise than in institutions, by all the Destitution Authorities put together. 8. That these competing systems of relieving child destitution by rival Local Authorities in the same town — in many cases simultaneously assisting the same children — without any effective machinery for recovering the cost from parents able to pay, and for prosecuting neglectful parents, are undermining parental responsibility, whilst still leaving many thousands of children inadequately fed. 9. That it is urgently necessary to put an end to this wasteful and demoralising overlapping, by making one Local Autliority in each district, and one only, responsible for the whole of whatever provision the State may choose to make for children of school age. 10. That the only practicable way of securing this unity of administration, and also the most desirable reform, is, in England and Wales, to entrust the whole of the public provision for children of school age (not being sick or mentally defective) to the Local Education Authorities, under the supervision of the Board of Education ; these Local Education Authorities having already, in their Directors of Education and their extensive staffs of teachers, their residential and their day feeding schools, their arrangements for medical inspection and treatment, their School Attendance Officers and Children's Care Committees, the machinery requisite for searching out every child destitute of the necessaries of life, for enforc- ing parental responsibility, and for obviating, by timely pressure and assistance, the actual crisis of destitution. 11. That in Scotland the whole of the public provision CONCLUSIONS 211 for children of school age might be entrusted, at any rate in the large towns, to the School Boards ; and elsewhere, perhaps, either to the District Health Committee or to the newly-formed " County Committee of the District," under the supervision of the Scotch Education Department. 12. That in Ireland, where no Local Education Authorities exist, it should be considered whether the whole of the public provision for children of school age might not advantageously be entrusted to the County and County Borough Councils, acting through special " Board- ing-out Committees," on which there should be women members, and sending the children to the existing day schools. CHAPTER V THE CURATIVE TREATMENT OF THE SICK BY RIVAL AUTHORITIES We find, throughout the United Kingdom, at the present time, two separate and distinct public authorities dealing with the sick poor, the Destitution Authority, providing medical attendance, nursing and medicine, and often institutional treatment, for destitute sick persons whatever their diseases ; and the Local Health Authority, providing, in the same area, medical attendance, nursing and medicine, together with institutional treatment where required, for persons, whatever their affluence, suffering from certain specific diseases. Alongside of these two ubiquitous rate- supported Medical Services, we find a whole array of medical charities of one sort or another, dealing with essentially the same classes of persons and many of the same diseases. (a) The Medical Service of the Poor Law Of the 915,000 simultaneous paupers in England and Wales, probably 120,000 are acutely sick, requiring, not merely maintenance, but also appropriate medical treat- ment. It is, therefore, somewhat remarkable that the Report of 1834 contained no recommendations as to the treatment of the sick. Among the four separate institu- tions which the authors of that Report recommended as the minimum for each Union, a hospital found no place. This was not because they were careless of the sufferings of the sick poor, but because the institutional treatment of 212 MEDICAL SERVICE OF POOR LAW 213 sick persons was, at that date, hardly recognised as important, either from a curative or a preventive stand- point. What the authors of the 1834 Report contemplated providing for the sick poor — what, indeed, was at that time the customary provision for the sick of all degrees — was merely the attendance of a medical man in their own homes and a plentiful supply of medicine. Accordingly, when the Poor Law Commissioners of 1834-47, instead of establishing in each Union these four separate institutions, pressed for the building of one General Mixed Workhouse, this did not include any specialised provision for the sick. The most that was done was to set aside a room for such of the Workhouse inmates as became ill, for medical attendance upon whom the Board of Guardians contracted with a local doctor. Thus, whether within the Workhouse or in the sufferers' own homes, the conception of medical care was, in 1834, of the simplest. During the past seventy years the influence of the Central Authority on the Boards of Guardians has, in this branch of their work, been of a twofold character : it has attempted to restrict the area of Outdoor Medical Relief, whilst striving to improve the quality of Indoor Medical Relief. The crusade against Outdoor Relief, conducted, as we have seen, by the Inspectorate of 1869-86, included as one of its departments a tightening-up of the conditions on which Medical Orders were habitually granted. Boards of Guardians were encouraged to subject the applicant for a Medical Order to the same inquisitorial inquiries and the same treatment by the Relieving OflScer as if the applica- tion had been for money or food ; to grant the relief " on loan," and to threaten to recover its cost; and generally to deter persons from applying for the services of the District Medical Officer, except in dire necessity. On the other hand, there has been, especially from 1866 onwards, a steady pressure on the Board of Guardians to improve the institutional provision for the sick poor, by erecting separate hospital buildings, by augmenting the medical staff, and by substituting trained nurses for the pauper attendants. This apparent inconsistency between the two parts of the medical policy of the Central Authority is 214 CURATIVE TREATMENT OF THE SICK explained by the assumption that Outdoor Medical Relief, whilst not in itself deterrent, was an open door to other forms of pauperism, to which it was apt to lead ; whilst Indoor Medical Relief, however good in quality, would, by its very nature, always be deterrent, owing to the necessary loss of liberty, and would thus never be taken advantage of by any but those who were absolutely destitute. The twofold policy thus emanating from the Local Government Board has been reflected in the medical administration of the Boards of Guardians up and down the country, in an irregular manner and to a varying degree. Some Boards have distinguished themselves for diminishing, almost to the vanishing point, the number of Medical Orders given for the attendance of the sick poor in their own homes. Other Boards have marked themselves out by the efl&ciency and elaborateness of the costly "infirmaries" or "hospitals" that they have pro- vided for the sick poor, and by the complete separation of these institutions from the General Mixed Workhouse. We have, however, to record that, in the great majority of Unions, especially those of rural or semi-rural character, the Boards of Guardians have shown themselves equally impervious to both sides of the advice and injunctions of the Local Government Board ; and have continued, with a minimum of improvement, much the same primitive provision for the sick poor, alike for those residing in their own homes and those within the General Mixed Workhouse, in which the authors of the Report of 1834 seem tacitly to have acquiesced. (b) Domiciliary Medical Treatment under the Poor Law The domiciliary medical treatment of the sick poor is entrusted, in England and Wales, to 3713 District Medical Officers, averaging five or six for each Union, severally appointed for life or during good behaviour by the Boards of Guardians concerned. The Local Government Board insists that the person appointed shall be legally qualified, that he shall reside within the district assigned to him, and that he shall receive a permanent and personal appoint- DOMICILIARY MEDICAL TREATMENT 215 ment. Subject to these requirements, the selection of the District Medical Officer, the amount of his remunera- tion, and the detailed conditions of his appointment are left entirely to the discretion of the Guardians, who have usually, for this purpose, no expert advice at their com- mand. In the first years of the Poor Law Commissioners the new Boards of Guardians were urged by them to put these appointments up to competition among the medical practitioners of the Union, and to appoint the man who, being duly qualified, ojffered to take the post (including the supply of the necessary medicines) at the lowest price. This gave rise to much objection, and the Poor Law Com- missioners and their successors in office gradually became converted to the advantage of transferring the competitive pressure from price to quality — offering an adequate salary for the duties required, of paying separately for drugs and other accessories of the treatment, and even of providing an official dispensary and a salaried dispenser. Unfortu- nately, but few of the 650 Boards of Guardians have yet adopted the new policy, in spite of all the pressure that the Local Government Board has exercised. In the great majority of Unions the District Medical Officers still have to find their own drugs and medicines, and any dressings and bandages that are required, and they are paid fixed stipends which vary from as little as XIO or £15 a year up to as much as £300 or £400, a very usual figure being £100 ; together with additional fees for midwifery cases and operations. Many of them declare that they do not receive more than 4d. or 6d. per visit. Both the amount and the method of the remuneration of the District Medical Officers have repeatedly been made the subject of official criticism, which was brought forcibly to our notice. " It is undeniable," testified the Poor Law Medical Inspector of the Local Government Board, "that the majority of medical officers, in or outdoor, are paid salaries miserably inadequate." This is obviously due to the continuance, in a veiled form, of the practice unfortunately encouraged by the Poor Law Commissioners, of putting the office up to competitive tender. The Medical Inspector himself informed us that when, on one occasion, he "was a candidate 216 CURATIVE TREATMENT OF THE SICK for an outdoor medical officership ... a colleague of mine offered to do the work for nothing for one year if he was appointed, and afterwards at a much less salary than I asked for." " When I tell guardians that their . . . medical officers are not adequately paid," remarked to us one of the General Inspectors of the Local Government Board, " they answer : * Well, at all events, we have only to advertise it, and we shall get any amount of candidates who are perfectly ready to come forward and do the work on the terms we offer. In the face of that can we, in the proper performance of our duty to the ratepayers, offer more than we can get what we want for?'" What was not fully considered by the Poor Law Commissioners, and is still not adequately realised by the Boards of Guardians, is that so long as these appointments are thrown open to private practitioners, they will be taken for other reasons than the salaries offered. " One knows," testified a com- petent witness, "that the medical men in a great many instances do not take office for the emolument which they will get from the office, but for various other considerations. Probably one of the chief considerations is to keep some- body else out. There are a certain number of men who have the medical work in a certain area between them- selves, and they naturally want to keep another practitioner from coming in. That is one motive. Another motive is that holding Poor Law offices does indirectly bring them practice. . . . Even taking all that into consideration, I do not think that there is any justification for not paying a man a fair value for his work. I think it is very undesir- able that Medical Officers should be able to say : ' Well, if they find fault with me, at all events I feel this — that I am giving them more than their money's worth.' " *' The evils arising, or likely to arise, from this underpayment," says a competent witness, " are various. The Medical Officer is compelled to economise his time too strictly ; he cannot afford to supply expensive medicines or to carry out modern improvements in medical treatment." Never- theless, only in two or three instances have the whole services of a Medical Officer been secured, at a " full-time " salary. Only in the Metropolis and a few other towns is DOMICILIARY MEDICAL TREATMENT 217 an official dispensary or a salaried dispenser provided. Practically only in these few cases is the District Medical Officer set free to prescribe what he may deem necessary for the patient, without having to pay for it out of his own pocket. Everywhere, with but two or three excep- tions, the whole duty is entrusted, at a scanty and inclusive stipend, to one of the local practitioners. The conditions under which the District Medical Officers carry out their duties are as unsatisfactory as their re- muneration is demoralising. They are at the beck and call of the Relieving Officer, a non-medical authority, who has the right, at his unaided discretion, to refuse a sufferer access, to direct him to call at the doctor's house, or (by merely marking the medical order " urgent ") to require the doctor himself immediately to visit the patient's resi- dence. If the District Medical Officer, obeying the dictates of humanity, attends any urgent case without the Reliev- ing Officer's order, he not infrequently finds him self refused, " on some frivolous pretext or another," the midwifery fee or other emolument to which he would normally have been entitled. The majority of the cases that he has to attend are, moreover, of the most disheartening kind — largely old people, with chronic complaints, or persons of more than the average degree of ignorance, carelessness, intemper- ance, and, above all, grinding poverty, with the drawbacks of bad housing, the poorest kind of clothing, insufficient and unsuitable food, inadequate attendance, and an almost total absence of skilled nursing. The Boards of Guardians have power to appoint salaried nurses for the outdoor sick, but they have almost uniformly refused to do so. In a small minority of Unions they pay a subscription to the local nursing association, so that the paupers may obtain a share of the services of the district nurse. But over the greater part of the country there is no district nurse ; and it is rare for the Guardians to make any sort of provision for nursing the outdoor sick poor. Our Medical Investi- gator reports that " In many villages and their surrounding neighbourhood, I found that no district nurse whatever was available. District Medical Officers complained very much of this want of assistance, and the complaint was 218 CURATIVE TREATMENT OF THE SICK well founded. . . . Quite unquestionably, in some rural districts the want of sick-nursing of paupers is a serious defect in the present system of Poor Law medical relief." This was, indeed, frankly stated by the General Inspectors of the Local Government Board. " The lack of nursing upon the outdoor sick poor," testified one of them, "is another source of hardship, and one which urgently needs to be dealt with." The fact that wool, lint and bandages are hardly ever supplied by the Guardians aggravates the evil. The District Medical Officer can order nothing better than clean rags for dressings, " lest " (as one of them said) " the bad legs should ruin him." As things are, it is unfortunately painfully true, as an experienced District Medical Officer informed us, that " many cases die simply from want of proper nursing. I cannot," he said, " speak strongly enough on this point. It is one of the Medical Officer's greatest drawbacks that he cannot get efficient nursing for his outdoor cases." "It is dreadful," reports a Local Government Board Inspector, " to think of the amount of unnecessary inconvenience, to say the least, suffered by outpatients now, looked upon as a matter of course, and allowed to continue with no practical effort to prevent it. If expense were incurred it would be doubly justifiable. Firstly, because of the suffering it would alleviate. Secondly, for the more cynical reason that it would restore the patient to health, and get him off the rates much more quickly. Medical Officers are handi- capped in their work when they have no intelligent nursing power behind them, and know that it is useless to try many things that might be done if there were the requisite attendance at hand." Finally, the District Medical Officers are deprived of the stimulus and encour- agement of official recognition or supervision. They have no medical superior to whom they can report; they are not even in official communication with the Medical Officers of Health of their districts, or with the County Medical Officer. As some of them have complained to us, they are never asked, either by the Boards of Guardians or by the Local Government Board, for particulars of their success or failure in treating cases, or for details of any DOMICILIARY MEDICAL TREATMENT 219 improvement in treatment that they may have introduced. There are no medical statistics of their work. According to the "year's count" of pauperism that the Commission had taken for England and Wales, no fewer than 216,022 persons received " Medical Relief only " in the course of one year, to say nothing of those who got other relief as well. Yet, by what seems to have been an official oversight that we do not understand, these 3713 District Medical Officers are left to do their work without either supervision or inspec- tion by the Local Government Board. From 1834 down to the present day there has been no official inspection of this Poor Law Medical Service, which costs in salaries, dispensaries and drugs alone nearly £500,000 sterling- annual ly. Under these circumstances, we were not surprised to find existing a certain dissatisfaction with the Outdoor Medical Service of the Poor Law. The Medical Inspector of the Local Government Board, who " has no duties in connection with the supervision or administration of Outdoor Medical Relief," informed us, in reply to our questions, that, " unofficially," he was " constantly hearing complaints " that patients on Outdoor Medical Relief were not well and sufficiently attended. The District Medical Officers, said one witness, " do the M^ork according to the pay." He did not think the paupers were treated as well as the paying patients. " The doctor," he said, " takes these positions in order to further his private practice, and I am afraid the poor very often have to suffer for that reason ; he takes it too cheap." " The present plan of medically assisting the poor under the Poor Law," says a medical practitioner, himself a Guardian, " is not an efficient system. The average Poor Law Medical Officer (outdoor) does not give the satisfac- tion he ought to his patients." "The working classes," says another medical practitioner, " have the idea that the attention they get from the- Poor Law Medical Officer is not satisfactory," " They feel," said another witness, " that the District Medical Officers have not the time to attend to them." '* I am inclined to think," deposed a Shropshire Guardian, " that they do not get much of his services. He goes round to them in a casual way, but there are 220 CURATIVE TREATMENT OF THE SICK great complaints that the patients of the Poor Law . . . do not get very much attention from the doctors. ... I merely speak from my knowledge of the cottagers them- selves, and where there is illness, I find if there are more important cases in the neighbourhood the poor are neglected," " The poor people are very dissatisfied, I find," said the Hon. Sydney Holland, "with the medical relief that they get from the Poor Law authorities ; it is given in a very grudging spirit, and they do not believe in it." One of the District Medical Officers himself admitted to us " that the tradition of the service is that every pauper is to be looked on as being such through his or her own fault, and the tendency is to treat the case accordingly. ... In the town ... I believe that the tradition, as to a pauper, is that he is a shade only above a criminal. . . . Now to this tradition the Medical Officer tends, like all other officers, to become a victim, and the tendency is that the case of sickness is treated as a 'pauper' and not as a 'patient.' The Commission will, I trust, see the distinction." These complaints appear to us to do less than justice to the District Medical Officers themselves. So far as we have been able to see anything of their work, we have been struck by their personal kindness to the poor, and by their desire to relieve suffering. When we consider the method and amount of their remuneration, and the conditions of their duties, we are impressed with the zeal and devotion displayed, with the humanity shown to the poor, and with the large amount of unpaid, unrecognised and unrecorded work performed by them as a class. But taking into account all the evidence, we have to make two main criticisms on the Outdoor Medical Service as a system involving a large expenditure of public money. In too many Unions, it is clear, outdoor medical relief begins and ends with a bottle of medicine, and, in the twentieth century, we have ceased to believe in the liottle of medicine. It is not regarded as any part of the duty of the Poor Law Medical Officer to insist on, or even to inculcate, the personal habits necessary for recovery. " Under the Poor Law," reports our Medical Investigator, DOMICILIARY MEDICAL TREATMENT 221 " there is practically no sanitary supervision of phthisis in the home of the patient, . . . Phthisis cases are main- tained in crowded, unventilated houses. . . . Diabetes cases live on the rates and eat what they please. Infirm men and women supported by the Poor Law are allowed to dwell in conditions of the utmost personal and domestic uncleanliness. ... It is not worth while entering on any reform of the Poor Law unless this policy is changed. Beneficiaries must be compelled to obedience, alike in their own and in the public interest. And the officers who are placed in direct charge of the beneficiaries must themselves be subject to supervision and discipline." Our second criticism is that, from first to last, there is, in the Poor Law Medical Service, no thought of anything but " relief." It is not regarded as any part of the duty of the District Medical Officer to take any steps to prevent disease, either in the way of recurrence in the same patient or in its spread to other persons. His work is entirely unconnected, on the one hand, with the institu- tional treatment of the sick in the workhouse or Poor Law Infirmary, and on the other with the operations of the Medical Officer of Health. It is not regarded as any matter of reproach to a Board of Guardians or to its staff, that numerous mild cases of scarlet fever or chickenpox, and even thirty or forty per cent of the cases of measles or whooping cough, ringworm or mumps, should be wholly destitute of medical attendance, to the serious danger of the public health. It is not even the business of the District Medical Officer to reduce the amount of sickness in his district. All that he is charged to do, as it is all that he is paid to do, is to " relieve destitution " in a certain specialised way, namely, to supply medical relief to those applicants who have braved the deterrent attitude of the Relieving Officer and satisfied him that they would otherwise be without it. From first to last, in short, the Outdoor Medical Service of the Poor Law has no con- ception of the Public Health point of view. 222 CURATIVE TREATMENT OF THE SICK (c) The Restriction of Domiciliary Medical Treatment In the early part of our inquiry it was brought to our notice by the advocates of strict administration, that many Boards of Guardians had failed to carry out the policy pressed on them by some of the Inspectors of the Local Government Board to restrict the grant of Medical Orders to persons actually destitute. We found, indeed, that in a large number of Unions the grant or refusal of a Medical Order was practically left to the discretion of the Reliev- ing Officer — on occasions, indeed, even to the discretion of the workhouse porter. One of our committees, for in- stance, after visiting a large urban Union, reported that the " orders for medical relief were sanctioned en hloc." Of another populous Union our committee reported that " the medical relief was in all cases ordered by the Reliev- ing Officer, the Committee (of the Board of Guardians) merely confirming his action. The order in each case lasted for a month." Under these circumstances the tend- ency naturally is for the Relieving Officers to grant Medical Orders freely and indiscriminately ; sometimes in order to protect themselves against the risk of having an applicant die for lack of help ; sometimes " with a view," as the President of the Association of Poor Law Unions informed us, of "getting rid of" applicants for relief on the easiest possible terms. A Relieving Officer will say, for instance, " We will give you a Medical Order if you like, but we will give you nothing else." Frequently every person, w^ell or ill, who receives Outdoor Relief, is put on " the permanent list," and becomes entitled himself to send for the District Medical Officer whenever he chooses. In the laxest Unions, as we have gathered. Medical Orders are given to all who apply for them, without even being entered in the Applica- tion and Report Book. We have even had it given in evidence that, in one Union, the practice is for the Reliev- ing Officers to sign a batch of such Orders at a time, with the names and dates blank, and to leave them with the shopkeepers of the villages, from whom any person gets one who chooses to ask for it. This lavish and indiscriminate grant of Medical Orders, RESTRICTION OF MEDICAL TREATMENT 223 by medically unqualified persons, without any verification of the fact of illness, or of its urgency or gravity, has, we think, a disastrous efiect, both on the quality of the service rendered and on the spirit in which it is accepted. Under such a system a District Medical Ofiicer is quite in the dark as to the weight to be attached to the Order that he receives from the Relieving Officer ; he can feel no assur- ance that his services are really needed, or that the case is one of urgency. We have even heard of instances in which he has suspected, apparently with some justification, that the Order has been applied for by a malingerer, given by a Relieving Officer, or marked by him urgent, in order to vex or harass the doctor in revenge for some former lack of compliance on his part with an unwarranted request. Moreover, a lavish distribution of Medical Orders to all applying for them is a contravention of the present contract with the District Medical Officer, who is paid a meagre salary for attendance only on parishioners who are both sick and actually destitute. All this tends to make the District Medical Officers reluctant and sus- picious — to quote again the words of one of them, to make them regard the holders of Medical Orders " as paupers rather than as patients." It is to the credit of the District Medical Officers that their representations to us have taken the form, in the main, of complaints that many poor persons who, in fact, need their attendance are, under the present system, deterred from getting it ; and that, when such persons do succeed in obtaining a Medical Order, the delay has often injurious results. It has been pointed out that this would not be the case if, instead of the Relieving Officer, it was the District Nurse, the Certi- fied Midwife, the Health Visitor, the Sanitary Inspector, or any qualified person under obligation to search out and report cases of illness, who notified to the District Medical Officer that a sick person was in need of medical attend- ance. Nor is the effect of this indiscriminate grant of peremptory orders to the District Medical Officer, to visit persons who may or may not be ill, any less harmful to the recipients. Whatever may be the advantage of a public organisation of medical assistance, as universal and 224 CUEATIVE TREATMENT OF THE SICK as free — if not also as compulsory — as that of education, a careless and ignorant issue, by a Destitution Authority, of Poor Law Medical Orders to persons not really entitled to them, encourages fraud and malingering. The holder of a Medical Order may have merely pretended to be ill or pretended to be destitute ; he is under no responsibility with regard to his own illness, or to the order which he has obtained; he presents it or not, as he chooses; he takes the medicine or throws it away at his option ; he follows the doctor's advice, or remains dirty and dissolute, exactly as he pleases — without feeling under any obliga- tion to the community to co-operate in his own cure, or under any kind of compulsion to abandon the evil courses which may have led to his ill-health. ' On the other hand, it was represented to us that, in some Unions, there has been a persistent, and in a sense successful, attempt to restrict the use by the sick poor of the services of the District Medical Oihcers provided for them. In these Unions "good administration of the Poor Law Medical Service " is apparently taken to mean not curing the sick or preventing ill-health, but cutting down the number of Medical Orders. This policy is even expressed in standing orders or by-laws. Thus, Relieving Officers are often forbidden to grant Medical Orders without first paying a personal visit to the home of the applicant and investigating his circumstances, in order, not to find out how best to cure the suff'erer, but if pos- sible to discover some ground which makes him ineligible for aid. Other Boards expressly say " that orders by the Relieving Officer for Medical attendance must be more charily given, due inquiries being made when possible at the house before being granted, or at any rate at the earliest moment possible after being granted." In some Unions the applicant for a Medical Order is required to attend personally before the Guardians at their meeting, and explain, to this non-medical authority, how he comes to need medical aid. "Midwifery Orders," says one Board, "shall not be given by the Relieving Officer, except in urgent cases, without the consent of the Board of Guardians, given on personal application to them." An RESTRICTION OF MEDICAL TREATMENT 225 even more usual way of staviug off applicants is, whatever their circumstances, to insist on granting the Medical Order only as "relief on loan," this being sometimes printed, as a matter of course, on the form. " All orders for medical attendance," says a Suffolk Board of Guardians, " shall be granted in the first instance by way of loan, the applicant to repay 10s. for each midwifery case, and 5s, for each other case." The applicants then remain liable to repay the cost ; and the Relieving Officer is sometimes allowed a commission of 20 per cent on what he can recover. Occasionally the grant of Medical Orders in midwifery cases is restricted to families having less than a prescribed income, it may be 15s. or 18s. or 21s. a week, whatever the number of children, or it may be at the rate of 2s., 2s. 6d., or 3s. a week for each member of the family. In the EUesmere Union we were informed that Medical Orders were never given to any one, however ill, who was not otherwise in receipt of relief; in fact, the Guardians were under the impression that it could not lawfully be done. A more ingenious way of deterring applicants is to resolve " that when relief is administered to a labouring man who is himself ill (if the disease is not contagious) the Board requires that some of the children shall come to the Workhouse during the sickness," that is to say, into the General Mixed Workhouse that we have described. When the Medical Order has been given, it is made the duty of the Relieving Officer to visit the case frequently and regu- larly, not to see whether the patient is obeying the doctor's orders, or whether anything else is needed to restore him to health, but in order to discover whether he has not some undisclosed resources which would permit of the relief being withdrawn. The Guardians are, in fact, as one committee reports, " strongly of opinion that a large number of the cases relieved would manage without assist- ance from the Guardians if they were properly and systematically visited and dealt with by the Relieving Officer." We have found the practice of some Boards of Guardians even more severely restrictive of the use of the District Medical Officers than is implied by the foregoing Bylaws. VOL. I Q 226 CURATIVE TREATMENT OF THE SICK Thus, the Bradfield Union in this way claims to have reduced the number of Medical Orders granted from 700 to forty -seven per annum. In the Bermondsey Union, where the poor are said to " have more difficulty in getting relief now than they used," the permanent list of those on whom the District Medical Officers have to attend has fallen from over 1000 in 1901 to 322 in 1906, not because there is less sickness in Bermondsey, or less destitution, but merely because more difficulty has been put in the way of the sick poor getting Medical Orders. Nor is there any doubt as to the cause of the reduction. One District Medical Officer informed us that he was convinced that the reduction in the number of Medical Orders granted in a particular Union was due entirely to the deterrent effect of insisting on prior investi- gation and personal application to the Board of Guardians. The St. Pancras Board of Guardians reduced the number of its Medical Orders from 5324 in 1899 to 2546 in 1903, by making stringent inquiries on every application, re- . quiring the applicant to appear personally before the Board, tendering the Medical Relief on loan in many cases, and offering the alternative of admission to the Workhouse whenever deemed advisable. Thus the Medical Superintendent of the Mill Hill Infirmary of the West Derby Union (Dr. Nathan Raw) states "people will struggle on with a disease and spend all their money, and then apply to the Poor Law, in some cases almost when the people are dying ... in many cases they are deterred from seeking it until it is too late." *' The neglect of the poor to apply for Medical Relief," says another witness, "is partly due to the idea that Poor Law relief is a degradation. It has been so officially styled by the Poor Law Boards and I believe it is so considered by many of those engaged in the administration of the Poor Law." " You will find," we were told, that " in most cases where " the delay in getting prompt medical assistance " is the fault of the people, it is because sending for the doctor means making themselves paupers." The representatives of the British Medical Association were emphatic in their testimony that the association of the public medical aid RESTRICTION OF MEDICAL TREATMENT 227 with the Poor Law was in itself deterrent ; it was, they said, "the experience of every practitioner . . . that people avoid calling in the parish doctor because he is the parish doctor." The reluctance to come forward and state their need is increased by the fact that it is not to a medical man or a nurse that the sick persons have to make their applications for public medical assistance, but to the Relieving Officer, who, as we have seen, almost inevitably comes to think of himself as bound to do all that he can to keep people "off the rates." To the Relieving Officer, under the instructions of the Local Government Board and the Bylaws of the Boards of Guardians, this medical treatment of the sick by the District Medical Officer, even without other aid, is not to be denied to those who are both in need of it and actually destitute, but nevertheless to be restricted to as few cases as possible. The Hon. Sydney Holland, who has been a Poor Law Guardian in two different Unions, and whose experience of hospital administration is very great, in- formed us that when he was a Guardian he himself entirely acquiesced in this policy and " thought it was a very good thing. I thought that everybody who came before us was a swindler and must be most carefully inquired into, and asked whether he had not drunk too much, and all the rest of it. That is the ideal Guardian, a man who prevents imposition. . . . All Poor Relief," he continues, "is given reluctantly. Every Guardian is told to give it reluctantly ; every Poor Law Officer gives it reluctantly, and, in fact . . . the only person you relieve in the Poor Law is the person who is starving. ... It is exactly the same with regard to medical relief. You are not to treat medically unless they are paupers." The result is, as he informed us, " that the poor people were dissatisfied with the medical relief they got from the Poor Law ; that it is given grudgingly . . . the man going to the Relieving Officer, being put in the dock, questioned up hill and down dale, and treated as a thief." The advocates of this policy of restricting the use of the District Medical Officers asserted that it resulted in no hardship to the poor, or injury to the community. 228 CURATIVE TREATMENT OF THE SICK Other witnesses declared that it was " a real danger to the public," and that it was responsible for much of the excessive mortality among infants and unnecessary ill- health and premature invalidity among the wage-earners. In face of this conflict of testimony, w^e thought it necessary, not only to appoint a special medical investi- gator, but also to consult those who were ofiicially responsible for the public health — taking evidence, oral or written, from no fewer than 51 Medical Ofiicers of Health. We regret to report that the authoritative testimony thus obtained does not support the optimistic assumptions of the advocates of restriction of public medical aid. Whilst some of the witnesses seemed to take for granted the present system as inevitable, and not to have noticed any of its drawbacks, the great majority of the medical practitioners who gave evidence were definitely of opinion that a "deterrent" administration of Poor Law Medical Relief had a gravely adverse efi"ect on the public health. Many of them went further, and deposed that, in their opinion, the stigma of pauperism that w^as attached to the mere use of the services of the District Medical Ofiicer, by the very fact of his connection with the Poor Law, and the inconvenience and delay caused by having first to make application to the Reliev- ing Officer, were, in themselves, even without stringent administration, inimical to the health of the district. This has been demonstrated by many instances. We were informed that the present high mortality from the diseases of young children, and also many serious com- plications among those who survive, are undoubtedly due to the common lack of medical attendance in the families of the poor for what are regarded as the simple afi'ections of measles and whooping-cough, and mild and often un- recognised cases of chicken-pox and scarlet fever. " There is a widespread disinclination," testified a Medical Officer of Health for a Metropolitan Borough, " to utilise the services of the Poor Law doctors. In consequence of this failure to seek skilled medical advice, many cases of in- fectious disease go unrecognised, and to this fact we must attribute the comparative inefl'ectiveness of our modern RESTRICTION OF MEDICAL TREATMENT 229 methods of dealing with scarlet fever and diphtheria." Nor does the Board of Guardians, aiming at restricting medical relief, make things easier for those responsible for the health of the district. " Both friendly suggestions," publicly states a Medical Officer of Health, " and simple reports appear to cause irritation and resentment on the part of Relieving Officers and all officials connected with the Poor Law administration." A case was brought to our notice in which, when an officer of the Public Health Department was seeking to get sick children treated by the District Medical Officer, this action was made the subject of serious reproof by the Destitution Authority. " As a typical illustration of the great waste of money entailed by the present methods of Poor Law administration," officially reports a Medical Officer of Health, " I may mention a case that occurred in this district. Two cases of scarlet fever occurred in a family of six children. The mother was a widow with no income. There was sufficient room in the house for the proper isolation of the cases, and they could have been nursed at home, if a little help could have been obtained. Every possible effort was made to get assistance from the Poor Law Authorities, but without success, and the cases were removed to the Isolation Hospital. Nine days later, two more children had to be removed, and ten days later still another two. The total cost to the district for the treatment of these cases was £55, whereas a total allowance of £5, or even of food only, would certainly have prevented this unnecessary ex- pense. This is a single instance. The sacrifice of life, health and money resulting from the untreated cases of disease is beyond estimation." " Among the poor," says the same authority, " there is a vast amount of infectious illness continually present. Many of such cases remain unreported, untreated, practically unknown. They serve, however, as a continual and ever-present focus for the spread of such diseases among the general public. There is thus constituted a most grave pubhc danger. The only possible way to remove such danger is to devise improved and more easily available means for treating these cases. Treatment and pre- vention are inseparably associated in practically all disease. The one is essentially the complement of the other. By adequately providing for the early recognition and the proper treatment of all disease, an almost incredible improvement in the public health would rapidly result. The mere existence of disease, altogether apart from any consideration as to whether it is accompanied by destitution or not, should be sufficient to ensure proper medical treatment, if the public are to be relieved 230 CUEATIVE TREATMENT OF THE SICK of the ever-present dread of the sudden and rapid spread of infection." Nor is the danger confined to the notifiable zymotic diseases. It was given in evidence on high authority that the very great mortality from phthisis — a disease to which no less than one-seventh of the total cost of the Poor Law is said to be directly or indirectly due — is to be attributed in no small degree to the fact that sufferers are not en- couraged to present themselves for treatment in the early stages of the disease, when it is often curable, but when they are still capable of going to work, and are not regarded as destitute and thus not technically eligible for a Medical Order. Under the present arrangements of the Poor Law medical service, such cases are left outside its ken, until in due course the ravages of the disease have reached a stage at which the suff'erer, having in the meantime perhaps infected other members of the family, becomes simultane- ously eligible for Poor Law medical relief and incapable of deriving from it any real advantage. In fact, the Poor Law doctor seldom knows phthisis in any but its incurable stage, shortly before the sufferer enters the Workhouse to die. In some places, we were informed, one-third, and even one-half, of the deaths from phthisis take place in the Poor Law Institutions. Much the same may be said of cancer, which fills so many Workhouse beds, but which the Poor Law doctor hardly ever sees at a stage at which he can operate with any advantage. "Every year," we were authoritatively informed, *' many persons die of cancer whose lives could have been saved had they sought medical advice in time. Especially is this true of the poor." The Poor Law medical officers, says our Medical Investigator, see any amount of "inoperable cancers, and incurable Bright's disease, and overlooked rheumatic fever in children, causing heart disease later on." Less dramatic, but even more frequent, are the cases of chronic disability brought about by rheumatism and gout, heart disease in its various forms, varicose veins and ulcerated legs, and other affections which account for so many of the premature invalids among the Workhouse inmates, and which could have been cured, and many RESTRICTION OF MEDICAL TREATMENT 231 years added to the working life of the sufferers, if they had received proper medical treatment at an early stage, before neglect of the incipient disease had led to actual cessation of wage-earning and consequent destitution. " I have carefully examined over 4000 cases of consumption," deposed the Medical Superintendent of a Poor Law In- firmary, " and of these people approximately 60 per cent would never have come within the range of the Poor Law had they not had that disease." In short, as one witness significantly put it, " Guardians who deter the poor from coming for medical relief are themselves causing pauper- ism, for, as Mr. Joseph Chamberlain has said, ' preventable disease is the great agent for filling our Workhouses.' " (d) The Hospitcd Branch of the Poor Laiv As we have seen, the authors of the 1834 Report, and the Poor Law Commissioners of 1834-47, never contem- plated the establishment, under the Poor Law, of institu- tions for the hospital treatment of the sick poor. What they visualised was a continuance of the practice of granting to the sick Outdoor Relief and the services of the District Medical Officer. In the course of a generation, however, the Workhouses were found to be very largely peopled by the infirm, the disabled, the chronically sick, and even the suff'erers from acute diseases. By 1869 it was recognised that what was then ofticially termed " the hospital branch of Poor Law administration " had reached large dimensions. The policy of the Central Authority thenceforth definitely took the form, so far as the sick were concerned, of pressing for the provision of the most efficient institutional treatment that could be obtained. " There is one thing," said the President of the Poor Law Board in 1865, "that we must peremptorily insist on, namely, the treatment of the sick in the Work- houses being conducted on an entirely difi'erent system, because the evils complained of have mainly arisen from the Workhouse management — which must, to a great extent, be of a deterrent character — having been applied to the sick, who are not pi'oper objects for such a system." 232 CURATIVE TREATMENT OF THE SICK " If you have a sick man upon your hands," said one of the Local Government Board Inspectors in 1888, "the best thing you can do with him is to give him the best possible attention, to cure him and restore him to his work again." Such an improvement in the institutional treatment of the sick seemed, to the Inspectorate of 1869-1886, a useful auxiliary, if not the logical complement, of their crusade against all Outdoor Relief. Especially since the establish- ment of the Local Government Board has the pressure of the Central Authority on the Boards of Guardians to get them to provide better structural accommodation, new infirmaries, elaborate hospital equipment, trained nurses, and additional medical staff been persistent and unrelenting. Unfortunately, the great majority of the Boards of Guardians have failed to carry out this policy. We have had it brought to our notice by the Medical Inspectors of the Local Government Board, by accredited representatives of the medical profession, by philanthropists acquainted with the Workhouses in the rural Unions and the smaller towns, as well as by Poor Law Guardians and their ofiicers, that two-thirds of the sick now receiving institutional treatment at the hands of the Destitution Authority — amounting, as we have reason to believe, in England and Wales alone, to something like 60,000 persons — are still in the General Mixed Workhouse that we have described. We were informed that they were, in many cases, receiving treatment inadequate to their needs and inappropriate to their diseases ; and that this was resulting, not only in unnecessary personal sufiering, but also in a prolongation of the period during which they were maintained at the public expense, and, in too many cases, in their premature permanent disability. On the other hand, so deterrent are the conditions in these General Mixed Workhouses that many poor persons suffering from incipient disease — sometimes of a contagious character — and requiring in- stitutional treatment, refuse to enter their doors, until they are driven in by actual destitution in a moribund state. So grave an indictment led us, in view of the importance of the subject to Public Health, to obtain HOSPITAL BEANCH OF POOR LAW 233 much medical evidence, to visit many sick wards, and to appoint our own Medical Investigator. We regret to have to report, after considering all the evidence, that the continued retention, in the General Mixed Workhouses — never even contemplated by the Report of 1834 — of a large number of sick persons requiring curative treatment, amounts at the present time to a grave public scandal. We may conveniently consider first the small rural Workhouse, of which there are about 300 with fewer than fifty sick-beds in each. Such a Workhouse — containing habitually a score of men and women with chronic rheu- matism and asthma, and suff'ering more or less from senile imbecility and paralysis; half-a-dozen children from one to thirteen, subject, from time to time, to the usual diseases of childhood; the "village idiot," and various harmless lunatics and feeble-minded of both sexes and all ages ; every few months a lying-in case ; a few phthisical patients ; occasionally individuals with all sorts of ailments ; and now and then a tramp with smallpox upon him — is, over nearly half the superficial area of England and Wales, the only institution in the nature of a hospital available for the country-side. These 300 small rural Workhouses accordingly deal, in the aggregate — apart altogether from the *' chronics " and the persons suffering merely from senility — with thousands of sick persons annually, who require curative treatment. In most of these rural Workhouses, the buildings — which, as we have seen, were never intended for the reception of sick patients — are, to quote the words of a Local Government Board Inspector, " old and ill adapted to meet modern requirements . . . for the treatment of the sick." Some of them, reports our Medical Investi- gator, were not even erected " for Workhouses, but for factories or other purposes ; and in one or two cases the institution consists of a curious conglomeration of old houses of various sorts, set up anywhere within the boundary walls, and apparently altered or added to in irregular fashion as occasion arose. ... In at least one case the buildings are much too crowded on the site. . . . The floors . . . were of wood, often old wood, with wide 234 CURATIVE TREATMENT OF THE SICK seams for dirt to lodge in." More than one-fourth of the wards that he had measured " failed to comply with requirements," as to the minimum cubic space per inmate. In more than one-third of those visited, the hot water supply — "an absolute essential for the proper management of a Workhouse or Workhouse infirmary " — was " more or less defective." The bathing and sanitary accommodation for the sick is, as we have ourselves noted, often sadly old-fashioned. Perhaps the most important consequence of the structural defects of the old Workhouse building — with its small and often ill-ventilated rooms, its old wooden floors and absorbent walls, and its primitive sanitation — is that they often involve a disposition of the patients that is, to say the least of it, neither comfortable nor curative. "At present," reports an Inspector, "in the sick wards of a small country Workhouse, it some- times happens that children and adults, persons sufi'ering from phthisis, off'ensive cases, and imbeciles are not separ- ated from each other, and it seems to me that classification in this respect is what is most needed." One of our own committees found, on visiting the sick wards of a pro- vincial Workhouse, " that one mentally deficient patient keeps crying out, day and night, at frequent intervals, disturbing the other patients. He seemed to be in great discomfort, if not pain ; but is not removed on the ground of economy." But however desirable may be the structural advantages of a modern hospital building, with elaborate classifica- tion by wards, we are bound to say that we regard the somewhat primitive buildings of the old rural Workhouses as the least of their drawbacks. We have come across, in Workhouse sick wards, no such scandalous instances of overcrowding, dirt and insanitation as were formerly revealed in Workhouse inquiries ; and, as we are glad to add, no such neglect and inhumanity. The worst defects of the rural Workhouse sick wards of the present day, apart from the general conditions of admission, centre round the medical attendance and nursing. None of these 300 rural Workhouses has, or indeed needs, a resi- dent Medical Officer ; but the conditions under which tlie HOSPITAL BEANCH OF POOR LAW 235 medical attendance is afforded are, in our judgment, such as to make curative treatment almost impossible. The Guardians appoint one of the local practitioners to be the Medical Officer of the Workhouse, and expect him, at the most meagre stipend, to do all that is required for all the patients. These stipends — we have it on the authority of the Medical Inspector of the Local Government Board — are, in the majority of cases, "miserably inadequate." In one Workhouse that we happened to visit, containing as many as sixty -seven sick patients, we found that the Medical Officer, who has held the post for thirty years, received only £70 a year, out of which he stated that he sometimes spent as much as £25 in medicines. We desire to bring no accusation against a hard-worked and ill-remunerated class of doctors. " It would be easy," we are told, "to name Medical Officers whose work is beyond praise. . . . Unfortunately, there is another side to the picture." We are unable to escape from the conclusion that, in not a few Unions, the Workhouse Medical Officer finds himself able to attend only irregularly and in- frequently, and to give only a perfunctory service. We learn that " instances may be quoted where (making all allowances for the possible inaccuracies in the porter's book) a few minutes in the House two or three times a week constitutes the ordinary attendance of the Work- house Medical Officer." Nor can they afford to spend much time when they do attend. " Entries recently taken from porters' books in several Unions," declares the Inspector, " show that some Medical Officers frequently only stay for a few minutes in the House, and very rarely long enough to make an examination of the bodily con- dition of the patients and of their surroundings. The Medical Officer should certainly, and with sufficient fre- quency to ensure the object, thoroughly examine each of the patients, and particularly the bedridden ones, as to bodily condition and cleanliness, also the beds, bedding, appliances, and all other details connected with the proper treatment and nursing of the cases." Our impres- sion of the inadequacy of the medical treatment afforded to the sick poor in some of the small rural Workhouses 236 CURATIVE TREATMENT OF THE SICK does not rest on such general evidence only. "It is most desirable," said to us one of the General Inspectors of the Local Government Board, " that the Medical Officers sliould be much better remunerated than they are. They should be so remunerated that they could fairly be called upon to do the work as it ought to be done. There is a difficulty now if you say to a Medical Officer, * I find that you have been very little in the Workhouse,' and he says, ' I do all that I consider necessary ; that is my business, not yours.' ... I have come across striking instances in which I have been able to show a complaint. I re- member going into a Workhouse when the Medical Officer was not there. I said to the nurse, ' Have you any bed- sores ? ' She said, ' There is not a bed-sore in the place.' I went into some of the wards, and I saw one man look- ing very miserable. I said to the nurse, * Is that man all right ? ' She said, ' Yes.' I said, * Let me see his back.' She turned him over. He had a bad bed-sore. I looked at several other cases, and I found many bed- sores. I sent for the doctor. ... * I am horrified,' he said. ... If (he) had been properly paid to do his work thoroughly, he would probably have examined those patients. But he took the nurse's word for it because he was receiving an inadequate salary, and did as much work as he thought the money was worth." We ourselves found on our visits some confirmation of this testimony. In one Workhouse where the sick ward seemed unsatis- factory, our committee saw the Workhouse Medical Officer, and on questioning him, he " quite frankly admitted that he was not able to give to the patients as much attention as they ought to have. This he laid at the door of the Guardians, who, he said, would neither remunerate him sufficiently nor provide him with an assistant." With the meagre remuneration of the Workhouse Medical Officer goes the system — in the rural Workhouses still, we are informed, almost universal — of requiring him to provide, at his own expense, all the medicines that he prescribes. This system leads to serious results. It encourages, we are told, the Workhouse Medical Officer to prescribe alcohol (which the Guardians pay for) instead of the HOSPITAL BRANCH OF POOR LAW 237 other remedies of the Pharmacopoeia. The Workhouse Medical Officer practically finds himself limited to the simplest remedies. *' Human nature," says one of the Inspectors, " will not allow him to use anything which is very expensive. He cannot try the up-to-date drugs which may save a person's life. ... It is a very import- ant point, and I believe the present system may cost the life of an inmate of a Workhouse." What is far worse is the fact that *' there is nothing to prevent an unscrupu- lous Medical Officer," as a Workhouse doctor himself pointed out to us, " from using inferior drugs and stinting his patients with medicine." That such things do happen is, unfortunately, borne out by authoritative evidence. " About three weeks ago," testified the Medical Inspector of the Local Government Board, " I was inspecting a Workhouse, and I noticed a case in bed : I asked the Medical Officer what the case was, and he told me that it was a case sufiering from syphilitic disease, and appar- ently, from what he said, it was curable. I asked him if the case was having drug treatment. He said, 'No, I cannot afi"ord it ; my salary is not sufficiently adequate for me to find the expensive drugs necessary.' I asked him then whether he had reported this matter to his Guardians, and he said, * No,' and I advised him to do so. ... I think," added Dr. Fuller, *' that is a very good example of cases that frequently come under m^y notice.'^ The inadequacy of the medical attendance in the small rural Workhouses is rendered more disastrous by defective nursing. In spite of all the efi"orts of the Local Govern- ment Board, which have, in the past two decades, eff'ected great improvements, there are still many rural Workhouses without even one trained nurse ; there are still scores in which there is absolutely no nurse, trained or untrained, available for night duty ; there are even some, so far as we can ascertain, in which there is no sort of salaried nurse at all. Everywhere the Master and Matron have still to employ pauper assistants to help in attending to the sick. In spite of all that has been done, "the Reports of the Local Government Board Inspectors . . . show very clearly that this deplorable system of pauper assistants is far from 238 CURATIVE TREATMENT OF THE SICK decreasing in as rapid a manner as may have been hoped after the issue of the Nursing Order of 1897." " Looking at the facts with regard to the individual rural Unions which I visited," reports our Medical Investigator, " I have concluded that the nursing staff is insufficient in the majority of them. ... In one Workhouse the sick wards contain twenty-four beds, of which sixteen were occupied, nine of them by bedridden cases, and one of these with a bed-sore. For all this work there was only a single nurse, both for night and day service, and her duty included attendance on confinements in the lying-in ward, though these fortunately were infrequent. ... In only two or three of the rural Workhouses have I been able to form the opinion that the staff is sufficient." It does not need statistics of the mortality and of the recoveries in Workhouses, which unfortunately are lack- ing, to persuade us that, under such conditions as we have described, curative treatment of the thousands of sick patients in the 300 small rural Workhouses is, to say the least, difficult. The phthisis cases, of which there are many hundreds, seem to be given up as hopeless, there being usually no sort of special provision for them. The acute cases needing prompt treatment, constant nursing or expensive remedies, appear sometimes to fare almost as badly. " When I came [to this Workhouse]," said a nurse, " I was told ' the pneumonia cases generally die with us.' " A dim appreciation of the medical conditions in these small rural Workhouses, combined with the stigma of pauperism, explains why the sick poor insist on remaining in their own homes, however insanitary and overcrowded these may be. The General Mixed Workhouse is, in fact, as long as possible, shunned even by those who would benefit by it, to the grave detriment of the public health. Where such conditions exist — and we fear that they are characteristic of the majority of the rural Unions — the Guardians, as it seems to us, would not be warranted in adopting a policy, so far as the sick are concerned, of " offering the House," and refusing Outdoor Relief. Any suggestion for entrusting to the Destitution Authority powers of compulsory removal to such a General Mixed HOSPITAL BRANCH OF POOR LAW 239 Workhouse as we have described — even of the worst cases of neglected sickness and dangerous insanitation — appears to us quite out of the question. We do not wish to suggest that the structural condi- tions and medical and nursing attendance characteristic of the 300 small rural Workhouses, with their few thousands of sick, are equally characteristic of the 300 General Mixed Workhouses of the urban or more populous Unions, in which, as we regret to infer, there are ten times as many sick cases. In London, and a score of other large towns, there have been developed separate Poor Law Infirmaries, which we shall presently describe. But short of this development there is, among the General Mixed Workhouses of the 300 urban Unions, every possible variety in the character and efficiency of their provision for the sick. Some of these General Mixed Workhouses are as old, as ill adapted for use in the "hospital branch of the Poor Law," as badly equipped, and furnished with as inadequate a medical and nursing staff as the worst of the small rural Workhouses that we have seen. But under the constant pressure of the Local Government Board there has gone on, for forty years, a steady process of improvement. Here and there we find new sick wards added to the old Workhouse building ; the Guardians have begun to provide the drugs and medicines ; the pauper attendants have been gradually replaced by salaried " ward- maids," and these by nurses ; the nurses have got trained and a superintendent nurse has been installed ; occasionally on the occurrence of a vacancy w^e find that a young resi- dent doctor has been appointed ; the Superintendent Nurse and the Resident Medical Officer gradually win greater independence from the Master and Matron ; until finally, when the Workhouse has long been overfull, the Guardians have perhaps yielded to the repeated suggestions of the Inspector, the criticisms of the Medical Inspector, and the injunctions of the Local Government Board itself, and agreed to erect an entirely new and independent Poor Law Infirmary. We have not found it possible to estimate how many Unions, and what proportion of their aggregate sick population of thirty or forty thousand, are, at this 240 CURATIVE TREATMENT OF THE SICK moment, at eacli of these various stages of development. But all these sick wards of General Mixed Workhouses, however far they may have developed along the lines of improvement, seem to us — from the standpoint of curative treatment of the sick — to suffer from the blight of being, and being felt to be, pauper establishments. This blight shows itself in the inability of the Boards of Guardians wholly to exclude — even from Workhouse infirmaries having a dozen paid nurses — the pauper " wardsman " and the pauper attendant ; it is seen in the incapacity of the Guardians to realise the necessity, in what is becoming virtually a hospital ward, of a medical and nursing staff out of all proportion to what had formerly been customary in the Workhouse day room or night dormitory ; it shows itself in the friction which so frequently arises between the Resident Medical Officer or the trained Superintendent Nurse, and the Workhouse Master and Matron, who remain in command of the whole institution ; and it is manifested, above all, in the repugnance of the sick poor to enter even an institution for curative treatment when admission brings them plainly into contact with the Work- house itself. We have now to pass to the separate Poor Law In- firmaries, which form, in the Metropolis and some other large towns, the most extreme development of, to use the official phrase, " the hospital branch of the Poor Law." These institutions, erected on separate sites apart from the Workhouse, independent of the Master and Matron, administered by their own Medical Superintendents, having their own resident staffs of doctors and nurses, and wholly free from pauper attendants, are increasing annually in number, in size, and in cost per bed, and now probably accommodate, though in only a few score of the most populous Unions, at least a third of the aggregate total of sick persons for whom the Boards of Guardians provide institutional treatment. Here undoubtedly, to quote the congratulatory words of a Northern Board of Guardians, the sick poor '' receive care and attention such as the average ratepayer would find it difficult to provide for himself and his family." Their "most significant HOSPITAL BRANCH OF POOK LAW 241 feature," we are informed, " is that they have become largely surgical," some of them having daily operations under general anaesthesia. In some places the Poor Law Infirmaries receive a large proportion of acute cases of many different kinds ; in some there are frequent cases of measles, whooping-cough, chicken-pox, and other infectious diseases ; in one or two the number of tuberculous cases is very large ; in others there are many cases of accident ; the maternity ward is sometimes non-existent, sometimes a speciality ; and in one we have it noted that it has a specially large amount of " surgical operative work . . . five-eighths of its cases belonging to the hospital as dis- tinguished from the infirmary class." We do not feel competent to determine how far the claim often made on behalf of these Poor Law Infirmaries — that they are now fully equal to the endowed or voluntary hospitals — can be substantiated. But we notice certain general character- istics of these most modern of the institutions of the Destitution Authority. The structure tends to be elab- orate, ornate, and expensive. The lighting and heating, the ventilation and sanitation, the operating room and the dispensary, are all of the most costly, if not always of the most useful character. On the other hand, it is clear that, in the proportion of doctors and nurses to patients, and in the variety and specialisation of the staff, even the best Poor Law Infirmary falls markedly below the standard of the London Hospitals. It has been suggested to us that this is at once caused and justified by the fact that the Poor Law Infirmaries, though receiving yearly an increasing variety of diseases and accidents, still habitually contain a large proportion of chronic cases, requiring neither specialised medical skill nor continuous nursing. To some extent, no doubt, this contention is valid, but we think the weight of medical evidence is in favour of the view that, so far at any rate as the surgical and acute cases are concerned, there is, even in the best of the Poor Law Infirmaries, still inadequacy of medical attendance and nursing. " My general conclusion is," says our Medical Investigator, " that even where Guardians provide excellent, or perhaps extravagant, modern buildings, and VOL. I R 242 CURATIVE TREATMENT OF THE SICK equip these most elaborately with the most modern medical and surgical appliances, and furniture and furnish- ings, yet when they come to the appointing of a staff to do the work of these fine institutions, liberality of policy fails them, and parsimony takes its place. They may have most advanced views as to the manner in which the poor should be housed and fed, but when they come to medical work they are likely to adopt unknowingly a policy of sweating both as to the amount of work required and as to the payment made for it." We are inclined to attribute the backwardness in medical attendance and nursing, not only to the inadequate salaries, but even more to the lack of other stimuli. The medical staff of a Poor Law Infirmary has not the advantage of being under the super- vision and inspection of the medical profession ; the Boards of Guardians publish no medical reports of their work ; they are tested by no statistics of recoveries or case mortality, and encouraged by no inquiries from the Guardians or the Local Government Board as to their remedial treatment or their surgical successes. And whilst their doors are, by Local Government Board order, shut to medical students, and their work is divorced from the general current of clinical research, they suffer also from being equally divorced from the laboratory experiments and statistical investigations of the oflBcers of the Public Health Authorities. Perhaps the most striking contrast between even the best of the Poor Law Infirmaries and a good London Hospital is the lack of specialism in the institution of the Destitution Authority. The Medical Superintendent has to admit every case sent to him by the Relieving Officers, and these non-medical functionaries naturally go more by urgency and destitution than by the kind of disease. In some Unions, indeed, the Guardians assume that all cases requiring medical attendance and nursing should be sent to the Infirmary, which has, accordingly, simultaneously to treat a congeries of hundreds of patients of the most diverse kinds — the acutely sick and mere "chronics"; the expectant mother and the senile feeble-minded; children with measles or whooping-cough, and the sufferers HOSPITAL BRANCH OF POOR LAW 243 in advanced stages of venereal disease ; the phthisical, the cancerous, and the rheumatic ; the man knocked down by a motor car and the charwoman with bronchitis. " Children suffering from . . . infectious diseases have to be mixed up with adult patients." There are not even any mutual arrangements among the thirty Poor Law Infirmaries of the Metropolis by which each of them, in addition to its general wards, could provide specialised accommodation for one particular class of disease. In every Poor Law Infirmary — and some of them exceed in size the largest voluntary hospitals in the Kingdom — all the cases have to lie in the common wards, and be diagnosed, physicked, and operated on by the overworked Medical Superinten- dent and his two or three assistant medical ofiicers. The absence, even in the Metropolis and the largest towns, of visiting physicians and surgeons is here a patent draw- back of these extraordinarily mixed institutions. We do not, however, gather that there has been any official encouragement to specialisation, but rather the contrary. The development of the " hospital branch of the Poor Law " has, in fact, brought us to the dilemma that it may become apparently too efficient. Boards of Guardians have been officially advised to provide for their lying-in cases in the General Mixed Workhouse, rather than develop a maternity ward at the Infirmary, on the ground that the former course would deter applicants, whereas " there would be considerable danger of the Infirmary becoming a lying-in hospital, as there is great readiness and facility for obtaining admission to an Infirmary of cases that would not come into the workhouse." The far-sighted provision, by the Bradford Board of Guardians, of an admirable sanatorium for cases of incipient phthisis, and the actual encouragement, by a circular to all the medical practitioners of the town, of such patients to come in and be treated, before they are actually destitute, has caused some apprehension among those who cling to the idea of restricting the area even of the medical side of the Poor Law. All specialisation in medical treatment, it is suggested, whether phthisis sanatoria, Finsen Light, or Rontgen Rays, or the new serums, should be excluded 244 CURATIVE TREATMENT OF THE SICK from the Poor Law institutions. " Unless some organisa- tion or co-ordination of the relief is arranged," urged the Senior Medical Inspector of the Local Government Board, " we shall have expensive specialisation set up for persons who qualify for its receipt by becoming paupers," " It would be a temptation to a man to come to the Poor Law " in order to obtain these privileges. For good or for evil the Poor Law Infirmaries are growing rapidly in popularity. The excellence of the dietary and the accommodation — even, as has been sug- gested to us, the freedom from the perpetual observation and discipline of the students and nurses of a voluntary hospital — are attracting to these Poor Law institutions an ever-increasing stream of non-destitute persons. It has become the custom, in certain residential quarters of the Metropolis, for the servants of wealthy households freely to use the Poor Law Infirmary. In the more industrial quarters, the skilled artisans and the smaller shopkeepers are coming to regard the Poor Law Infirmary — especially when, as in Camberwell, or Woolwich, or Wandsworth, it happens to be the only general hospital in the locality — much as they do the public park or library — as a muni- cipal institution, paid for by their rates, and maintained for their convenience and welfare. To use the phrase of more than one of our witnesses, the Poor Law Infirmaries ** are fast becoming rate-aided hospitals." "It seems to me," observed to us the Chairman of one of the most populous Unions, ** an important point for the Commission to decide whether this state of things should be allowed to continue and increase, or whether it should be retarded." We did not have time to make any systematic investi- gation into the Poor Law Medical Service of Scotland, which was the subject of inquiry by a Departmental Com- mittee in 1904. From the information that we obtained, we formed the opinion that Poor Law Medical Relief in Scotland did not differ essentially from that in England and Wales, and that it was open to the same criticisms. The General Mixed Poorhouses seemed to us to exhibit the same defects, as institutions for the treatment of the sick, as the General Mixed Workhouses of England and Wales. HOSPITAL BRANCH OF POOR LAW 245 There is the same tendency to the development of a "hospital branch" of the Poor Law. "Owing to the splendid equipment of our modern Poorhouse hospitals," reports the Departmental Committee on the Methods of Administering Poor Relief in Eight Great Towns of Scot- land (1905), "it is not thought a degradation to have relatives treated in them. They are, to a large extent, taking the place of public hospitals or infirmaries, and being separate establishments their connection with the Poorhouse is altogether lost sight of. In the case of the three hospitals recently erected by the Glasgow Parish Council the name ' Poorhouse ' has been dropped." On the other hand, the largest Poorhouses, even in the most important towns, appear to be sometimes terribly understaffed. One of our committees gave us the following report after visiting two of the most important Poorhouses in Scotland. " In one of the Workhouses there were about 600, in the other about 800, inmates of all kinds, the numbers rising 25 to 30 per cent in the winter. Each of these vast Workhouses had only a single resident medical officer — in both cases a young woman. Aided only by a consultant visiting thrice a week, her duties were to examine thoroughly every inmate on entrance, in order to discover what exactly was his or her disease or infirmity ; to certify which of the adults — all presumably non-able-bodied — were fit for the ' test ' (work) ; to settle the diet and treatment of all persons actually sick ; and to supervise the arrangements for the children and infants. In each of the Workhouses the ' hospital cases ' alone numbered between two and three hundred. In one of them, at any rate, there was a phthisical ward, a surgical ward, an ophthalmic ward, a lying-inward, and, strangely enough, a male venereal ward — all under the sole charge of the same young lady doctor who had the medical super- vision of the rest of the establishment. The nursing stafi' was far below an English standard, extensive use being made of pauper inmates. In many of the large wards that I entered there was no trained nurse in attendance, even in the daytime. In one of these institutions (I forgot to ask in the other) there were only three night nurses for all the 246 CURATIVE TREATMENT OF THE SICK hundreds of patients. The operations — some abdominal sections, and others of apparent difficulty — were performed by the same one young lady doctor with the help of the consultant, who was a physician 1 No record of the results was kept. The same one young lady doctor had to extract the teeth of patients requiring this service. " Altogether, I venture to suggest to the Commission that the condition of the hospital wards in these two large Workhouses demands special investigation." (e) The Defects of the Poor Law Medical Service traced to their Root We have, therefore, to report that the Medical Branch of the Poor Law, now becoming an exceedingly costly service, is, in our opinion, far from being in a satisfactory condition. There is, to begin with, all over the kingdom a remarkable lack of uniformity between district and dis- trict in the treatment accorded to the sick poor. In respect of domiciliary medical attendance we find in some places the doctor's services lavished on all who ask for them, whilst in other places they are refused to any one who is not actually destitute of the means of subsistence. *' It is indefensible," rightly declares the Poor Law Medical Inspector of the Local Government Board, "that a sick and destitute person who happens to be ill in one Union should be less well nursed than his confrere who falls ill in the next Union, where he is well cared for and restored to the community at a much earlier period on this account alone, while his confrere in the neighbourino- Union, owing to the inadequacy or inefficiency of the nurs- ing staff, or both, becomes a permanent charge upon the rates." Yet the institutional treatment provided for the sick poor varies from mere reception in the General Mixed Workhouse that we have described, with little or nothing beyond pauper nursing and the scanty visits and inefficient treatment of an underpaid Medical Officer, unable to afford either the time or even the remedies required by the disease, up to the almost luxurious maintenance and relatively excel- lent medical care and nursing of the newest Poor Law DEFECTS OF POOR LAW SERVICE 247 infirmaries, not unjustly called rate -supported hospitals. These extremes of deterrence and attractiveness in the insti- tutions provided by the Destitution Authority in different districts for the sick poor, result in an even greater diversity in the classes of persons maintained in them under the common designation of paupers — varying from those miserables whom nothing but the imminent approach of starvation drives into the hated General Mixed AYork- house, up to the domestic servants of the wealthy, the highest grades of skilled artisans and even the lower middle class, who now claim as a right the attractive ministrations of the rate-maintained Poor Law hospitals characteristic of some of the great towns. But the absence of national uniformity, which the authors of the 1834 Report regarded with such disfavour, appears to us, in 1909, the least of the evils to which we have to call attention. What seems, from the standpoint of the community, most urgently needing reform is the deterrent character which, in all but a few districts, clogs and im- pedes the curative treatment offered to the sick under the Poor Law. It has been demonstrated to us beyond all dispute that the deterrent aspect which the medical branch of the Poor Law acquires through its association with the Destitution Authority, causes, merely by preventing prompt and early application by the sick poor, an untold amount of aggravation of disease, personal suffering, and reduction in the wealth-producing power of the manual working-class. Scarcely less harmful in our eyes is the unconditional character of the "medical relief" given under the Poor Law. The District Medical Officer finds it no part of his duty — for it, indeed, he is neither paid nor encouraged — to inculcate better methods of living among his patients, to advise as to personal and domestic hygiene, or to insist on the necessity of greater regularity of conduct. No attempt is made to follow into their homes the hundreds of phthisical and other patients dis- charged every week from the sick wards of the Work- houses and Poor Law infirmaries, in order to ensure at any rate some sort of observance of the hygienic pre- cautions without which they, or their near neighbours, 248 CURATIVE TREATMENT OF THE SICK must soon be again numbered among the sick. From one end to the other of the Poor Law Medical Service, costly as it now is, we find, in fact, a complete and absolute ignoring of the preventive aspect of State medicine. To the Relieving Officer it is officially a matter of indifference whether the applicant is most likely to recover, or to recover most rapidly or most completely, in the Work- house or in his own home. It is no part of his duty to consider whether the applicant's wife and children will suffer most in health by his removal to the infirmary, or by his struggling on in his avocation, with his lungs getting steadily worse, in order to avoid the stigma of pauperism. If a poor family takes measles or whooping-cough badly, and cannot afford competent medical attendance, it seems to the Destitution Authority a wanton incitement to pauperism to urge them to apply for the attendance of the District Medical Officer — though abstention may mean, through neglected sequelw, the lifelong crippling of the health of one or more of the children. The prevalence of ophthalmia of the newly born, with its result of entirely preventable blindness, will not appear as any matter of reproach to those Destitution Authorities which have managed to restrict their Midwifery Orders. Nearly the whole of the children of a slum quarter may go on year after year suffering from adenoids, inflamed glands, en- larged tonsils, defects of eyesight, chronic ear discharges, etc., which will eventually prevent many of them from earning their livelihood, without inducing the Relieving Officer and the Destitution Authority to notice anything beyond the total sum coming in to the household of each applicant for a Medical Order or other relief. Even to the average Poor Law doctor, it does not seem so im- portant to prevent the spread of disease, or its recurrence in the individual patients, as to relieve their present troubles. In short, from beginning to end of a Poor Law expenditure of over £4,000,000 annually upon the sick, there is no thought of promoting medical science or medical education, practically no idea of preventing the spread of disease, and little consideration even of how to prevent its recurrence in the individual. The question DEFECTS OF POOR LAW SERVICE 249 cannot fail to arise whether so large an expenditure on mere " relief," with so complete an ignoring of preventive medicine, can nowadays be justified. Under these circumstances we cannot recommend any extension of Public Medical Service by the Destitution Authority. We do not think, for instance, that it is desirable for the Destitution Authority to undertake the urgently needed service of the treatment of tuberculosis in its early stages — still less that it should, as at Bradford, actually encourage persons to become paupers in order to be treated. We agree with the Senior Poor Law Medical Inspector of the Local Government Board in deploring the tendency for the Destitution Authority to *' set up . . . expensive specialisation" in the treatment of the sick " for persons who qualify for its receipt by becoming paupers." An equally pressing public need, urged upon us by every sort of witness, is some power of compulsory removal to an institution of persons found lying neglected, dangerously sick or contaminating their surroundings. Yet so long as the institutions for the sick poor are in the hands of a Destitution Authority, with its stigma of pauperism, its deterrent machinery, and its failure in many districts to provide anything better for the unwilling patient than the General Mixed Workhouse that we have described, no responsible Minister of the Crown could propose, and no Parliament would permit, the concession to an authority dominated by the idea of "relieving desti- tution " of any such power of compulsory removal. Thus, all the defects and all the shortcomings of the Poor Law Medical Service as it at present exists are inherent in its association with the Destitution Authority. (f) The Treatment of the Sick hy Voluntary Agencies It has been represented to us that the whole provision for the sick now made by the Destitution Authority, alike in its domiciliary treatment and in its " hospital branch " — being legally confined to the destitute — is but the fringe of a more general provision for the sick made by other agencies ; that these other agencies impinge upon the 250 CURATIVE TREATMENT OF THE SICK medical work of the Poor Law, and are themselves im- peded by it ; and that, if the Poor Law medical work were brought to an end or seriously restricted, they might with advantage undertake the whole service. These voluntary agencies in some cases provide their service gratuitously ; others claim to be wholly self-supporting ; whilst others again exact a partial contribution for their benefits. Across this classification runs the cleavage be- tween those voluntary agencies maintaining residential institutions and those supplying only domiciliary treat- ment. To begin with the domiciliary treatment of the sick poor, we find overlapping the work of the District Medical Officer, (a) the Free Dispensary or " Medical Mission " ; (b) the out-patient department of the voluntary hospital ; (c) the doctor's medical club, or the Friendly Society or other " contract practice " ; and (d) the Medical Provident Association started by a combination of the local doctors, or the Provident Dispensary managed by a philanthropic committee. These four classes of agencies for domiciliary treatment of the sick poor difler widely from one another in their geographical extension, the doctor's medical club or contract practice being, for instance, wide-spread over town and country alike, and the out-patients' department being confined to the Metropolis and a few large towns. They difi"er also in the degree to which, in one place or another, they impinge upon or overlap the Poor Law. The free dispensaries and " medical missions," on the one hand, and the out-patients' departments of the volun- tary hospitals on the other, have in common the attribute of ofi"ering medical attendance and medicine gratuitously to those who come for it at prescribed times and places — sometimes without the slightest fee or formality, sometimes on presentation of a subscriber's letter, and sometimes on payment of a few pence for the medicine supplied. Started originally on a small scale, in order to afi"ord relief to the suffering poor who had access to no other doctor, these centres of gratuitous doctoring now minister, in the Metropolis and in certain other towns, to literally hundreds of thousands of cases aimually. Here, at any rate, we BY VOLUNTARY AGENCIES 251 have unrestricted access to medical treatment — a widely advertised gratuitous provision which to some extent mitigates the hardship of a restriction of Poor Law Medical Relief, and which goes far to explain, in the Metropolis and the other towns in which it exists, the slow growth of any form of medical insurance. " In our great cities," states a great hospital authority, " and especially in the Metropolis, the vast out-patients' depart- ments of the voluntary hospitals, with their ever-open doors, oifering gratuitous treatment to all comers, are a standing obstacle to any efficient reform of the home treatment of the sick poor. No organisation of Provident Dispensaries or Public Medical Service, no system of mutual insurance for medical attendance, no scheme based on thrift, supplemented by State aid, can hope success- fully to compete with the open hand and high prestige of the great voluntary hospitals." This objection to the out-patient departments — that of preventing more self- supporting forms of medical treatment — will, however, not be conclusive to those who desire that the sick poor should have every possible access to medical assistance in their hour of need. What appears more serious is the assertion that the treatment afforded to the bulk of the patients is, from the standpoint of preventive or really curative treatment, wholly un- satisfactory. " These great institutions," continues the eminent physician of Guy's Hospital whom we have already quoted, " while preventing the proper development of other agencies, are quite unable efficiently to fill their places. They cannot carry their services to within reasonable distance of every patient's door, nor can they follow the patient to his home when too ill to attend at the out-patient department, and not ill enough, or not suitably ill, for admission to the wards." Indeed, from the necessarily hurried way in which the work has to be done, no less than from the crowding together of all sorts of sick persons — sometimes men, women, and children of all ages — with sores and ulcers, with coughs and expectorations, not infrequently with a case of zymotic disease among them, kept waiting for hours cooped up in dirty and insanitary 252 CURATIVE TREATMENT OF THE SICK waiting-rooms, we cannot help regarding these mammoth out-patients' departments as positive dangers to the public health. Nor is this merely our own opinion. " As a matter of well-known fact," testified a medical practitioner of experience, " the out-patient department is so crowded that the work has to be done in a slipshod fashion, and unless the case happens to be an ' interesting ' one, the patient is put off with the stereotyped ' How are you to- day ? ' * Put out your tongue ' ; ' Go on with your medicine.' No one who knows the system can blame the infirmary doctors, as they are notoriously overworked. Many people go there who could well afford to pay for outside adAace, and whose complaints are of the most trivial character. The consequence is that cases which really require time and consideration frequently fail to get it from the overworked house-surgeon or physician." However profitable may be the out-patients' department in attracting the subscriptions of the benevolent ; however convenient it may be as a means by which the hospital can pick out " interesting " cases which are wanted inside ; and however genuinely useful it may be as a preliminary diagnosis which promptly sifts out and admits the cases requiring constitutional treatment, we are bound to conclude that, to a large proportion of the patients dealt with, it is, so far as any preventive or really curative effect is concerned, little better than a delusion. It is, indeed, difficult to take seriously in the twentieth century, as an organisation professing to treat disease, the typical arrangement under which an overworked and harassed house-surgeon gives a few minutes each to a continuous stream of the most varied patients ; without knowledge of their diet, habits, or diathesis ; without any but the most perfunctory examina- tion of the most obvious bodily symptoms ; without even the slightest " interrogation of the functions " ; and without any attempt at domiciliary inspection and visitation. " At present," summed up one experienced medical practitioner, the out-patient department of the voluntary hospital " is to a great extent a shop for giving people large quantities of medicine." We need not describe the Free Dispensaries and BY VOLUNTARY AGENCIES 253 " Medical Missions " which abound in the slum districts of a few large towns. All the arguments against the gratui- tous, indiscriminate, and unconditional medical attendance afforded by the out-patients' departments of the hospitals appear to us to apply, in even greater strength, to the Free Dispensaries and Medical Missions ; with the added draw- backs, that they are not, as a rule, under responsible and specialised medical supervision, and that they are not able to offer immediate institutional treatment to those of their patients whom they find to require it. The " Medical Missions," in particular, were stated to us to be " the worst of the whole lot . . . mixing up medicine and religion," and seeking to attract persons to religious services by the bait of " cheap doctoring." In our opinion, all these centres for the gratuitous, indiscriminate, and uncondi- tional dispensing of medical advice and medicine, far from meriting encouragement, or offering opportunities for ex- tension, call imperatively — at any rate where they involve the gathering of crowds of sick persons in halls and passages — ^for systematic inspection and supervision by the local Medical Officer of Health, in order to ensure that they are not actually spreading more disease than they are curing. We pass now to those agencies for domiciliary treat- ment which are based on contributions from the persons attended to, wholly or partially covering the cost of the service. The most widespread of these agencies is the more or less formally organised medical ** club," or " con- tract practice " — it may be a regular friendly society giving also sick pay ; it may, on the other hand, be merely a scratch enrolment of members got up by the doctor himself for his own convenience and profit — the members in either case paying a small sum weekly or quarterly whilst they are well, in order that, when they happen to be ill, they may obtain medical attendance and medicine free of charge. This " club practice," which has, in one or other form, greatly increased during the past few decades, has plainly some advantages. The poor pay something towards their own doctoring, and the feeling that they are themselves paying for it increases their independence and self-reliance. They pay for it, too, by the device of insurance, by which 254 CURATIVE TREATMENT OF THE SICK the cost of the years of sickness, being spread over a large number of persons, falls in effect upon the years of good health, when the small periodical instalments can be borne with the least inconvenience. Notwithstanding these advantages, there is, we notice, a feeling of uneasiness among the medical profession, and, we think, also among the clients of this club or contract practice, as to the real benefits of the arrangement. The contracts so extensively made by the organised Friendly Societies for medical attendance on their members are constantly producing strain and friction in the relations between the societies and the local practitioners whom they employ, breaking at intervals into open warfare. The doctors allege that the remuneration allowed to them is so insufficient as hardly to cover expenses, whilst many persons of substantial means take advantage of the society membership. The members of the friendly societies, on the other hand, complain that they get only perfunctory attend- ance, that the doctor favours the committee men or other influential members, and that he seeks to recoup himself by charging fees for all the other members of the family. We need not consider these mutual recriminations, except in so far as they reveal conditions inherently inimical to the cure and prevention of disease. We have it in evidence that " the club doctor is not infrequently regarded as an inferior kind of practitioner. I have known," says a Medical Officer of Health, "several cases where members of clubs, on the occur- rence of serious illness in themselves or their families, have discarded the services of the club doctor and incurred the expense of employing a private practitioner. A few weeks ago I was asked by a workman whether I thought a ' club doctor ' was competent to treat a case of scarlet fever. . . . From my own experience in club practice, I can testify to the extremely unsatisfactory conditions under which it is carried on. The examination of a patient should be conducted on the principle laid down by Trousseau : * Interrogate all the functions,' but in a busy club practice it is impossible to interrogate even one function with sufficient care." But besides the adverse influence on public health which medical attendance upon such conditions must necessarily BY VOLUNTARY AGENCIES 255 exercise, the contract price of Friendly Societies fails altogetlier to provide for some of the classes for whom the provision of medical aid is, in the public interest, most essential. Speaking broadly, the Friendly Societies do not provide medical assistance for any woman, whether married or single, or for children. They do not, if they can help it, admit " bad lives," against which all Friendly Societies protect themselves by a medical examination prior to admission, or any persons suffering from constitutional defects or incipient disease. Nor do they provide for persons, even if already admitted to membership, who suffer from venereal diseases or the results of alcoholic excess. Taken together these excluded classes must amount to more than three-fourths of the population. Much the same objection applies to the private medical clubs established by doctors for their own profit. It is true that, unlike most of the Friendly Societies, they do provide for children and also for wives, though midwifery is not included. But the remuneration is practically never sufficient to enable the doctor to devote the time and attention necessary for really curative work. There is the same exclusion of " bad lives," with the additional drawback that, in the doctor's own medical club, there is no obligation to continue the membership of any member who develops chronic disease, or even to continue the club at all if he thinks that the average sickness becomes too great. Needless to say there is no idea of prevention, or even of taking precautions against the communication of disease. " The long waiting in the crowded waiting- rooms at the doctor's surgery," we are authoritatively informed, " tends to spread infectious disease, to injure the health of the patient, and to cause a considerable loss of time, which in many cases inflicts inconvenience or even actual loss on the poor. Moreover the doctor should take account of the home conditions of the patient. In the home there are various influences which assist or retard recovery, and the doctor should make himself acquainted as far as possible with those conditions and endeavour to modify them in the interest of the patient. For instance, sanitary defects should be reported to the 256 CURATIVE TREATMENT OF THE SICK Sanitary Authority, and advice should be given as to the due sanitary ordering of home. The overworked club doctor, however, has time for none of these things. He reduces his domiciliary work as much as possible, and encourages the patients to come up to his surgery for treatment, and it is extremely rare for him to report anything to the Sanitary Authority except cases of noti- fiable infectious disease." There is the same temptation to supply only the cheapest medicines that we have seen to prevail where the Poor Law Medical Officer has himself to provide drugs. There is even a tendency, it is said, to pander to the medical superstitions of the sick rather than correct their bad hygienic habits. " To the poor people who crowd his surgery," as one overworked club doctor explained, " he must be equally subservient. They must not be allowed to grumble about the club medical man ; and to ensure their goodwill it is best to treat them more in accordance with their palates than with their symptoms. To satisfy these patients it is necessary to give them a lot of medicine. It must be a dark medicine with a strong taste, preferably of peppermint." Hence we are not surprised to be informed by a responsible medical witness that, to the "medical profession, club practice is most distasteful. No practitioner remains a club doctor any longer than he can possibly help. The disadvantages of club practice constitute a burning question for the medical profession at the present time. In various parts of the country practitioners are banding together to resist what are spoken of as the * sweating ' methods of the clubs, and the weapon of the strike (with the concomitant ostracism of the ' blackleg ') is being freely employed by these associations of medical practitioners in their struggle for better conditions of club practice." To quote the words used by a medical witness, himself a Poor Law Guardian, " the clubs are a failure, both for the patients and for the medical men." It is, we think, impossible to avoid the conclusion that the spontaneous and competitive organisation of medical insurance — far from being in a position to supersede the Poor Law Medical Service — has, in all its varied forms, BY VOLUNTARY AGENCIES 257 proved in practice to be inimical alike to the medical profession and to the public health. This result has gradually forced itself upon the conviction of philan- thropists and the medical organisations. In certain provincial towns the local medical practitioners have combined to establish " Provident Medical Associations," on a plan which, after some hesitation, has received the endorsement of the British Medical Association. These Provident Medical Associations difl'er from the medical clubs got up by individual doctors, and from the contract practice of the Friendly Societies, only in the fact that all the medical men of the locality who are willing to take part share in the practice and in the con- tributions, in exact proportion to the number of members who select each of them as their doctor. " We consider it undesirable," testified the representatives of the British Medical Association, " that there should be the existing monopoly in contract practices ; we think they should be thrown open so that all the patients should have a choice of all the medical men in the district." The Provident Dispensaries established by philanthropists in London and some other places, are, for the most part, based upon the same plan of allowing the contributing member a choice of doctors, and sharing the contributions among all the doctors on the list in proportion to the number of patients whom they severally attract. These deliberately organised arrangements for combining medical insurance with free choice of doctors have made little headway ; owing, it is said, to the difficulty of inducing the doctors to combine, and, in the Metropolis and other large centres of popula- tion, also to the rivalry of Free Dispensaries and Medical Missions and the out-patients' departments of the hospitals that we have already described. But as it has been suggested to us by responsible witnesses that charitable persons might be urged to foster the Provident Dis- pensaries and Provident Medical Associations ; that Poor Law Medical Relief might be so restricted as to compel all poor persons to join them, as the only way by which they could obtain medical assistance in their hour of need ; and even that some such system of Provident Medical VOL. I s 258 CURATIVE TREATMENT OF THE SICK Insurance, with free choice of doctors, might well receive a State subsidy, and might actually be made to take the place of the Outdoor Poor Law Medical Service, — we have felt compelled to examine with some care both its results and its possibilities. After careful consideration of the working and results of medical insurance in all its various forms, our conclusion is that we should hesitate before recommending to the charitable any deliberate extension of it, even at its best. " It must be borne in mind," observes a Medical Officer of Health, "that the 'self-supporting' character of a medical club is largely an illusion. There are many diseases that a club doctor does not attempt to treat. The vast majority of notifiable cases of infectious disease, lunacy, and an increasing number of cases of tuberculosis are treated in rate -supported institutions. Abdominal surgery, ophthalmic surgery, any surgical operation except the most trivial, and many other con- ditions are treated in hospitals that are supported by private charity. If these institutions were not available, clubs and provident dispensaries could not be conducted on their present conditions, and, therefore, it is true to say that, in a sense, these so-called ' self-supporting ' medical agencies are partly supported by the rates and partly by private charity." But even with regard to the kind of sickness with which they actually deal ; the indigestions, the chronic catarrhs, the sores and eruptions, the palpitations, the dragging pains of the woman worker, the rheumatism and lumbago of the outdoor labourer — the quality of their ministrations leaves, as we have seen, much to be desired. In nearly all these cases, as has been over and over again pointed out to us in evidence, what is needed is not so much " a bottle of physic " or an oint- ment, as some alteration in the unhygienic methods of living to which so many of the poor, whether from ignor- ance, from sheer poverty or from lack of self-control, are unfortunately addicted. But this is just where all the forms of provident clubs or dispensary practice fail. To quote the words of an experienced physician " they give people a bottle of medicine, but they do not do much else. BY VOLUNTARY AGENCIES 259 They take no supervision of their home surroundings, and no supervision of the general hygiene, and they never provide anything in the way of food and nourishment. It is very often much more food that is wanted, for instance, with the children. The cost of feeding an infant alone is 3s. a week, and the people cannot always afford it. They only get an attempt at food in the shape of cod-liver oil or something of that kind from the hospital." " The amount of medicine consumed," deposed a medical expert with regard to perhaps the largest and most flourishing of the Provident Dispensaries, '* is out of all proportion to the amount of advice taken." All this applies with even greater force where, to the device of medical insurance, there is added a free choice of doctors. The medical practitioner who is chary with his drugs, but prodigal and plain spoken in his advice about giving up bad habits and injurious excesses in eating and drinking, is seldom popular among the poor. To give either public encourage- ment or public aid to any system of medical attendance among the poor that was based on a free choice of doctors, and on their remuneration according to the number of patients that they severally attracted, could not fail, in our opinion, to perpetuate and intensify the popular superstitution as to the value of medicine and the popular reluctance to adopt hygienic methods of life ; and — as we fear we must add — could not fail also to foster the injurious ** medical demagogy " to which, in the stress of competition, these popular feelings already give occasion. Apart from the general shortcomings of any system of medical insurance so far as its contributing members are concerned, it is, in our judgment, for other reasons quite impossible to employ it as a substitute for the Poor Law Medical Service. We note, to begin with, that neither the Medical Association nor the Provident Dispensaries have themselves had any hope of including in their membership those for whom the Poor Law Medical Service is provided, namely, the destitute. It has, however, been suggested to us that the Local Authority, instead of having a Poor Law Medical Officer, might enroll all the persons now or hereafter entitled to medical 260 CURATIVE TREATMENT OF THE SICK relief as members of the local Provident Association, simply by paying the requisite contributions in their names. But, if this were done, or done whenever any case might prove to require medical aid, we fail to see what motive there would be for any person to pay his own contribution to the Association. We have it in evidence that one of the strongest inducements at present to join a medical club or otherwise to pay for one's own doctoring is the free choice of doctors which is thus secured. The poor, we are told, strongly resent having to go to one particular doctor whether or not they like him or have confidence in his treatment. But if the labourer who has neglected to contribute to the Provident Medical Associa- tion finds himself, when illness overtakes him, with just the same privilege of choosing his own doctor and of changing with equal facility from one doctor to another, as if he had himself contributed, it is difficult to see why anybody should be at the pains of contributing at all. Thus the use of these Provident Medical Associations by the Destitution Authority, in order to provide for the paupers requiring medical treatment, would very shortly bring the self-supporting side of these associations to an end. It has been suggested that the difficulty would be avoided if the Provident Medical Associations were fortified by a compulsory enactment, requiring every adult to become a member for himself and his dependents. The short answer to this suggestion is that it is in this country, under present conditions, totally impracticable. For the Government to extract any weekly contribution — let alone the substantial contribution that would be necessary — from the millions of unskilled and casually employed labourers of our great cities, from the hundreds of thousands of home workers in the sweated trades, from the women workers everywhere, from the tens of thousands of vagrants and their dependents, would be an impossible task. To bring the Government into the field as a rival collector of weekly pence in the skilled trades — whether or not deducted by the employer from the wage — would excite the strongest opposition not only from those doctors BY VOLUNTARY AGENCIES 261 who have large medical clubs of their own, but also from the whole Trade Union movement, from all the friendly societies and from the tens of thousands of agents and collectors and the millions of policy-holders of the industrial insurance companies — an irresistible phalanx ! Nor would such a method of levying the revenue required to pay for universal medical attendance be, in accordance with the classic canons of taxation, economically justified. It would, in short, be in the nature of a poll-tax ; and England has not had a poll-tax since 1381. Finally, for the Government in this way to guarantee the revenue of these Provident Medical Associations would, we suggest, involve the Government in the necessity of guaranteeing the management. We should thus have got round again to a State Medical Service, but this time to one of gigantic dimensions. We have left to the last the objection that seems to us the most serious against the proposal to supersede the Poor Law Medical Service by any system of medical insurance, whether voluntary or compulsory, which involves the free choice of doctors by the persons for whom the medical attendance is provided. In the treatment of poor persons, the problem is complicated by the frequent necessity for supplementing the medical attendance and medicine by " medical extras," that is to say, nourishing food and stimulants of one sort or another. It must necessarily be left to the doctor to recommend authoritatively in which cases this extra nourishment is required for curative treatment. If the patient can choose his doctor, he will inevitably choose the one who is most addicted to ordering '' medical extras," and the medical practitioner whose remuneration is dependent on the number of patients whom he attracts will be under a constant temptation to recommend, for any person who looks anaemic, at the cost of the ratepayer, the additional food or stimulant for which all poor patients have a craving. To give to the destitute, at the cost of the rates, not access to the particular medical treatment that their ailments really require, but the power to choose, and to enrich with their fees, that one among all the doctors of 262 CURATIVE TREATMENT OF THE SICK the town who most commeDcls himself to them, would be, we suggest, most disastrously to aggravate all the existing temptations to " medical demagogy." To expect this freely-chosen doctor to give, not the " strong medicine " beloved by the poor, or the appetising " medical extras " for which they crave, but the stern advice about habits of life on which recovery really depends — to look to him to speak plainly about the excessive drinking or the unwise eating which cause two-thirds of the ill-health of the poor ; or to stop the overcrowding and bad ventilation that encourage tuberculosis ; to insist, in measles or whooping-cough, on the troublesome precautions against infection which may check the spread of these diseases ; or to press for the removal of his patients to an institution whenever he believes that they would be better cured there — would clearly be chimerical. What would tend to be provided under such a system would be, not preventive or curative treatment or hygienic advice, but, in the literal sense of the words, medical relief, and that wholly without conditions. On all these grounds, the proposal to supersede the Poor Law Medical Service by any system of universal medical insurance appears to us, not only politically impracticable, but also entirely retrograde in policy, and likely to be fraught with the greatest dangers to public health and to the moral character of the poor. We have still to consider the institutional treatment of the sick provided by voluntary agencies. This is practically confined to the endowed and voluntary hospitals, and, of these, fortunately, the merits are so well known as to enable us to be brief. They are already made use of freely by the very poorest, and Boards of Guardians everywhere transfer suitable cases to them from the Workhouse infirmary, usually making, as is recommended by the Local Government Board, a contribution towards the cost of maintenance either of these particular patients or of the institution as a whole. But the endowed and voluntary hospitals are very far from sufficing for the needs of the sick poor. They appear to provide in the aggregate little more than 25,000 beds, which is only about one-fourth BY VOLUNTARY AGENCIES 263 of the number of sick beds already actually occupied in the Workhouses and Workhouse infirmaries. More- over, instead of being distributed geographically as re- quired, the voluntary hospitals, whether general or special, are mainly concentrated in London and the sixty or seventy larger or more ancient provincial towns, where physicians and surgeons and their students love to congre- gate. The selection of the diseases which these hospitals are willing to admit for treatment is, alike from the stand- point of preventive medicine and from that of the needs of the poor, equally arbitrary. It was because the volun- tary hospitals refused to provide for zymotic diseases, or for any epidemic, that the municipal hospitals arose. It was because they would not deal with cases of chronic disablement that the Poor liaw had to develop its " hospital branch." "No general hospital," stated a Local Govern- ment Board Inspector, " will admit a man who is suffering from delirium tremens : hence the Poor Law Infirmaries are charged with such cases." "All cases of venereal disease," says a Poor Law Medical Officer, " are now practically debarred from the genuine hospitals, to the great detriment of the community." To-day there is no sign of any development of medical charity competent to provide institutional treatment all over the country for the two gravest national diseases, tuberculosis and syphilis. In fact, what the voluntary hospitals like to deal with is the acute case and the unique or '* interesting " case — just those which are least prevalent, and which, in all probability, are, to preventive medicine, the least im- portant. Moreover, even where voluntary hospitals exist, and even in those diseases which they select for treatment, their provision, excellent as it is so far as it goes, has the capital drawback of disconnection with domiciliary inspec- tion and supervision before and after the acute stage of the illness. In fact, as it has been paradoxically put, the voluntary hospital is not concerned with the treatment of disease : what it treats and treats so magnificently is collapse from disease ; until the patient is so ill that he cannot continue at his employment, he does not enter the hospital. As soon as he is well enough to be discharged, 264 CURATIVE TREATMENT OF THE SICK his case disappears from the ken of the hospital staff. And it has been given in evidence that this tendency to get rid of a case as soon as the acute stage is passed, or as soon as it is apparent that the disease is a chronic or incurable one, is leading more and more to the prompt transfer of such patients from the hospital to the Work- house or Poor Law Infirmary. Thus, whilst it may be foreseen that the Local Authority dealing with the sick poor will, under proper conditions as to payment, be able to make increasing use of the voluntary hospitals for the treatment of the acute stages of certain diseases, and especially for operative surgery, these hospitals, far from rendering unnecessary " the Hospital Branch " of the Poor Law Medical Service, will, on the contrary, tend more and more to reject or to transfer all other cases to rate- supported institutions of one kind or another. (g) The Treatment of the Sick by the Public Health Authorities The voluntary agencies treating the sick poor are not the only rivals whose work overlaps or surrounds that of the Poor Law Medical Service. It has been formally brought to our notice by the Medical Officer of the Local Government Board for England and Wales, by the Medical Member of the Local Government Board for Scotland, and by the Medical Commissioner of the Local Government Board for Ireland, as well as by the Medical Officer of the Board of Education for England and Wales, that ubiquitous and expensive as is the Poor Law Medical Service, it is not the only one maintained out of the rates. Every part of the United Kingdom is now provided with an equally ubiquitous, quite as highly qualified, and nearly as costly a service of public medical officers, maintained by the Local Sanitary Authorities. To mention only England and Wales, under the various Public Health Acts, the Municipal and Urban District Councils on the one hand and the Rural District Councils on the other, are charged, under the supervision of the County Councils, with explicit responsibility for the health of their several districts — BY PUBLIC HEALTH AUTHORITIES 265 that is to say, for the maintenance in health of all the inhabitants thereof. To this end the councils have been granted elaborate statutory powers, both of regulation and provision, some of them optional and some obligatory. We have had described to us by the responsible heads of the medical departments above mentioned, as well as by numerous medical ojQ&cers of the Local Authorities concerned, the very extensive functions which those Authorities are now fulfilling in the treatment and cure of the sick poor amounting, in fact, to the provision of medical advice, attendance or medicine, in one way or another, for possibly nearly as many patients — certainly as many acutely sick patients — as are under the care of the Poor Law Medical Service. And it has been given in evidence by the responsible heads of the Departments concerned, as well as by the Medical Ofiicers of Health themselves, that neither in legal theory nor in practical administration are the destitute sick excluded from their ministrations. We have, in fact, in every part of the Kingdom, two public medical authorities legally respon- sible for, and in many cases simultaneously treating the same class of poor persons, sometimes even for the same diseases. So extensive and costly an overlapping has compelled us to explore in some detail and to describe at length the various developments of the Public Health as well as of the Poor Law service. (i.) Municipal Hospitals Starting from the provision of temporary isolation hospitals for cholera patients and then for those attacked by small-pox, the Public Health Authorities now maintain over 700 permanent municipal hospitals, having, in the aggregate, nearly 25,000 beds, or nearly as many as all the endowed and voluntary hospitals put together. These vary in size and elaboration, from the cottage or shed with two or three beds set aside for an occasional small- pox patient, up to such an institution as the Liverpool City Hospital, divided into seven distinct sections in as many different parts of the city, and having altogether 266 CURATIVE TREATMENT OF THE SICK 938 beds, served by six resident and seven visiting doctors, and treating nearly 5000 patients a year, for an average period of seven or eight weeks. The Manchester Town Council maintains the Monsall Fever Hospital, with 415 beds, which makes no charge whatever to the patients; another at Baguley, with 100 beds; and a third at Clayton Hill for small -pox cases. The Birmingliam Town Council has a couple of hospitals, having together 610 beds. The Leeds Town Council provides a series of hospitals and isolation dwellings, principally for scarlet fever, diphtheria and small -pox, accommodating over 600 persons, where patients are admitted " without any charge whether they belong to the families of ratepayers or of paupers." These towns are typical of many others. Mention must here be made of the hospitals of the Metropolitan Asylums Board, because, though administered by a body largely made up of repre- sentatives of Boards of Guardians, and actually maintained out of the poor rates, they have become, both by statute and by Local Covernment Board decisions, practically public health institutions. The dozen great hospitals thus maintained for small-pox, scarlet fever, enteric fever and diphtheria, now admit all cases recommended by any medical practitioner, irrespective of the patient's affluence. The maintenance and treatment, once made matter of charge, is now by virtue of the Public Health (London) Act, 1891, universally free. The inmates, originally exclusively paupers, are now explicitly declared to be not pauperised, the treatment, and even the maintenance, being (by the Diseases Prevention Act of 1883) expressly stated not to be parochial relief and to involve no stigma of disqualification whatsoever. The 3,000 to 6,000 patients in these hospitals, costing nearly £1,000,000 a year, may, therefore, be reckoned, though under a Poor Law authority, as virtually patients of a Public Health Department, and they are accordingly excluded by the Local Government Board from the statistics and computed cost of pauperism. The municipal hospitals of the provincial towns, provided in the first instance usually for small-pox, have had their spheres extended to scarlet fever, enteric fever, and usually MUNICIPAL HOSPITALS 267 diphtheria ; in addition to any stray cases of plague, cholera or typhus that may turn up. But they do not stop there. The Public Health Acts do not prescribe the kind of disease to be treated in the hospital which they authorise, and whatever may have been the primary object for which it was established, there is nothing to prevent the Local Authority from admitting any sick patients what- soever. Hence, although it is generally assumed that these so-called " Isolation Hospitals " are for infectious cases only, the list of diseases dealt with is steadily growing. In most towns of any size the municipal hospitals are willing to deal with puerperal fever (as at Crewe) and with serious ery- sipelas. Cases of chicken-pox are occasionally found in them ; children suffering from scabies and pediculosis are occasionally admitted for temporary treatment ; and the door is now being opened to the two most deadly diseases of children beyond infancy. The Liverpool Town Council has decided to receive in its municipal hospitals " infants suffering from whooping-cough and measles . . . together with the mother or other natural guardian of the child if necessary," so far as there is room ; and since it is recog- nised that " the isolation of the infectious sick in hospital is important and necessary," special steps have been taken to make room. " Provision of hospital accommodation for a limited number of cases," reports the Medical Officer of Health, "has now been made for measles." Moreover, " isolation for a limited number of [whooping-cough] cases has been found." At Liverpool, indeed, the municipal hospitals admitted and treated during the year 1905 nearly 200 cases, and in 1906 between 500 and 600 cases, of other diseases, including gastro- enteritis, pneumonia, tubercular meningitis, bronchitis, tubercular peritonitis, cystitis and nephritis, erythema, influenza, varicella, septicaemia, abdomi- nal tumour, empyema and tubercle, psoas abscess, tetanus, syphilis, tonsilitis, laryngitis, pharyngitis, angina ludovici, and appendicitis, besides four cases of poisoning. It appears to us difficult to believe that these can all be explained as being cases of mistaken diagnosis. The assumption that the power of the Public Health Authority in the provision of hospitals is limited to con- 268 CURATIVE TREATMENT OF THE SICK tagious or infectious disease is, indeed, a mistake, though a common one. There are no such words of limitation in the sections of the Public Health Acts dealing with the matter. For a long time, however, probably influenced by the common impression that their powers applied only to in- fectious diseases, no Public Health Authority sought to establish anything but an isolation hospital. In 1900 the Barry Urban District Council (which sends its infectious cases to a joint isolation hospital at Cardiff, and provides home nurses for such of them as are not moved), established, with the express sanction of the Local Government Board, a free municipal hospital exclusively for non-infectious cases, intended principally for accidents and urgent surgical cases. This municipal hospital has a medical staff of eight visiting surgeons and physicians, an organised nursiug staff, and maintains seven beds. The Widnes Urban District Council, which runs a fever hospital and a temporary small-pox hospital, was definitely informed by the Local Government Board that it was free to start also an accident hospital, and accordingly did so. But the greatest recent development has been in the provision for tuberculosis. The Brighton Municipal Hos- pital in 1906 actually dealt with more cases of phthisis than of any other disease, they forming a third of its whole number of patients, and amounting to nearly 2 per 1,000 of the entire population of the town. The object of their admission is not so much immediate cure as treatment with a view to instruction in good hygienic habits. They are therefore admitted preferably at an early stage, before being invalided, and they are retained only a few weeks, passing then to their homes, where they are periodically visited. About half of all the known consumptives in Brighton have already been thus through the municipal hospital, with the result, it is believed, of great prolongation of life. Special hospital provision for tuberculosis primarily with educational objects is accordingly now being made, one way or another, by many public health authorities. At Manchester, the Town Council not only pays for beds at the Delamere and Bowden Sanatoria, but has for several years opened special phthisis wards at its Clayton Vale MUNICIPAL HOSPITALS 269 Hospital. At Leicester, the Town Council has set aside a special hospital block for curable cases, no charge being made for maintenance and treatment during the first month. They may stay for a second, a third and even a fourth month, on payment of 10s. a week. It is, however, not only by admission to hospital that public health authorities now treat individual cases. In certain instances, and for particular purposes, individual cases of disease are dealt with out of hospital. Alike in numbers and in degree this municipal outdoor medical service is rapidly growing. In Scotland it has even been definitely laid down by the Local Government Board that it is for the Local Health Authority to treat all cases of phthisis ; and that sufferers from this disease should not come under the Poor Law at all. (ii.) Notification and Disinfection We may notice first the notification of disease, the inspection as to isolation, the treatment of " contacts," and the arrangements for disinfection. This organisation, at first dependent on voluntary, and only subsequently on obligatory notification, has been extended from disease to disease, until it now covers not only plague, cholera and typhus ; erysipelas, puerperal fever, small-pox, scarlet fever, enteric and diphtheria ; but also, in one town or another, for this or that period, influenza, measles and chicken-pox. Puerperal fever too has become in a sort of way also separately notifiable by mid wives. Arrangements for the voluntary notification of phthisis have been made in numerous towns (including Liverpool, Blackburn, Brighton, Northampton, South wark, Finsbury), a payment of 2s. 6d. being made for each case. At Sheffield and Bolton this notification of phthisis has been made obligatory by a Local Act. Scotland has gone still further. Under the Infec- tious Diseases (Notification) Act, 1889, phthisis is com- pulsorily notifiable in Edinburgh and a large part of the country, including the whole of Lanarkshire outside Glasgow ; and with or without compulsory notification, the local Health Authorities are now required to deal with phthisis as with other infectious diseases. And now. 270 CURATIVE TREATMENT OF THE SICK throughout England and Wales, the Local Government Board has ordered the Poor Law Authorities everywhere to notify to the Local Health Authorities every case of phthisis that is observed in the pauper population. Arrangements are also made by direction of the Board of Education for the Medical Officer of Health to receive weekly notifica- tions, from the head teachers of all the public elementary schools, of all cases in which the children stay away on account of such diseases as measles, whooping-cough, chicken- pox, mumps, ringworm, scabies, etc. A Board of Guardians has strongly urged that ophthalmia should be made com- pulsorily notifiable. Medical Officers are now suggesting that not only pneumonia, influenza and diarrhoea, but also cancer should be added to the list of notifiable diseases. " As the result ... of recent additions to our knowledge of cancer," reports one Medical Officer of Health (and this is only an echo of similar proposals made at Finsbury and elsewhere during the past decade), "I am of opinion that it is a disease which calls for public health measures ; not indeed of a stringent nature, but dealing more with the necessity of destroying the dressings of cancerous ulcers, and for issuing warnings that persons dressing these cases should be careful to protect cuts or wounds of the hands, and to boil sheets and pillow-cases used by patients. (iii.) Supply of Medicines and Anti-Toxin The importance, in certain diseases, of the prompt administration of specific remedies has led the Public Health Authorities to supply these gratuitously to all who will accept them: just as vaccination has, since 1840, been performed by the Poor Law Authorities free of charge, on all who will submit to it. The Manchester Town Council, and various other bodies, distribute bottles of diarrhoea mixture to any one in need of them, using all the police stations as distributing agencies. But the remedy usually distributed gratuitously is the anti-toxin serum for diphtheritic cases. The extreme importance of promptitude in the administration of this remedy, and MEDICINES AND ANTI-TOXIN 271 the great saving of expense implied by the prevention of the spread of diphtheria, have led very many Public Health Authorities, sometimes after a vain attempt to enlist the co-operation of the Board of Guardians, to supply it gratis, on demand, to any medical practitioner ; some- times, as at Blackburn, through the police stations among other agencies. In some cases the Municipal Authorities have gone further, and have paid Poor Law doctors and private medical practitioners to use it. Thus, the urban district council of Fenton, in Staffordshire, decided in October 1905, on the advice of the Medical Officer of Health, and as being less costly to the ratepayers than institutional treatment, to undertake the domiciliary treatment, so far as the injection of an ti- toxin was con- cerned, of all diphtheritic patients, and of all who had come in contact with them. For this purpose every medical practitioner in the district, including the District Medical Officers of the Board of Guardians, was, in effect, made, temporarily, an additional officer of the Urban District Council as Public Health Authority, and paid a fee for each case so treated — amounting, for the next few months, to three or four per week. (iv.) Municipal Out-patients' Departments Another direction in which the Public Health Authorities have extended their treatment of individual cases is by opening an out-patients' department. At Willesden, finding that from 25 to 50 per cent of the cases were without any sort of medical treatment, the Public Health Authority, on the recommendation of the Medical Officer of Health, has established an out-patients' depart- ment at its isolation hospital for persons suffering from ringworm, impetigo, scabies, or ophthalmia. At Newcastle- on-Tyne, where the Town Council subscribes 100 guineas a year to the Dispensary, something like eight hundred "letters" are, in return, placed at the disposal of the Municipality. These ** letters " each entitle the bearer to two months' gratuitous treatment, including domiciliary visits where required, and, in practice, recommendations 272 CURATIVE TREATMENT OF THE SICK for admission to various voluntary hospitals, etc., if institu- tional treatment is necessary. At present, these " letters " are distributed by Town Councillors. The Town Council also maintains salaried Health Visitors, who go round the town under the direction of the Medical Officer of Health, and who thus discover many cases of disease, but have at present no organised method of securing medical attendance. " The Medical Officer of Health himself has . . . recently suggested to the Corporation that they should increase their subscription to the Dispensary . . . with the object of getting more letters, and that these letters should he distributed by the Health Visitors." (v.) Pediculosis and Scabies For the particular bodily affections of pediculosis and scabies — which, as being morbid conditions of the body susceptible of treatment and cure, must be classed as diseases — Parliament has expressly authorised gratuitous provision, which is not to be deemed parochial relief or charitable allowance. " Baths and disinfecting chambers for the cleansing and purifying of the bodies and clothing of persons infested with vermin or parasites" are now provided by various municipal authorities. " No charge is made for the use of these facilities, and applicants will be treated with every consideration." This small " attempt in the treatment of certain skin diseases," as it has been apologetically described, represents, it is admitted " a departure from the principle of not treating disease, but it has its justification in the contagious nature of such disease " — a justification which would carry us far. But even for pediculosis alone one Public Health Authority (that of Marylebone) has successfully treated 32,500 patients in seven years. (vi.) Health Visiting The system of " health visiting," which we have already described in Chapter III., now adopted in some scores of towns is, of course, not confined to newly-born infants and children in "baby farms," The Health HEALTH VISITING 273 Visitors go at once to every house at which either an infantile death or a death from phthisis or any infectious disease is notified, with a view of inquiring into the sanitary condition of the premises, ensuring the execution of any necessary disinfection, and (with regard to deaths of infants under two years old) also obtaining elaborate particulars as to the method of feeding, source of milk supply, etc. The health visitor goes also to any house in which sanitary defects are complained of. She follows up " contacts." She visits all the cases reported from the public elementary schools of children staying away or excluded on account of measles, whooping - cough, ring- worm, etc. She investigates cases of erysipelas for the Medical Officer of Health. She visits the patients dis- charged from the municipal hospital, and exercises a certain amount of supervision over them. She may even, so far as time permits, visit from house to house in blocks or districts in which special sanitary care is for any reason required. Wherever she goes, she makes such inspection of the inmates as she can ; she is able to report to the Medical Officer of Health where and what diseases exist, and which cases are without medical attendance ; she gives hygienic advice ; she makes known the facilities with regard to phthisis ; and she advises the calling in of a medical practitioner where necessary. Her advice is found specially useful in those children's ailments which are so often treated lightly without medical aid. The Medical Officer of Health for Warwickshire points out in one of his reports (1903) that " the work of the Health Visitor does not trench on the work of the Sanitary Inspector ; that she is not an inspector in any sense of the word, and that her functions are those of friend of the household to which she gains access. He also states that although at first there may have been some opposition to her entering a house, it rapidly died away, and in numerous instances she has been asked to return and aid the family by her help and counsel. He also believes that in this new departure of carrying sanitation into the home, we have not only an important, but almost the only, means of further improving the health of the people, and that in VOL. I T 274 CURATIVE TREATMENT OF THE SICK the future, although sanitary authorities, by providing water supply, drainage and decent houses, have done much in the past, the most important advance will come from an appreciation by the people themselves of the value of good health." (vii.) Municipal Home Nursing In addition to the work of the health visitors and school nurses, some Public Health Authorities have begun a system of domiciliary treatment of the adult sick by municipal home nurses. At Brighton, for instance, under a Local Act, the Town Council employs a trained nurse, who is employed in attending at home on cases, such as puerperal fever or erysipelas, in which removal to hospital is not considered desirable. Nurses are also provided, " in special cases of infectious diseases," by the Barry Urban District Council. Even more interesting is the action of the Health Committee of the Worcestershire County Council, which maintains a staff of nurses for the domiciliary treatment of the sick poor in certain of the sanitary districts within the county, in which the Local Authorities do not, either in their capacity of Guardians of the Poor or in that of Rural District Councillors, make adequate provision for home-nursing. (viii.) Diagnosis One of the most important branches of the Public Health Medical Service is that of diagnosis. The bacterio- logical laboratory of the Medical Officer of Health, or that at the municipal hospital, frequently undertakes the in- vestigation of " swabs " for diphtheria or of sputum for tuberculosis, for all the medical practitioners of the district. But the service does not stop here. The Medical Officer of Health frequently acts himself as diagnostician in indi- vidual cases, being called in (without payment) by the medical practitioner to suspected cases of small-]X)x, etc. In times of epidemic, the active Medical Officer of Health goes even further and himself spontaneously visits the DIAGNOSIS 275 common lodging-houses and other suspected, centres, in order to search out cases of small-pox which are not being medically attended at all, and to hurry them off to the municipal hospital. The services of the Medical Officer of Health as diagnostician are rapidly extending. Not only in diphtheria and tuberculosis cases, but also in typhoid fever, in cerebro-spinal meningitis, in afifections of the throat, and in the whole realm of opsonic diagnosis, he is more and more coming to serve as the general consultant of the district. It is he who considers "suspects" and " contacts " and " carriers," who, not being themselves ill, are not remunerative patients. Yet it may be upon their prompt treatment that the health of the district depends. (ix.) Home Aliment Possibly more important in its future development is the practice of Local Health Authorities of granting free lodging and an alimentary allowance to " contacts " or persons (whether dependents or not) who have been in contact with a patient suffering from infectious disease. In order to prevent new cases of disease these " contacts " are often segregated and kept under medical observation. It then becomes necessary to provide for the maintenance of the persons thus prevented from working. The Leeds Town Council has " frequently paid part wages of those who, though not themselves apparently ill, have at request remained away from work on account of having been exposed to contagious disease. . . . The practice has been to pay half the wages, and to maintain the contacts in . . . cottages . . . under medical observation." They may, however, in other cases, remain at home but abstain from working, receiving allowances for their maintenance. This practice is followed as a matter of course in cases of suspected plague or cholera, and frequently for small-pox. With regard to other infectious diseases, the state of things is chaotic, and great hardship arises. One such case has been brought specially before the Commission. A widow working as a laundry woman had a child ill with fever, who was removed by the Local Health Authority to its 276 CURATIVE TREATMENT OF THE SICK hospital. The Local Health Authority, apparently, in the public interest, stretching its legal powers, peremptorily ordered the widowed mother not to go to work, it being a penal offence to spread infection. The widow being thus rendered destitute, applied to the Relieving Officer, who refused to give Outdoor Relief, and referred her to the Local Health Authority ; from which, however, she re- ceived no maintenance allowance. The Board of Guardians thereupon reported the matter to us, demanding legisla- tion to make it obligatory on the Local Health Authority to grant aliment to heads of families so prevented from working, owing to their having come in contact with infectious disease. The question of allowing aliment to " contacts " forced, in the public interest, temporarily to suspend work, is, however, comparatively simple. The practice of the Local Health Authorities brings them, as the Medical Officer of Health for Manchester has explained to us, up against the far more serious problem presented by the necessity of granting aliment to the dependents of patients admitted to the municipal hospitals or sanatoria. The Poor Law Authorities in many places grant Outdoor Relief freely for the families of men in hospital. This, however, involves the stigma of pauperism, and accordingly (as is actually intended and desired by the Boards of Guardians) many respectable wage-earners struggle to continue at work in gradually failing health, and put off entering the hospital as long as they possibly can. In cases of tuberculosis, especially, this delay, besides spreading the disease, mili- tates against a cure ; and makes, in fact, in the vast majority of cases, all recovery hopeless. The Local Govern- ment Board Inspector attending *' Out-relief Committees . . . hears of men and women who have struggled with the disease as long as possible before applying for relief, often sleeping in small rooms with children. It too often happens that application is made too late for the disease to be arrested." Even when they enter an institution, they are so eager to get back to work to maintain their families, " that as soon as the disease is arrested, they take their discharge before a cure is effected," and return soon ** much HOME ALIMENT 277 worse than when they first came under treatment. . . . Finally, the sufferer enters the Workhouse infirmary to die, in the meantime possibly having infected other mem- bers of his family." In this dilemma the Bradford Board of Guardians, like the Brighton Town Council, seeks actually to induce and persuade the man with phthisis to come into its sanatorium at an early stage of the disease, when he can still earn wages. " All persons resident in the Union," states the Clerk to the Guardians, " found to be in that stage of the disease, whose income does not allow them to reside at a private sanatorium, are accepted on the recommendation of their private medical attendant." This particular " Workhouse " is clearly run almost on the lines of a municipal hospital, with the added advantage that the Board of Guardians is able to induce people to take advantage of it by proffering liberal Outdoor Relief to their families. Some Local Health Authorities now want to use the same inducement. Dr. Niven has ex- plained to the Commission the importance of the Health Committee of the Manchester Town Council being free to provide aliment, without the stigma of pauperism, for the dependents of patients suffering from incipient phthisis, whether removed to hospital or treated by the municipal doctor in their own homes. "It is to my mind very plain," says Dr. Niven, " that this would be an economic expenditure. One of the great means of combating phthisis would be to raise the nutrition of the families in presence of the disease. The family falling into a state of poverty, the rest of the family are exposed to infection just in that condition which lays them open to attack, and if we are to deal really effectually with the prevention of consumption, I feel sure that it is necessary to improve the nutrition of the families in presence of the disease." Dr. Niven explained that he would put it on the same plane as money given in the plague or cholera cases. Hitherto Local Health Authorities have limited any such grant of aliment to cases connected with plague, cholera and small-pox, and have always coupled it with complete isolation of the patient. There does not, however, appear to be any legal limitation to their power to grant such aliment, at any rate 278 CURATIVE TREATMENT OF THE SICK as regards all notifiable diseases. This incipient develop- ment of a second public body granting what is virtually Outdoor Relief to the sick poor appears to us to demand the most serious consideration. We shall recur to this point in our subsequent chapter on "The Scheme of Reform." (x. ) The Characteristics of the Public Health Authority's Treatment of Disease All treatment of the individual patient by the Local Health Authority has for its object, not the relief of im- mediate suffering, but the prevention of disease. It is plain that this involves the treatment and cure of existing diseases in the individual patient, because, as one Medical Officer of Health remarks, " the cure of a sick person tends to prevent disease in that person." But, unlike Poor Law medical practice, even of the best type, it involves much more. In the obviously communicable diseases, such as plague, cholera and typhus, small-pox, scarlet fever and enteric, it involves the securing of complete isolation of the patient, and even the isolation and medical observation of healthy " contacts." In other infective cases, such as phthisis, trachoma and chronic ear, throat and skin afi'ec- tions, it involves the education of the patient in a method of living calculated to minimise the recurrence or spread of the disease. But the special sphere of the Public Health Authority in the treatment of disease is not that of infec- tious or contagious, but of preventable disease. It was, indeed, not to stop the spread of disease from individual to individual, but to prevent its arising from dirt and filth, that the Poor Law Commissioners first made their public health investigations, and importuned the Government to give the local authorities public health powers. It was preventable disease which Chadwick found to be so great a cause of unnecessary pauperism. It was for the reduc- tion to a minimum of this preventable disease that the Public Health Act of 1848 was passed; and it is to pre- ventable disease, whether communicable or not, that the powers and duties of Public Health Authorities to-day PUBLIC HEALTH AUTHORITY'S TREATMENT 279 extend. The accident of the widely-published advance of bacteriological science since 1848 has tended unduly to concentrate attention on the zymotic diseases, which, taken altogether, cause only 11 per cent of the deaths, and account, probably, for only a twentieth or a thirtieth of the persons ill at any one time. But, as the Medical Officer of Health for Coventry remarks : " It is a great mistake to suppose that it is only infectious diseases that are preventable." " Our activity as health officers," writes another Medical Officer of Health, " cannot be limited to the infectious diseases. There are indeed greater oppor- tunities of preventing illness among the non -infectious ailments, e.g. ailments of the digestive system, almost, than in the case of infectious illnesses." To the long list of common infective diseases already given, we must add as plainly preventable : " infectious eye diseases, such as conjunctivitis in most of its forms (trachoma, etc.) ; infectious ear diseases (abscesses, etc.); infectious nose and throat diseases; abscesses of all kinds not due to tuber- culosis ; parasitic skin diseases, and some others. To these again we may add as due to immediate environment, and preventable, the occupational (non-infectious) diseases : chronic arsenical poisoning, chronic lead poisoning, chronic phosphorus poisoning, mercury poisoning, coal -miner's lung, steel-grinder's lung ; the diseases due to dusty occu- pations, skin diseases, lung diseases, bowel diseases ; and many others due to special manufactures, as rubber works, chemical works, dry cleaning, rag works, etc. etc. . . . Similar reasoning can be legitimately applied to chronic bronchitis, which can usually be prevented if the acute stage is properly treated ; to catarrhal pneumonia, which is often the precursor of phthisis; to the heart diseases that are due to acute rheumatism ; to chronic kidney disease, which often follows neglect of acute kidney disease ; to some forms of cancer, which are curable if operation is early enough." Thus, the special characteristic of the treatment of disease by the Local Health Authority is, not to wait until the patient is so ill that he is driven to apply, but positively to search out every case, even in its most incipient stage. *'An active Medical Officer of 280 CURATIVE TREATMENT OF THE SICK Health," sums up one of them, " attempts anything and everything which promises to reduce death-rates or to prevent disease." The one recurring note of all the state- ments and oral evidence of the Medical Officers of Health is the vital importance of " early diagnosis." " I am satisfied," writes Dr. Newman, " that much illness is pro- longed quite unnecessarily, and that there is a lamentable and disastrous amount of failure to deal with the begin- nings of disease. Neglect of such things leads to mortality more than many other factors." The disastrous effects of failure to seek early treatment, in consumption, diphtheria and other diseases, are continually coming to the notice of medical men. It is a necessary condition of the Public Health Medical Service that there must be no delay in searching out and discovering all the cases ; there must be no delay in securing the necessary isolation ; there must be no delay in applying the necessary treatment; there must be no delay in the adoption of the appropriate hygienic habits. It is the consciousness of the importance of this " early diagnosis," the immense superiority in attractiveness of the incipient over the advanced " case," the overwhelming sense of the dire calamities that may come from a single " missed case," that mark the charac- teristic machinery of the Public Health Medical Service — its notification ; its birth, death and case visitation ; its bacteriological examination ; its school intimations ; its house-to-house visitation ; its domiciliary disinfection ; its medical observation of '* contacts " ; and its prolonged domiciliary supervision of " recoveries " and patients discharged from institutions in order to detect the " return case." But besides the preventable diseases brought about by environment, and by neglect of acute diseases, there are those now recognised to be caused by bad hygienic habits of the individual himself " The chief factor in disease production," says Dr. Newman, "is personal rather than external." To quote the epigram of a distinguished doctor : " We have pretty well removed the filth from outside the human body ; what we have now to do, in order to lower the death-rate, is to remove the filth from inside." " Diseases spread not alone by infection and PUBLIC HEALTH AUTHORITY'S TREATMENT 281 contagion," says another Medical Officer of Health. " The habits and practices of people are responsible in even greater measures for the continuance of diseases. These cannot be combated by the popular panacea of a bottle of medicine." It may be said, in fact, that " the public health method of treatment is superior to that of the Poor Law because it is largely educative and for the future." Nor is this merely a matter of cleanly living and the avoidance of excess. The prevention of disease, which, as the Medical Officer of Health always remembers, " is far more effective and infinitely less costly than the treatment of dis- ease that is accrued," may depend on the adoption of a particular mode of life. Incipient phthisis, in particular, may be thus curable. " Such conditions as diabetes, granular kidney and aneurism," says another authority, " are not necessarily diseases. If the condition is recognised early, and the patient adopts the proper regimen, the symptoms which really constitute the disease may be postponed for a considerable period." We come even to the study of individual proclivity or diathesis as a branch of preventive medicine. " Thousands, nay, hundreds of thousands of young men and women with hereditary or acquired tendencies to various diseases are, owing to want of knowledge, brought up, enter upon occupations, and lead modes of life which inevitably result in disease and early death." Passing from the characteristics of the Public Health Medical Service to its effects on its patients, there comes to light an interesting contrast with the Poor Law Medical Service. It has been strongly urged upon the Commission that Poor Law Medical Relief is not merely " deterrent," but that, when accepted, it breaks down the independence of the recipient and frequently leads him to become a chronic pauper. It is alleged that the labourer who begins by asking the Relieving Officer for a midwifery order, or for medical attendance on his ailing infant, is easily led on to apply for a medical order for himself, and presently for Outdoor Relief. No such allegation is made with regard to submission to medical treatment of the Local Health Authority. On the contrary there is absolute 282 CURATIVE TREATMENT OF THE SICK uniformity of testimony, from all sorts of witnesses in all parts of the country, that the medical attendance and medicine of the Public Health Department has no pauper- ising tendency. The fever-stricken patient who is removed to the isolation hospital, or the mother who receives hygienic advice about her infant, is not thereby induced to find her way to the Poor Law. Indeed, it has been repeatedly given in evidence by witnesses with practical experience that the essential characteristic of the Public Health Medical Service — that it is rendered in the interest of the community, and not in order merely to relieve the suffering of the individual — actually creates in the re- cipient an increased feeling of personal obligation, and even a new sense of social responsibility. This sense of obligation is, we are informed, seen in a new responsibility as to not creating nuisances or infecting relations and neighbours ; in a deliberate intention to remain healthy, and therefore to control physical impulses ; and in an altogether heightened parental responsibility in the matter of the conscientious fulfilment of the daily — even the hourly — details of family regimen necessary for the rear- ing of the infant or the recovery of the invalid. The very aim of sanitarians is to train the people to better habits of life. The object of health visiting is to make the people understand that prevention is better than cure. It has, indeed, been urged upon us that actual experience of public health administration indicates that universal medical inspection, hygienic advice, and the appropriate institutional treatment of those found out of health might have as bracing an efiect on personal character, by impos- ing a new standard of physical self-control, as it would have on corporeal health. Nor is this a mere figment of the imagination. " The form in which medical aid would be given," states Dr. Newsholme, the Medical Officer of the Local Government Board, in the light of his actual experience with the hundreds of phthisical patients whom he has treated, " would be such as constantly to enforce on the minds of the patients their duty to the community and to themselves in matters of health. Though they would pay nothing, they would not be merely passive PUBLIC HEALTH AUTHORITY'S TREATMENT 283 recipients of advice and attention. The influence of the doctor would demand from them habits of life and even sacrifices of personal taste in the interest of the health of the community, their families, and themselves, which would leave them conscious of a sensible discharge of duty in return for the attention which they received. The discipline of responsibility into which the system would educate them should, in my judgment, suffice to avoid the loss of self-respect liable to arise from the merely passive receipt of gifts ; and it would introduce into the national life an attitude towards matters of personal health that would have an indirect influence upon conduct while directly restricting disease." But the Public Health Medical Service, as it exists to-day, has grave defects. Though nominally co-extensive with the kingdom and applicable to all preventable disease, it exists, over a large part of the country, merely in skeleton outline. So far as we have been able to ascertain, positively a majority of the 650 rural Sanitary Authorities of England and Wales and not a few of the smaller urban Sanitary Authorities, have no hospitals even for the most infectious diseases, no domiciliary visitation for the searching out of disease, and nothing more in the way of a Medical Officer of Health than the scrap of the time of a private practitioner, to whom the small fee of a few guineas comes with instruc- tions "not to be meddlesome." Some sanitary districts are far too small for efficiency, there being even " urban districts" with less than 1000 population. It is true that there is provision for voluntary combinations of districts, and such exist ; but they are difficult to arrange, and not permanently satisfactory. Even in many considerable urban districts the Local Authorities have not yet realised the importance either of extending their isolation hospitals to anything but three or four of the " chief zymotics," or of any sort of supervision of infantile ailments. A large town like Norwich was, in 1906, making "no provision for the treatment of other infectious ailments, such as measles, German measles, whooping-cough, chicken-pox and mumps ; nor for the tuberculous diseases, nor for such contagious diseases as scabies and the other pediculi. 284 CURATIVE TREATMENT OF THE SICK nor for venereal diseases." The varied activities that we have described have, in fact, often emanated from the zeal and energy of the Medical Officer of Health himself. It is a further drawback that the apathy of the Local Authorities is not systematically exposed by any regular inspection by the Local Government Board, and that the zeal and enterprise of the best among them meets, so far as published documents go, with little official recognition or encouragement. Even in the largest provincial centres of population, where the Public Health Medical Service is most fully developed, the systematic medical observation of the children is limited to the entirely arbitrary period of the first twelve months ; there is no regular inspection or house-to-house visitation for children between one and five, during which ages measles and whooping-cough are most deadly ; the medical supervision of pupils at school is practically restricted to those whom the teachers report as absent through illness ; there is no systematic treat- ment of their affections of the eyes, ears, nose, teeth, throat, and skin — not to mention incipient curvature; there is no study of diathesis in order to advise as to occupation ; and there is no regular system of observation of the " children of larger growth " — not even of the pregnant mothers of the race. After infancy, in fact, the activity of the most public - spirited Medical Officer of Health is limited practically to particular diseases, to such, in fact, as the Local Authority may choose to consider sufficiently infectious. The most energetic are no further advanced than, following the lead of Dr. Niven at Man- chester, and Dr. Newsholme at Brighton, to have begun to include tuberculosis, and to provide for a tiny propor- tion of the cases — usually the advanced cases — of phthisis in their districts ; though " between the ages of fifteen and thirty-five more than one-third of all deaths are due to this cause." None of them, so far as we have been able to ascertain, deal with venereal diseases, though these account, it is said, for an enormous proportion of the inmates of lunatic asylums and a vast amount of the pauperism of disease. In short, the Public Health Medical Service, though excellent in its aims and results, NEED FOR A UNIFIED MEDICAL SERVICE 285 and demonstrably successful in a few zealous districts, for such diseases as it has there touched, is, from a national standpoint, suicidally deficient in its volume and geo- graphical extension. (h) The Need for a Unified Medical Service It is, we think, impossible, after considering all the evidence, to avoid the conclusion that what is before all else needed, with regard to the curative treatment of the sick poor, is the establishment of one united Public Medical Service, in which the Medical Services of the Poor Law and the Public Health Authorities would be merged. It has been abundantly proved to us that : "At the present time the question of treatment of sickness is in a state of chaos and confusion, entailing a great deal of over- lapping and unnecessary expense." " There is," we are told, *' considerable waste of energy and money. Two sets of officials visit the same houses, one for one object, the other for another. Neither completely attains his object — the cure of the social bad habit — and neither has much hope of doing so under existing circumstances. Much of this waste of money and energy would be saved by amalgamation of Poor Law and Sanitary Authorities." In consequence of this overlapping and confusion, the community is at present spending an untold amount of public money — apparently as much as seven or eight millions sterling annually — on the curative treatment of the sick by the rival Authorities. In return for this large expenditure we have two conflicting Public Medical Services, both rate -paid, overlapping in their spheres, practically without communication with each other, working on diametrically opposite lines, and sometimes positively hindering each other's operations. Between them, as we have it in evidence, they fail to provide for a large proportion of the illness — even of the preventable illness — of the community. The number of cases of sick- ness — even of dangerous infective sickness — that go entirely without medical attendance of any sort, private 286 CURATIVE TREATMENT OF THE SICK or public, is demonstrably enormous. The proportion of uncertified deaths, indicating a total lack of any sort of medical attendance even in the most advanced stages of disease, amounts, as the Registrar-General warns us, in certain towns in England to 4 or 5 per cent, in certain counties of Scotland to 20 and even 30 per cent, in some islands to as many as 60 or 70 per cent. But to the community it is of less importance that people should die without medical attendance than that they should live without it. What is above all deplorable is the enormous amount of incipient disease .that exists — undiscovered, untreated and unchecked — in the infants, school children, and young persons who constitute one-half of the entire population, and upon whose health the productive power of the next generation depends. Even in the Metropolis, where hospitals and free dispensaries abound, and where the Poor Law Medical Relief is specially well organised, it is evident that a large proportion of the 18,000 infants who die annually in the first year of life are medically attended, if at all, only in the last days or hours of their brief existence — often merely in order to avoid trouble with the coroner or the insurance company. Among the 1,000,000 or more older children in the Metropolis, some 40,000 of whom are probably ill at any one time, thousands of the cases of measles and whooping-cough are not medically attended at all. The married woman, left without medical or even midwifery attendance at her first childbirth, is not infrequently injured for life, both as mother and as industrial worker. The young artisan, with the seeds of tuberculosis in him, goes on, for lack of medical inspection and advice, in habits of life which presently bring him, too late to be cured — after, perhaps, he has infected a whole family — to the sick ward of the Workhouse. Scarcely less important to the nation are the ravages of venereal disease, which now goes almost entirely untreated, either by the Public Health Medical Service or by the Poor Law Medical Service (except when advanced cases enter the Workhouse as destitute), whilst the sick clubs and provident dispensaries definitely or by implication exclude treatment of such cases. Yet it is proved that, owing to lack NEED FOR A UNIFIED MEDICAL SERVICE 287 of medical treatment or to insufficient medical treatment, such diseases as syphilis and gonorrhoea are eventually responsible for a very large proportion of the pauperism of disease and insanity. For all these cases, so vital to the interests of the community, the Poor Law Medical Service — costly though it be — is, with its stigma of pauperism, its deterrent tests, its consequent failure to get hold of incipient disease, its total ignoring of the preventive aspect of medicine, its lack of co-ordination between domiciliary inspection and institutional treatment, practically useless. Medical "relief" may even be regarded, for all its attempted palliation of individual suffering, from the standpoint of national health (at any rate in a large proportion of cases), as worse than useless. In so far as it encourages in the patient faith in the taking of medicine instead of reliance on hygienic regimen — wherever the District Medical Officer dispenses physic rather than advice — it positively counteracts the effi^rts of the Public Health Medical Service in the promotion of personal hygiene. And when the District Medical Officer, conscious that his physic will not avail, orders '* medical extras," he provides the fatal introduction of the patient to reliance on the food or money doled out by the Relieving Officer. On the other hand, the existence of a separate Poor Law Medical Service, with its hundreds of thousands of patients under medical treatment in the course of each year, gives the Local Health Authority an excuse for not — except for this or that particular disease, or for infants under twelve months old — acting upon what are actually its statutory powers to provide hospital accommodation for all, and temporary medical attendance and medicine for the poorer classes. It is, we think, equally clear that the United Public Medical Service, in which those of the Poor Law and Public Health Authorities will have to be merged, must be estab- lished on the lines of scientific prevention of disease and the appropriate treatment at the earliest possible stage of such disease as is not prevented — its medical practice, in short, must be based upon Public Health rather than upon Poor Law principles. We might have hesitated to express 288 CURATIVE TREATMENT OF THE SICK so definite an opinion on such a subject as the proper basis of organisation of the Public Medical Service of the State — vitally connected as it must be with the prevention and treatment of destitution and pauperism' — were it not for the fact that the Commission has been led to investigate this part of its subject-matter with special thoroughness, and that the weight of testimony, both administrative and medical, appears to us to be overwhelming, A certain number of the doctors whom we have consulted, including private practitioners and Poor Law doctors, and even some Medical Officers of Health, have, indeed, like many of the Poor Law officials, expressed themselves as inimical to a unified Public Medical Service, either because they were, through long habit, not conscious of the defects in the existing arrangements, or because they could not see how a united service would work. Some of these — forgetting, we think, the large amount of actual treatment of disease now carried on by the Public Health Authorities — urged upon us that it was possibly advantageous for preventive work to be carried out by one department and curative work by another. We have, however, been much impressed by the very wide concurrence in the recognition of the superior advantages of a unified State Service expressed by those who had given thought to the subject. The Medical Investigator whom we appointed specially to inform us on this subject found himself, as he relates, irresistibly driven to the same conclusion. What is perhaps even more convincing is the fact that the impera- tive need for unifying the present competing Public Medical Services is felt by the heads of all the four public departments concerned. " I think it was unfortunate," says the Medical Commissioner of the Local Government Board for Ireland, " that Public Health did not precede Poor Law, and that the medical relief of the poor, both indoor and outdoor, was not organised as a Public Health Service. A Health Service, having for its first and great aim the prevention of disease, embracing the present Public Health, Medical Charities and Poor Law Hospital Services, and in fact charged with the prevention and treatment of disease among the poor, would, I consider, NEED FOR A UNIFIED MEDICAL SERVICE 289 particularly if managed as a State service, be a forward step of immense benefit to the public health and poor of the country. Everything points to the fact that the future of all medicine, but particularly of Poor Law medicine, lies in the adoption of preventive measures ; the time has passed when the principal function of the Poor Law Medical Officer is merely to dispense drugs." The need for union of the rival medical services has been equally pressed on us by Dr. Newman, formerly Medical Officer of Health for Finsbury and for the County of Bedford, and now Medical Officer of the Board of Educa- tion. " My experience," says Dr. Newman, " convinces me that from a medical point of view further co-ordination is imperatively necessary . . . between Public Medical Services, and if practicable a unification under one Authority. . . . Personally I am disposed to think that the medical part of the Poor Law Service might suitably be organised, partly or wholly, in conjunction with the Health Authorities. ... By some such unifica- tion the Medical Service would be more economical as well as more efficient and eff'ectual." We have already quoted the striking testimony to the same efi'ect of Dr. Leslie Mackenzie, the Medical Member of the Local Government Board for Scotland, as to the urgent need for a complete provision by the community for all cases of sickness. Most emphatic and impressive of all has been the evidence in confirmation of Dr. Newsholme, given first as Medical Officer of Health for Brighton, and then on wider and fuller information officially repeated to us by him as Medical Officer of the Local Government Board for England and Wales. " Under the present conditions of treatment of sickness for the poor," says Dr. Newsholme, '* diagnosis is usually belated, treatment is curtailed, and its efficiency is correspondingly diminished. ... I enter- tain little hope of success (in respect of measles and whooping-cough) until more efficient medical attendance is promptly available in the homes of the very poor. . . . The divided responsibility as to cases of puerperal fever and erysipelas needing institutional treatment at the present time leads to inefficient arrangement for such VOL. I u 290 CURATIVE TREATMENT OF THE SICK cases, and to much suffering and some loss of life. . . . Such instances represent only a small part of the mischief caused by the division of responsibility and powers." And he sums up significantly " that the present division of medical duties is gravely mischievous to public health, and the imification suggested is very desirable." Such authoritative official testimony, we feel, cannot be dis- regarded. (i) Conclusions We have therefore to report : — 1. That the continued existence of two separate rate- supported Medical Services in all parts of the Kingdom, costing, in the aggregate, six or seven millions sterling annually — overlapping, unco-ordinated with each other, and sometimes actually conflicting with each other's work — cannot be justified. 2. That the very principle of the Poor Law Medical Service — its restriction to persons who prove themselves to be destitute — involves delay and reluctance in the application of the sick person for treatment ; hesitation and delay in beginning the treatment ; and, in strictly administered districts, actual refusal of all treatment to persons who are in need of it, but who can manage to pay for some cheap substitute. These defects, which we regard as inherent in any medical service adminis- tered by a Destitution Authority, stand in the way of the discovery and early treatment of incipient disease, and accordingly deprive the medical treatment of most of its value. 3. That it has been demonstrated to us beyond all dis- pute that the deterrent aspect which the medical branch of the Poor Law acquires through its association with the Destitution Authority causes, merely by preventing prompt and early application by the sick poor for medical treatment, an untold amount of aggravation of disease, personal suffering and reduction in the wealth-producing power of the manual working class. 4. That the operations of the Poor Law Medical CONCLUSIONS 291 Service, being controlled by Destitution Authorities and administered by Destitution Officers, inevitably take on the character of unconditional "medical relief" — that is, relief of the real or fancied painful symptoms — as distinguished from remedial changes of regimen and removal of injurious conditions, upon which any really curative treatment, or any effective prevention of the spread or recurrence of disease, is nowadays recognised to depend. 5. That whilst domiciliary treatment of the sick poor is appropriate in many cases, it ought to be withheld : — (i.) Where proper treatment in the home is im- practicable. (ii.) Where the patient persistently malingers or refuses to conform to the prescribed regimen ; or, (iii.) Where the patient is a source of danger to others. It has become imperative in the public interest that there should be, for extreme cases, powers of compulsory removal to a proper place of treatment. Such powers cannot, and in our opinion should not, be granted to a Destitution Authority. 6. That where Destitution Authorities cease to abide by the limitation of their work to persons really destitute, or pass beyond the dole of " Medical Relief," their attempt to extend the range or improve the quality of the Poor Law Medical Service brings new perils. We cannot regard with favour any action which, in order to promote treat- ment, openly or tacitly invites people voluntarily to range themselves among the destitute ; or which tempts them, by the prospect of getting costly and specialised forms of treatment, to simulate destitution. Nor do we think that an Authority charged with the relief of destitution, what- ever its method of appointment, or whatever the area over which it acts, or any Authority acting through officers concerned with such relief, whatever their official designa- tion, can ever administer a Medical Service with efficiency and economy. 7. That, with regard to the suggestion that the medical treatment of the sick poor should be left either to provident medical insurance or to voluntary charity, it 292 CURATIVE TREATMENT OF THE SICK has been demonstrated to us that these offer no possible alternative to the provision for the sick made by the Public Authority. With regard to domiciliary treatment, the evidence as to medical clubs, " contract practice," Provident Dispensaries, and the out-patients' departments of hospitals, is such as to make it impossible to recommend, in their favour, any restriction of the services at present afforded by the District Medical Officers and Poor Law Dispensaries. Nor do we feel warranted in giving any support to the proposal made to us that the whole of this Outdoor Medical Service of the Poor Law should be super- seded by a publicly subsidised system of letting the poor choose their own doctors. Any such system would, in our judgment, lead to an extravagant expenditure of public funds on popular remedies and "medical extras," without obtaining, in return for this enlarged " Medical Relief," greater regularity of life or more hygienic habits in the patient. With regard to institutional treatment, we gladly recognise the inestimable services rendered to the sick poor by the hospitals, sanatoria and convalescent homes supported by endowments or voluntary contribu- tions. We approve of the use now made of these institu- tions by Public Authorities, and we think that many more suitable cases than at present might, on proper arrange- ments as to payment, be transferred from rate-maintained to voluntary institutions. But it is clear that such institu- tions provide only for a small fraction of the need, and that they leave untouched whole districts for some cases, and whole classes of cases everywhere, which there is no pro- spect of their being able or willing to undertake. 8. That the Medical Service of the Public Health Authorities, which now extensively treats disease, and actually maintains out of the rates a steadily increasing number of the sick poor, is based on principles more suited to a State medical service than that of the Poor Law. These principles, which lead, in practice as well as in theory, to searching out disease, securing the earliest possible diagnosis, taking hold of the incipient case, re- moving injurious conditions, applying specialised treat- ment, enforcing healthy surroundings and personal CONCLUSIONS 293 hygiene, and aiming always at preventing either recur- rence or spread of disease — in contrast to the mere "relief" of the individual — furnish in fact the only proper basis for the expenditure of public money on a Medical Service. 9. That such compulsory powers of removal in extreme cases, as have been asked for, are analogous to those already exercised, with full public approval, by the Public Health Authorities ; and that the proposed extension of such pow^ers can properly be granted only to an authority proceeding on Public Health lines. 10. That we therefore agree with the responsible heads of all the four Medical Departments concerned — the Chief Medical Officer of the Local Government Board for Eng- land and Wales, the Medical Member of the Local Govern- ment Board for Scotland, the Medical Commissioner of the Local Government Board for Ireland, and the Medical Officer of the Board of Education — in ascribing the defects of the existing arrangements fundamentally to the lack of a unified Medical Service based on Public Health principles. IL That in such a unified Medical Service, organised in districts of suitable extent, the existing Medical Officers of Health, Hospital Superintendents, School Doctors, District Medical Officers, Workhouse and Dispensary Doctors and Medical Superintendents of Poor Law In- firmaries — the clinicians as well as the sanitarians — would all find appropriate spheres ; that one among them being placed in administrative control who had developed most administrative capacity. 12. That we do not agree with the suggestion that the establishment of a unified Medical Service on Public Health lines necessarily involves the gratuitous provision of medical treatment to all applicants. It is clear that, in the public interest, neither the promptitude nor the efficiency of the medical treatment must be in any way limited by considerations of whether the patient can or should repay its cost. But we see no reason why Parlia- ment should not embody, in a clear and consistent code, definite rules of Chargeability, either relating to the treat- 294 CURATIVE TREATMENT OF THE SICK ment of all diseases, or of all but those specifically named ; and of Recovery of the charge thus made from all patients who are able to pay. In our chapter on " The Scheme of Reform," we propose new machinery for automatically making and recovering all such charges that Parliament may from time to time impose. CHAPTER VI THE MENTALLY DEFECTIVE The Mentally Defective were scarcely alluded to in the Report of 1834. To-day in the United Kingdom they number, in all their grades, more than one-sixth of the entire pauper host — an army approaching 200,000 in number, constantly receiving maintenance from the rates, in respect, nominally of their destitution, but really, as we shall see, by reason of their infirmity. In view of the elaborate investigations of the Vice-Regal Commission on Poor Law Reform in Ireland (1902-6) and of the Royal Commission on the Care and Control of the Feeble-minded (1904-8), although we received some useful testimony, we have abstained from doing more than cursorily surveying this part of the field of the Poor Law, and we accept the valuable evidence obtained by those Commissions as if given to ourselves. (a) The Rival Authorities for the Mentally Defective In England and Wales, Scotland and Ireland alike, in spite of minor variations, we find the public provision for the diff"erent grades of the Mentally Defective everywhere divided between two or more Local Authorities acting for the same districts ; and supervised by two, by three, and even by four difi'erent Departments of the National Govern- ment ; with the result that whilst there is, in some respects, duplication and overlapping, the total provision made is far from satisfactory, and we have it in evidence that there has been considerable waste of money. In England and Wales it is, speaking generally, the 295 296 THE MENTALLY DEFECTIVE County or County Borough Council, acting through its Asylums Committee, which is the Local Lunacy Authority, charged by statute to make the necessary institutional provision for persons certified to be of unsound mind, irrespective of their affluence. If they, or any one on their behalf, repay to the Council the average weekly cost of their maintenance (not including the cost of the asylum site and buildings), they rank as "private patients," and are not deemed to be in receipt of relief. But in nine cases out of ten no payment is made direct to the Council ; and the sum is then claimed from the Board of Guardians of the Union in which the patient has a settlement. That Board endeavours to recover some contribution from the relatives liable to maintain the patient, who remains a pauper whether or not the full cost is repaid to the Desti- tution Authority. The relations legally liable for his main- tenance also become constructively paupers by the mere presence of a dependant in the County Asylums as a pauper. It is a curious feature of the arrangement that the Asylums Committee of the County or County Borough Council has practically no interest in managing its asylums economically, as the actual weekly cost has to be paid by the Boards of Guardians concerned. On the other hand, these Boards of Guardians, who pay the bill, have no connection whatever with the management. Indeed, as we shall subsequently describe, the National Government chooses to make its grants-in-aid in such a way as to afford the Boards of Guardians a direct financial inducement to get as many persons as possible certified to be of unsound mind, to transfer as many of them as possible to the more expensive institutions, and to refrain from obtaining repay- ment from relatives of more than a portion of the cost. Meanwhile the supervision and control of the Local Lunacy Authorities is divided among no fewer than three Govern- ment Departments — the Home Office, the Lunacy Commis- sioners, and the Local Government Board — each of them, nominally, wielding peremptory powers, but none of them charged with clearly defined responsibility for either the efficiency of the service as a whole, or for economy, and none of them exercising any control over the large Grants- RIVAL AUTHORITIES 297 in- Aid that the Government contributes towards the expenditure of the Local Authorities. The result is that the capital cost of a lunatic asylum has mounted up to £300, £400, and even to £500 per patient, because there is no one Government Department strong enough, and expert enough, to combine technical and financial control ; and the total cost of the public provision for persons certified to be of unsound mind has risen, in England and Wales alone, to more than £3,000,000 annually. The bulk of this amount is paid by the Boards of Guardians out of the Poor Rates. But they, too, make extensive provision of their own, alongside that made by the County or Borough Council, for the various grades of the Mentally Defective. Whilst more than four-fifths of the persons actually certified to be of unsound mind are now in asylums, the Boards of Guardians have over 5000 on Outdoor Relief, and they still maintain more than 11,000 of these certified lunatics, imbeciles and idiots, in the General Mixed Workhouses. Moreover, as has been proved by the elaborate investigations of the Royal Com- mission on the Care and Control of the Feeble-minded, there is, in these Workhouses, a further contingent who ought to be certified as being distinctly " feeble-minded " or epileptic, and requiring special treatment, numbering, if we may accept the careful estimate made by the Royal Commission, of 12 per cent of the inmates of the urban Workhouses and 1 8 per cent of those in the rural Work- houses, at least 40,000, besides 12,000 more among the paupers on Outdoor Relief. Thus the Boards of Guardians of England and Wales, notwithstanding their very free use of the County Asylums, have to-day, under their own administration, nearly 70,000 mentally defective persons. The Asylums Committees of the County and Borough Councils, though professedly the Local Lunacy Authorities, have themselves no more than 120,000. There is yet another Local Authority entering the field to spend public money in providing for the Mentally Defective. Under statutes of 1899 and 1902 the Local Education Authority is authorised and required to provide for the mentally defective children, of whom it appears 298 THE MENTALLY DEFECTIVE there are no fewer than 47,000, iu some cases up to sixteen years of age. In London and in some other large towns special schools for these children are being provided ; they are sometimes " boarded-out " in families to enable them to attend such schools ; and they are now even maintained in residential schools at the cost of the Education Rate. To quote the phrase of one of our colleagues, in this way " a considerable relief system of so-called maintenance is growing up " without any co-ordination with the Poor Law or with the Lunacy Authorities. In the Metropolis, in particular, " the residential homes of the Metropolitan Asylums Board duplicate, for so-called defective pauper children, the homes which have been established by the Education Committee for school children who are equally defective though not technically pauper." It happens now in London that a father may find one child thus taken off his hands by the Local Education Authority, whilst another may be sent to an industrial school, and the others, perhaps, supplied with school dinners, whilst he or his wife may be getting infirmary treatment, or even Outdoor Relief, without one Authority necessarily even knowing what the others are doing. The various authorities will even compete among themselves. " There has been with us," stated one witness, " several times a conflict between the Education Committee and the Guardians as to who was responsible " for the custodial care of Mentally Defective Children. In Scotland there is a similar duplication of Authorities, though to a lesser extent. The Local Lunacy Authorities are the District Boards of Lunacy, which are, in effect, district committees of County Councils, or joint committees of groups of County Councils, These District Boards of Lunacy provide asylums, to which the Destitution Authori- ties (the Parish Councils) remit their certified patients, much as in England and Wales. The Parish Councils, however, retain under their own charge, not only a small number of certified persons whom they maintain on Out- door Relief, but also 2780 whom they "board out" for payment to persons who make use of the lunatic's labour, and also 1300 who reside in "certified wards" of the Poorhouses. In the ordinary wards of the Poorhouses it is mVAL AUTHOEITIES 299 estimated that there are, in addition, at least one or two thousand persons who ought to be certified as distinctly feeble-minded or epileptic. Thus, apart from the fact that six important Parish Councils are themselves the Lunacy Authorities as well as the Destitution Authorities, these latter are actually in charge of half as many Mentally Defective persons as the District Boards of Lunacy. In Ireland, herein differing from Great Britain, the County Lunatic Asylums are in no way connected with the Poor Law, and maintenance in them, even if gratuitous, involves no pauperism. But, alongside of the Asylums Committees of the County and Borough Councils, the Boards of Guardians also maintain, out of the Poor Rate, as paupers, more than 3000 certified lunatics and idiots in the General Mixed Workhouses, besides a number more on Outdoor Relief. Moreover, there are estimated to be, in these Workhouses, at least 6000 more who ought to be certified as distinctly feeble-minded and needing appro- priate treatment. Thus the Boards of Guardians in Ireland have under their own charge half as many Mentally Defective persons as the Local Lunacy Authorities them- selves. We have still to mention the asylums for inebriates, which are maintained in one or two cases by Local Authorities, and elsewhere by voluntary committees administering funds which are almost entirely derived from the rates and taxes ; and the special institutions for epileptics, which two or three Boards of Guardians have combined to establish. (b) The Mentally Defective under the Poor Law Apart from the unnecessary expense to the public, and the wanton undermining of family responsibility, that this overlapping and confusion of Authorities necessarily causes, we find grave deficiencies in the service itself. We have been painfully impressed, in our visits to the General Mixed Workhouses in England, Wales and Ireland, with the almost universal herding of the idiots, imbeciles, epileptics and feeble-minded of all grades indiscriminately 300 THE MENTALLY DEFECTIVE with the other inmates of these institutions. This is an extensive, and, we regret to say, contrary to the usual im- pression, an increasing evil. In 1859 there were, in all the Workhouses of England and Wales, only 7963 persons certified to be of unsound mind. In 1906 there were in these same Workhouses no fewer than 11,151, an increase during the forty-seven years of 40 per cent. And though the numbers of these actually certified persons have, of recent years, remained nearly stationary, by no means all the imbeciles are certified as such ; and, with the change that has come over the Workhouse population, the propor- tion of those who ought to be certified as distinctly feeble- minded is now estimated to amount, in addition to the certified lunatics and idiots in the LTrban Unions, to more than 12 per cent, and in Rural Unions to more than 18 per cent, of the total. The total number of mentally defective persons now residing in the ordinary wards of the General Mixed Workhouses of the United Kingdom must amount to more than 60,000. These 60,000 persons, of all ages and conditions, ex- hibiting all grades of mental defectiveness, are receiving practically nothing in the way of ameliorative treatment. We do not suggest that all the 60,000 are suflPering, either in body or mind, from this lack of special care or treat- ment. In many a small Rural Workhouse, under a kindly Master and Matron, among companions in misfortune who happen not to tease or wrangle, we have found the merely feeble-minded middle-aged men and women harmlessly and happily employed. But we have ourselves witnessed terrible sights. We have seen feeble-minded boys growing up in the Workhouse year after year untaught and un- trained, alternately neglected and tormented by the other inmates, because it had not occurred to the Board of Guardians to send them to (and to pay for them at) a suit- able institution. We have ourselves seen — what one of the Local Government Board Inspectors describes as of common occurrence — " idiots who are physically ofi'ensive or mischievous, or so noisy as to create a disturbance by day and by night with their howls," living in the ordinary wards, to the perpetual annoyance and disgust of the other UNDER THE POOR LAW 301 inmates. We have seen imbeciles annoying the sane, and the sane tormenting the imbeciles. We have seen half-witted women nursing the sick, feeble-minded women in charge of the babies, and imbecile old men put to look after the boys out of school hours. We have seen ex- pectant mothers, who have come in for their confinements, by day and by night working, eating and sleeping in close companionship with idiots and imbeciles of revolting habits and hideous appearance. " I have known," testifies Dr. Milsom Rhodes, " a noisy dement in the next bed to a case of acute pneumonia, to whom sleep was an absolute necessity, a sine qua non she had small chance of obtaining," *' All over England, urban and rural," says our Medical Investigator, " epileptics are found lodged in Workhouses and Poor Law infirmaries. Sometimes there are only a very few . , . sometimes as many as fifty. Often they occupy day rooms and dormitories along with ordinary or imbecile inmates. ... In smaller Workhouses in the rural districts the arrangements are usually most inadequate. . . . The epileptics may not have suitable and sufficient outdoor employment, they cannot have the best kind of supervision, nor be preserved against irritation by their companions, and the spectacle of their seizures is detrimental to ordinary inmates." The Irish Workhouses, declares the General Inspector of the Local Government Board, as "is only too obvious to any one who has had an opportunity of inspecting them," are " under existing management . . . most unsuitable places for the accom- modation of persons of unsound mind, and . . . the condi- tion of the latter at present housed in these establishments is in ma7iy instances disgraceful.'' We cannot but agree with our own Medical Investigator that this " herding of imbeciles with the ordinary inmates of a Workhouse is injurious to both. . . . The sane -minded should not be compelled to have continually amongst them the victims of imbecility and the gibbering speech and untidy habits of some of the afflicted." The evil consequences of this herding in the Work- houses of the mentally defective with the sane have been repeatedly pointed out for the last two decades. For 302 THE MENTALLY DEFECTIVE at least twelve years they have been referred to, almost every year, in the Annual Reports of the Local Govern- ment Board for England and Wales, yet it has been found impossible to move the Board of Guardians to reform. To them, indeed, by their very nature as Destitution Authori- ties, the idea of ameliorative treatment does not seem to occur. What they are doing is merely " relieving destitu- tion." For these unfortunate imbeciles and epileptics, as for all other paupers, "the system of indoor relief" is, as Mr. Adrian, the Legal Adviser to the Local Government Board, has pointed out, legally only "a housing system." It was in vain that the scandal of the retention of imbe- ciles and idiots in the old people's wards of the Workhouses was pointed out in one of the Reports of the Royal Commission on the Aged Poor. It was in vain that the Select Committee of the House of Commons in 1899 recommended the removal of all mentally defective per- sons from the Workhouses. Ten years have elapsed since that recommendation, and the number of mentally defective persons in the Workhouses is actually greater than at that date. So obstinate a neglect to carry out an obvious reform provokes inquiry into its cause. We think we are not wrong in attributing the retention of these 60,000 mentally defective persons in the Workhouses to the fact that their labour is found useful — in the small rural Workhouses, indeed, actually indispensable to their administration on present lines. We have ourselves been informed, in Work- house after Workhouse, that they had to rely on the imbeciles for practically all the manual work of the establishment. We gather that it was principally on this ground that the Local Government Board for England and Wales did not issue an Order requiring compliance with the recommendation of the House of Commons Committee of 1899, and the removal of all imbeciles from the Work- houses. The President seems to have been advised that, without the mentally defective women in particular, the General Mixed Workhouse in the rural Unions could not be carried on. "If," said an objector, "you remove the feeble-minded women from the Workhouse who will do the scrubbing ? " UNDER LOCAL LUNACY AUTHORITIES 303 (c) The Mentally Defective under the Local Lunacy Authorities We turn now to the 100,000 mentally defective pauper patients in the County and Borough Asylums in England and Wales and the District Asylums in Scotland. Built and equipped at great expense, by the watchful care of the Lunacy Commissioners in England and Wales and the General Board of Lunacy in Scotland, well staffed with doctors and nurses, and maintained at a cost for annual maintenance alone of something like £3,000,000 annually, these 180 institutions have become highly efficient mental hospitals for brain disease. Whilst many cases are perma- nent and hopeless, some 10,000 patients are discharged annually as cured. The average stay of all the patients, indeed, works out at less than five years ; and of the curable cases, the majority remain under treatment only a few months. Here the great blot appears to us to be the stigma of pauperism which is, in England and Wales, needlessly and uselessly inflicted on these persons and on their rela- tions : — " The households in which the presence of a mentally afflicted member of the family is a danger, a degradation and an intolerable burden, are not necessarily those of paupers . . . many of " the so-called pauper patients " have never been in a Workhouse, and some of them cost the local rates nothing at all. Many of them are children of small farmers, tradesmen in a small way of busi- ness, clerks, artisans and others, who, unable to pay the full charge, are yet able to contribute 5s. or 6s. per week, or even more, for the maintenance and training of their children. In order to make up the full charge of from 10s. 6d. to 14s. per week, the parents pay their contributions to the Board of Guardians, who receive the 4s. grant, add to it the parents' contributions, and thus, in some instances, make up the required amount. This pauperises the parent, though it does not do so in the case of children sent to blind or deaf and dumb institutions, or educated at Public Ele- mentary Schools, where the schooling is paid for out of the rates, or even in the case of criminal or neglected children sent to reformatory or industrial schools." The case is all the harder when a wife, a child, or a parent 304 THE MENTALLY DEFECTIVE is compulsorily removed to an asylum, on the ground of possible danger, or even merely of annoyance to the neigh- bours. The relations liable are then called upon to con- tribute 10s. or 12s. a week, on pain of being stigmatised as paupers and deprived of the franchise. Indeed, unless they take care to make the full payments direct to the County or Borough Council, they will, notwithstanding their repayment to the Board of Guardians of the whole of the cost, still leave the patient a 'pauper, and included in the statistics of pauperism : — The evidence shows that the division between pauper and non-pauper is quite unreal in the case of the mentally defective. The son of respectable parents, who is permanently supported, wholly or in part, by relatives and friends, requires, as mentally defective, the same treatment as another person whose relatives and friends cannot help him at all ; and the greater or less possi- bility of obtaining payment for the treatment — the more or less poverty or destitution — is not the dividing line in these cases, but the existence of or non-existence of mental disease. In Scotland, the Court of Session has held that the maintenance of a dependant of unsound mind out of the Poor Kate does not pauperise those responsible for him. In Ireland the patient in the County Lunatic Asylum has, from first to last, no connection with the Poor Law, and even if he is treated gratuitously, neither he nor his relatives are thereby made paupers. (d) The Recoramendations of the Royal Commission on the Feeble-minded We are relieved from formulating any judgment of our own upon the Mentally Defective under the Poor Law, by the authoritative findings and unanimous recommendations, not only of the Vice-Regal Commission on Poor Law Reform in Ireland (1902-1906), but now also of the Royal Com- mission on the Care and Control of the Feeble-minded (1904-1908). The latter extend to the whole range of the Mentally Defective, from the merely feeble-minded child, the inebriate unable to restrain himself from alcohol and the sane epileptic, up to the dangerous lunatic and the THE ROYAL COMMISSION 305 undeveloped idiot. AVitli regard to the whole of this army of poor persons, probably approaching 200,000 in number, being more than one-sixth of the entire pauper host, the Royal Commission is emphatic in its judgment that '* a Poor Law Authority cannot suitably undertake the care of the Mentally Defective." Both Commissions are decisive in their recommendation that the Mentally Defective should be wholly removed from the Workhouses. It is accord- ingly recommended that the Mentally Defective of all grades and all ages should be taken out of the Poor Law, and that the Destitution Authority should henceforth have nothing to do with their maintenance or treatment. It is declared to be — " The mental condition of these persons, and neither their poverty nor their crime," that " is the real ground of their claim for help from the State. It follows that their aid and supervision should be undertaken by some powerful Local Authority, who can ensure that they will receive it from other quarters, or, failing this, will provide it themselves. Hitherto, a large number of adults, young persons and children, who cannot be certified under the Lunacy and Idiots Acts, have been supported by Public Authorities as paupers, on the ground of destitution, or, as prisoners, on account of their crime, but they have not been dealt with primarily on the ground of their mental defect." " In the development of any organisation for the care of the Mentally Defective, the precedent of the Lunacy Acts should, we think, be followed, rather than the precedent of the Poor Law. Under the Lunacy Acts, intervention is due to the existence of mental incapacity ; under the Poor Law, to the existence of poverty and destitution." "If there is to be co-ordination between the Authorities and agencies concerned, it is essential that the care of the Mentally Defective should be made a duty not of the Poor Law Authorities, but of specially qualified Authorities organised with that object." " There should be one Authority in the County or County Borough, which should have supervision of all institutions for the Mentally Defective, and be able, through its Medical Otficers and hy its annual survey of all cases, to ensure that the institutions should, as far as possible, be used each for its several purposes, and that those persons who require custodial treatment should be passed on to institutions fitted for them." The Local Education Authority should give up the pro- VOL. I X 306 THE MENTALLY DEFECTIVE vision that it is beginning to make for mentally defective children. The fact that there was throughout and for all purposes one single and responsible Authority would make irrelevant all proposals for the transfer of the child at a certain age from one Authority to another, as, for instance, as some have suggested, at sixteen, or any age up to twenty-one, from the care of the Education Authority to the Board of Guardians, and from them to the Lunacy Authority. Whatever the mentally defective person might be, and in whatever way the Local Authority might provide for his maintenance, he would remain under the care and control of one Local Authority only. It is accordingly recommended that the entire responsi- bility for the Mentally Defective of all grades and at all ages should be entrusted in England, Wales and Ireland to a committee of the County or County Borough Council, to be called the Committee for the Mentally Defective, in which the existing Asylums Committee would be merged, and in Scotland to the County Councils and principal Town Councils, from which the District Boards of Lunacy are at present selected. (e) The Withdrawal of the Mentally Defective from the Poor Laiv We do not see how, in face of the facts now definitely revealed, and of the unanimous recommendations of so authoritative a Commission, any other conclusion is possible. We entirely concur in these recommendations, and we are glad to find ourselves, on this point, in agreement with the majority of our colleagues. We, however, think that the withdrawal from the Destitution Authorities of so large a number of paupers as 200,000, and particularly the com- plete removal of the whole class of the feeble-minded from the Workhouses, entails, in practice, the break up of the Poor Law system. The Royal Commission on the Care and Control of the Feeble-minded has come, in fact, with regard to all grades of the Mentally Defective, to the same conclusions to which we, with regard to the children and the sick, have concurrently been driven, namely, the super- WITHDRAWAL FROM POOR LAW 307 session of the Destitution Authority in favour of an Authority dealing with these patients in respect of the cause and character of their distress. It would indeed be strange to remove from the charge of the Destitution Authority, from the demoralising General Mixed Work- house, and from the stigma of pauperism, the inebriates, the feeble-minded, and the epileptics, and to leave in the same unsatisfactory conditions the promising children and the curable sick. We may confidently predict that, unless we break up the Destitution Authority, and allocate to the more specialised Local Authorities the classes with which they severally deal, we shall find, years hence, the General Mixed Workhouse continuing still in existence, and the imbeciles and feeble-minded still herding within its walls. (p) Conclusions We have therefore to report : — 1. That the existing provision for the Mentally Defective persons maintained in the United Kingdom at the public expense, probably approaching 200,000 in number, is far from satisfactory. 2. That the existence everywhere of rival Local Authorities maintaining the Mentally Defective, and the division of the supervision and control over their work among three (or even four) different Government Depart- ments, no one of which has full responsibility, or combines in itself technical knowledge and financial control, involves — to use the emphatic words, formally given in evidence, of the Local Government Board for England and Wales — "a large amount of uiinecessa^'y expenditure.^^ 3. That the continued detention in the General Mixed Workhouses of England, Wales and Ireland, and, to a lesser degree, those of Scotland, of no fewer than 60,000 Mentally Defective persons, including not a few children, without education or ameliorative treatment, and herded indiscriminately with the sane, amounts to a public scandal. 4. That the practice of Ireland, where the inmates of the County Lunatic Asylums are wholly unconnected with 308 THE MENTALLY DEFECTIVE the Poor Law, and are not stigmatised as paupers, should be adopted for Great Britain. 5. That we concur with the Vice-Kegal Commission on Poor Law Reform in Ireland in thinking that all persons of unsound mind, whatever their mental state, and w^hatever their age, should be everywhere wholly removed from the AVorkhouses. 6. That, in the words of the Royal Commission on the Care and Control of the Feeble-minded, it is " the mental condition of these persons, and neither their poverty nor their crime " that " is the real ground of their claim for help from the State." 7. That we accordingly concur with that Commission in the view that all grades of the Mentally Defective (including the feeble-minded, the epileptics, the inebriates, the imbeciles, the lunatics and the idiots) should, at all ages, be wholly withdrawn from the charge of the Destitu- tion Authorities, and from pauperism, as well as from the Local Education Authorities, and that the entire responsi- bility for their discovery, certification and appropriate treatment (whether institutional or domiciliary) should be entrusted in England, Wales and Ireland, to the County and County Borough Councils, acting by statutory Com- mittees for the Mentally Defective, in which the present Asylums Committees would be merged, and in Scotland to the County Councils and principal Town Councils, from which the District Boards of Lunacy are (with the exception of six towns) selected. 8. That the whole duty of supervision and control of the action of the Local Authorities in respect of the Mentally Defective, including the administration of the Gran ts-in- Aid, should be concentrated, in England (includ- ing Wales), Scotland and Ireland respectively, in a single self-contained and fully equipped Division or Department, concerned with the Mentally Defective alone, however that Division or Department may be grouped with others under a Minister responsible to Parliament. CHAPTER VII THE AGED AND INFIRM The Aged and Infirm, who constitute about one-third of the entire pauper host, make up the most baffling of the categories into which the non-able-bodied poor are, under the Poor Law Amendment Act and the Orders of the Local Government Board for England and Wales, officially classified. It is to be noted that, ever since the Elizabethan Poor Law, the Old and Impotent — who have since been officially designated the Aged and Infirm — are always referred to as forming one and the same class, of which no official definition has ever been given. The persons included in this class from time to time, by the instruc- tions of the Central Authority and the practice of the Boards of Guardians in England, Wales and Ireland and the Parish Councils in Scotland, comprise, in fact, all sorts and conditions of men, children only excepted. We find among them persons so sick as to require continuous medical treatment and nursing ; others so mentally de- fective as to be continuously under restraint ; others on the verge of imbecility ; others, again, so fully able-bodied and intelligent as to be given quite a fair day's work. No man or woman is too young to be comprised within this class, if only they are permanently incapacitated ; none are too vigorous or skilled if they are over a certain age, often arbitrarily fixed at sixty. Men and women, married or widowed, of every grade or variety of character or conduct, past or present, are alike included ; persons who have been thrifty and industrious or wastrel and drunken ; persons who are respectable and refined or dirty and 309 310 THE AGED AND INFIRM dissolute ; the orderly or disorderly ; the active-minded and intelligent, the mentally defective and the senile. In view of the numerous official inquiries of the past fifteen years into the question of the provision for the aged poor, we have narrowly limited our own investigation into this part of our subject, taking evidence and inspecting institutions principally with the object of ascertaining how far the voluminous information that has been accumulated needed modification or correction in the light of the exist- ing condition of things. We have not needed, in this branch of our subject, to go beyond the operations of the Poor Law itself. It is one of the many anomalies of the situation that, whereas there are, as we have seen, two rival Local Authorities for dealing with the sick poor, three different Local Authorities for treating those who are mentally defective, and four separate Local Authorities competing for the care of infants and children, there has been, down to the autumn of 1908, only one Local Authority providing for all the diversified medley of individuals classed as Aged and Infirm. Whether they are sick or well, able-bodied or incapacitated, over seventy or under forty, intelligent or feeble-minded, of admirable past and present conduct or the very dregs of the populace, they have been, in England and Wales, Scotland and Ireland alike, all heaped up imder the jurisdiction of the Destitution Authority. (a) The Three Policies of the Destitutio7i Authority Since 1834 there have been, in England and Wales, three successive lines of policy laid down by the Central Authority for the treatment of the Aged and Infirm — either by Orders, or through the Inspectorate, or in the President's Circulars. These three policies may be con- veniently termed : — (a) The Policy of an indiscriminate use of the General Mixed Workhouse, tempered in practice by general Outdoor Relief to all kinds of Aged and Infirm ; (6) The Policy of applying the Workhouse Test THE THREE POLICIES 311 to the Aged and Infirm, assumed to be mitigated by the extraction of support from relations or the charitable ; and (c) The Policy, so far as the Aged alone are con- cerned, of deliberate discrimination by Boards of Guardians according to past or present character, with generous treatment of the deserving. These three lines of policy are, in our judgment, incon- sistent and incompatible with each other ; they have all left their marks on the authoritative documents that are still in force ; they have all been more or less adopted by one or another of the 1679 separate Destitution Authorities of the United Kingdom ; and the result is the confusion, uncertainties, and inequalities that to-day especially mark this department of Poor Law administration. The first of the three Policies with regard to the Aged and Infirm was established by the Poor Law Commissioners of 1834-47, and continued by the Poor Law Board of 1847-71. This was not due to the 1834 Report. The meagre references to the Aged and Infirm in the Report of 1834 can hardly be said to amount to any recommendations as to policy. The authors of that Report accepted without question the almost universal practice of relieving the Aged and Infirm by small weekly allowances in their own homes, and they suggested no alteration in this practice. The one change that they definitely advocated with regard to the Aged was that, where these had to be maintained in institutions, they were to be rescued from the General Mixed Workhouse, and accommodated in entirely separate buildings, under entirely separate management, expressly in order that '* the old might enjoy their indulgences." Unfortunately, as we have seen, the Poor Law Commis- sioners quickly found that, with the Destitution Authority that the Act of 1834 had established, it was impracticable to carry out the strong and reiterated recommendations of the Report of 1834 for the abolition of the General Mixed Workhouse. The separate institutions for the Aged, where "the old might enjoy their indulgences," were therefore not established. But a further step followed. As the existence of the Destitution Authority had involved the 312 THE AGED AND INFIEM continuance of the General Mixed Workhouse, so the use of that institution for all classes of paupers prevented even the humane and considerate treatment of the Aged, on which the authors of the 1834 Eeport had laid stress. The Poor Law Commissioners found that they had to set themselves strictly against any discrimination inside the Workhouse between one class of paupers and another. There was, as they recognised in 1839, "a strong disposi- tion on the part of a portion of the public" — who had perhaps read the 1834 Eeport — "so to modify the arrange- ments [of the Aged and Infirm Wards of the Workhouse] ... as to place them on the footing of almshouses. The consequences which would flow from this change have only to be pointed out to show its inexpediency and its danger. If the condition of the inmates of a Workhouse were to be so regulated as to invite the Aged and Infirm of the labouring class to take refuge in it, it tvould immediately he useless as a test hettveen indigence and indolence and fraud.'' On the other hand, so far at any rate as their official documents or public utterances are concerned, neither the Poor Law Commissioners of 1834-47, nor the Poor Law Board of 1847-71, saw any reason to discountenance the very general practice of the Boards of Guardians of pro- viding,, by means of Outdoor Eelief, for all the Aged and Infirm who could anyhow manage to exist upon what was allowed to them. There had been no such suggestion in 1834 Eeport. "It is not our intention," the Commis- sioners had declared in 1839, 'Ho issue any such ride [requiring the Aged and Infirm to receive relief only in the workhouse]" unless we shall see, in any particular Union or Unions, frauds or abuses imperatively calling for our interference." No such Order was ever issued. It is to be noted that the Central Authority always argued against any discrimination between one aged person and another according to past character, and even according to past thrift. No person was to be relieved uuless he was destitute ; no more was to be given than sufficed to sustain life ; and no less could possibly be given even to the worst person. It was expressly held that any allow- THE THREE POLICIES 313 auce from a Friendly Society, or other income, was to be counted at its full amount. The policy of indiscriminate, insufHcient, and unconditional Outdoor Relief to all the Aged and Infirm who could manage to exist outside, coupled with indiscriminate accommodation in the General Mixed Workhouse for the rest of them, was that adopted in practically all the Unions of England and Wales be- tween 1834 and 1871. What it has always tended to be in practice is a sort of bargain between a good-natured but penurious Destitution Authority, and each Aged or Infirm person in turn, as to how little that person would consent to make shift on, rather than come into the abhorred General Mixed Workhouse. The second of the three policies — that of applying the test of "the offer of the House" to the Aged and Infirm, as to other classes — appears to have prevailed among most of the Inspectors of the Local Government Board between 1871 and 1890, and the school of "strict administrators" with whom they were in communication. We may take as the best exponent of this policy Mr., afterwards Sir Henry Longley, K.C.B., an able, zealous, and experienced official of great influence in Poor Law administration, whose reports on the subject obtained a wide circulation. Mr. Longley assumed, in every paragraph of his well- known Report of 1873-74, that the "Workhouse principle" w^as universally applicable to " the Disabled " — that being the term he used for the Aged and Infirm — as well as to the Able-bodied. His policy seems to have embodied, in what we think a confused way, several different hypotheses. It was advocated as an inducement to individual saving. A rigid adherence to the policy of " ofi'ering the House " would, Mr. Longley argued, lead the poor to provide, or induce their relations to provide, for old age as well as for sickness and widowhood. If the aged had, however, not been able to save, and had no relations legally liable to maintain them, the " ofi"er of the House" would, it was alleged, bring forward other relations, not legally liable, who, rather than have the disgrace of a relation in the Workhouse, would support them. This was even held, in some queer way, to be specially true of the aged who had 314 THE AGED AND INFIRM led really good lives. Finally, in the cases, which were assumed to be very rare, of the deserving aged person having been neither able to save nor to attract the affec- tion of relations able to support him, voluntary charity was supposed to come to the rescue. It was an integral part of the policy that Mr. Longley strongly deprecated any deviation in particular cases from what he euphemisti- cally called "the offer of indoor relief." "That which an applicant does not know certainly that he will not get," he forcibly argued, " he readily persuades himself if he wishes for it that he will get ; and the poor, to whom any inducement is held out to regard an application for relief as a sort of gambling speculation, in which, though many fail, some will succeed, will, like other gamblers, reckon upon their own success." For every " hard case " he relied on the springing up in every Union of intelligently directed private charity. " It is, in fact, the very existence of charity " — assumed thus to be always at hand whenever required — " which strengthens the hands of the Poor Law administration in adherence to rule." There was thus to be a sharp division between those aged and infirm who were provided for in their old age by their own savings, by the kindness of their relations and friends, or by voluntary charity, on the one hand — assumed to be coincident with " the deserving " — and on the other hand those aged and infirm who had no alternative but Poor Law relief. For these latter — assumed to be coincident with " the undeserving " — there was to be nothing but the General Mixed Workhouse. And in order to emphasise this assumed coincidence of the aged who bad to accept Poor Law relief and those who were undeserving, every effort was made to retain and even to deepen the " stigma of pauperism." This was officially expressed in the phrase " the degradation of parish support." ** I think," said in 1893 the then Chief General Inspector and Assistant Secretary of the Board, " that a man should feel that there is some degradation in living upon funds that have been raised . . . hy compulsion from his neighbours." Mr. Longley's Reports so far received the endorsement of the Local Government Board that they were not only THli: THREE POLICIES 315 published with commendation, but were officially circulated to Boards of Guardians. Other Inspectors were always pressing the same views. The half a dozen Unions that adopted this policy of " Thorough " were repeatedly held up for admiration by the Inspectorate and in the Official Reports. It even came to be commonly assumed that this was, in some special sense, the " orthodox " Poor Law policy. We do not, however, find that the Local Govern- ment Board ever expressly embodied it in any published Order, Circular, or other authoritative document. This policy of " offering the House " to all aged persons was qualified by exceptions. Thus the Paddington Board of Guardians adopted the following rules : "Outdoor Relief may be granted only to such aged and infirm persons as — " (1) Are deserving at the time of application. " (2) Have shown signs of thrift. " (3) Have no relations legally or morally bound to, and able to, support them. " (4) Are unable to obtain sufficient assistance from charitable sources ; and " (5) Are desirous of living out of the Work- house and can be properly taken care of." It will, however, be noted that it was still definitely laid down that persons who complied with Nos. 1, 2 and 4 of the regulations, but not with No. 3 or No. 5 — persons, that is, who were admittedly deserving, thrifty and wholly destitute, but whose relations (not being legally liable) refused to support them ; or who had no one to look after their little needs — were to be relieved only in the Workhouse — in the General Mixed Work- house, made deterrent and intended only for the undeserving. We pass now to the third policy — that of discriminat- ing, with regard to persons over some prescribed age, between the deserving and the undeserving poor, alike in the amount of Outdoor Relief, and in the amenities of institutional treatment. This policy, diametrically opposed as it was to that inculcated by the Inspectorate of 1871-1890, has been described to us, by the present 316 THE AGED AND INFIRM Chief Inspector of the Local Government Board, as characteristic of " the political decade of Poor Law administration." By this ambiguous phrase — unusual in the mouth of a Civil Servant — we understand to be meant that the policy was adopted by the Local Govern- ment Board in obedience to the wishes of Parliament and. in compliance with a widespread public opinion. We note that the policy has been equally characteristic of Presidents of different political parties. It is interesting to see that the new departure began over the indulgence of an allowance of tobacco. The Liverpool Select Vestry — the Destitution Authority of that great city — determined to give the well-conducted old men in the Workhouse the privilege of a weekly screw of tobacco, whether or not they were employed on disagreeable duties. The Auditor objected. The Vestry insisted. The Central Authority was obdurate. The local body appealed to its Parliamentary representatives. It was suggested as a compromise that the medical officer might be got to include it in the dietary table, when the Central Authority would not 'refuse to sanction it. The Vestry declined to compromise, and insisted on allowing tobacco as a non- dietetic indulgence. Finally, the Inspector was instructed to say that objection was withdrawn. No publicity was given to the concession, but it gradually leaked out. During the year 1892 we see the Central Authority sanctioning by letter, without any official publication on the subject, such applications as w^ere made by individual Boards of Guardians to be permitted to allow an ounce of tobacco weekly to the men over sixty in the Workhouse. At last, in November 1892, a General Order was issued permitting it in all Unions, irrespective of sex, and without limit of amount. Little more than a year later, as some compensation to the old women (though they had not been excluded, in terms, from the indulgence of tobacco or snuff) they were allowed " dry tea " with sugar and milk, irrespective of that provided for in the dietary table. Presently this indulgence is extended to " dry coffee or cocoa " if preferred, and the men also arc allowed to receive it. THE THREE POLICIES 317 Meanwhile au agitation had grown up in favour of the giant of pensions, quite apart from the Poor Law, to the aged deserving poor. This movement led to a series of official inquiries into the condition and treatment of the aged poor, beginning with the Royal Commission of 1893-95. This Commission, which alike from its member- ship and the extent of its inquiries must be accounted as of great authority in Poor Law administration, found that neither the exercise of thrift, nor the support of relations, nor the intervention of voluntary charity, could be absolutely relied on to prevent deserving persons from requiring public assistance in old age ; and they recom- mended that Boards of Guardians should be advised to discriminate in their relief between the deserving and the undeserving. They insisted that Outdoor Relief ought to be given in all suitable cases ; and that when the deserving aged had to accept institutional relief, they should be separated from, and treated quite differently from, the undeserving ; and that these conditions should be definitely published to the poor, so that they might know with certainty what they might rely on in their old age. In conformity with this extremely authoritative recommendation, the Local Government Board issued two lengthy Circulars in 1895 and 1896, under the presidency of Sir Henry Fowler and Mr. Chaplin respectively, systematically laying down principles of Workhouse administration, so far as the aged were concerned, in sharp contrast with those advocated by Mr. Longley, and, indeed, with those which had been inculcated from 1835 to 1892. It was expressly stated that, as the character of the Workhouse population had so completely changed since 1834, the administration no longer needed to be so deterrent. The old idea of fixed uniform times of ffoino- to bed and rising and of taking meals was given up, it being expressly left to the Master and Matron to allow any of the aged (as well as the infirm and the young children) to retire to rest, to rise and to have their meals at whatever hours it was thought fit. The visiting committees of Workhouses were now specially enjoined 318 THE AGED AND INFIRM to see that the aged were properly attended to, and recommended to confer with them as to any grievances without any officials being present. It was suggested that the great sleeping wards should be partitioned into separate cubicles. The Guardians were reminded that aged and infirm couples might be provided with separate rooms. The well-behaved aged and infirm were to be allowed, within reasonable limits, to go out for walks, to visit their friends, and to attend their own places of worship on Sundays. The rules were to be relaxed to allow them to receive visits in the Workhouse from their friends. There was to be no distinctive dress. Those of them who were of good conduct and who had "previously led moral and respectable lives" were to be separated from the rest, who were "likely to cause them discomfort," and were to have the enjoyment of a separate day-room. The whole note of the administration of the old people's wards of the Workhouses was, in fact, to be changed, so far as the Central Authority could change it. In the words of the 1834 Report, the old were to enjoy their indulgences. Four years later another Circular was issued in stronger terms, reiterating the suggestions of privileges that the Guardians ought to allow to the deserv- ing inmates over sixty-five — freedom to get up and go to bed and have their meals when they liked, to have their own locked cupboards for their little treasures, in all cases to have their tobacco and dry tea, to be free to go out when they chose, and to be allowed to receive the visits of their friends. They were to be given separate cubicles to sleep in, and special day-rooms, "which might, if thought desirable, be available for members of both sexes . . , and in which their meals, other than dinner, might be served at hours fixed by the Guardians. ... It is hoped that where there is room the Guardians will not hesitate to take steps to bring about improvements of the kind indi- cated in the arrangements for the aged deserving poor." Four or five months later the Guardians were stirred up by letter, and asked what they had done towards creating the specially privileged class of deserving aged inmates that had been so strongly pressed on them. THE THREE POLICIES 319 Nor was there any hesitation on the part of the Local Government Board in equally accepting and endorsing the new policy with regard to the grant of Outdoor Relief to the Aged. In July 1896, the Board, under the presidency of Mr. Chaplin, issued a Circular to Boards of Guardians outside the Metropolis, drawing attention to the importance of the Relieving Officers and Medical Officers discharging their duties with the greatest particularity. In a conclud- ing paragraph the Board significantly reminds the Guardians of the recommendations of the Royal Commission on the Aged Poor, of which an extract is appended. " We are convinced," runs the recommendation thus exceptionally brought to the Guardians' notice, " that there is a strong feeling that in the administration of relief there should be greater discrimination between the respectable aged who become destitute, and those whose destitution is distinctly the consequence of their own misconduct ; and we recom- mend that Boards of Guardians, in dealing with applications for relief, should inquire with special care into the ante- cedents of destitute persons whose physical faculties have failed by reason of age and infirmity ; and that Outdoor Relief should in such cases he given those who are shown to have been of good character, thrifty according to their opportunities, and generally independent in early life, and who are not living under conditions of health or surround- ing circumstances which make it evident that the relief given should be indoor relief." But this was not all. The poor, far from being left uncertain as to the grant of Outdoor Relief, were to be specially told that they would receive it if only they led deserving lives. " It accordingly appears to us eminently desirable," continues the Report of the Royal Commissioners, as communicated to the Boards of Guardians, " that Boards of Guardians should adopt rules in accordance with the general principles which we have indicated, by which they may be broadly guided in dealing with individual applications for relief, and that such rides should he generally made known for the information of the poor of the Union, in order that those really in need may not be discouraged from apply- ing." This policy was emphasised four years later, still 320 THE AGED AND INFIRM under Mr. Chapliu's Presidency, by another Circular urging that " aged deserving persons should not be urged to enter the Workhouse at all," unless from actual infirmity and lack of a suitable home ; but that adequate Outdoor Relief should be granted to them. Nor did the Central Authority rest content with a mere Circular. Letters were sent a few months later to all the Boards of Guardians, asking what action had been taken with regard to the suggestion that Outdoor Relief should be granted to the deserving aged, and, in particular, whether the practice was to grant an adequate amount in each case. This is, down to this day, the latest official utterance of policy with regard to the deserving aged. (b) The Aged and Injii'm under the Destitution Authority of To-day We have to report, after considering all the evidence afforded by the numerous official inquiries of the past decade into the condition of the Aged and Infirm, and after supplementing this evidence by fresh witnesses and inspections of our own, that we find all the three policies that we have just described, as well as an indefinite number of modifications or combinations of these policies, simul- taneously in full operation at the present day among the Destitution Authorities of England and Wales, Scotland and Ireland. We infer from our investigations that the First Policy — that of indiscriminate, insufficient and un- conditional weekly doles, coupled with the General Mixed Workhouse for all who cannot subsist on them — is to-day the policy adopted by practically all the Destitution Authorities of Ireland and Wales, and by a considerable majority of the Destitution Authorities of England. This policy is at once cruel to many of the deserving and wholly undeterrent to the undeserving. We could give in support of this judgment a mass of evidence ; but it must suffice here to quote the very authoritative statement, with regard to the two-thirds of the aged who are existing on Outdoor Relief, of the present Chief Inspector of the Local Government Board, Mr. J. S. Davy. UNDER THE DESTITUTION AUTHORITY 321 " The relief," deposed this witness in 1893, " which is now usually given to outdoor paupers is inadequate, and the pauper is not properly looked after as he ought to be, either by the relieving officer or by the medical officer. This is part of the system. . . . Half a crown a week is about the outside relief that is given to old people. ... It is not enough for them to live upon." " When," he continued, the G-uardians "have by a quasi-jndiQial decision accepted a man as a pauper, and given him Outdoor Eehef, they are responsible for his treatment. They ought to see that he is properly clothed, properly housed, and properly fed. They have no business to send him 28. a week and wash their hands of him." The same information has been given by other official witnesses. " I think," said an experienced Inspector in 1898, " the way in which relief is administered now in too many cases is intensely cruel to the [aged] poor ; I think that to try to make old people live on 2s. 6d. and a loaf for a week is intensely cruel." We have already described in how large a proportion of all the two or three hundred thousand cases of Outdoor Relief this is the standard adopted. " It is rare," summed up the Royal Commission on the Aged Poor, " to find a Union in which it is not the exception to give sums which would suffice alone to provide even the barest necessities of life. ... It cannot be doubted that, owing to the absence of the other means generally pre-supposed, great hardship must result." Unfortunately, it is only too clear that what was described by Mr. Davy in 1893 and by Mr. Baldwin Fleming in 1898, as "the system," is, in nine-tenths of the Unions of England and Wales, still " the system" in 1909. "I do not think to-day," deposed one of the Inspectors of the Local Government Board, " that the aged and deserving poor, in the immense majority of cases, receive sixpence more than they did before the Circular (of 1900) was issued." We have ourselves seen cases of aged and obviously respectable persons, linger- ing out an existence in the most squalid surroundings, on a dole of Outdoor Relief insufficient to provide even the barest food, clothing, and shelter ; not merely un- provided with any of the comforts, indulgences, or amenities of life, but actually without fire or necessary VOL. I T 322 THE AGED AND INFIRM covering. We realise that this irresponsible penuriousness of the Destitution Authority may, in the neighbourliness of rural life and in the customary generosity of the Irish and the Welsh to the aged, be supplemented by casual gifts which may frequently obviate the worst hardships. But the majority of the destitute aged in England and Wales are now to be found in large towns of mean streets and migratory populations, where such supplements are, as experience only too sadly proves, not sufficiently to be counted on. There is even worse to be told. It is a common practice of, we fear, the great majority of Boards of Guardians to refuse Outdoor Relief altogether to the most destitute of all the cases that come before them — however genuinely deserving such cases may in all respects be — merely on the ground that the applicants have no resources whatever. *' The rule of the Board," we were told with regard to one Union, " is, and always has been, that they never give (Outdoor Relief) to those who have nothing." This strange policy, which, however well in- tentioned, we cannot but condemn as cruel, of providing nothing better than the General Mixed Workhouse, even for the most deserving of the aged, on the ground of the extremity of their destitution, is, we fear, to be attributed to the characteristic penuriousness of a Destitution Authority. Rather than give a lonely old woman as much as seven shillings a week, they refuse to give any- thing. But the policy may be due, in part, to a wholly unfounded belief, derived from the early Orders of the Poor Law Commissioners, that it is illegal, or in some way objectionable, to meet the rent out of the Poor Rate. " Unless," said one witness, " the rent is covered we decline to give Out-relief," even to the most deserving cases. " We cannot pay a pauper's rent," expressly stated another witness. The worst of the tragedy is that it is especially the shrinking, silent semi - starvation of the lonely old women, or disabled old men, of respectability and moral refinement, who have outlived relations and friends, which is least likely to be helped. When such persons, finding starvation actually upon them, consent to enter the workhouse — the General Mixed Workhouse that UNDER THE DESTITUTION AUTHORITY 323 we have described — they come in, to use the expressive words of Miss Clifford, " with a feeling that it is just like death." On the other hand, this policy of indiscriminate and unconditional weekly doles, however inadequate in amount, combined with optional sojourns in the promiscuous General Mixed Workhouse, with its ample food, sleep, and warmth, and its unlimited idleness and low gossip, is exactly what suits the inclinations of the dirty, dissolute, and vicious old man or woman, who can, by bringing petty pilfering and assiduous begging to the aid of the Guardians' dole, manage to make out a not disagreeable life. The Guardians who pursue this policy in crowded urban districts find themselves faced by two problems which, for a Destitution Authority, are hopelessly insoluble. No inconsiderable number of aged persons in the great towns are now, as the Local Government Board's Inspectors have described to us, regularly spending their Outdoor Relief at the public-house, whilst habitually living in a condition "verminous and dirty beyond description," in rooms " stinking and loathsome " ; a positive danger to the Public Health. The Destitution Authority would like to relieve them only in the Workhouse ; but they refuse to come in, and it cannot bring itself absolutely to refuse its dole of inadequate Outdoor Relief. It would like to have authority to compel them to come in, but it has nowhere in which to receive them, except the hated General Mixed Workhouse — with its promiscuity, its brand of pauperism, and its chilling deterrence into which no Parliament will ever force anybody. An equally in- tractable problem to a Destitution Authority is that presented by those aged persons who belong to the army of " Ins-and-Outs." At the first snap of cold weather, there crowd into the urban Workhouses, autumn after autumn, a herd of the worthless old persons of either sex, who manage in the warm weather to pick up some sort of a living ; but who prefer, for the winter, the substantial comforts and agreeable promiscuity of the General Mixed Workhouse. Many of these persons know exactly how to dodge the limited powers of detention which alone can be 324 THE AGED AND INFIRM confided to a Destitution Authority ; and we see them about once a week "taking their discharge" in the morning and invariably presenting themselves in the evening at the porter's lodge, often in a more or less intoxicated state, for re -admission in time for supper. For this problem the Destitution Authority has no other remedy than compulsorily detaining the " In-and-Out " person for as long as a week, the maximum term allowed by law. This amounts, in practice, to no more than limiting the " day out " to one per week. And the very nature of a Destitution Authority and its General Mixed Workhouse stands in the way of Parliament granting any further powers of detention, which is the remedy asked for. We cannot but conclude, therefore, that the provision for the aged and infirm actually made by the great mass of Boards of Guardians in England, Wales, and Ireland is wholly unsatisfactory, and, in a quite peculiar sense, " too bad for the good and too good for the bad." The Second Policy — that of applying the " Workhouse Test" to the Aged and Infirm, with the object of restrict- ing Poor Law relief to the undeserving, and giving it only in the form of maintenance in a deterrent Workhouse — is unknown in Ireland and Wales, and has only been feebly attempted in a few parishes in Scotland. But in England the manifest success — judged only by the standard of reducing the number of persons accepting relief — of this policy of applying the "Workhouse Test" to the Aged and Infirm, or, to use Mr. Longley's term, the Disabled, led, between 1871 and 1890, to its partial adoption by an increasing number of Unions. The policy was, indeed, as easy to administer as it was certain in its results. If, as Mr. Longley suggested, the General Mixed Workhouse was to be kept deterrent and disciplinary ; if it was to be deemed the resort of the undeserving ; and if every one who entered its portals was to be made to feel the " degradation of parish support," it was clear that those only who were reduced to the last extremity of want would " pass the test." Hence, although in the Unions in which this policy was adopted with any thoroughness nearly the UNDER THE DESTITUTION AUTHORITY 325 whole expenditure on Outdoor Relief was saved, the number of persons in the General Mixed Workhouse did not increase. In defiance of the authoritative directions of the Local Government Board, half a dozen Boards of Guardians continue to this day to enforce this policy in all its severity. We recognise that the advocates of this policy, actuated by the greatest humanity, profess to arrange so that only " the undeserving " aged have actually to enter the Work- house, all others being adequately provided for outside the Poor Law, either by friends or relations or by voluntary charity. How little these optimistic assurances are to be depended on is shown by the elaborate investigations that we set on foot into the results of the refusal of Outdoor Relief in some of the so-called "strict" Unions. But whether or not it is impossible in any Union to provide by voluntary charity for all the deserving aged persons who are legally entitled to apply for relief to the Board of Guardians, we cannot understand how it can be contended that any public body has the right, by a policy of with- holding Poor Law relief from destitute persons, to force them to accept voluntary charity. If there is to be discrimination in the treatment of the deserving and the undeserving aged, the deserving person may certainly claim to receive his allotted treatment at the hands of the public authority, instead of being relegated to the caprices, the irresponsible judgments, and the arbitrary conditions of the individual private donor. Unfortunately, it is only too plain that, at any rate in the populous cities, not a few aged persons, who ought to be relieved, linger out their existence in semi-starvation, quite inadequately provided for, and eventually succumb prematurely to disease and privation, rather than apply for admission to the Work- house. We must content ourselves with quoting here the testimony of one who has had a lifetime of experience and devoted personal service among the poor of Manchester, Mr. Alderman Macdougall, who has been for many years a leading member of the Board of Guardians there : — "The large majority," testifies this exceptionally competent witness, "of those who endure biting poverty without seeking 326 THE AGED AND INFIRM relief from the Guardians are women. Men do not so frequently attain to old age under disadvantageous circumstances as women do. Old men go more readily into the Workhouse than old women. Women struggle louger and with greater determination with the difficulties of poverty, and the incapacities of old age. Families in poor circumstances find it is less possible to provide food and shelter for an old man who is a relative than for an old woman. He is more in the way, he expects not only a larger portion of the food, but to share in the better portions. He does not fit into the household of a working family as an old woman does, and is not so useful in domestic matters. His welcome is colder, and he desires to get out of the way, and goes to the work- house. A decent old woman will cling to a home where she may be regarded as the drudge rather than as the grandmother or the aunt, and she will exist on the plainer portions of the meals, and will wedge in both day and night without encroaching much on the means of the family." But there are even harder cases. '" There are, in every Union, aged women of good character, who belong to no famihes into whose domestic life they can fit and on whom they can depend — women who have been domestic servants, assistants in shops, mill hands, nurses, seamstresses, women who have denied themselves in younger days to support parents and bring up younger sisters and brothers, widows of good repute who have out-lived husbands and children, daughters of fathers who have failed in business, and women left with some provision which has been exhausted. If absolutely unable to earn small sums, they must, of course, apply for relief, but many of them do manage, by sewing, knitting, washing, hawking of small articles, or minding children for mothers going to work, to eke out a very scanty living. They dread the associations of pauper life. Having been self-sup- porting up to old age, they have the most intense desire to keep from even Outdoor Eelief, and an utter repugnance to entering the Workhouse. Yet they have the daily fear that the Workhouse must be the final refuge, and this fear is harder to bear than the pinch of hunger, the cold of insufficient clothing, or the poverty of their surroundings." We must refer here to a special form of this policy of applying the "Workhouse Test" to the aged, which appears to prevail — to the serious hardship of some of the aged poor — iu about a score of Unions. In some Unions in which Outdoor Relief is not systematically refused to the well-conducted deserving aged, there is a practice of refusing it iu particular cases, not because of any defect in the applicant, but as a means of inducing relations or friends to come forward and undertake the maintenance of UNDER THE DESTITUTION AUTHORITY 327 the destitute aged person. There is the same liability to contribute, and the same powers of enforcing contribution for any person chargeable to the Poor Rate, whether the relief is indoor or outdoor. But as there is usually a much greater repugnance in relations or friends to allowing a person in whom they are interested to enter the General Mixed Workhouse than to allowing him to receive Outdoor Relief, the Guardians, without regard to the hardships to the destitute person himself, play upon this repugnance, and refuse Outdoor Relief, with the object of extracting contribu- tions from relations or friends who might otherwise refuse to make them. Sometimes Outdoor Relief is refused and an " ofler of the House " is made, or the Outdoor Relief is reduced to a purely nominal amount, when there are sons legally liable to contribute, merely as an alte7mative to enforcing contribution — the Destitution Authority choos- ing to let the old people suffer the consequences of their sons' neglect, rather than take the proper legal steps for compelling these to contribute. More often, however, the refusal of Outdoor Relief takes place with a similar object when there are no relations legally bound to contribute, but when there are other relations under no such liability, or even mere friends or benevolent persons, whom the Guardians hope, by threatening the destitute person with the horrors of the General Mixed Workhouse, to persuade to contribute. This policy is occasionally even carried so far — we should not have credited it had it not been avowed by the Chairman of the Board of Guardians concerned — as to refuse all relief whatsoever, either indoor or outdoor, in order to make such non-liable relations or friends under- take, on pain of seeing the person in whom they may be interested suffer, a duty which, whether rightly or wrongly, the law has cast, not on them, but on the Destitution Authority. We regret to say that, in some Unions, this refusal, for ulterior objects, of Outdoor Relief to persons otherwise deserving it, is not merely a matter of practice, but is actually embodied in rules, which have not — so far as we can ascertain — been objected to by the District Auditors or by the Inspectors of the Local Government Board. It is not infrequent to find in the rules a 328 THE AGED AND INFIRM prohibition of Outdoor Relief to persons who, being other- wise in all respects qualified, have relations, not legally- liable to support them, but who are, as the Guardians consider, "morally bound" to do so, or "in a position" to do so, or " fully capable " of doing so. The Third Policy — that promulgated by the Local Government Board in 1895-6 and the one now in force — of securing to every aged, deserving, destitute person Outdoor Relief fully adequate for subsistence, or, if he or she is unwilling or unable to use such an allowance, good maintenance in comfortable quarters apart from the General Mixed Workhouse, has, despite the fact that it is the authoritative policy of the Local Government Board, been adopted by only about a score of Boards of Guardians in England. The policy has usually been adopted subject to certain arbitrary qualifications, such as the absence of relations " morally bound " to contribute, the fact of con- tinuous residence for twenty years within the boundaries of a particular Union, or the attainment of eighty years of age. We have already given our criticism of the first of these qualifications — the attempt on the part of a public authority, by an arbitrary exercise of its discretion, to force a third party to do something that the law does not require, by deliberately subjecting the person as to whom the discretion has to be exercised to a course of treatment which is not that deemed the most suitable to his con- dition. When, however, the alternative to Outdoor Relief is not, as at Brixworth or Bradfield, the General Mixed Workhouse, but maintenance on a higher scale in comfort- able sei)arate quarters, where the old people can come and go at their will, the policy of " offering the House " with the object of putting pressure on other people loses much of its cruelty and objectionableness. But then it loses also most of its efficacy. It becomes, in fact, a policy of " bluff," which may succeed in proportion to the ignorance or simplicity of the third party — those alone being imposed upon who remain unaware of the genuine superiority of the indoor provision made for the deserving old people. With regard to the stipulation that only such aged persons as have completed ten or twenty years'continuous residence UNDER THE DESTITUTION AUTHORITY 329 within the particular Union, we have only to observe that it amounts, in effect, to an attempt, on the part of a particular Board of Guardians — as we think, an illegiti- mate attempt — to alter the Law of Settlement as enacted by Parliament. Even stranger for a public Authority charged with the relief of destitution is the rule of several Unions making the amount of the Outdoor Relief vary according to the age of the pauper ; actually giving, irre- spective of the cost of subsistence in any particular case, sometimes sixpence additional for each lustrum attained in excess of sixty-five years. Omitting such strangely irrelevant local qualifications of the policy laid down since 1895-6 by the Local Govern- ment Board, we have to express our appreciation of the admirable provision for the aged deserving poor now made, according to this policy, by such Unions as Bradford, Sheffield, Ecclesall Bierlow, Woolwich, Hunslet, Dewsbury, Sculcoates, and Birmingham. The Boards of Guardians of these and a few other Unions have definitely adopted the policy of allowing, to their selected class of deserving destitute aged, Outdoor Relief of 5s. a week for each person. The assumption, at any rate, is that no such person will ever be forced to accept indoor relief. If the aged person is unable to get properly taken care of, or for any other reason prefers to come inside, he or she is main- tained in comfortably furnished apartments, separate from the General Mixed Workhouse, sometimes (as at Dewsbury and Birmingham) in a distinct block, sometimes (as at Woolwich) in a separate house quite away from the Work- house premises, sometimes (as at Bradford) in a quadrangle of separate tenements, or (as at Sheffield) in a row of cottages, each with two inmates. They have often each a room to themselves, or at least (as at Birmingham) a cubicle, furnished with carpet, chair, and dressing-table with drawers underneath. Sometimes (as at Nottingham) " afternoon tea " is served at 4 p.m. Dinners are usually cooked in a common kitchen and served in common in a separate dining-room, but the old people may often prepare their other meals for themselves, over their own fires. They have tea, sugar, tobacco and snuff served out to them 330 THE AGED AND INFIRM weekly, to be used when they like. They have comfort- able, non-distinctive clothing provided for them, or they may retain their own ; and they may receive visits in their own apartments and come and go during the daytime at their will. They are sometimes allowed to retain pet animals, and to cultivate their own little gardens. They may receive and retain for themselves any gifts from friends, other than alcoholic drink. " They get up when they like and go to bed as they please." They need do no work unless they choose, but if they desire to do so, they are to be provided with " congenial " employment, " suited to their age and capacity." With the one exception that no pocket-money is provided for them, and subject to this one drawback that, disguise it as we may, the inmates of these comfortable quarters for the aged are, owing to their being under the Destitution Authority, legally stigmatised as paupers, the small and highly selected class of deserving aged have, in these few Unions, where the new policy of the Local Government Board has been fully adopted, as good conditions as could possibly be desired. It is to the credit of the Destitution Authorities of Scotla'nd that, with the cognizance of the Local Govern- ment Board for Scotland, they have for the most part long adopted an equally generous policy with regard to the deserving aged. In one respect they have even gone farther than the most up-to-date of the English Boards of Guardians. They have combined the provision of agree- able quarters with Outdoor Relief In the comfortable cottages, or in the old villa residences that are termed, in some Scotch Parishes, " Parochial Homes," we ourselves found the deserving aged inmates, not only enjoying the furnished lodgings, free firing, and attendance that is pro- vided, but receiving in addition, to dispense as they think fit, their *' aliment" of three or four shillings a week. They may, if they choose, hand their money, or any part of it, to the salaried housekeeper, to provide their meals with ; or they may, if they prefer, make any or all of their purchases for themselves, and cook their own meals over their own fires in their own way. This appears to us the best thing that has yet been done in the way of public UNDER THE DESTITUTION AUTHORITY 331 provision for the aged. We can only regret that this policy of discrimination and generous treatment of the deserving aged has been extended, in England, owing to the inability of the Local Government Board to over- come in most places the almost inevitable reluctance of a Destitution Authority to provide anything beyond the barest subsistence, to only an insignificant minority of the deserving aged. To the infirm and permanently incapacitated who are not " aged " — whatever be the age-limit locally adopted — the new policy has not yet been applied at all, with the one partial exception of the sane epileptics, for whom, in the Manchester, Chorlton, Bradford, and one or two other Unions, special provision is made. There is obviously just as much need for classification according to present char- acter among the infirm and incapacitated who are young, as among those who are old. There are just as many deserving persons among them. " It is very hard," as one witness pointed out to us, "upon the younger persons, who are thoroughly infirm, to be kept as they are with rather a degraded class. The younger infirm people do not get the liberties that the old people do, and they have really nothing to brighten their lives." For the physically defective, the crippled, the half-paralysed, the blind and the semi-blind, the gravely rheumatic, and other men and women, not acutely sick, but chronically unable to earn in the competitive labour market an independent subsist- ence — of whom there are, we fear, many thousands destitute — we find nothing better prevailing than a fluctuating alternation between the First Policy and the Second ; with the result that these thousands of physically incapacitated persons either get unconditional doles of inadequate Out- door Relief, or are herded with the rest in the General Mixed Workhouse. Here no special provision is made for them. The sane epileptics, in particular, "spend their time . . . fighting and quarrelling, and passing a miser- able existence till they die." "No arrangements," said another witness, " are made for their occupation ; the disease grows upon them ; they deteriorate morally and mentally till a worse fate befalls them, and they end their 332 THE AGED AND INFIRM days in the lunatic wards." Moreover, among these in- capacitated men and women — whether crippled or merely broken down by infirmity, epileptic, half-blind or partly paralysed — even more than among the aged, there has accordingly been developed a terrible variety of parasitic outdoor paupers, or of Workhouse " Ins-and-Outs," who alternate their periods of begging and pilfering and living in filth and degradation, with recuperative spells in the idleness, gossip, food, and warmth of the Workhouse. For the many thousands of the young infirm, even more than for the aged, the provision made by the Destitution Authorities is, indeed, everywhere wholly unsatisfactory — cruel to the deserving, demoralisingly attractive to the undeserving, and degrading to all. (c) The Establishment of a National Pension Scheme The definite adoption by the Local Government Board since 1895-1896 of what we have called the Third Policy — of discrimination among diff"erent classes of the Aged, with generous treatment of the deserving — has now de- veloped into the establishment, during the year 1908, of a National Pension Scheme. Under the Old-Age Pen- sions Act of 1908, which is not yet actually in full operation, every person of British nationality and twenty years' residence within the United Kingdom, becomes entitled as of right, on attaining the age of seventy, to a pension payable from the Exchequer, if he does not come into any of certain definitely excepted categories. These excepted categories comprise : — (a) Those who have incomes exceeding £31 : lOs. per annum. (6) Those who have " habitually failed to work . . . according to ability, opportunity and need, for the maintenance " of themselves and " those legally dependent " on them. (c) Those actually under detention as lunatics, (a) Those undergoing a sentence of imprisonment, or under a judicial order of disqualification for not NATIONAL PENSION SCHEME 333 exceeding ten years, subsequent to imprisonment or detention under the Inebriates Act ; and (e) Temporarily, until 31st December 1910, those who are, or who have been at any time since 1st January 1908, in receipt of Poor Law Relief other than medical relief. The amount of the pension, beginning from 1st January, 1909, or from any subsequent award, will, if the aged person has not more than £21 per annum of income, be 5s. a week ; and if the aged person has between £21 and £31 : 10s. of income, be from Is. to 4s. per week according to a fixed scale. Finally, it remains to be said that the whole class of aged persons thus becoming National Pensioners are to be wholly taken out of the Poor Law, and removed from any connection with the Destitution Authorities, the whole of the business relating to the award and payment of the pensions being assigned, sub- ject to the appeal to the Local Government Board, to special Pension Committees of the County and County Borough Councils, and the Councils of Boroughs and urban districts exceeding 20,000 in population, with the aid of the Post Office and of a staff of special Pension Officers appointed by and responsible to the Treasury. There will accordingly be, from now onwards, a new class of the Aged, that of National Pensioners, whose applications for public assistance, though they may be destitute, will not be dealt with by the Destitution Authorities. It is estimated that this new class will, before the expiration of the first year, amount to between 500,000 and 600,000. It is, however, quite impossible, pending further experience of the working of the Act, to estimate with any precision what proportion of the persons who now become paupers and are classed as Aged and Infirm will, in future years, become National Pen- sioners and thus escape the Destitution Authorities. The National Pension Scheme is, indeed, admittedly incom- plete, as it has yet to be decided by Parliament what, after the end of 1910, is to be the position of those tem- porarily disqualified for a pension on the ground merely of having received Poor Law Relief of other than the 334 THE AGED AND INFIRM excepted kinds between the arbitrary dates of 1st January 1908, and 31st December 1910. (d) The Need for Diversified Provision for the Aged and Infirm After the most careful consideration we have to report that the diverse medley of persons who are officially included within the class of the Aged and Infirm do not appear to us, in any scientific analysis, to constitute a single category. Apart from those old persons who are acutely sick or mentally defective — who fall, notwith- standing their age, into the categories of the Sick and Mentally Defective respectively, to be dealt with by the Authorities charged with those services — we must distin- guish among the Aged and Infirm no fewer than five separate classes for which distinct provision has, in our judgment, necessarily to be made. (i.) The National Pensioners We may conveniently begin with the National Pen- sioners, the class of aged persons to whom the community as a whole decides to grant, as of right, an unconditional national superannuation allowance. By the passage into law of the Old Age Pensions Act of 1908, we are relieved from the necessity of discussing, in principle, the propriety of such a policy, in which we fully concur. Some of our witnesses — nearly all of them unconnected either with the wage -earning class or with the actual working of the Friendly Societies — have taken the view, based, as we understand, on a priori theory, that such non-contributory pensions would be likely to discourage thrift and saving. We have, however, been more impressed by the fact that, of the representatives of Friendly Societies and Trade Unions who gave evidence before us, the official leaders and a majority of the witnesses were in favour of some such system of national superannuation allowances, with- out specific personal contributions, to be granted, on the attainment of a prescribed age, to all who need them. NATIONAL PENSIONERS 335 These witnesses, from their experience of Friendly Societies and of working-class life, anticipated that such a national pension scheme — far from being injurious to the existing Friendly Societies and Trade Unions — would, by removing the present difficulty felt by the poorer labourers in ever being able to save enough to become independent of Poor Law relief, and with it their consequent scepticism as to saving for old age being of any avail, actually encourage thrift and saving, and increase the membership of all provident associations. Accepting, therefore, the principle that the needy aged should be provided for by national superannuation allow- ances, we have to report that the Old-Age Pensions Act of 1908 fails, in various respects, to dispose of even this part of the problem of the Destitution Authorities. This Act, in the first place, obviously requires to be amended before the end of 1910 so as to remove the disqualification of those persons who, being otherwise eligible for a pen- sion, happen to have received Poor Law relief, other than Medical Relief, since the arbitrarily chosen date of 1st January 1908. As it has been decided — a decision in which we fully agree — that pauperism prior to 1st January 1908, however prolonged and whatever the cause, should not disqualify, there can be no justice in withholding pensions from deserving aged persons, merely because — without having any notice of the intention of the Govern- ment — they accepted, after that date, the provision which the law had made for them. The Local Government Board itself, as we have seen, has, since 1896, deliberately instructed the Boards of Guardians in England and Wales to make generally known the advantages to be ofi'ered under the Poor Law to the deserving aged, " so that those really in need may not he discouraged from a'pjplying" Under this official encouragement the number of deserving aged paupers (a majority of them being women) has, year by year, steadily increased. For the Government now to turn round, and penalise by ineligibility for a pension the very men and women whom it has been trying to en- courage to apply for Poor Law relief — and, so far as concerns those who became paupers between January and 336 THE AGED AND INFIRM July 1908, actually without notice that this would make them ineligible for a pension — is plainly unjust. We fully agree with the Departmental Committee of 1900 in think- ing it " by no means easy to defend the exclusion of those aged paupers who could give reasonable proof that, had they not had the misfortune to pass the Rubicon in pre- pensionable days, they would have been able to satisfy the requirements of the Pension Authority." To retain any such disqualification as the acceptance of Poor Law relief, even after notice given that such relief will disqualify for a pension, appears to us both undesirable and in practice impossible. In view of the fact that the most thrifty and deserving persons may be rendered destitute by some accidental cause, to deprive them of their right to eventual superannuation merely because they had, in the time of their need, accepted for their dependents or themselves the provision which the law had made for them, would be felt to be unfair. It must be remembered that the receipt of parochial relief is fiual and conclusive in its disqualifying effect. Even if the whole cost is subsequently repaid to the Guardians, the disqualijication remains. Even if the sons or other relatives pay their contributions to the Guardians before the aged person receives his dole of Outdoor Relief or his maintenance in the Workhouse, so that there is not even a monetary expense to the Guardians, the case is not altered. These facts add weight to the practical objection that evasions could not be prevented. It would, in many cases (and in a rapidly increasing number of cases), be impracticable, in future years, to find out whether or not an applicant for a national pension had received Poor Law relief at any time since 1907. Poor Law relief is being given this year separately by each of the 646 Unions in England and Wales, by each of 874 parishes in Scotland, and by each of 159 Unions in Ireland. Many of these 1679 separate Poor Law Authorities are keeping very imperfect records even of their present proceedings ; and they have still more imperfect records for 1908. The almost universal practice is to treat each application as a new case, and to record particulars in separate entries, case NATIONAL PENSIONERS 337 by case. There is, of course, no common aggregate list of paupers. Tliere is not even in any place a list of the persons who have received Poor Law relief during the past in the one Union. There is seldom even a complete list of the paupers of any one year in any one Union ; and where such a list is compiled, it is nearly always made up separately for each of the score of constituent parishes of the Union ; and then often altogether omits some minor classes of paupers. In very few cases would even these incomplete and separate lists be in alphabetical order. It might be difficult in any populous Union to prove, years hence, that a particular applicant, admittedly resident in that same Union, and not some other person of the same name, had received Poor Law relief ten or fifteen years before. It would be impossible, amid all the confusion of registers of diff'erent years and different classes of relief, for any officer of that Union to be sure (and therefore to certify) that the applicant had never received any one of the various kinds of Poor Law relief at any time since 1907 — even if the inquiry were confined to the one Union. What clerk to a Board of Guardians could feel certain that the applicant, or some member of his family for whom he was liable, had not, years before, spent a night in the Workhouse, or had a loaf of bread from the Eelieving Officer on " sudden or urgent necessity " ? The pauper does not always give his real name — he sometimes gives somebody else's name ; and there are Unions in which the registration of such names as are given is by no means perfect. But the relief may not have been given in the Union in which the applicant resides. A large proportion of the population, especially that of great towns, and that of new or rapidly growing urban centres, such as Barrow-in- Furness and Middlesbrough, Cardiff and Barry, is, or has been, migratory. It must be remembered that the Poor Law relief given by each Union is not confined to the settled inhabitants of that Union ; though even a settle- ment is now acquired by three years' residence, and, in the case of a woman, by mere marriage. A person may have had in his life half a dozen settlements in succession. VOL. I z 338 THE AGED AND INFIRM Kelief is given in the Casual Ward or in the Workhouse proper, or even (by way of " sudden or urgent necessity ") at his home, to any destitute person, whatever his real or pretended residence, and however brief his stay in the Union. A large proportion of the applicants for old-age pensions will, at various times, have resided in other Unions ; and they can hardly be compelled to recount all their wanderings and all their excursions on "hopping," or " haymaking," or merely on holidays. Those who had received Poor Law relief, and who subsequently wished to apply for a pension, would naturally remove, and apply in some other Union. If they found it necessary to apply for their pensions in their real names (so as to prove age by birth registers) they would soon learn to make their application for Poor Law relief under assumed names, so as to have their real names untainted when they attained the pensionable age. How can it be certified, years hence, that the applicant (or any member of his family for whom he is liable) has not, under any name whatsoever, received Poor Law relief, in any one of its numerous forms, from any one of the 1679 Poor Law Authorities of the United Kingdom, during any one of the preceding years since 1907 ? Who could search all the records, for instance, of the Casual Wards all over England, Ireland and Wales ; and what value would he give to the particular names under which their nightly inmates, knowing the penalties to which habitual tramping exposed them, chose to register themselves? Who could certify that an Iri.sh applicant for a pension had not received temporary relief on some haymaking or harvesting tour in England or Scotland? How would it be possible to be assured that the applicant in Bermondsey or Bethnal Green had not been, since 1907, temporarily accommodated in the Workhouse of some Kentish Union on one or other of his annual " hoppings " ? It is true that various small and local pension endow- ments do prescribe as a condition of eligibility that the applicants shall not have been in receipt of parochial relief during a certain period. But it is to be noted : — (a) That the term is a short one, usually five years; NATIONAL PENSIONEKS 339 (h) That the applicant is always required also to have been a resident during at least that period in the particular parish, so that it is comparatively easy to ensure that he has not had parochial relief at his residence ; (c) That the pensions are given as a matter of favour to such applicants as the trustees may choose, so that any doubtful case can be rejected without cause assigned ; and (d) That the condition has for its main object to ensure that pension and Poor Law relief shall not be received by the same person simultaneously, so that a mere general compliance completely attains its purpose, irrespective of possible chance receipt of temporary relief years ago in some other Union. All these considerations would be absent in the case of a national superannuation allowance. It is, perhaps, a minor point that, so far as women are concerned, the incident of marriage may present great difficulties to any making of pauperism a disqualification for an old-age pension. There is first the change of name. Wives receive relief in their married names, and their maiden names are not recorded. But there is nothing to prevent them eventually resuming their maiden names and at seventy applying for a pension, duly armed with a birth certificate, and sinking all mention of the marriage (or one or other of their marriages), during which they had received parochial relief. They might well feel that it was their husbands who were really the paupers, not themselves. Indeed, it must be conceded that a wife accompanying her husband has no option in the matter. She cannot prevent her husband making her a 2^auper if he chooses to do so. It is very doubtful, in strict law, whether a wife or a child can ever be said to have accepted parochial relief. It does not seem possible to deprive her eventually of her national superannuation allowance on this ground. In fact, we gather that the better opinion is that no woman is legally disqualified in respect of relief received as a wife. Far more important, both numerically and otherwise, 340 THE AGED AND INFIRM are the difficulties presented by widowhood, to which not less than 30 per cent of all the pauperism is due. The young widow of the labourer, suddenly bereft of the bread- winner, with a family of young children on her hands, often incapacitated for earning a livelihood by having an infant in arms, is the most pathetic and the most difficult of the Poor Law problems. At all times and in all places her moral claim to at least temporary Poor Law relief has been admitted. In the most strictly administered Unions, at the most severely restrictive periods of Poor Law history, under the advice of the most rigorous Poor Law critics, the claim of the widow has not been rejected. But whether or not the widow will be eligible for a pension at seventy, or whatever may be the pensionable age, will, under the Old- Age Pensions Act of 1908, depend on whether she had been lucky enough to have her husband die, and to pass through her inevitable time of difficulty, before 1908 ! In this fortunate conjecture she may have taken her six months' Outdoor Relief, which the Local Government Board regulations freely allow, and may hope to get into a position of earning her livelihood — probably by marrying again — and thus be eligible for a pension. If, however, cruel fate permitted her husband to live on until after January 1, 1908, and then carried him off, her " widow's six months " of Outdoor Relief, which is often necessary to prevent the children from starving, and which the harshest economist has not denied her, will carry with it, however hard and however successfully she might subsequently work to maintain herself in inde- pendence, the eventual loss of her old-age pension — unless, indeed, she is sharp enough to suppress all mention of her unlucky episode of marriage and its consequent widowhood and pauperism, and to present herself at seventy, smiling, in her second husband's name (which would, indeed, be the natural case) ; or even in her maiden name, under which she would never have received parochial relief anywhere. In view of the fact that the sudden or premature removal of the family bread-winner, as things are now ordered, almost necessarily plunges into pauperism, at least for a time, a large proportion of the families of the NATIONAL PENSIONERS 341 wage-earning class, and that, under existing marital arrangements, it is usually quite impossible for the wife either to compel her husband to provide for her possible widowhood, or to *' make a purse" for herself, even if it were desirable for her to do so, it is submitted that any disqualification of widows by reason of their having, subse- quent to January 1, 1908, at some time of their widow- hood, accepted parochial relief, would be inequitable. Indeed, if they find themselves without the means of properly bringing up their children, they are legally bound to apply for parochial relief on their children's behalf ; and they can be criminally prosecuted for not doing so. It is, moreover, clearly in the interests of the community that they should apply for parochial relief in such cases, in order that the children may not suff'er. It is plainly against public policy to penalise such an act by eventually disqualifying the mother for her national superannuation allowance. It would be felt to be a monstrous injustice to make relief to a widow a ground of disqualification, when relief to a wife is not. Even if the difficulty of discovering who had received Poor Law relief could be overcome (as it might be by postponing the operation of the condition for fifty years, and in the meantime introducing a scientific system of registration by thumb-marks, and a well-arranged national register), there would still remain the difficulties pre- sented by the difi'erences in the law and practice between one place and another. We regret to learn that the Com- missioners of Inland Revenue have given instructions to the Pension Officers all over the Kingdom — contrary to the decision of the Court of Appeal in Kirhhouse v. Blakeway — that maintenance in the Workhouse or Workhouse In- firmary is never to be regarded as Medical Relief, and is always to be held to disqualify for a pension, even if the applicant has been admitted on the recommendation of the Medical Officer, for the sole purpose of being medically treated. If this interpretation of the law, under which many hundreds of helpless poor persons are actually being denied their pensions, is ultimately upheld, we shall be face to face with a new crop of anomalies. Whether the 342 THE AGED AND INFIRM person stricken with sickness, and institutionally treated at the public expense, thereby becomes disqualified for a pension, will depend solely on whether he lives in one part of the United Kingdom or another, or even in one town or another. Thus, outside the Metropolis, a person who becomes anywhere in the United Kingdom an inmate of any Poor Law Institution — it may be as a patient enter- ing a Poor Law Infirmary with an infectious disease — thereby necessarily becomes a pauper, and, as the Com- missioners of Inland Revenue are now declaring, disquali- fied for an Old-Age Pension. But within the Metropolis (and those adjacent Unions who happen to have made agreements with the Metropolitan Asylums Board) admission to certain institutions of that particular Poor Law Authority, though these were established exclusively for paupers and are still maintained out of the Poor Rate, is, by law, not to be deemed parochial relief, and, there- fore, does not disqualify for a pension. It is a further anomaly that this privilege does not attach to all the institutions of the Metropolitan Asylums Board, but only to some of them ; and not even to all those that deal with infectious diseases. Moreover, in Scotland, where, as we have mentioned, the Poor Law does not allow any kind of relief of the able-bodied, at any rate for adult men, all admissions to the Poorhouse take place on the recom- mendation of the Parish Doctor, who certifies that the applicant is suff'ering from some ailment — it may be sciatica, it may be rheumatism, it may even be no more than sore feet — for which he needs medical or surgical treatment, including food and comforts. Even the pro- vision for Vagrants has to be called, not a Casual Ward, but a " Casual Sick House." Thus, all the inmates of the Poorhouses of Scotland who have come in on medical certificate for treatment — though we have definitely ascer- tained that many of them are just as "able-bodied" as the inmates of the Workhouses of England, Wales and Ireland — may claim to be in receipt of Medical Relief only ; and not to be disqualified, under the terms of the Olcl-Age Pensions Act of 1908, for a national superannua- tion allowance. To continue a disqualification which may NATIONAL PENSIONEES 343 affect practically no Scottish pauper — or, at any rate, no male adult — not even tlie most disreputable " Ins-and- Outs " or week-enders, or the most hardened old Vagrants — whilst it operates against the most deserving of those who may be driven to take temporary refuge as able- bodied in an English or Irish Workhouse, will be politically impossible. But the diversity in practice is far more perplexing than these geographical differences in the law. Thus, throughout the Kingdom there is, as we have described in Chapter V., a second rate-supported medical organisation, conducted by the Local Authorities under the Public Health Acts, the use of which entails no stigma of pauperism. The relative spheres of the Poor Law, assist- ance from which is held to disqualify for a pension, and the Public Health Department, assistance from which does not disqualify, vary indefinitely from place to place. If a patient, unable to get cared for at home, is taken to one of the seven hundred Municipal Hospitals — established primarily for certain infectious diseases, but now often extending their work to others — he does not, even if his treatment is gratuitous, lose his future pension. If he happens to be taken to a Poor Law Institution for the very same disease, he is to be deprived of his pension, even if he contributes or repays the whole cost. If a man is found in the streets, senseless or helpless, he may (if the case looks like one of acute accident) be taken by the police to one of the voluntary hospitals, in the sixty or seventy towns which alone enjoy such institutions, treat- ment at which does not make him a pauper. But the patient may, equally probably, be taken, even in those same towns, to the nearest Poor Law Infirmary, treatment at which necessarily and irrevocably disqualifies him for a pension, even if he subsequently sends ten guineas to repay the cost of his treatment. In many parts of the United Kingdom there is no alternative. In the absence of any municipal or voluntary hospital all patients meet- ing with accidents in the open, or found helpless or sense- less on the road, or requiring treatment which cannot be given them at home, are taken to the Workhouse, where 344 THE AGED AND INFIRM they become, for the time, paupers ; and, according to the present interpretation of the law, will be eventually dis- qualified for an Old-Age Pension. The difference in practice between one locality and another applies even to the case of institutions established for the treatment of the same disease. At Brighton, for instance, a workman having incipient phthisis is received into the Municipal Phthisis Sanatorium, taught how to live, and discharged, all without the stigma of pauperism. At Bradford exactly the same kind of institution, treat- ing the same disease in the same way, and receiving largely the same class of patients, is maintained hy the Board of Guardians out of the Poor Rate. At Bradford, as at Brighton, the workman with incipient phthisis is sought out and urged, in the public interest, to come in and be treated at the public expense. At Bradford he becomes technically a pauper by so doing and loses thereby his right to a pension ; at Brighton he does not. No less striking is the variety of practice with regard to the co-operation of the Board of Guardians with the Town or District Council in regard to the Municipal Isola- tion Hospital. It is common, as we have mentioned, for the Board of Guardians to make a payment to the Town or District Council, so as to be able to send patients to these hospitals in order to avoid having to treat them in the "Workhouse. The status of the patient in such cases depends merely on the form, in which the payment is made. In those towns in which no payment is made, or where a fixed annual contribution is paid, the patient is not a pauper while in the Municipal Hospital, even if he is sent from the Workhouse, and he does not lose his right to a pension. In those towns in which the payment is made at so much per head per week, the patient admitted to the Municipal Hospital at the request of the Board of Guardians becomes or remains a pauper (being, by the Local Government Board's instructions, registered as in receipt of Outdoor Relief) even if he has not previously been in receipt of relief. He is not a pauper in any of these Municipal Hospitals if he is admitted on the order of the Medical Officer of Health ; he is a pauper (but only NATIONAL PENSIONEES 345 in some towns) if he is admitted on the order of the District Medical Officer. Whether or not he is disqualified for an Old-Age Pension depends, therefore, in practice, on which doctor gets hold of the case first. In the same town the form of the payment by the Board of Guardians has sometimes been varied within recent times. Thus, the scarlet-fever patient will, or will not, have been registered as in receipt of parochial relief according to the year in which the disease occurred. Or a town may change the character of its provision for such cases. In Bristol, the Board of Guardians for some years provided its own hospital for infectious cases. Subse- quently this was abandoned, and the Town Council Hospitals were used at a fixed annual payment. In such towns, accordingly, whether or not the patients so treated were registered as paupers, will be found to depend on the date of their disease. Much the same may happen in every town which provides for the first time — as a score or two do each year — a Municipal Hospital. A similar change is taking place, in one town after another, with regard to the provision for sujQferers from phthisis. Sometimes the difi'erence of practice depends on the kind of disease. In some towns the Municipal Hospitals will only take in cases of small-pox, enteric, and scarlet fever. Patients with other diseases must go to the Work- house or Poor Law Infirmary, and become paupers. In other towns the Municipal Hospitals will take in diphtheria, phthisis, and even measles and whooping-cough, and thus enlarge the area of non-pauper treatment. In Scotland, we understand that, by the order of the Local Govern- ment Board, all phthisis patients are henceforth to be dealt with by the Local Health Authorities. In England and Wales they are mostly treated by the Destitution Authorities. At Barry and Widnes there are Municipal Hospitals for accidents and surgical cases. If a drunken labourer breaks his leg or falls over a scythe, he will, in most parts of England, usually be taken to the AVork- house, and will become a pauper and lose his right to a pension ; if he does so in Barry or Widnes, he will be 346 THE AGED AND INFIRM equally treated at the expense of the rates, but will not become a pauper nor be disqualified for a pension. We have accordingly to report that it is not only inequitable, but also quite impracticable, to withhold the national superannuation allowance from those who, whilst satisfying all the other conditions, have, at some time or another, received the kind of public assistance that the law has provided for their case. Even this widening of the scope of the Old -Age Pensions Act of 1908 will leave undealt with a large number of aged persons who now are provided for by the Destitution Authorities. So long as the pensionable age remains at seventy, the widest scheme of national super- annuation allowances will fail to meet the general need. It is between sixty and seventy years of age that the majority of those who have hitherto maintained them- selves in independence, succumb to the dread necessity of submitting to the pauper's fate. We recognise that any national scheme of superannuation must necessarily adopt a relatively high age-limit. But the effect of all our evidence appears to us to support the now generally admitted contention that any age-limit above that of sixty-five — we might even say over sixty — will do little more than touch the fringe of the problem of Old- Age pauperism. (ii.) Provision for Persons ineligible for National Pensions The suggestion has been made to us that the pensions for persons excluded from the national scheme, and especially the provision for breakdown before the age at which the national superannuation allowances begin, should be made dependent on some system of contributory insur- ance in early life. We have every hope that optional and voluntary methods of insurance, so as to provide for the period prior to the commencement of the national superannuation allowance, or in supplement of it when granted, will, under the stimulating effect of the Old-Age Pensions Act of 1908, be greatly developed. But after PERSONS INELIGIBLE FOR PENSIONS 347 carefully considering all the proposals that have been published we fail to see that any such system of insurance, voluntary or compulsory, can take the place of the provision now made uuder the Poor Law for the majority of aged and infirm persons excluded, for one reason or another, from the National Pension Scheme. The insuperable difiiculties inherent in any contributory scheme of Old-Age Pensions have been Avell expressed in the Reports of the Royal Commission on the Aged Poor in 1895, and of the Committee on Old-Age Pensions in 1898, in a manner and with an authority that we take to be conclusive. Those difficulties, which may be said to have prevented the adoption of any such scheme as the basis for the national superannuation allowances, appear to us to be even greater when it is a question of providing a supplementary pension. To state summarily the objections and difficulties that compel us to dismiss any contributory scheme for this purpose, we must first distinguish between proposals for voluntary and those for compulsory contributions. If it is suggested that contri- butions for the supplementary pension should be optional and wholly voluntary, the State contributing nothing, we have only to say that such a scheme amounts to no more than is provided, or could easily be provided, by the deferred annuity department of the Post Office, or by the existing Friendly Societies, Trade Unions and Insurance Companies. But unfortunately we cannot anticipate that these will be taken advantage of by the poorest labourers or by many women, and it is from the ranks of these that come the most numerous and most deserving cases of Old- Age destitution. If it is suggested that the cost of such voluntary insurance should be lowered by means of a subsidy from the Exchequer, then, whilst the scheme would still inevitably fail to bring in either the women or the poorest men, the objections to it become consider- able. Such a subsidy would involve the taxation of the very poorest for the benefit exclusively of those who were better ofi", largely the taxation of women for the benefit mainly of men ; its benefits would be enjoyed only by a limited section of the relatively well-paid artisan 348 THE AGED AND INFIRM class, ricli enough to be able to take advantage of it, and not too rich to expect to be able to do without it ; those benefits could not, except by extraordinarily costly temporary arrangements, themselves open to grave objec- tion, begin to accrue for a whole generation ; if the scheme were worked through the Post Office alone, it would be in serious competition with the existing Friendly Societies; if these also were subsidised, it would bring them into unfair competition with the Trade Unions giving friendly benefits, which would demand to be granted equal advantages ; the State could hardl}^ subsidise any of them without appearing to guarantee their eventual solvency, and this it could not do without exercising a right of supervision and control to which neither Trade Unions nor Friendly Societies would submit. And after all the expense to the community had been incurred, and the difficulties had been overcome, the problem of dealing with the destitute deserving aged who, for some reason or another, had not insured and who could not get the national superannuation allowance, would still be upon us. If, in order to avoid some of these objections, it be suggested that the scheme should be made compulsory and universally applicable, it becomes at once, at any rate in this country, wholly impracticable. A universal and compulsory scheme would not be able to confine itself, as the far from universal scheme of the German Government mainly does (so far as the actual securing of adequate pensions is concerned), to persons in relatively stable wage-earniDg employment. For the Government of the United Kingdom to seek to extract — for a benefit to be enjoyed many years hence if the contributor lives so long — a weekly contribution, not only from the rela- tively well-paid and durably employed skilled artisans, but also from the hundreds of thousands of casual labourers and sweated home-workers, from the crofters and peasants of Scotland, Ireland and AVales, from all the uncounted host of hawkers and pedlars and costermongers and petty dealers of one kind or another, and from the millions of independent working women, appears to us to be wholly impracticable. Moreover, even if this could PERSONS INELIGIBLE FOR PENSIONS 349 be done, it would still leave untouched the huge problem — which the German Government Scheme has not yet been able to touch — of how to include the 7,000,000 or 8,000,000 of non-wage-earning wives of the wage-earning class, who unfortunately furnish the greater part of the Old -Age destitution. No scheme which leaves out of account this large section of the population — and practi- cally every scheme for contributory pensions that we have seen does leave them out of account — can possibly obviate the need for non-contributory pensions, or have any chance of acceptance. But apart from these funda- mental objections, the mere difficulties of a universal compulsory contributory scheme appear to us insuperable. To keep the separate accounts for half a century of all these millions, to register them in their changes from industry to industry and from place to place, and to receive and manage all the contributions, would in itself be a colossal task ; and to enforce against the defaulters the obligation of payment would be an impossible one. But, in this country at any rate, the Government would never be permitted to undertake it. It is clear that, as Mr. Broadhurst, speaking specially on behalf of the Trade Unions, pointed out in his Minority Report in 1895 — Any scheme involving contributions otherwise than through the rates or taxes would meet with much opposition from the wage-earners of every grade. The Friendly Societies and the Trade Unions, to which the working-class owe so much, naturally view with some apprehension the creation of a gigantic rival insurance society, backed by the whole power of the Government. The collection of contributions from millions of ill-paid households is already found to be a task of great difficulty, intensified by every depression of trade or other calamity. For the State to enter into competition for the available subscriptions of the wage- earners must necessarily increase the difficulty of all Friendly Societies, Trade Unions and Industrial Insurance Companies, whose members and customers within the United Kingdom probably number, in the aggregate, from 11,000,000 to 12,000,000 of persons. Any attempt to enforce on the people of this country — whether for supplementary pensions, provision for sick- ness or invalidity, or anything else — a system of direct, 350 THE AGED AND INFIRM personal, weekly contributions must, in our judgment, in face of so powerful a phalanx as the combined Friendly Societies, Trade Unions and Industrial Insurance Com- panies, fighting in defence of their own business, prove politically disastrous. (iii.) Local Pensioners We come, therefore, to the conclusion that the minimum provision for the destitute aged who are temporarily or permanently omitted from the National Pension Scheme must take the form of Local Pensions, not dependent on personal contributions, and granted only to the destitute aged who live decent lives upon such pensions. There will be, for instance, the case of the man who has resided in England since childhood, but is not a British subject, or has only recently become naturalised ; the case of the woman who has lost her British nationality by marrying such a man ; the case of the British subject who has returned to his home after residence in the Colonies or abroad, or the widow who has come home after her hus- band's death ; there will be the case of the man or woman who finds himself disqualified merely on account of some trivial breach of the conditions. Moreover, whatever the age-limit, there will be many cases of thoroughly deserving persons who are physically and mentally older than their recorded age in years — men and women who are as thoroughly broken down and permanently incapacitated at sixty-one or sixty-two as others are at seventy. For all such persons who have fallen into destitution, the only proper -provision, as some witnesses have suggested to us, is, so long as the applicants are in good health, or can be properly looked after at home, a Local Pension, such a pension, in fact, as many of the Destitution Authorities have already been driven, in effect, to award, under the sruise of 5s. or even 7s. a week Outdoor Relief. Such Local Pensions, to our mind, would, for this class, have actually an advantage over what might be secured by a contributory scheme, in that they would not need to be awarded and continued unconditionally as of right. We LOCAL PENSIONERS 351 regard it as distinctly advantageous that they should be granted and continued only on condition of decent living and orderly behaviour. We see no advantage in connecting the grant of these Local Pensions with the Destitution Authority. In fact, with a separate Pension Committee awarding the national superannuation allow- ances, there would be grave difficulties and dangers in any other body but that Pension Committee dealing with the matter. The dijQference between a Local Pension and a National Pension, according to our view, should be merely that the Local Pension — (i.) would be payable from local funds ; (ii.) would be given and continued, not as of right, but only to such persons, settled in the locality, as the Pension Committee find could and would live decently by its aid ; and (iii.) might begin at as early an age as sixty, if deemed advisable. (iv.) The Helpless Aged It has to be recognised that there are amonor the deserving aged many persons who from infirmity of body and lack of friends are unable to live independently on their small means, or on the Outdoor Relief that they may receive. At present there is, over the greater part of the Kingdom, no more satisfactory provision for these helpless aged persons, however deserving they may be, than the General Mixed Workhouse, with its promiscuity, its hated associations and its stigma of pauperism. To give one instance out of many, we have ourselves seen, in a small Rural Workhouse, an aged postman, who had by long and honourable service earned a pension of 12s. a week. But he was helpless from paralysis, and having no family or friends, had no other refuge available in which to linger out his life than the ordinary ward of the General Mixed Workhouse, enjoying conditions no more eligible than those allotted to the most debased old vagabond of the Union, The Board of Guardians impounded his pension, which fully covered all the cost of his maintenance. 352 THE AGED AND INFIEM Nevertheless he was, and remained, a pauper. Such cases will, it is clear, become much more numerous when the national superannuation allowances have become payable. Besides the persons in this condition who come volun- tarily to the Workhouse, for lack of better refuge, there are, as many witnesses have told us, many helpless aged persons who struggle on, sometimes among their friends, more often in their lonely lodgings, with their tiny pensions or Friendly Society pay, their casual pittance of alms, or, at present, their dole of Outdoor Relief, whose conditions become steadily more insanitary and their wretchedness more extreme. These, too, will become much more numerous when the national superannuation allowances become payable. But already such cases are frequent enough to cause much trouble to the Destitution Authorities, which have sometimes to watch them day by day so as to prevent actual starvation or death from neglect. There is no subject brought before us on which there has been such unanimity of testimony as the need, in the public interests, for some power of compulsory removal of infirm old men or women who refuse to accept an order for admission to the Workhouse, and who linger on, alone and uncared for, in the most shocking conditions of filth and insanitation. But so long as the only accommodation available is the General Mixed Workhouse, deliberately made deterrent, and publicly stated to be intended for the undeserving, no Parliament could possibly grant compulsory powers of removal to, and detention in, such an institution. More- over, it is not compulsory removal and detention that, in the vast majority of these cases, is really needed. What these cases require is an Authority which, by its daily operations, will automatically become aware of them before the neglect or the inanition reaches extremity ; an Authority which can provide from its staflf of nurses the necessary daily attendance which is all that many of the cases need ; an Authority which would have available, under medical superintendence, suitable asylums for the really helpless deserving aged persons who cannot be said to be, in the ordinary sense, wholly destitute ; an THE HELPLESS AGED 353 Authority, therefore, which must be quite unconnected with the Destitution Authority. This duty, it appears to us, should fall to the Public Health Authority. Just as that Authority already exercises what is, in effect, a kind of general guardianship over infants, in order to be able to step in where there is neglect, so it must exercise a similar guardianship over the citizen falling into second childhood. By the staff of Health Visitors and Sanitary Inspectors, daily going their rounds, the Public Health Authority will become aware of cases in which the help- less deserving aged, notwithstanding their little pensions or the attentions of the charitable, are suffering from neglect or lack of care. There ought, moreover, to be some practicable method by which a helpless old person may escape from or protect himself against the tyranny and repeated petty cruelties to which the aged are occa- sionally subjected, even by their own children. There should be for all such cases, available in every district, asylums or " retreats under a more accurate and less de- grading title " than that of Workhouse, " and under less stringent and kindlier discipline " — often taking the form of voluntary almshouses provided by private charity — where the helpless deserving aged can be looked after by nurses and doctors just as much as required, and where their little pensions will go far to cover the cost of their maintenance. The " Parochial Homes " for the deserving aged which we find in some of the parishes of Scotland, and the endowed almshouses which exist in various parts of England come nearest to the kind of institution that needs to be available under the superintendence of the Medical Officer of Health of every district. If such a system were established of kindly guardianship of the aged, of providing the necessary attendance on lonely old people, and of maintaining for their reception when really unable to live alone such " almshouses " or " Homes for the Aged " as we have described, there would be little need for compulsory powers of removal ; and such as might, in exceptional cases, still be required for the pre- vention of insanitary conditions or of conditions actually endangering life would form but a small and unobjectionable VOL. I 2 a 354 THE AGED AND INFIRM extension of those already exercised without demur by the Public Health Authority. Besides those aged poor who live decently on their tiny means, and the helpless deserving poor for whom Homes for the Aged have to be provided, there exists, we regret to say, no inconsiderable class of old men and women whose persistent addiction to drink makes it necessary to refuse them any but institutional provision. For this class, indeed, the Aged Poor of Bad Conduct, out of all the pauper host, it might well be urged that the Destitution Authority at present makes a not unsatis- factory provision. For old men and women of this kind, the General Mixed Workhouse, with its stigma of pauperism, its dull routine, its exaction of such work as its inmates can perform, and its deterrent regulations, seems a fitting place in which to end a mis-spent life. But, far from being a deterrent, experience shows that what the Destitution Authority provides, whether in the Workhouse or outside, is exactly what suits the inclina- tions of this class, from which some of the most habitual " Ins-and-Outs " are, in fact, recruited. They pass in and out of the Poor Law at their will — they come on the rates when they choose, and are free, whenever they choose, to live as they like. In this way, we combine the maximum of demoralisation and contamination of those with whom, either in or out of the Workhouse, they are perpetually coming in contact. To regard these old persons as " able - bodied," and to commit them to the charge of the Authority maintaining disciplinary Colonies for the Able-bodied, would be inevitably to relax the discipline of these establishments for the really able-bodied man in the prime of life. Repeated experience of the Able- bodied Test Workhouses (which we shall describe in Part 11. of our Report) has proved that the introduction of men of sixty-five or seventy, even if medically certified as able-bodied, into an establishment designed for men of thirty or forty, gradually but surely destroys the regimen. It is vital to the efficacy of the semi - penal establishment for the really able-bodied man that the man of advanced age should be otherwise dealt with. What THE HELPLESS AGED 355 seems essential in the institutional provision for this class is that it should be undertaken by an Authority having through its ordinary staff the means of becoming aware of the disreputable existence of such old persons, and providing suitable institutions for their reception, with powers, in cases in which they were leading grossly insanitary lives, of obtaining magisterial orders for com- pulsory removal and detention — not for the sake of punishing these old people, who cannot be reformed, and can hardly be made of any value to the community, but in order to place them where they will be as far as possible prevented from indulging their evil propensities, where they will be put to do such work as they may be capable of, and where they will, at any rate, be unable to contaminate the rest of the community. This need not be a prison. The aged person cannot usually be reformed, but experience shows that, within an institu- tion, he is not, as a matter of fact, either recalcitrant or badly conducted. We cannot help thinking that the duty of looking after this class, to whom Outdoor Belief would be rigidly refused, seems, accordingly, to fall most appropriately to the Public Health Authority, with its constant " searching out " of cases, and the compulsory powers of removal and detention which it already enjoys in cases of infectious disease. To sum up, whatever institutional provision has to be made from public funds for the aged had better be administered by the Local Health Authority. This does not mean the agglomeration of all the helpless aged, deserving or undeserving, well-conducted or ill-conducted, into one and the same huge establishment. On the con- trary, there will have to be a grading of Homes for the Aged, and classification of the inmates — not, we suggest, according to past conduct or desert, on which no human being can really be a judge — but partly according to physical needs, and still more according to present charac- teristics and conduct. What we look to see is the provision, for all the destitute aged who have not received pensions, or who cannot live decently on their pensions, and have failed to find admission into any of the various almshouses 356 THE AGED AND INFIRM or asylums for the Aged, of a number of small establish- ments for each sex ; each accommodating only a few dozen or a few score of persons ; of various grades of comfort and permitting of various degrees of liberty. Into these the old people would be sorted, as far as may be in accord- ance with their present characteristics and conduct, with power to transfer inmates from grade to grade according to the occurrence of vacancies and to actual behaviour within the institution. (v.) The Infirm and Permanently Incapacitated under Pension Age We pass now to what is perhaps the most difficult of all the problems presented by the non-able-bodied poor, the provision to be made for those who, being under the age at which either the national superannuation allowance or the local pension can begin, are nevertheless so infirm or so injured in mind or body as to be incapable of earning their maintenance in competitive industry. These persons may be of either sex ; of any age between childhood and pension time ; deserving or undeserving ; well-conducted or vicious ; helpless or fully able to manage for them- selves; with friends or without. Their one common characteristic — and this suffices for their classification — is that, whereas they are at a time of life at which they are expected to maintain themselves, such independent maintenance, in the world of competitive industry, is really and permanently beyond their power. One large section of this class — a section which includes a consider- able proportion of the present Workhouse population — has already been dealt with. Should the proposals of the Royal Commission on the Feeble-minded be adopted, those whose incapacity is due to " feeble-mindedness " will be removed altogether from the category of the destitute, and dealt with, along with lunatics and idiots, by the committees of the County and County Borough Councils charged with the care of all the Mentally Defective. But for all the others some appropriate provision has to be found. There Ls the common case of the man or woman INCAPACITATED UNDER PENSION AGE 357 seriously crippled from birth, or maimed by some accident or disease. There is the case of the man or woman dis- abled by rheumatism or arthritis. There are those par- tially disabled by hemiplegia in its early stages, or by epilepsy unaccompanied by lunacy. There are the blind and the deaf and dumb. For all these infirm and permanently incapacitated under pension age there is at present no other provision than the General Mixed Workhouse or the unconditional dole of Outdoor Relief. Apart from other disadvantages of their presence in these unspecialised institutions, where no proper provision can be made for them, it has been brought to our notice that, owing to the absence of specialised consideration of each case by a medical man, there is, in the General Mixed Workhouses of England, Wales and Ireland, and in the precisely similar Poor- houses of Scotland, no small amount of malingering among those classed as infirm or incapacitated. It is, in the General Mixed Workhouses of England, Wales and Ireland, or in the gigantic Poorhouses now characteristic of the great towns of Scotland, with their insufficient medical staff, the business of no particular person to see that they get well ; it is nobody's business to consider whether, by some special treatment or operation, or by the aid of special sur- gical appliances, they could not be made fit for work ; it is nobody's business to take care that they do not deliberately keep their sores open or their shrunken limbs weak. We do not feel sure that all the men whom we have seen in idleness because they have hernia or varicose veins are in- curable. We shall recur to this point when, in Part II. of this Report, we come to deal with the Able-bodied. We shall see that, if there is to be any genuine enforcement on the able-bodied of a proper task of work, experience shows it to be imperative that the able-bodied should be by them- selves alone. But the present intermixture in the Work- house of able-bodied men with men in various stages of defectiveness, whilst it destroys all chance of proper treat- ment of the able-bodied, is disastrous to the man who is really infirm or incapacitated. In the General Mixed Workhouse of to-day, no real attempt can be made to sort 358 THE AGED AND INFIRM out the different individuals according to their particular defects ; to give to each of them the regimen that he needs ; to promote, if not their cure, at any rate whatever ameliora- tion of their several states may be possible ; to provide them all with such industrial and other training as they are proved capable of; and at any rate to set them all to work at appropriate tasks, so that not only may the rate- payers' pockets be spared, but the inmates themselves may have the advantage and happiness of doing something towards their maintenance. On the other hand, to turn these blind or crippled, epileptic or paralysed men and women out into the streets on an unconditional dole of Outdoor Relief is, in many cases, to condemn them to much suffering, to a life of demoralising mendicity, if not of vice, and to conditions of squalor and disease which are not in the public interest. We may mention here a matter which has been brought to our notice in connection with the Workmen's Compen- sation Act. A certain proportion of the present destitu- tion of the infirm and incapacitated has been caused by industrial accidents, for which, in the past, little or no compensation has been paid. This, it was hoped, would be obviated, as regards accidents occurring after 1897, by the obligation then placed upon the employer of paying lifelong compensation for permanent incapacity equal to half the wages previously earned. Unfortunately, as it seems to us, it is provided that this weekly payment, like the compensation payable to the widow and children when the accident is fatal, may be commuted for a lump sum, without any guarantee being taken that the money will not be squandered and dissipated, or, through some mis- fortune, lost. There are, accordingly, already many cases in which persons, permanently incapacitated by industrial accidents since 1897, or the widows or children of persons killed by such accidents, have, notwithstanding the pay- ment of full compensation, subsequently become destitute, and are now a burden upon the Poor Rates. In these cases an onerous obligation has been imposed by law upon the employer, and through him, on the consumers, with- out the community being protected from having, in effect. INCAPACITATED UNDEE PENSION AGE 359 to pay over again for the results of the accident. This defect in the law, which will become year after year of ever-increasing gravity until it is remedied, appears to us to arise from the habit of regarding the compensation for an accident as a debt due from the employer to the injured man, or to his widow and orphaned children. It ought rather to be regarded, even in those cases in which it may be provided by individual insurance, as a provision which the State requires to be made for the future maintenance of those from whom the accident has withdrawn the bread- winning capacity. Here, as elsewhere, we object to relief being given to a sufferer, by means of a compulsory levy — even if the levy be on an individual employer — without the community taking steps to ensure that the provision thus made is applied in a manner to attain the social object aimed at. We think that the law should be promptly amended so as to provide that, whether by agreement or in the course of legal proceedings, no commutation of the weekly compensation payments should be permitted, and no lump sums paid in respect of fatal accidents, otherwise than through the County Court, or the special tribunal of Public Assistance that we shall hereafter describe, and that such sums should in all cases be invested in trust for the maintenance of those from whom the accident has with- drawn the means of support. If this were done, not only would some temptation be removed from the workman to whom an accident may at present be a source of profit, and much of the compensation money be saved from dissipation ; but also there would at least be some security to the community that it w^ould be protected from having the very considerable army of maimed, widowed and orphaned paupers still annually recruited in consequence of the industrial accidents assumed to be compensated for. But whether or not the victims of industrial accidents can ever all be suitably provided for by compensation there must always be many cases in which the infirmity or incapacity has no connection with industrial accident. What has to be done is to provide for these incapables conditions of existence more suitable to their needs than 360 THE- AGED AND INFIRM the competitive world. There are cases in which, under careful medical supervision, it may be desirable, so to speak, to " board out" the cripple or the blind man among friends or relations. For the most part, however, some sort of institutional provision seems preferable. This can often be best secured by making use of existing special institutions under voluntary management. AU these need, however, to be regularly inspected. We do not feel able to say how far it would be possible or desirable to group together in a single institution the infirm and physically defective of difi'erent kinds. There seems much to be said for combined Farm Colonies where the lame could help the blind, and the epileptic be attended to by the crippled. But there would probably have to be a certain amount of classification by physical condition as well as by sex and by conduct. But whether in one institution or in several, in town or in country, in so far as voluntary benevolence has not provided suitable accommodation, there must be for all these persons, as it seems to us, appropriate resi- dential institutions maintained from public funds. In view of the medical superintendence that is involved, of the constant need for medical and surgical attendance and nursing, of the importance of securing, wherever possible, a curative or ameliorative treatment, and of the necessity of taking appropriate measures to detect and extrude malingerers, we consider that the maintenance of the infirm and incapacitated, whether on home aliment or in special institutions, voluntary or municipal, ought to form part of the duty of the Public Health Authority. (e) Conclusions We have therefore to report : — 1. That the inclusion, under the Poor Law, in one and the same category, of the congeries of difi'erent classes known as '* the aged and infirm," is fundamentally incon- sistent with any efi'ective administration. 2. That the majority of Destitution Authorities of England, Wales and Ireland make no other provision for CONCLUSIONS 361 this aggregate of diverse individuals, of all ages and of different mental and physical characteristics, than the General Mixed Workhouse on the one hand and indiscrimi- nate, inadequate and unconditional Out-Relief on the other — forms of Relief cruel to the deserving, and demoralis- ingly attractive to those who are depraved. 3. That some of the Parish Councils of Scotland and a few Boards of Guardians in England have honourably dis- tinguished themselves by providing, for aged persons of deserving conduct, either comfortable quarters or pensions in their own homes ; though in the English Unions this provision has been unduly restricted by irrelevant conditions as to prolonged residence in one district, or as to the existence of relations not legally liable to contribute. 4. That no corresponding classification has been made among persons permanently, though prematurely, incapaci- tated, so that even the most deserving of these are very harshly dealt with. 5. That it is a necessary preliminary of any effective reform to break up the present unscientific category of " the Aged and Infirm," and to deal separately with distinct classes according to the age and the mental and physical characteristics of the individuals concerned. 6. That we concur with the Royal Commission on the Care and Control of the Feeble-minded that all persons, whatever their age, who are certified to belong to one or other grades of the Mentally Defective — including not only the lunatics and idiots, but also the feeble-minded and those suffering from senile dementia — should be entirely removed from contact of any form of Poor Law and should be placed wholly in charge of the Local Authority for the Mentally Defective. 7. That the establishment by Parliament in 1908 of a National Pension Scheme affords the proper provision for the aged who satisfy the necessary conditions in respect to income, residence in the United Kingdom, and conduct; but that it will be requisite at the earliest possible date to lower the pensionable age to sixty-five, if not to sixty ; and that it is neither practicable nor desirable to make 362 THE AGED AND INFIRM tlie previous receipt of any form of public assistance a ground for disqualification. 8. That, as there must always be a certain proportion of persons technically disqualified for a National Pension, for whom public provision must be made, and for whom institutional provision is neither necessary nor desirable, the Pension Committees of the Local Authorities should be empowered to grant out of the Rates, according to conditions settled by their Councils and approved by the Central Authority, pensions to persons of decent life, not being less than sixty years of age, who are not eligible for a National Pension. 9. That, whilst we anticipate considerable growth of voluntary agencies for securing, by insurance, supple- mentary pensions and provision for premature invalidity, we cannot recommend that the State should enter into competition for the workers' weekly pence with the Friendly Societies and Trade Unions, by any scheme of compulsory insurance ; which would, we think, provoke the strenuous opposition of these societies, if they were left outside the scheme ; and which must inevitably entail a national guarantee of their solvency, and Govern- mental control, if they were to be made part of the compulsory scheme. 10. That the responsibility for making suitable pro- vision, domiciliary or institutional, for the prematurely incapacitated, and the helpless aged, together with the necessary institutional provision for the aged to whom pensions are refused, should be entrusted to the Local Health Authority. 11. That the Local Health Authority should be granted compulsory powers of removal and detention similar to those which it now possesses in respect to certain infectious diseases, with regard to all aged and infirm persons who are found to be endangering their own lives, or becoming, through mental or physical incapacity to take care of themselves, a nuisance to the public. 12. That, whilst all the obligations to support aged and infirm relations that are imposed by law should be CONCLUSIONS 363 strictly enforced by the appointed officers, where there is proof of ability to pay, no attempt should be made by any public authority to extract contributions from persons not legally liable, by subjecting aged or infirm persons, or threatening to subject them, to any treatment other than that deemed most suitable to their state. CHAPTER VIII CHARGE AND RECOVERY BY LOCAL AUTHORITIES All the public bodies making provision for the non- able-bodied poor — the Destitution Authority, the Public Health Authority, the Education Authority and the Police Authority — now possess definite legal powers of charging the cost upon the individual benefited or the persons liable to maintain him. These powers difi'er from service to service and from Authority to Authority, alike in the amount or proportion of the expense that is chargeable, in the discretion allowed to the Authority to charge or not to charge as it sees fit, in the conditions attached to the charge or exemption from payment, in the degree of poverty entitling to exemption, in the degree of relationship entailing payment for dependents, and in the process of recovery and its eff'ectiveness. This chaotic agglomeration of legal powers, conferred on different Authorities at diff'erent dates, for different purposes, but all alike entailing on the individual citizen definite financial responsibilities, proceeds upon no common prin- ciple. Moreover, the practice of the innumerable Authori- ties concerned is even more wanting in principle than the law ; varying, indeed, from systematic omission to charge or recover anything, up to attempts to exact from the individual an entirely prohibitive payment for the service nominally off'ered. And this jungle of personal liabilities and what are in fiscal science technically called " special assessments " is practically unexplored. In no branch of our subject have we found it so difficult to ascertain the exact facts : in no part of the problem of the provision for 864 CHARGE AND RECOVERY 365 the non- able -bodied poor have we found an extensive alteration in both law and administration so urgently needed and so little worked out in detail by the advocates of reform. (a) Charge and Recovery hy the Destitution Authority The Boards of Guardians in England and Wales have at present two separate and distinct powers of charge and recovery of the expenditure that they incur in the relief of particular persons, namely, against the particular person relieved, and against other persons liable for his maintenance. (i.) Contributions hy Relations Under the Elizabethan Poor Law there seems to have been no question of recovering the cost of relief from the person relieved. The very condition of the relief was destitution, and the system of free relief at the expense of the Poor Rate was but the successor of a system of free alms which had existed from time immemorial. But the free relief from the Poor Rate enjoyed by the destitute person did not release from their obligation those who were required to maintain him. This obligation of the relations was specifically enacted by the Elizabethan statesmen. Under the Poor Relief Act of 1601 (43 Eliz. c. 4, sec. 7) " the father and grandfather, and the mother and grandmother, and the children of every poor, old, blind, lame and impotent person, or other poor person not being able to work, being of a sufficient ability, shall at their own charges, relieve and maintain every such poor person in that manner and according to that rate as by the justices . . . shall be assessed." Thus, this legal liability to maintain others applies only to certain specified cases of blood-relationship — to grandparents, for instance, though not to grandchildren ; and to grand- parents even though the parents are alive, and themselves able to maintain their children. It applies, moreover, only to the non-able-bodied — a qualification which, as we have found, is not always remembered by Poor Law 366 CHARGE AND RECOVERY officials. It is curious that in the Elizabethan statute there is no mention of the liability of husbands to main- tain their wives, any more than that of wives to maintain their husbands. The omission has been rectified by subsequent legislation, under which a husband can be compelled to contribute to the cost of relief given to his wife, and a wife having a separate estate can, in England and Wales, be compelled to contribute to the cost of relief given to her husband. But for this last change, and for the fact that in Ireland grandparents are not liable for their grandchildren, the area of liability seems to be the same throughout the United Kingdom. The process of recovering contributions from relations is partly in the hands of an administrative body, the Destitution Authority ; and partly in those of a judicial body, the local magistracy. It is entirely within the dis- cretion of the Destitution Authority whether or not it will ask for any contributions from any of the relations legally liable, and, if so, how much, and from which relations. If the relations do not comply with the demand of the Desti- tution Authority, it is open to that body, if it chooses, to apply to a Court of Summary Jurisdiction — in England and Wales, the Justices in Petty Sessions — for an order charging the relation who is liable with the payment of a definite amount per week for so long as the person remains chargeable. The Court has to satisfy itself that the rela- tion whom it is sought to charge is legally liable and of ability to pay, and has to determine at what rate, not exceeding the whole cost of the relief, the relation shall be ordered to contribute. When the order has been made, it is again within the discretion of the Destitution Authority, in the case of non-payment, whether or not to take steps to enforce the order. It can summon for arrears and get an order of the Court for their payment, and eventually a distress warrant. If there are no goods on which to distrain, another summons is necessary, calling on the defendant to show cause why he should not be committed to prison for Contempt of Court. Upon the defendant appearing, the Destitution Authority has to prove that he has the means of paying what is due before CONTRIBUTIONS BY RELATIONS 367 an order for committal to prison will be granted. In short, though enforceable in a Court of Summary Jurisdic- tion instead of merely in the County Court, the contribu- tions due from relations are, in law, merely civil debts ; and are not (as are payments on orders made under the Bastardy Acts and the Reformatory and Industrial Schools Acts, the latter now re-enacted in the Children's Act, 1908) payments enforceable as if they were fines or penalties by committal to prison, without evidence of means. The special assessments levied on the relations of paupers, or on the paupers themselves, under this law and by this procedure, in the guise of repayments of the relief afforded, yield, in the aggregate, a large and steadily in- creasing revenue, having more than doubled in the last twenty years. In 1888-89, for England and Wales alone, it was £211,061, or about 2^ per cent of the expenditure, and in 1906-7 no less than £442,355, or 3 per cent of the expenditure. Unfortunately, none of the statistics of the Local Government Board enable us to discover in what proportion this amount is made up of certain very different constituent items. More than one-half, we know, comes in the form of charges made upon the relations of persons certified to be of unsound mind, and maintained in the asylums of the Lunacy Authority. The balance is nearly wholly made up of two distinct items, namely, the contri- butions obtained from the relations of persons admitted to the Poor Law infirmaries, and the contributions obtained from sons towards the Outdoor Relief afi'orded to their aged parents. The contributions recovered towards the cost of main- tenance of persons of unsound mind constitute the greater part of these recoupments of the Destitution Authority. In this class of case, by a peculiar anomaly of the law, pauperism is, as we have already described, virtually en- forced upon the patient, and upon his relations legally liable to support him. Thus, the pauper patients in the lunatic asylum really include a large number of persons from families who are in no sense destitute ; many of them, in fact, belonging to the skilled artisan or the lower middle olasB. The Board of Guardians, having to pay the 368 CHARGE AND RECOVERY Lunacy Authority something like 12s. per week for every person in the asylum who belongs to the Union, and who does not enter voluntarily as a paying patient, naturally seeks to recover this sum in as many cases as possible. The Government grant provides 4s. per head per week. The balance of about 8s. per week, if not obtainable from the property of the patient himself, is claimed from the husbands, parents, grandparents or children of the patients. As so large a proportion of the cases are from families by no means destitute, the amount thus recovered is consider- able, in many cases covering the whole cost of the patient. It is to be noted that, even if the whole cost be repaid to the Board of Guardians, the patient remains a pauper and he is included as such in the statistics of pauperism. We have had it brought to our notice by the London County Council that, as the collectors of the Boards of Guardians are paid by commission, it is not only to their pecuniary interest to have as many persons as possible certified as of unsound mind, but also to have them entered and re- tained as pauper lunatics, even if their relatives are paying the entire cost of their maintenance ; rather than have them entered as private patients, when the payments would be made direct to the Lunacy Authority. More- over, the mere maintenance of a dependent in an asylum as a pauper lunatic, even if a contribution is made towards the cost, is, in strict law, deemed to be parochial relief to the person on whom he is dependent. When, in the Old Age Pensions Act of 1908 it was desired to prevent the mere admission of a dependent to a lunatic asylum dis- qualifying for a pension as being parochial relief, this needed express enactment. Yet, as has been forcibly observed, by the Royal Commission on the Care and Control of the Feeble-Minded : — In the case of so-called pauper patients in idiot asylums, many of them have never been in a Workhouse, and some of them cost the local rates nothing at all. Many of them are children of small farmers, tradesmen in a small way of business, clerks, artisans and others, who, unable to pay the full charge, are yet able to con- tribute 5s. or 6s. per week, or even more, for the maintenance and training of their children. In order to make up the full charge of from 10s. 6d. to 14s. per week, the parents pay their contributioDS CONTRIBUTIONS BY RELATIONS 369 to the Board of Guardians who receive the 4s. grant [from the Exchequer], add to it the parents' contributions, and thus, in some instances, make up the required amount. This pauperises the parent, though it does not do so in the case of children sent to blind or deaf and dumb institutions, or educated at the Public Elementary Schools, where the schooling is paid for out of the rates, or even in the case of criminal or neglected children sent to Reformatory or Industrial Schools. The amount charged upon " relations " for the treat- ment in Poor Law infirmaries of patients in whom they are interested is large and rapidly increasing. We were, for instance, informed that the three Boards of Guardians of Liverpool recover over £4000 a year from their patients, whilst the general hospitals of that great city do not receive from their patients more than £400 a year. We notice, in the evidence by the Medical Superintendent of one of these Poor Law infirmaries, that the fiction that these repayments come from the relations of the " desti- tute" persons whom the Guardians are maintaining, is quietly abandoned. It is taken as a matter of course that the maintenance and medical treatment which is being afforded by the Destitution Authority to its patients is, as a matter of fact, being paid for, to a considerable ex- tent, by these " destitute " persons themselves. The fact, which is not peculiar to Liverpool, that the Poor Law infirmaries are receiving no small number of "paying patients," is an interesting corollary of the gradual trans- formation that we have already described of some of the institutions of the Destitution Authority into public establishments, made use of indiscriminately by the wage- earning and lower middle classes. ** We have thus," as it has been pointed out to us, " the administrative paradox that an institution intended by statute for the ' friendless impotent poor ' has evolved into a ' pay ' hospital for poor persons that may be paid for by their friends." But this unperceived change results in curious anomalies. A person who is pay- ing for his treatment in the Liverpool hospital known as the Mill Road Infirmary, however much he pays, becomes a pauper ; is included in the statistics of pauperism published by the Local Government Board ; cannot, in law, vote at the VOL. I 2 B 370 CHARGE AND RECOVERY election of the West Derby Board of Guardians ; and will be excluded or not from the Register of Parliamentary- electors according to the varying interpretations which the officers may put on the phrase " medical relief." The same person, treated absolutely free of charge in the Liverpool Royal Infirmary, or in the hospitals of the Liverpool Town Council, is not a pauper. This anomaly becomes the more remarkable when a Board of Guardians (as at Dewsbury), with the cordial sanction of the Local Government Board, deliberately elects to limit its own provision for sick paupers to such as suffices for the easier cases, whilst sending all that are difficult to the voluntary hospitals of neighbouring towns, to which it makes contributions from the poor rates. Under these arrangements, which are be- coming common in all but the largest towns, the sick persons become paupers or not, and their relations become liable to contribute to their maintenance or not, according to quite irrelevant accidents. Those retained in the institutions of the Destitution Authority are chargeable to their relations and are legally paupers, however much their relations may pay. Those who are sent for the more specialised treatment of the voluntary hospitals, which are partly maintained out of the poor rate, are not paupers, and their relations cannot be required to contribute to their maintenance — unless, indeed, as is sometimes the case, the subvention of the Board of Guardians to the hospital takes the form, not of an annual subscription, but of the payment of so much per patient per week. In the latter case the sum so paid is, by direction of the Local Government Board, entered in the books as Outdoor Relief ; the person in respect of whom it is paid is included in the statistics of pauperism as in receipt of Outdoor Relief; and his relations become liable to repay the amount. The net result of these anomalies is that those patients for whose maintenance and treatment full pay- ment is being made, by themselves or their relations, are all certainly paupers ; those who are being treated entirely gratuitously stand a good chance of retaining the status of independent citizenship. We come now to the charges made upon sons by way CONTRIBUTIONS BY RELATIONS 371 of contributions towards the Outdoor Relief that their aged parents are receiving. The Board of Guardians finds an aged person destitute, grants Outdoor Relief, and pro- ceeds, under the Elizabethan Statute, to make a claim upon the sons. It has, however, been brought to our notice that the procedure has, in some Unions, been so extended as to have become merely the means of " putting people on the relief list with the object of settling a family- dispute." ** In a large number of cases," deposed one witness, " the children are colliers earning very good wages, but owing to family disagreements between themselves, they quarrel as to how much each son should contribute. One son has a wife and several children ; he thinks he ought to contribute a less sum than the son who is unmarried and is earning good wages, and so on. They cannot agree among themselves. Over and over again they come to the relieving ofiicer, and the old woman or the father is granted 3s. 6d. or 4s., and then the sons are summoned." In these cases " relief is granted where it is not needed, with the sole object of getting it repaid from the sons and daughters." This is said to be " a common occurrence " both in London and in the North of England, the whole of the Outdoor Relief given to the aged person being " in a large number of cases " thus recovered. But even if the whole amount is repaid, the aged persons are legally paupers ; they are in- cluded in the ofiicial statistics as paupers ; and the family becomes entangled in, and acquires a demoralising famili- arity with, the machinery of the Destitution Authority. To remedy this anomaly many Guardians and Poor Law officers have recommended that the law should enable aged persons themselves to take proceedings against their chil- dren, who are legally liable to support them, and that a Court of Summary Jurisdiction should be empowered to make an order for the payment of a weekly sum by the son direct to the parent, without the case coming in any way under the purview of the Destitution Authority. We cannot endorse this recommendation. To give to every aged parent who was without means the right at any time to apply to the Justices for a legal order peremptorily requiring his or her sons to make weekly payments for his 372 CHARGE AND RECOVERY or her support would not, we think, promote either filial affection or family harmony ; and might, it has been sug- gested, open up a field for disreputable extortion at the instigation of unscrupulous persons. Even more important is the objection that such a power in the hands of the aged could not be made dependent on their personal conduct. There are, unfortunately, among the aged not a few per- sons of disreputable life, who spend every available penny in drink. We should wholly disapprove of Outdoor Relief being granted to such persons unconditionally and without supervision. We equally object to empowering disreput- able old men and women, who are unwilling, and perhaps unable, to lead decent lives, to exact contributions from their sons, over the spending of which the sons would have no control. Such aged persons, if allowed to live outside an institution at all, ought, at any rate, to feel that their maintenance is dependent on reputable conduct. This can be to some extent secured at present by the supervision and control exercised over those to whom Outdoor Relief is granted. What needs to be got rid of is not the super- vision and control, which we regard as essential for all whose maintenance is provided for them otherwise than by their own exertions, but the association with pauperism and the Destitution Authority. This can be secured, as we shall see later, in quite another way. The needless " stigma of pauperism," inflicted alike on the " paying patients " of the Poor Law Infirmary, and on the aged persons on Outdoor Relief who are really being supported by their children, and the unreal exaggeration of the pauper statistics that this causes, are not, in our opinion, the most serious defects of the present system of levying special assessments on the relations of persons in receipt of public assistance. What is more important in its evil consequence — if only because it affects every case — is the arbitrariness, and even the partiality, with which these " special assessments " are made. It is axiomatic that whenever, by the authority of the Government, a pecuniary contribution is levied upon individuals, this contribution should be levied equally, impartially and universally upon every person coming within the category CONTRIBUTIONS BY RELATIONS 373 of those legally liable to the imposition. In the whole range of the Poor Law, in this matter of contributions from relations, equality, impartiality, and universality are con- spicuous by their absence. We find in practice a total lack of uniformity as to whether the relations of a sick pauper shall or shall not be asked to contribute to his maintenance, and upon what scale. One Union will, in this respect, differ entirely from its next-door neighbour. In the Fulham Union, for instance, maintenance from every discoverable relation legally liable is rigorously exacted in every case. In the Chelsea Union, institutional treatment and maintenance seem to be granted free of charge to all sick persons unable to gain admission to the voluntary hospitals of the neighbourhood, without their relations being even asked to contribute. The same sort of contrast appears to be exhibited in the practice of the Lambeth and Camber well Boards of Guardians. In some provincial Unions — notably some in South Wales — especially where there are no endowed or voluntary hospitals. Boards of Guardians evidently lay themselves out on a considerable scale for "paying patients"; they have separate Commit- tees on " Ability of Relatives," staffs of collectors, and large receipts. In most of the rural Unions, on the other hand, where medical treatment has not risen above the Work- house ward, Guardians seldom think of expecting any repayment of the cost of indoor relief or of making any charge for Workhouse treatment. This inequality between Union and Union in the practice with regard to these special assessments is even more glaring when the expenditure in respect of which the charge is made takes the form of Outdoor Relief We find, in fact, the utmost diversity, not merely between Union and Union, but between case and case. A few Boards of Guardians pursue a systematic policy. In so- called "strict" Unions, such as Atcham, Bradfield and St. George's-in-the-East, every discoverable relation who is legally liable, and who is earning as much as the regular wages of a mere labourer, is definitely charged something, and as far as practicable compelled to contribute. In the Unions of East Anglia, on the other hand, we found it 374 CHARGE AND RECOVERY taken for granted that the ordinary agricultural labourer, even when unmarried and in full work, could not be ex- pected to contribute anything towards the maintenance of his aged parents — some of the farmers frankly admitting that this practice had been adopted from their fear that attempts to charge even a shilling a week would help to drive the labourers into the towns. " I have been present at a Board meeting," deposed a Local Government Board Inspector, " when a Guardian employing two single labourers at full wages has protested against their being required to pay a shilling a week towards the support of their father, as the effect might be to drive them out of the Union where labour was badly wanted. They were excused." Occasionally there are regular scales, showing what contributions are to be expected from sons in differ- ent circumstances. "Some Guardians," reports our own Investigator, " take into consideration the entire earnings going into the house, others consider what sons and daughters give, others, again, consider the individual earnings (of the relations liable) only." But in most Unions every case is " considered on its merits." What this means in practice is that it depends on the mood of the Guardians, or even on which Guardians happen to be present, whether, in any particular case, much or little or nothing at all is demanded from relations known to be legally liable. " There is," said a witness, " no standard. I have known a man earning 23s. per week be asked to pay 9s. weekly towards the keep of his wife in the In- firmary, and the following week a single man getting 24s. per week asked to pay 2s. 6d. towards the maintenance of his parent. The single man was young, the married man greyheaded and homeless, living in lodgings at 4s. 6d. per week. This is termed judging each case on its merits." In a large Midland town, where, on the Board of Guardians, "the public-house interest is far too numerously repre- sented {i.e. by seven or eight members)," an experienced witness informed us that he did not " know of a single case in which there is any repayment to the Guardians from children. If the Guardians give Out -relief there is no real effort to make the grown-up sons and CONTRIBUTIONS BY RELATIONS 375 daughters, who might be able to pay, pay something back." " In one Union," reports an Inspector, " an in- stance came under my notice where a widow had three sons, one of them was a Guardian , but none of these were asked to contribute. The total Out-relief was over £3000. The amount collected from relations was c£33 : 3 : 6, but deducting collections on account of lunatics and deaf and dumb, the total recovered in one year was £6:11:3. It is not surprising that the relief in this Union is amongst the highest in my district." But the abandonment of the practice of making a charge may be due to real differences of opinion as to policy, quite apart from anything like corrupt motives. *' The friendly societies," declared their representative on a North country Board of Guardians, " are totally opposed to the practice of the Guardians of compelling a working- man (who has a wife and three or four little children, and whose income is not more than 26s. per week) to pay towards the maintenance of his father or mother who may have become recipients of Poor Law relief. This practice they consider perpetuates pauperism." Nor is this evil consequence to the next generation without confirmation. " In many cases," deposed a Poor Law Guardian, " the maintenance of the old parent works to the detriment of the children's children." On the other hand, some Guardians, not content with the power to charge conferred by the Elizabethan Statute, actually try to go beyond the law, and to compel grown-up sons to con- tribute towards the support of their brothers and sisters, on the disingenuous legal fiction — which, however, fails to support the proposal — that relief afforded to children is deemed to be relief to their parent. Even this diversity of practice of the Boards of Guardians does not exhaust the measure of the inequality and partiality with which these special assessments are levied. When the Guardians have arrived at a decision as to what they will charge, they may or may not attempt to get their decision embodied in a magistrate's order, without which it is of no legal authority. Some Boards take this step, but the majority do not. " The applications 376 CHARGE AND RECOVERY for a magistrate's order," we were informed, "are com- paratively few." The person sought to be charged may appear before the magistrate, and show cause against the making of an order. No definite ruling has been given as to what constitutes "sufficient ability." Hence, to use the words of an Inspector, '* the enforcement by Boards of Guardians of their decisions depends a good deal upon the caprice of individual magistrates." This introduces a second element of inequality and uncertainty. Finally, when the order is obtained, it depends on the mood of the Board of Guardians, or on the caprice of its clerk — per- haps, also, on the method of remuneration of its collector — whether or not the order will be enforced by distraint or by proceedings for committal to prison. The extent of the real hardship on the relations against whom such orders are made may be gauged by the fact that the number of those annually committed to prison for default can in the whole of England and Wales hardly fail to reach several hundreds. But in the majority of cases the proceedings are not pushed to such an extremity. Those who have undertaken to pay presently fall into arrears, and the Board of Guardians *' wipes off the debt." In fact, those who pay are the honest and the simple. The man who knows how to take advantage of the Guardians' difficulties, and is obstinate in refusing to pay, usually escapes scot free. " There are," we were told by the Clerk to a Board of Guardians, " many of those cases." This tends to bring the whole system into contempt. We desire to refer here once more to the practice of some Boards of Guardians of attempting to exact repay- ment of the cost of maintenance of paupers from relations who are under no legal liability to contribute to their support. We find that it is a common practice of some Unions to make inquisitorial investigations into the economic circumstances of persons who have been dis- covered to be relations of applicants for relief — though relatives not legally liable to contribute — with a view to ascertaining whether, according to the judgment of the Board of Guardians, they ought to be supporting the relations who have fallen into destitution, and whether CONTRIBUTIONS BY RELATIONS 377 the Board of Guardians should not apply for a contribution towards their maintenance. We think this practice open to grave objection ; and we are glad to find, among experienced Poor Law Officers, a certain hesitation in undertaking investigations of this kind, for which there seems no lawful warrant. *' I dare say they may not make perhaps the same inquiries," said a Guardian, with regard to the Relieving Officers' investigations of the means of relations not legally liable, "indeed they would not, into the particulars of such a case, as they would where there was a legal liability. Perhaps, for instance, they might not apply to the employers to ascertain the wages of the son-in-law. I do not know that they have any right to make such inquiries." But the process of seeking to exact contributions from persons who are not legally liable to make them does not stop at these inquisitorial inquiries, objectionable as these may be. When the Relieving Officer has ascertained that the uncle or the nephew, the son-in-law or the cousin, has an income which, in the opinion of the Board of Guardians, suffices to permit him to undertake a liability which the law does not place upon him, there begins in some Unions a systematic policy of pressure upon his will to induce him — possibly to the detriment of his own children — to shoulder the burden of the ratepayer. Beyond an application or tw^o, the pressure on him is not direct, for the Board of Guardians is power- less to alter his position. But the Guardians calculate that they can apply some pressure on his will indirectly, by deliberately making things unpleasant for the unfortun- ate pauper who has come under their control. He may be stinted in his Outdoor Relief by a deduction equal to what the Guardians are pleased to think that his relations ought to allow him weekly. He may even be refused Outdoor Relief altogether, though Outdoor Relief would admittedly be appropriate to his case, and compelled to come into the General Mixed Workhouse. AVe can see no justification for a Destitution Authority to exercise its discretion as to the relief that it will grant, or the kind of that relief, on any other consideration than that of what is the treatment most appropriate to the destitute person 378 CHARGE AND RECOVERY himself. For the Destitution Authority to use the discre- tion with which Parliament has entrusted it, as a means of deliberately seeking to enlarge the circle of liability to support relations which Parliament has established, appears to us wholly unwarranted. We have already expressed our objection to this policy from the stand-point of its effect on the destitute person himself. Here we wish to emphasise the objection to it from the stand-point of the relation who is under no legal liability in the matter. We have ourselves found cases in which such an illegitimate use of the Guardians' powers has worked with partiality and injustice. A kindly and humane man, with means no greater than suffice for his own household, may find him- self driven to undertake onerous responsibilities, which the law has not intended for him, in order to save a brother, a father-in-law, or an uncle from being left to linger on with admittedly inadequate Outdoor Relief, or forced into the General Mixed Workhouse, or even, as we have occasionally found, denied admission to the Poor Law Infirmary. The careless or inhumane man laughs at the efforts of the Board of Guardians to extract money from him by threatening to oppress, or even actually oppressing, destitute relations for whom he is not legally liable ; and, leaving these to the fate decreed for them, he escapes scot free. A special defence of this practice of throwing the burden of the destitute upon individuals not liable for their support is made when the applicant for relief actually resides with non-liable relations, and the aggregate income of the household is, in the eyes of the Board of Guardians, sufficient for its complete support. In such cases many Boards of Guardians refuse all relief. The effect of this policy is to prevent persons offering lodging and personal attendance to their aged relations, unless they can also find them in food and clothing without stinting their own families. It adds to the hardship of the situation that the same Boards of Guardians will refuse Outdoor Relief to the old person if he tries to live alone, on the plea that he has no one to look after him. It is urged in defence of the policy of reckoning the whole income of the household as comraunistically available for CONTRIBUTIONS BY RELATIONS 379 the support of all its members, including a mere lodger if in any way related to the others, that any other course would involve the grant of relief where there was no actual destitution. We do not see that this follows. It is for the Destitution Authority to ascertain in each case whether or not the applicant is, as a matter of fact, suffering from insufficient food, clothing, warmth and shelter. " The party's wants," said one of our witnesses, " would be the primary consideration in the case." If he has, in fact, nourishment insufficient for health, inadequate clothing and warmth, or a lodging that is not sanitary, and if he has himself no means of providing these, it is the legal duty of the Destitution Authority to grant relief, even if some other persons in the household, not legally liable for his maintenance, have means that might, as an act of charity, be given to him for this purpose. There is, in law, no justification for a Destitution Authority denying relief to a person legally eligible for it, merely as a means of inducing some other person, out of charity or kindly feel- ing, to give alms. Thus, the fact that the aggregate income of the household would, if communistically dealt with, suffice to feed all its members, is, in itself, no evidence that the lodger — or, for that matter, the child found unfed at school — is not destitute. It may well be that the Relieving Officer of a Board of Guardians is not qualified to investigate and to judge whether destitution, in the sense of insufficiency of nourishment, clothing, warmth, or shelter, from a standpoint of physiological efficiency or health, does or does not exist, and that such a Destitution Officer can get no nearer than an arithmetical computation of weekly income per head, to whomsoever the income belongs. But this is only to say that a mere Destitution Authority, with merely Destitution Officers, is not well adapted to deal with what is essentially a Public Health problem. It is significant that, in Scotland, the opinion of the Medical Officer would be taken in every such case, at any rate so far as adult male applicants were con- cerned. 380 CHARGE AND RECOVERY (ii.) The Device of Relief on Loan We have already noted that under the Elizabethan Poor Law the Overseers' dole was a free gift for the relief of the destitute. Under the Poor Law Amendment Act of 1834, the obligation to grant relief as a free gift to destitute applicants was in no way abrogated. But a clause of that Act established a new and additional kind of relief previously quite unknown to the Poor Law, namely, that of a loan. It was enacted that any relief that the Central Authority might declare or direct to be by way of loan should be legally recoverable by the Board of Guardians as a debt due by the person relieved, even by attachment of wages. The Central Authority promptly directed, by its Orders, that the Board of Guardians might, at their discre- tion, declare any lawful relief to adult persons to be made by way of loan. This practice has continued in some Unions, and under certain circumstances, down to the present day. But it is one thing to declare that your assistance of a destitute person is by way of loan, and quite another thing to get the money back. The process of recovery of relief made by way of loan is even more difficult than in the case of contributions from relatives. The loan is a civil debt, for which the Board of Guardians can sue in the County Court ; and on getting judgment, can proceed by way of distraint upon goods ; or, upon proof of means, can obtain an order for committal of the defendant to prison for contempt of Court. Or, when the person relieved by way of loan has got into wage-earning employment, the Board of Guardians may apply to a magistrate for an order requiring the em^^loyer to pay over to the Guardians, in repayment of the loan, such part of the wages as the magistrate, taking into con- sideration the circumstances of the man and his family, sees fit to direct. We have been unable to discover exactly what Parlia- ment intended to eff'ect by its establishment of Relief on Loan. Three distinct uses of this device have been suggested to us ; and the Legislature may have intended any one of them. There is, first, the use of the device of DEVICE OF RELIEF ON LOAN 381 Relief on Loan as a way of giving assistance to a destitute person supplementary to the mere relief of destitution, for the purpose of enabling him to better his position : as when he is provided with an outfit of tools or stock for trading — the kind of "relief" which could not be given to everybody, but which, as the experience of voluntary benevolent societies shows, may be advantageously afforded to selected persons likely to repay the sum advanced. A second and quite different use of the device of granting relief by way of loan is to strengthen the legal position of the Destitution Authority with regard to recovering the amount of the relief, in the event of the person relieved (though momentarily destitute of food or lodging) having property that could presently be converted into money, or coming, at some future time, into possession of property or an income enabling him to repay the debt. The third use of the device of Relief on Loan is a deterrent accompani- ment of the ordinary relief of destitution, in order, by holding over him the threat of exacting repayment at some future time, to deter a destitute person from accepting, or even applying for, such relief. These three distinct uses of the device of Relief on Loan — as Supplementary Assist- ance to persons to enable them to better their condition, as a Method of Recoupment from the property of the persons relieved, and as a Deterrent Clog on ordinary relief — have all been advocated before us. The use of the device of Relief on Loan as a means of affording Supplementary Assistance to necessitous persons, in order to enable them to better their condition, is seen at its best in the work of the admirable Voluntary Institu- tion in London and Manchester known as the Jewish Board of Guardians. This body does not confine itself to relieving the momentary destitution of its clients, but habitually makes small advances to many of them, in order to enable them to change their occupations, to obtain tools, or stock, or even industrial training, so that they may be enabled to better their condition. During the first few years of the New Poor Law, some of the Boards of Guardians seem to have assumed that this was the use of Relief on Loan that Parliament had intended ; and they made 382 CHARGE AND RECOVERY certain attempts to give this kind of Supplementary Assistance. The Poor Law Commissioners imagined, at any rate, that nothing would be granted by way of loan except with the real intention of the loan being repaid. Presently, however, the Poor Law Board intervened, and prohibited any such use of the device of Relief on Loan. It was held, in effect, that Relief on Loan was not a new or additional relief, but only another form in which the ordinary relief of actual destitution might be given. What could not lawfully be given was not to be lent. Accom- panying this prohibition of Relief on Loan as Supple- mentary Assistance to enable people to better their condition, the Poor Law Commissioners suggested what we have termed the second use of the device, namely, as a Method of Recoupment from the property of the person relieved or from that of those liable to maintain him. As an example of occasions suitable for Relief on Loan, the Poor Law Commissioners adduced, not, be it noted, any case of Medical Relief, but the destitution of a mentally defective person enjoying a regular and sufficient income, but nevertheless, from incapacity to manage his property, sometimes without food. Other examples given were those of the wives or children of persons having means who were found apart from their husbands or fathers in a state of destitution. A further instance supplied was that of the mother of an illegitimate child, who had the right to receive periodical payments from the putative father. This use of the device of Relief on Loan seems, however, never to have prevailed to any considerable extent, and it was, perhaps, presently rendered unnecessary by amend- ments in the law, which made clear the leo-al ris^ht of the Destitution Authority to recoup itself by appropriating any property or valuable securities found in the pauper's possession, or after his death; to recover, as an ordinary civil debt, the cost of any Poor Law relief aff'orded to lunatics ; to claim from the husband the cost of any relief afforded to his wife ; and to proceed against a wife having separate estate for relief afforded to her husband. Nevertheless we find to-day one or two Boards of Guardians — perhaps as the result of some unfortunate legal experience — formally DEVICE OF RELIEF ON LOAN 383 declaring, with regard to all the relief that they grant, indoor as well as outdoor, whatever may be the circum- stances of the recipient, that it is " on loan " ; these words being printed as a matter of course on all the orders for relief of any kind, on the supposition that they would, in some way, strengthen a possible future claim to recover the cost of the relief in case any pauper eventually became entitled to a legacy, or otherwise came into a fortune. The third use of the device of Relief on Loan — that of making it a Deterrent Clog on the grant of relief — was, we gather, introduced by the able Inspectorate of the Local Government Board between 1871 and 1890, as a part of their campaign against Outdoor Relief of any kind. By affixing this Deterrent Clog to relief, or to some particular kinds of relief, these Inspectors hoped to prevent many persons from applying to the Destitution Authority, or to prevent them from accepting the relief wdien offered. It was suggested, in particular, that the device might advan- tageously be used with regard to Medical Relief, on the ground that this was often the " first step to pauperism," among a class "not wholly destitute of means." We have sought to discover what exactly is the legal position of the Destitution Authority in making this use of the device of Relief on Loan. A Board of Guardians has clearly the power, under the Statutes and the Orders, to declare any lawful relief that it offers to be granted by way of loan. But it is equally clear that a destitute person is under no legal obligation to accept the relief in that form or subject to any condition of future repayment. It was, for instance, definitely laid down by the Local Government Board in 1880 that "the Relieving Officer has no power to compel any appli- cant to accept relief on loan." Moreover, in order to incur legal liability to repay, it must definitely be made known to the person to be relieved, at the time of making the relief, that it is by way of loan ; the person relieved must presumably be in a position to accept the relief as a loan ; and he must, by implication at least, by himself or by some one having authority to pledge his credit, consent to receive the relief as a loan. Thus, relief 384 CHARGE AND RECOVERY cannot be given to a lunatic by way of loan in such a way as to render the amount recoverable from him if he became sane. Similarly, we were authoritatively advised that relief could not be given, as by way of loan, to a person suffering from delirium tremens, unless, indeed, he had a lucid interval. Nor can the grant of an order of admission to the Workhouse to a man so drunk as to be incapable of understanding be made by way of loan. And if a destitute person refuses to consent to receive the relief as on loan, or is not in a state in which he can consent, the Destitu- tion Authority is nevertheless under a legal obligation to give him the relief that his necessities require. Thus, if all destitute applicants were made aware of the actual state of the law, this use of the device of Relief on Loan, so ingeniously invented by the Inspectorate of 1871-1890, would become impossible. Moreover, it is not easy to see how the legal position of the Guardians in the way of recovering the cost of the relief if the recipient should afterwards prove to have means, is, at the present day, in any way strengthened by the relief having been given by way of loan. Thus, whether or not the relief has been granted by way of loan, where a pauper has in his posses- sion any money or valuable security for money, or is found at his death to have had such, the Board of Guardians may recoup itself from such property to the extent of twelve months' relief. Further, the Guardians have a right to recover, as ordinary creditors, for six years' maintenance of a pauper lunatic to whom any legacy or other debt becomes payable. Army and Navy pensions accruing to paupers can be attached and appropriated to the cost of their relief. We have to report that, notwithstanding the uncertainty as to the legal position, the device of Relief on Loan, as a Deterrent Clog on relief, or "as a form of test," is still employed by various Boards of Guardians — more especially in the rural Unions — to a not inconsiderable extent. According to the published rules of a dozen or more Unions, relief is, with the avowed object of deterring applicants, to be granted only by way of loan to all men, whatever their likelihood of ever being able to repay the amount, who are disabled " by accident " or by " temporary DEVICE OF RELIEF ON LOAN 385 illness " ; and in midwifery cases ; and for funeral expenses ; and to all single men and women under sixty. We have it in evidence that the Bradfield Board of Guardians, by making all its Medical Relief by way of Loan, and by charging as much as 6s. for the service of the District Medical Officer, reduced the number of its Medical Orders from 700 a year to 47. A similar practice prevails at St. Neot's. There is evidence that in the case of Medical Relief, the practice of giving it only on loan has, especially when first established and with regard to any but the most serious ailments, a very deterrent effect on applicants. "It has," even in the Metropolis, "a certain effect in preventing persons applying who would otherwise have applied." Hence, some of the Inspectors of the Local Government Board, who still aim at restricting as much as possible the services of the Poor Law, continue to recom- mend this use of the device of Relief on Loan. But the more usual opinion, alike of Clerks to Boards of Guardians and Local Government Board Inspectors, is that Relief on Loan " appears to be almost an empty threat," any deter- rent effect being found to " gradually pass away." It is, in fact, quickly discovered that there is very little practical power of recovering the loan by legal proceedings. Those to whom the so-called loans are made are seldom in a position to repay them, and the Board of Guardians does not find it profitable to take legal proceedings to recover its debt. The amount voluntarily repaid is "comparatively trivial," and " more trouble than it is worth," even when collectors are spurred to activity by a 20 per cent commis- sion. The process of obtaining a magistrate's order for the attachment of wages has gone entirely out of use. If the Board of Guardians goes to the trouble and expense of proceedings in the County Court, it may get judgment, but it will probably find no goods worth distraining on, even if it deemed it good policy to strip the miserable apology for a home of those whose destitution it would then have again to relieve. If an order for committal to prison is applied, proof of means must be given ; and, as a Guardian of a large Metropolitan Union deposed, "we have never yet, although we have tried several times, been able to get a VOL. I 2 c 386 CHARGE AND RECOVERY case in which we could give . . . clear evidence that the man could pay," without which the proceedings were "merely a costly process with no result." But apart from the difficulty of recovering the loans, the whole policy of using the device of Relief on Loan as a Deterrent Clog has fallen into disrepute. Even those Poor Law administrators who still believe in the desirability of " deterring " destitute persons from applying for relief recognise that it is demoralising to pretend that a liability exists which can be denied, which will be ignored by the practised pauper, and which will bear hardly only on the really deserving, guileless applicant. " It would be rather absurd," said the present Chief Inspector of the Local Government Board, "to give a man relief on loan when it is perfectly obvious that he cannot repay it." The practice may, morever, work in a direction exactly opposite to that intended by its advocates. Those who watch it in operation have misgivings as to whether it does not lead to a more lax and less discriminating grant of Outdoor Relief than would be the case if there were no pretence that the money was going to be repaid. It may even induce people to apply who would otherwise have abstained. "My experience," said the Clerk of a Metropolitan Board of Guardians, "is that it is un- workable and in many cases undesirable, and my reason is that the pauper gets to regard it as a sort of loan society, and thinks that he does not get [Poor Law] relief. He comes and says, ' I require a certain thing, an order for my wife, and I am going to pay you back,' and he never does pay it back. . . . The amount recovered was so infinitesimal and so much labour was attached in getting anything, that we have practically discontinued it." If a charge is made for the services of the District Medical Officer, and this relief is granted " on loan," and actually repaid, it has been suggested to us, on high authority, that the Board of Guardians runs a risk of competing with Medical Clubs and other forms of medical insurance. " Relief on Loan is objectionable," says another witness, because " in the first place it is a very serious deterrent. In the next place, the Guardians get very little repaid, so DEVICE OF RELIEF ON LOAN 387 it is of very little good. And in the third place, it impoverishes the family just at the time when they want more money, when there is illness in the house — which costs a great deal of money, as we all know. That is just the time when you should not burden the family. Then it is demoralising in most cases, because the man does not pay it back, and in many cases he cannot, and there is the debt hanging on his back. Altogether making relief a loan is usually a very bad thing." Finally, even in the case where a deserving man has accepted, with the utmost integrity, the relief as a loan, it is seldom desirable that he should have to repay the amount. " It would be at variance with " a proper Poor Law policy, declared the Local Government Board itself in 1877, "if every recipient of relief were to feel that, after he had again succeeded in obtaining employment, any savings he might be able to put by would be liable for the repayment of the relief which he might have received." "The loan system," declared a medical witness, " should be abolished, as it is calculated to increase pauperism . . . and discourage thrift." In fact, a Relieving Officer informed us that, in his opinion, " there is nothing more absurd than relief on loan of any kind." (b) Charge and Recovery by the Public Health Authority Individual chargeability is not confined to the realm of the Poor Law. The Local Health Authority may, in England and Wales only, under the Public Health Acts and Isolation Hospitals Acts, make a definite charge for maintenance in its hospitals, for which it can sue the patient. But it is a personal charge only ; the relations of the patient come under no liability. If the patient is a minor it does not appear that any such charge is legally recoverable ; and if the patient dies it seems doubtful whether the charge could, in the absence of any agree- ment, be enforced against his estate. Under these pro- visions of the Public Health Acts and the Isolation Hospitals Acts, all sorts of arrangements are made by different authorities for the recovery from the patients of 388 CHARGE AND RECOVERY a part or the whole of the cost of their maintenauce and medical treatmcDt. In a few towns, in the cases of some or all of the patients, the patient himself, or the father or other responsible person, is invited to enter into an agree- ment for the payment of various sums, any such special contract being in all cases only voluntary. In some towns the patient, without a contract, is charged according to his ability to pay, the rough test being the rateable value of his domicile ; under £25 a year free, or a nominal sum ; £25 to £50 a year a substantial contribution ; over £50 a year the whole cost. This scale is, however, criticised as logically inequitable, those patients who are large rate- payers already contributing in larger proportion to the municipal expenditure than those who pay less in rates. Hence some Local Health Authorities prefer to take income as the test of ability to pay, admitting, for instance, rate- payers earning less than £1 a week free of charge ; those earning between 20s. and 30s. at half- a- crown a week ; those between 30s. and 40s., at 5s. a week; those between 40s. and 50s., at 7s. 6d. a week; those between 50s. and 60s., at 10s. a week; those between 60s. and 80s., at 15s. a week ; whilst those over 80s. are charged £1 a week. Others, again, make a discrimination between local rate- payers and strangers or "visitors"; the latter, as at Romney Marsh, " being asked to pay the entire cost of their maintenance and treatment " ; or, as at Bridlington, being charged from 10s. to 40s. according to circumstances, as may be decided by the committee. In another town it is usual to make no charge to local residents having incomes under £2 per week. In the great majority of instances, however, no charge whatever is made, either for medical treatment or for maintenance, in the general wards of the municipal hospitals. Experience soon showed that if it was desired to get these hospitals generally used — and this was most keenly desired in the case of small- pox and other demonstrably dangerous diseases — it was necessary to make them absolutely free. Accordingly, with the approval of the Local Government Board, all attempt to make a charge has been generally abandoned. " The more enlightened sanitary authorities," says a Local BY PUBLIC HEALTH AUTHORITY 389 Government Board Inspector, " make no charge for patients in the isolation hospitals, and this is the proper line to take. The cases are not removed as a matter of relief, but for the protection of the public health. All classes of the community are made to contribute to the support of the hospitals, and all classes are entitled to the benefits they confer. Directly a payment is imposed an influence adverse to the use of the hospital is introduced. The great object in view is to do everything possible to get all the cases which cannot be effectively isolated at home into hospital at the earliest possible date. It is by this means that the patients stand the best chance of favour- able treatment, and that the spread of disease is stopped at once." Parliament has expressly sanctioned this view, so far as the Metropolis is concerned, first by a provision in the Diseases Prevention (London) Act of 1883, and then, in 1891, by omitting from the Public Health (London) Act of that year, all provisions as to making a charge or recovering any contribution. On the other hand, a few Town Councils make charges for the use of their Municipal Hospitals at such prohibitive rates as to cause them to remain practically empty. Thus, at Shrewsbury, the Town Council admits persons suffering from infectious disease to its Isolation Hospital, the only one in the whole county, upon terms of their finding their own doctor and nurse, providing their own food and other necessaries, and paying, in addition, 20s. per week during their stay by way of rent. The result is that the Hospital usually stands empty ; and cases of scarlet fever and enteric fever, like diphtheria and measles, have to be treated at home, however little possibility of isolation there may be. Even the local Board of Guardians (that of Atcham) has to treat paupers sufiering from infectious disease in the General Mixed Workhouse, "in the midst of a community of four or five hundred, many of whom are children," rather than comply with the prohibitive terms by which the Shrewsbury Town Council chooses to nullify the intention of the statute. This would be in- comprehensible in Scotland. The more usual adoption of the principle of gratuitous 390 CHARGE AND RECOVERY admission to the Municipal Hospitals does not mean that none of the inmates contribute to their maintenance. At the Brighton Town Council's Sanatorium for Consumption there are among the patients some paying as much as 30s. a week. These are allowed private bedrooms. In other cases even more may be charged, in return for particular privileges, such as a special nurse. The Town Council of Eastbourne reserves four of the pavilions of its hospital for the Eastbourne schoolmasters' and schoolmistresses' associations, for the admission of the pupils of their ex- pensive private boarding schools, in return for retaining fees of £150 and £180 per annum respectively. What is most remarkable is that the Town Council often obtains payment for the admission to its hospitals of precisely the very poorest class of patients. The Local Government Board has decided that the Public Health Authority is under no obligation to provide hospital accommodation for the not inconsiderable proportion of the inhabitants of its district who happen to be destitute. For these persons, whether already in receipt of Poor Relief or not, it is the duty of the Board of Guardians to provide what is necessary, even in cases of infectious disease. Accord- ingly, some Public Health Authorities refuse to admit to their hospitals Workhouse inmates {including occupants of the casual ward) suffering from infectious disease. In other cases they have agreed to receive such patients only on payment by the Board of Guardians. The status of the patient so admitted, his liability to refund the cost of his maintenance, and the obligation of his relations to contribute in default, as we have already mentioned, all depend, in law and in practice, on the particular character of the voluntary arrangement entered into between the Poor Law and Public Healtli Authorities. In those Unions in which the Board of Guardians prefer to pay a fixed annual sum, which ranges in fact from £2 (as at Yeovil) to £300 (as at Bristol) — as also in those Unions in which the Public Health Authority admits the Poor Law patients, like others, free of charge — the pauper admitted to the Municipal Hospital thereupon instantly ceases to be a pauper ; and neither he nor his relations are BY PUBLIC HEALTH AUTHORITY 391 liable for any part of his cost, or subject to any stigma or disqualification. On the other hand, in those Unions in which the Board of Guardians pays at a rate per head — sometimes as much as 7s. per diem — the pauper patient, lying in the general ward among non-pauper patients who are admitted free, remains a pauper ; he is liable to repay the full cost of his maintenance; he is disqualified for the franchise ; and his relations are liable to contribute. Thus, we have the paradox that under the present con- flicting jurisdictions of the Poor Law and Public Health Authorities, it is in respect of the most destitute of its patients that the Public Health Authority recovers the most ; whilst when such most destitute patients or their relations contribute — being perhaps the only patients who contribute at all — they nevertheless remain paupers, sub- ject to a stigma and to disqualifications from which those patients who are maintained and treated wholly free of charge are entirely exempt. (c) Charge and Recovery for the Maintenance of Children hy the Education Authority and the Police Authority With the almost universal abolition of fees in the Public Elementary Schools, the Education Authority has given up the bulk of the charges that it formally made on parents for the education of their children. In the rapidly extending field of Secondary and University Education, so far as the institutions are maintained by the Local Educa- tion Authorities, the charging of substantial fees (which do not, however, cover more than a fraction of the cost) is almost universal. This is mitigated by an abundance of Scholarships, usually carrying whole or partial maintenance, as well as free schooling, by means of which somewhere between 50,000 and 100,000 of the poorer children, includ- ing a few who are or have lately been in receipt of Poor Relief, are now being educated. What is more nearly akin to the practice of the Destitution and Public Health Authorities is the provision of maintenance in residential schools, and the charges made for it. 392 CHARGE AND RECOVERY So far as the residential institutions of the Education Authorities of Secondary or University grade are con- cerned (boarding schools, pupil-teacher centres or training colleges), admission is purely a matter of voluntary agree- ment, the fees charged are usually received in advance, and, if not paid, they are recovered only as civil debts. But, for the most part, the pupils at these institutions are maintained and educated free of charge, as a method of training teachers. In London and some other large towns where there are residential schools for mentally or physically defective children, the parents are required by the Council to pay Is., 2s. or 3s. per week towards their maintenance, which charges are in practice agreed to by the parents, and are then recoverable as civil debts. Where the parents are really unable to pay (and this is, in London, the case only in about one-eighth of the families) no charge is made. There are even some scores of blind or deaf children " boarded out " by the London Education Authority, so that they may reside near schools suitable to their needs ; and in these cases the parents are charged a weekly sum. Taking the whole of the defective children thus provided for by the London Education Authority, paying and not paying, a sum of lid. per week for each child was, in 1906-7, actually collected from the parents. In the day schools for blind, deaf or crippled children in London, which contain nearly 3000 boys and girls, meals are pro- vided for all the pupils, towards which the parents are required to make a weekly contribution for the cost of the food ; and an average of Id. per day per child is thus collected. On the other hand, for the 100,000 children who, as we have seen, were supplied with meals last winter under the auspices and largely at the expense of the Education Authorities, practically nothing is charged to or recovered from the parents. In a large number of cases — in London alone about 1600 — the families are simultaneously in receipt of Outdoor Relief from the Destitution Authority ; in a small number they are being relieved of the mainten- ance of one or more children by the Industrial Schools FOR MAINTAINANCE OF CHILDREN 393 of the Education Authority or the Reformatory Schools. There is no co-ordination, or even mutual knowledge of these various activities ; and if the Education Authority were seriously to attempt to recover the cost of the meals, we should have the curious anomaly of three different authorities endeavouring to collect charges from the same family. For the 30,000 children maintained in the schools under the Reformatory and Industrial Schools Acts, by County and County Borough Councils and by voluntary Committees under the supervision of the Home Office, the parents are required, by magistrate's order, in about 40 per cent of the cases, to make some weekly payment, usually at Is., 2s. or 3s. each, according to their means. The practice is to leave a definite sum per head, over and above the rent, for the family maintenance, and to limit the order to such payment as can then be afforded out of the wages. In about 30 per cent of the cases, mostly those in which there are no discoverable parents, or the parents are absolutely destitute, no order for payment is made. The payments are generally collected by the police, acting as the agents of the Home Office, and are paid in to the Exchequer. Failure to pay can be followed by an order by the magistrate committing the defaulting parent to prison for a short term — not, as in the case of the Board of Guardians' recovery of Relief on Loan, on proof of means, for Contempt of Court — but in mere consequence of the failure to pay, without evidence of means, as if the amount due had been a fine or penalty. We have had suggested to us that Destitution Autho- rities should be given the same powers of collecting their personal assessments, by putting summarily into prison, without any evidence of means, those who fail to keep up their weekly payments, as is used by the Home Office in the case of payments for children in Reformatory and Industrial Schools. It must be remembered, however, that in the latter cases, the charge itself is made by a judicial authority, after inquiry into means, not by a mere resolution of an administrative body ; and that it is to some extent in the nature of a .penalty upon the parent 394 CHARGE AND RECOVERY for allowing his child to become liable to be detained in a Reformatory or Industrial School. Moreover, we gravely doubt the advantage of putting a man in prison merely because he does not pay his debts. We have ourselves come across cases — though we believe that the Home Office endeavours in all such instances to excuse payment — in which, whilst the agents of the Home Office were exacting a weekly payment from the father, the local Board of Guardians was having to relieve him and his family as destitute — was, in fact, partly supplying, week by week, from the Poor Rate, the money which was being collected from him for the Exchequer. In other cases we have found the family reduced to pauperism, because the father had been committed to prison for non-payment of such a contribution for a child in an Industrial School. (d) The Need for Uniformity of Principle and Judicial Adjudication in Personal Assessments The foregoing survey of the process of charge on and recovery from individuals of the cost of maintenance, by all the various Local Authorities concerned, reveals a lack of principle and uniformity, and a chaos of careless laxity and arbitrary oppression, which are demoralising alike to the Authorities themselves, to their officers, and to the persons upon whom these special assessments are levied or not levied. The first need appears to be the adoption by the Legislature of some definite principle according to which these special assessments should be made, and its uniform application, by express enactment, to all the various kinds of services. At present there is no common or consistent principle discoverable in the medley of clauses in the diff'erent statutes of the past three centuries defining the pecuniary obligations of individual citizens for services rendered by the Local Authorities to themselves or their relations. We do not mean merely that some of these public services are, by law, made gratuitous, like elementary schooling and ordinary sanitation, whilst others, such as compulsory residence in a lunatic asylum, or the treatment of illness in a Poor Law Infirmary, are made the subject NEED FOR UNIFORMITY 395 of personal assessments on the patients themselves and even on their relations. Some such differentiation among services, so that some are gratuitous and others charged for, is plainly only reasonable ; though here, we think, it would be well for the Legislature to reconsider the anomalies into which it has been led. What, however, is urgent is the adoption of some uniform principle, with regard to charging or not charging, throughout the whole of each service, whether it is administered by one Local Authority or by another. Thus, in the maintenance and treatment of sick persons in the Isolation Hospitals maintained out of the Poor Rate, the Metropolitan Asylums Board cannot charge even the patients themselves, however rich they may be; outside London, the Public Health Authority may treat any disease, and insist on payment from the patients in its hospitals, however poor they may be, but cannot make a charge on any of their relations — not even upon fathers for their dependent children ; whilst the Destitution Authority may recover the cost of those sick persons whom it treats, whether they are suffering from infectious disease or not, not merely from the patients themselves, but from their relations — even from a grandfather for a grandson whom he has never seen. A similar diversity prevails in the liability of parents to contribute towards the support of their young children, according to whether the children fall into the hands of the Poor Law Authority, the Education Authority, or the Police Authority under the Reformatory and Industrial Schools Acts ; the legal powers of recovery being far more drastic in the last case than in the first. Moreover, there have crept into the law certain anomalous procedures which require to be considered. One of these is the device of Relief on Loan, established under the Poor Law Amendment Act of 1834, and, strangely enough, limited to the Authority which can lawfully deal only with persons who are destitute, and therefore the very last to whom credit should be given. This legalised procedure of empty threats, and deterrent clogs on the performance of the sei-vice, appears to us wholly injurious, and ought to be at once abolished. The inconsistencies of the law with regard to these 396 CHARGE AND RECOVERY personal assessments are, however, less important in their demoralising partiality than the chaos of arbitrary in- equalities that prevails in the administration. This chaos results from leaving the decision, as to whether or not these personal assessments should be made, to the unguided discretion of innumerable administrative bodies, occupied with heterogeneous services, with different views as to policy, and having shifting memberships. There is, first of all, the absence of co-ordination among the different Local Authorities with regard to their decisions as to personal assessments. It is nothing short of scan- dalous that the Education Committee of the Town Council should be putting a father in prison for not contributing to the maintenance of one of his children in an Industrial School, at the very moment that the Board of Guardians is granting him Outdoor Relief to maintain his other children. It is equally absurd for a Board of Guardians to be levying a contribution on a man for the maintenance of his aged father, whilst the Education Committee is exempting him, on the ground of poverty, from paying for the meals supplied at school to his hungry children. It does not seem reasonable that the Medical Officer of Health should be supplying an infant with milk and medical advice absolutely free of charge, whilst the Asylums Committee is insisting on being paid by the father for the maintenance of the mother as a person temporarily insane. Still more objectionable is it that the practised and unscrupulous "cadger" can get help free of charge from all the different Authorities in the town — his children fed and medically attended to at the school, his wife gratuitously taken in for her confinements at the Workhouse, and his own ailments cured in the com- fortable hospital of the Public Health Committee — all without any of these public authorities necessarily having any knowledge of what the others are doing. It is im- perative that there should be in each locality at least a common register of these different forms of public assistance of one and the same family. But the existence of a common register of public assistance, to which all the Local Authorities of the area NEED FOR UNIFORMITY 397 concerned had easy access, though it might prevent the overlapping due to ignorance of each other's activities, would not cure the inconsistencies of policy and inequalities of execution of the different Local Authorities, with regard to the personal assessments levied on the families with whom they dealt. In such a matter we do not think that the policy of charging or not charging ought to be left to be determined by the Local Authority at all. The charge is a compulsory levy, to be enforced by all the power of the law. These special assessments upon individuals in respect of particular services, as to the acceptance of which they have practically no option, amount, in reality, to taxation ; and taxation is a matter upon which, if only for the sake of geographical uniformity, the decision of the Legislature should prevail. It is, for instance, inequitable that in one Welsh town the Public Health Authority should be maintaining a free hospital for the gratuitous treatment of all ailments whatsoever, whilst in an English town on the Welsh Border, the Public Health Authority levies a charge of almost prohibitive amount for the treat- ment even of scarlet fever cases. It is inequitable that in one Union a lax Board of Guardians should be allowing negligent parents to thrust their children into expensive Poor Law schools absolutely free of charge, whilst, in the very next Union, compulsory contributions are rigorously levied for all children in the Workhouse, even (in Great Britain, but not in Ireland) on grandfathers in the position of agricultural labourers. The work of adjudicating upon particular cases — of assessing how much each person should pay, or whether he should be excused on the ground of poverty — appears to us no less unsuitable for a local administrative body than the general decision of whether or not the tax should be levied at all. Whether the policy to be pursued is determined by Parliament or by the Local Authority, its application to individual cases, according to the evidence adduced with regard to each, is work for which a many- headed tribunal, mutable in its membership, is inherently and inevitably wholly unfitted. We do not need to repeat what we have said on this point with regard to the decision 398 CHARGE AND RECOVERY whether or not a particular case comes within the rules entitling it to receive Outdoor Relief. The same con- siderations — the need for excluding neighbourly partiality, personal friendship, individual idiosyncracies or personal views as to policy, and for avoiding variations in decisions according to the presence or absence of this or that member — apply with doubled force when what is at issue is whether the case comes within the rules, not for the grant of money but for the levying of a tax. Nor are these arguments affected by the substitution of a nominated for an elected body. When the levying of taxes on individuals is at stake, a nominated committee is even less satisfactory than one resting upon the authority of popular election. But there is au additional argument, in this matter of charges or personal assessments, against the performance of the work by an administrative committee. With regard to Outdoor Relief at present, the same body that awards it orders its issue. With regard to the charges to be made on individuals, the administrative body which tells a man that he must pay cannot itself enforce the payment. For this purpose the Local Authority must have recourse to a judicial officer — it may be (as under the Elizabethan statute or under the Reformatory and Industrial Schools Act) for a magistrate's order charging a definite sum per week ; it may be (as in the recovery of Poor Law relief from the recipient, and Relief on Loan) by way of civil suit in the County Court. The magistrate or County Court Judge before whom the case happens to be brought has to exercise his own discretion, and inevitably some- times takes a different view from that of the administrative body, either as to the legal liability, or as to the policy of making a charge at all, or as to what constitutes means of repayment. This division of authority enables many to escape payment who expected to be made to pay ; and this brings both the law and the Local Authority into contempt. Thus, it seems desirable that the Authority deciding, according to the law and policy otherwise deter- mined, upon the charges to be made upon particular individuals, ought itself to have the power, by whatever means are lawfully appropriate, of actually enforcing the NEED FOR UNIFORMITY 399 payment. It is clear that such powers of enforcing payment could not be granted to an administrative committee. These arguments apply, it will be seen, equally to the charges or personal assessments made by the Local Educa- tion Authority and the Local Health Authority, as to those made by the Destitution Authority. Moreover, as all the Local Authorities may be dealing with the same persons, or the same families, it seems essential that the work of adjudication, in this matter of personal assess- ments, should be performed for all of them by a common Authority — in fact, by one and the same officer, especially versed in the law, and acting in a judicial capacity. The same officer might appropriately be placed in charge of the common register, to which we have already referred, of all the public assistance, whatever its kind, afforded to the residents within his district. (e) Conclusions We have therefore to report : — 1. That the existing provisions of the law for charging to, and recovering from, particular individuals, the cost of various forms of public assistance afforded to them, to their dependents or to other persons for whom they are legally liable to contribute, are confused and inconsistent with each other, and are based on no discoverable principle. 2. That the practice of the multifarious Local Authori- ties, with regard to charging or recovering the cost of public assistance, varies, for identical services rendered to persons in identical economic circumstances, from place to place, from case to case, and even from time to time in one and the same case, according to the idiosyncracies of the members who happen to be present at successive meetings. 3. That the confused and uncertain state of the law, and the haphazard conflict of practice, lead to hardship and oppression on the one hand, and to demoralising laxity on the other ; the net result being that a serious loss of revenue is incurred, the law-abiding citizen paying, 400 CHARGE AND RECOVEKY and the habitual " cadger " escaping scot-free ; with the additional absurdity that the patient for whom the cost is repaid is often classed as a pauper, whilst other patients suffering from the same disease get wholly gratuitous treatment and retain their status of citizenship. 4. That we recommend that a Departmental Committee should be appointed to consider the whole question of what forms of public assistance can properly be made the subject of these " Special Assessments," and upon what persons these assessments should be made ; in order that the law may be amended on some definite principle, and consoli- dated by Parliament into a single statute. 5. That the duty of determining what Special Assess- ments are due according to the law, and from whom, together with the decision whether the person liable is of sufficient ability to pay, and the duty of enforcing pay- ment by proper legal process, ought to be entirely separated from the work of administering the public assistance ; and it would be most suitably undertaken, for all the forms of public assistance afforded in a given district, by a salaried officer of adequate status, appointed by and acting under the County or County Borough Council, but unconnected with either the Health, Education, Mentally Defectives or Pension Committees. 6. That we wholly disapprove and condemn the practice of some Boards of Guardians in England of varying the treatment, or threatening to vary the treat- ment — offering the Workhouse, for instance, instead of Outdoor Relief — in respect of persons entitled to relief from them, with a view to extracting contributions from other persons, whether or not these are legally liable for the payment. We think that it should be definitely laid down that the kind and amount of relief or assistance granted in any case should be determined solely by a consideration of the circumstances of the applicant or patient himself, and ought never to be made dependent on whether somebody else fulfils, or does not fulfil, a legal or moral obligation. CHAPTER IX SETTLEMENT AND REMOVAL Closely connected with the conception of Charge and Recovery of the cost of the relief or treatment aftbrded by- Local Authorities is that of Settlement and Removal. (a) The Game of " General Post" As the law now stands, a Board of Guardians in England and Wales, whilst bound to afford relief in some form to every destitute person within the area of the Union of whose destitution it becomes aware, is empowered, under certain circumstances, to obtain from the Justices an order for the compulsory removal of the person relieved to his " parish of settlement," where thS responsibility for his maintenance falls upon the Board of Guardians of the Union in which that parish is situated. This legal provision for safeguarding Destitution Authorities against having to maintain paupers who do not " belong" to their districts, has, from 1795 down to 1900, been so far modified by successive statutes, and is now so far left unutilised by the increasing good sense and humanity of the Destitution Authorities, that the number of cases in which paupers are compulsorily removed is probably less than at any previous date. Thus, a settlement in a parish in England and Wales is nowadays acquired, not only by birth there, but also by apprenticeship, the ownership of real estate, renting a tenement or paying rates there, or by being the child or becoming the wife of a person having a settlement there, and even by mere residence there for VOL. I 401 2d 402 SETTLEMENT AND REMOVAL three years. Moreover, even if a settlement has not been acquired, whole classes of paupers cannot legally be removed. There can, of course, be no removal of a person whose settlement is unknown and cannot be ascertained. There is no power to remove mere Vagrants relieved as such. No person can be removed who has continuously resided for one year within the Union in which he applies for relief. A widow cannot be removed for one year after her husband's death in the parish. Finally — most important exception of all — no warrant can be granted for the removal of any person relieved in respect of sickness or accident, not only unless the sufferer is fit to be moved, but also not unless it is expressly certified by the Justices that they are satisfied that the sickness or accident will produce permanent disability. Hence a very large proportion of the pauper population are, in practice, for one reason or another, outside the sphere of removal altogether. The result is that the expense now incurred in the administration of the law as to Settlement and Removal, and especially the cost of litigation among different Destitution Authorities as to which of them shall bear the expense of maintaining particular paupers, has steadily decreased. Nevertheless, there are to this day, in England and Wales alone, upwards of 12,000 poor persons actually deported annually, under compulsory orders, and often against their will, from one Union to another — occasionally from one end of the Kingdom to the other; a form of "exile by administra- tive order" which in some cases causes great hardship. The various stages of this process of shifting citizens — not to the places in which they are wanted, or where they would be most useful, but simply to the parishes in which they are deemed to have their legal "settlement" — absorb, in every Union, a large amount of official time ; and in some large Unions there are even officers wholly devoted to the service. " A large amount of preliminary clerical work," we are told, "is involved in ascertaining the particulars of the chargeability of these cases ; in eliminating those who cannot at the time be legally removed on account of their suffering from sickness of GAME OF "GENERAL POST" 403 only a temporary character ; and in making a separate oral examination as to the previous history of each case taken in hand. In addition to which there are numerous cases in which expert personal inquiry by the Settlement Officers in towns and villages in both near and distant parts of England are essential, in order to gather evidence on which to base applications to the Magistrates for the removal of paupers elsewhere." The Manchester, Chorlton and Prestwich Unions have accordingly agreed, for the past twelve years, not to raise any question of settlement as among themselves. Nevertheless, the cases investigated in Manchester alone exceed 3000 annually. In England and Wales the actual expenses of removal and litigation alone, without official salaries, cost over £20,000 a year. In Scotland the controversies between the 874 parishes are incessant, and, in spite of arbitration by the Local Government Board for Scotland, there is still an absurd amount of costly litigation on the subject. We estimate that, in the whole United Kingdom, including the cost of the official staff engaged, there is an expense not far short of £100,000 a year still incurred, directly or indirectly, in this troublesome and, from a national standpoint, entirely useless game of " general post," in which each Union succeeds in getting rid of some paupers, at the cost of having others thrust upon it. (b) The Proposal to abolish Settlement and Removal It is to be noted that this peculiar arrangement is characteristic of the Destitution Authorities alone, and those only of Great Britain. In Ireland under the Poor Law there is no Law of Settlement, and no power of Removal. Every destitute person is relieved where he happens to be. There is nowhere in the United Kingdom any protection analo- gous to the Law of Settlement in the case of the services of other Local Authorities, even when these are obligatory. The Local Health Authorities and the Local Education Authorities are under a statutory duty to provide their obli- gatory services for all local residents, however recent their migration or however transient their stay, without power 404 SETTLEMENT AND REMOVAL either of ejecting them from the district or of recovering the cost of their treatment from any other district to which they may be assumed "to belong." Notwithstanding these facts, if we were proposing the continuance of a general Destitution Authority, we should be in agreement with the majority of our colleagues in not recommending the abolition of the Law of Settlement, nor yet the total abrogation of the power of removal. The Parliamentary experience of the past three-quarters of a century, during which innumerable proposals have been made for the abolition of the Law of Settlement, shows that any such proposal, though often popular at first sight, arouses after a short time considerable apprehension in many, if not in most, districts. The Metropolis becomes concerned about the possible attraction of poor persons from the country. The rural districts become alarmed at a possible " backwash " of worn-out persons from the towns. The seaports fear the influx of destitute seamen and travellers, who could not be passed on to their inland homes. The result has hitherto always been an irresistible opposition to the proposed reform. We are even more impressed by the possible dangers of an abolition of the Law of Settlement, in its effect on the minds of local administrators. The gross evils, existing both in the institutional and in the domiciliary treatment of the poor, that we have described in the preceding chapters, make it imperative that great improvements should be effected in nearly all districts. Experience shows that it will be more difficult to induce Local Authorities to effect those improvements, especially in the cases of the aged, the sick, and the children, if it can be alleged in opposition that the expense to be thereby thrown on the local ratepayers will cause an influx of destitute persons from other districts to enjoy the new advantages. We think that it would prejudice the chances of securing the reforms which are, in our judgment, essential to the well-being of the community, if all barriers against such an influx were simultaneously to be removed. Thus, any continuance of a general Desti- tution Authority makes it necessary to continue the Law of Settlement and Removal. Hence, whilst we cannot but PROPOSAL FOR ABOLITION 405 feel that it is an immense advantage that, under the scheme of reform to which our conclusions in respect of each service in turn have irresistibly led us, the Law of Settle- ment and Removal, being exclusively a Poor Law pro- vision, would automatically cease to exist, we have still to consider to what extent and in what way provisions analo- gous to those of the Law of Settlement and Removal need to be instituted to give the necessary safeguards to the administration of the several specialised services, under different Authorities, that we recommend as the successors of the Destitution Authorities. (c) The Provisions necessary in the Reformed A dministration We may note, in the first place, that the provision for the aged by a National Pension Scheme, especially if the Old Age Pensions Act of 1908 is amended as we propose, will, in itself, remove a large and constantly increasing proportion of the aged from any application of the Law of Settlement and Removal. As the provision for the aged pensioners comes out of national funds, no Local Authority will be affected by any migration of these old people. And we must here mention that, when in Part II. of this Report we deal with the different sections of the Able-bodied — the Vagrants, the adult male inmates of the able-bodied w^ards of the General Mixed Workhouses or Poorhouses, and the Unemployed — we shall have to recommend that the expense of providing for them should fall upon the National Ex- chequer. In their cases, too, we may assume generally that few questions as to Settlement will arise. Moreover, with the classes who will remain a local charge — the infants and children, the sick and mentally defective, the infirm and the aged unprovided for as National Pensioners — the substitution of the County or County Borough, for the Union or Parish, as the unit of administration and of rating, will, in itself, enormously diminish the number of cases in which any question of Settlement would need to occur, or in which any removal would take place. We find at present, for instance, that in the Metropolis nine-tenths 406 SETTLEMENT AND REMOVAL of the Settlement cases occur between two Unions, and will not arise when the services pass to the County Authorities. Everywhere, we are informed, the great majority of the cases arise with closely adjacent Unions, most — though, of course, not all — of which would, under the new organisa- tion, form part of the same County Service. (i.) Safeguards for the Local Health Authority It will be found that, under the scheme of breaking up' the Poor Law that we propose, a majority of the persons at present maintained by the. Destitution Authorities — the mothers in the lying-in wards, the infants under school age, the sick and the infirm of all kinds, and the institution- ally-treated aged — will fall to the charge of the Local Health Authority. That Authority has at present nothing in the nature of a Law of Settlement. Whatever it provides in the way of sanitation and health visiting, milk dispensaries and hospital accommodation, it provides for all who happen to be residing within its district. Moreover, as we have seen, even under the Destitution Authorities, the Law of Settlement and Removal has practically no application for the sick, as distinguished from the permanently in- capacitated. It might accordingly well be argued that, even with the enlarged sphere of the Local Health Authority of the future, there would be, especially in a County Service, no need for any such safeguard of the local ratepayer. We do not altogether share this view. We believe that in the vast majority of cases no question of eligibility will be raised ; especially if, as we recommend, a substantial Grant-in- Aid from the National Exchequer is paid expressly in respect of the cost of the work of the Local Health Authority. Nevertheless, we are so much impressed with the importance of removing all possible hostility to the provision of suitable institutional treatment for the sick that we are inclined to propose that the Local Health Authority should be empowered, in respect of certain of its services, to confine its benefits (except on adequate payment), if it thinks fit, to those who have resided for SAFEGUARDS FOR HEALTH AUTHORITY 407 not less than twelve months in the district. This pro- posal relates entirely to specialised institutional treatment. It is clear that, for a long time to come, some Local Health Authorities — notably those of London, Liver- pool and Manchester, and many other of the County Boroughs — may be expected to provide specialised hos- pitals and sanatoria which will be in advance of those of the majority of the rural Counties, It will be possible, in a large town, to provide such specialised treatment for disease after disease. The necessary institutional pro- vision for tuberculosis, for instance — with the vital importance of which we have been deeply impressed — is not likely, for many years to come, to be made everywhere to the same degree of adequacy. Even at present the Local Health Authority sometimes makes a special charge to persons not belonging to its district. The Brighton Town Council, for instance, does not necessarily admit to its Municipal Hospital for Tuberculosis, free of charge, patients coming into Brighton from the surrounding villages ; in fact, it does not admit any patient who has not, immediately before admission, resided for two years within the Borough. Unless some corresponding pro- vision is made with regard to all the various forms of specialised institutional treatment, it will, we fear, be difficult to persuade Local Health Authorities to make those progressive developments on which the health of the community depends. We propose, therefore, that whilst (following the precedent set by the conditions of the Scottish Medical Relief Grant) it should be made a condition of the Grant-in-Aid of the expenditure of the Local Health Authority that no question of past residence should be raised with regard to the domiciliary treatment of the sick, or with regard to the admission of patients to the general infirmaries or similar institutions of its district, or to the admission of urgent cases anywhere, the Local Health Authority should not be legally bound to admit to any specialised institution that it may establish, except in cases where the refusal of admission would involve risk of death, any but persons who have resided there for not less than twelve months next previously to their application. 408 SETTLEMENT AND KEMOVAL For any other persons admitted, whether in cases of urgency or by agreement, there should, we think, be power to make a charge (or an extra charge over and above that made to local residents) equal to the net cost of the service, abstraction being made of any Grant-in- Aid. Power should be given to the Local Health Authority of the district to which the patient belongs to pay the charge thus made if it chooses to do so. In default of payment, the admission of the patient to the specialised institution might be refused, or if already admitted he might be removed, under much the same formalities and with much the same safeguards as under the present law, either to the local general infirmary, or to the specialised institution of the district to which he belonged. We think that the same law should apply to all parts of the United Kingdom. (ii.) Safeguards for the Local Authority for the Mentally Defective With regard to the Mentally Defective of all grades, the case is more simple. AVe see no reason why the same condition of eligibility — one year's residence as applied to persons certified to be of unsound mind, and who are maintained in a County or Borough or District Board Asylum, should not be applicable, alike as to chargeability to other districts and as to removal, to all the patients placed under the care of the Local Authority for the Mentally Defective whether in England and Wales, Scot- land or Ireland. The adoption of the County or County Borough, instead of the Union or Parish, as the unit of residential eligibility and of rating, will, however, enormously reduce the number of cases in which any question will occur. (iii.) Safeguards for the Local Education Authoiity At present the Local Education Authority in Great Britain provides for all the residents within its district, and nothing akin to the Law of Settlement has any appli- SAFEGUAKDS FOE EDUCATION AUTHORITY 409 cation. It is, however, protected in England and Wales against having to provide schools for other than residents by the power to exclude those who live in one area and wish to go to school in another, unless the Local Educa- tion Authority concerned will contribute towards the cost. It is also protected against the deliberate invasion of its district by children sent by any Destitution Authority to be " boarded out," by a statutory provision enabling a proportionate contribution to be made towards the cost of providing any additional school accommodation that the invasion may occasion. In view of the importance of keeping open every possible opportunity of " boarding- out," we propose that this provision should be continued. With regard to the provision for the maintenance of neces- sitous children, we think it undesirable that any part of the existing Law of Settlement and Removal should be made applicable to the Local Education Authority. The very large Grants-in-Aid from the National Exchequer which that Authority receives in respect of each child may, we think, fairly be held to compensate for any temporary inequality of local burden, first here and then there, that may be caused by the migration of the necessitous child population ; and again, following the precedent of the Medical Relief Grant in Scotland, we suggest that it should be made one of the conditions of these grants that (apart from the special provision as to school accommoda- tion for " boarded-out " children) no question as to the admissibility or eligibility of children born elsewhere but actually resident in the district should be raised. (d) Conclusions We have therefore to report : — 1. That the existing Law of Settlement and Removal, wasteful in its cost and occasionally the cause of hardship to the poor, will, under the scheme of reform which we are proposing, automatically cease to be applicable ; and all the statutes bearing on the subject should be definitely repealed. 410 SETTLEMENT AND REMOVAL 2. That the assumption of the greater part of the charge for the aged by the National Government, and the pro- posed transfer to a Government Department of the provision for all sections of the able-bodied, will, in a large proportion of cases, obviate the necessity for raising the question of eligibility of an applicant for public assistance in respect of his previous residence. 3. That the reorganisation of the various services now included in the Poor Law on the lines of a County or County Borough administration under the several com- mittees concerned, with the County or County Borough as the unit for rating, will, in the great majority of cases, render it unnecessary to raise the question of past residence. 4. That with regard to services rendered by the Local Health Authority, it should be made a condition of the proposed Grant-in-Aid that no question of the past resi- dence of any applicant should be raised, except only with regard to admission to any specialised institution ; and in the latter case admission may, if thought fit, be confined, except on terms to be prescribed, to persons who have resided in the district for one year — any other persons being, if thought fit, refused admission (except when such refusal would involve danger to life) and relegated to the General Infirmary, or removed, under proper conditions and safeguards, to the specialised institution of the County to which they belong. 5. That (beyond the retention of the power to contri- bute towards school accommodation for " boarded-out " children) there is no need for any question of past resi- dence to be raised in connection with the work of the Local Education Committee ; and this should be made a condition of the Government Grants. 6. That whatever provisions are made in this respect, there should be identical and reciprocal rights as between England and Wales, Scotland and Ireland. CHAPTER X GRANTS-IN-AID When the various Local Authorities providing for the poor have recovered what they can from the persons benefited, and from those liable for their support, and when they have, as among themselves, adjusted the burden as far as is permitted by the Law of Settlement and analogous provisions, they are further aided by extensive subventions derived from the National Ex- chequer. These Grants-in-Aid have, on the various Local Authorities, a threefold effect, differing according to the amount and the conditions of the subventions. In all cases they relieve the ratepayers in the particular localities of a portion of their burden. In most cases, by the mere selection of one particular service for subvention, and still more by the conditions attached to that subvention, they may specially encourage the increase and development of one kind of expenditure rather than another. Finally, if the grant is, by appropriate conditions, made to depend upon a certain prescribed efficiency, and on the sanction of the Central Authority, a greatly increased effectiveness may be given to the power of suggestion, criticism and control possessed by that Authority. The Grants-in-Aid of the Boards of Guardians and the various Local Authorities making provision for the poor differ greatly among themselves in all three respects ; and we have received many suggestions for their improvement. So far as Great Britain is concerned, a special com- plication has been introduced by the changes made with regard to most of these Grants-in-Aid by the Local 411 412 GRANTS-IN-AID Government Act of 1888 (England and Wales), and the Local Government Act of 1889 (Scotland), both of them modified by the Finance Acts of 1907-8 and 1908-9. The total efi"ect of these successive changes has been, so far as the Exchequer is concerned, to substitute, for nearly all the Grants-in-Aid to different Local Authorities, definite lump sums or specific revenues assigned, in England and Wales, to the County and County Borough Councils, whilst requiring these bodies to distribute, on certain fixed principles, Grants-in-Aid to the minor Local Authorities, if any, within their areas. Thus, from the standpoint of the Treasury, the Grants-in-Aid of the Poor Law expendi- ture of English Boards of Guardians have ceased, being merged in larger payments to the County Council, etc. So far as the Boards of Guardians are concerned, these Grants-in-Aid still continue, only they are received through the County or County Borough Council, instead of direct from the Treasury. The change was, indeed, made the occasion of a new Grant-in-Aid to Boards of Guardians, both in London and the provinces ; but while in the provinces the new grant was payable by the County or County Borough Council out of the lump sums received from the Exchequer, in London the grant (calculated on a different basis) was made payable out of the County Fund, the sums allocated to London being insufficient to meet it. And as the balances of these lump sums, if any, are retained by the County Councils for their own purposes, the final effect is that it is virtually on the funds of the County or County Borough Councils that the payment of these Grants- in-Aid now falls, though these funds are subsidised by the Central Government, which retains in its own hands the whole of the control over the service, giving none to the County Council, its intermediary. No such change has been made with regard to the Grants-in-Aid made to the Local Education Authority, to the Local Unemployment Authority, or to the Industrial and Reformatory Schools under the Home Office ; nor yet with regard to any of the Grants-in-Aid made to Local Authorities in Ireland. All these continue to be made direct from National Funds, without (in the case of bodies other than Committees t)f GRANTS-IN-AID 413 the County Council, etc.) the intervention of the County Councils, etc. In Scotland too, though definite sums or assigned revenues are paid to a Local Taxation Account, the subventions received by Burgh and Parish Councils, as well as by County Councils, are paid direct to these Authorities. It will, therefore, be convenient for the purposes of this Report, to look at the question from the standpoint of the Local Authorities receiving the Grants- in-Aid, irrespective of whether they are paid direct from the Exchequer, or paid by the County Council out of larger sums received from the Exchequer — thus ignoring all the "Exchequer Contribution Accounts " and "Local Taxation Accounts " and " assigned revenues," by which the whole subject of Local Government Finance has, since 1888, been needlessly mystified. The Grants - in - Aid received by the Destitution Authorities amount, in the United Kingdom, to nearly three and a half millions sterling per annum, or between one-fifth and one-sixth of the total expenditure connected with the relief of the poor under the Poor Laws. But they differ so considerably in their amount, in their kind, and in their conditions, among the three parts of the United Kingdom, that we can only consider their efiects by taking them separately. (a) England and Wales outside the Metropolis The Grants - in - Aid receivable by the Boards of Guardians in England and Wales now amount to more than £2,600,000 sterling annually, payable in five separate grants. [Table 414 GRANTS-IN-AID Grants-in-Aid receivable by Boards of Guardians IN England and Wales Grant. Amount in 1907-8. Fixed Grant under Local Government Act, 1888 (Sec. 43 for London Unions, Sec. 26 for those elsewhere) ..... Fixed Grant under Agricultural Bates Act, 1896. Four shillings per head per week for lunatics in asylums, etc. ..... Payments in respect of teachers in Poor Law schools ....... Repayment of school fees paid for children sent from Workhouses to public elementary schools ....... £1,350,000 461,000 800,000 25,000 2,000 £2,638,000 In considering the effect of these Grants-in-Aid on the administration, we must omit, for the moment, the Boards of Guardians of the Metropolis, where the position is further complicated by an internal system of local equalisa- tion of rates and the existence of a federal Poor Law Authority. (i.) The Relief to the Local Ratepayers Taking first the relief afforded outside the Metropolis to the local ratepayer, we have to note that, owing to the arbitrary manner in which the two principal fixed Grants were allocated, and the changes that have taken place in the last two decades, the amount and the proportion of the relief varies enormously from Union to Union, and that it bears no relation whatever to the policy or to the relative efficiency and economy of the Boards of Guardians. The amount by which the rates are lowered owing to the whole of these Grants-in-Aid appears to be less than Id. in the £ in the Fylde Union; less than 2d. in the £ in tlie Lancaster and Bootle Unions ; and less than 3d. in the £ in some other Unions. On the other hand, owing to these same Grants-in-Aid, the ratepayers in the little Caxton and Arlington Union find their burdens lightened EELIEF TO LOCAL. RATEPAYERS 415 by nearly Is. 6d. in the £ ; and those in Fordingbridge and Anglesea Unions by more than Is. in the £. In the little Union of Longtown the total Grants-in-Aid now amount to over 58 per cent of the expenditure of the Board of Guardians ; in that of Belford they amount to over 50 per cent ; whilst in some other Unions they come to over 40 per cent. On the other hand, in the Bedwellty Union the whole of the Grants-in-Aid are less than 13 per cent of the expenditure ; in the King's Lynn Union they come to less than 1 5 per cent ; and in the Unions of Bury St. Edmunds and Great Yarmouth, to less than 18 per cent. The result is that the Poor Rates vary from less than 3d. in the £ in the Fylde and Garstang Unions, up to more than 2s. in the £ in the Mildenhall, King's Lynn, Ris- bridge and Carnarvon Unions. Whatever may be thought of the policy of contributing a sum of £2,600,000 in relief of the payers of Poor Rate in England and Wales, we cannot conceive of any argument that would justify the continuance of such gross and entirely arbitrary in- equalities between Union and Union, not in any way dependent on the conduct of the local administrators, as the present system involves. (ii.) Discrimination in favour of Desirable Expenditure The second effect of Grants-in-Aid may be to encour- age particular forms of expenditure as compared with others. Here we must ignore the two fixed Grants which are, in effect, made in aid of the Guardians' funds gener- ally, however these are expended. The three smaller Grants vary according to the amounts expended by the Boards of Guardians on particular services, and thus tend to encourage the growth of these services. One of these Grants, that for the payment of school fees, has with the almost universal adoption of free schools become of trivial amount. Another, that towards the salaries of teachers in Poor Law Schools, whilst still serving to encourage the Boards of Guardians to staff these schools with more qualified teachers, has, with the continuous tendency to cede the educational work connected with pauper children 416 GRANTS-IN-AID to the Local Education Authorities, become of little consequence, and may even tend to discourage the most approved methods of dealing with pauper children. The other Grant, that of 4s. per head per week for every certified pauper lunatic placed in proper asylums under the care of the Lunacy Authority, still has important results. By paying the grant only for such persons as have been transferred to lunatic asylums, etc., and withholding it in those cases in which the person of unsound mind is retained in the General Mixed Workhouse, Parliament and the Central Authority have striven to encourage that elimination of lunatics from the Workhouse which is so desirable. Under this encouragement, the number of paupers of unsound mind in the asylums of the County and Borough Councils has risen from 16,369 in 1859 to 85,990 in 1906. So far the Grant may be said to have attained its object. It has, however, as has been forcibly represented to us, three grave defects. It ofifers a standing inducement to Boards of Guardians to get people certified as persons of unsound mind who are not really lunatics or idiots, merely as a means of getting rid of them from the General Mixed Workhouse, and obtaining the Grant in respect of them. We have had it brought to our notice that some Unions, particularly those in which additional Workhouse accommodation would otherwise have to be provided at great cost, make a practice of sending to the very costly " mental hospitals " of the County and Borough Councils a large number of aged men and women who are suffering only from the feeble- mindedness of senility, and who ought not properly to be certified to be of unsound mind. This result is due, in great measure, to the arbitrary separation of some classes of mentally defective persons from others ; to the putting of some under the Lunacy Authorities and leaving others to be dealt with only by the Destitution Authorities ; and to the confining of the Grant-in-Aid to some only of these classes of the mentally defective whilst withholding it from others. On the other hand, where there is ample Work- house accommodation, the sum of 4s. has proved insuffi- IN FAVOUR OF DESIRABLE EXPENDITURE 417 cient to bribe the Boards of Guardians to remove even those who are really lunatics or idiots from the General Mixed Workhouse. Especially in the country Work- houses, where the actual expenditure per head on food and clothing is only 4s. or 5s. per week, there is, even counting the 4s. grant, still a considerable additional expenditure to the Union involved in sending the lunatic or idiot to the County Asylum, where the charge made to the Board of Guardians is usually about 12s. per week. Hence, as we have ourselves seen in our visits, and as has been stated by many witnesses, many lunatics and idiots are still, out of motives of mere parsimony, kept in the General Mixed Workhouse, where they mix freely with the other inmates, even with the children, where they are often the cause of annoyance, sleeplessness and disgust to their associates, and where they themselves can neither be scientifically treated nor properly cared for. The number of certified lunatics and idiots in the General Mixed Workhouses has, in the last fifty years, even increased from 7963 in 1859 to 11,151 in 1906. Owing to the insufficiency of the rate, this grant of 4s. per head per week has therefore failed — and still fails — to get the ordinary Destitution Authority to see the necessity of doing anything more than " relieve the destitution" of the harmless lunatic or the village idiot, who accordingly remains in the General Mixed Workhouse, to his own hurt and the annoyance of the other inmates. The third defect of the Lunacy Grant is of another character. By a condition, for which we do not see any reason at all, the grant of 4s. is only allowed in those cases in which the weekly cost of the lunatic's mainten- ance, after deducting sums recovered from relations, or otherwise, is not less than this sum. The result is that if, as is usually the case, the asylum charge is 12s. a week, a Board of Guardians is under no inducement to get relations to contribute more than 8s. a week, as anything more than that will not benefit the Board of Guardians or the local ratepayer. Nay, more ; if the relations pay a shilling or two per week more than will just leave 4s. to be borne by the Union, the Union will actually lose by VOL. I 2 E 418 GRANTS-IN-AID their liberality, as it will have to bear the whole balance itself, and will not be able to draw the 4s. grant. The result is that the relations' contribution tends to be restricted as a maximum to what will just leave a balance of 4s. to be borne by the public. We have ourselves heard cases discussed by Boards of Guardians in which, for this very reason, the amount to be contributed by relations has been deliberately restricted. Incidentally, this course serves to maintain the stigma of pauperism in cases where the lunatic's estate or relations could furnish the entire cost of maintenance. It is not gener- ally known that, if this were done, the patient would no longer be classed as a " pauper lunatic." We see, therefore, that there is, on several grounds, the most urgent need for an alteration in the Lunacy Grant. And whilst the selection for a special Grant-in-Aid of the particular service of providing for certified lunatics and idiots has led to these equivocal results, no attempt has been made so to arrange the Gran ts-in- Aid as to encourage other developments which the Local Government Board has been, for several decades, pressing in vain on the Boards of Guardians. Whilst wishing devoutly to get the children out of the General Mixed Workhouses, the Local Government Board has (outside the Metropolis) made no suggestion that any Grant should be made dependent on the number of children more properly provided for. Whilst striving continuously to get the provision for the sick brought more up to the level of contemporary hospital administration, the Local Government Board has (outside the Metropolis) made none of the Grants bear any propor- tion to the expenditure on Poor Law infirmaries, or the maintenance of the sick poor, nor made any of them conditional on the local arrangements for medical attend- ance and nursing attaining what its Inspectors report to be an adequate standard. The result, as we have seen, is that a large proj)ortion of Unions fall, in these respects, deplorably short of even a decent provision. GIVING AUTHORITY TO CENTRAL CONTROL 419 (iii.) Giving Authority to Central Control Finally, we have to consider these Grants-in-Aid to the English Boards of Guardians from the standpoint of their effect on the suggestions, criticism and authoritative instructions by which the Central Authority seeks to secure greater efficiency and economy of administration. This, indeed, is by far the most important aspect of Grants-in-Aid. The verdict of administrative experience is that, properly devised, they afford a basis for the best of all relations between the National Government and the Local Authorities. A century of experience has demon- strated that it is undesirable for Local Authorities to be subject to no administrative control whatsoever from a Central Authority, for them to be left without independent inspection or audit, without access to centralised experi- ence and specialist knowledge, without any enforcement of the minimum indispensably required for the common weal, and without mitigation of the stupendous inequality of local rates that complete autonomy involves. On the other hand, the grant to a Government Department of arbitrary powers to sanction or disallow, or peremptorily to order this or that, is felt, in this country, to be derogatory to the independence, the dignity and the spontaneous activity of freely elected representatives of local ratepayers, spending their own funds. Such mandatory instructions from a Government Office in Whitehall can be enforced only by cumbrous legal pro- cesses; and they have proved, in practice, to give the Government Department little real power over recalcitrant local bodies. It is in vain that Parliament endows the Local Government Board with ample statutory powers — on paper — to compel typhoid-smitten Little Pedlington to provide itself with a proper drainage system and water- supply. Little Pedlington flatly refuses, or stubbornly neglects to do so. The Local Government Board, for all its paper powers of coercing Little Pedlington by Man- damus or by independent action in default, finds itself practically impotent ; and hundreds of Little Pedlingtons 420 GRANTS-IN-AID retain to this day their primitive in sanitation triumph- antly. Very different has been the experience of the influence of a Central Authority wielding the instrument of a well-devised Grant-in-Aid. Between 1830 and 1856 there was felt to be urgent need of a well-organised con- stabulary force in the provincial boroughs and counties. By the Act of 1835 Parliament attempted to make it compulsory on the Municipal Boroughs to establish such a force. In the Counties the Justices were empowered to establish one. In both Boroughs and Counties the con- stabulary remained weak and inefiicient. By an Act of 1856 the establishment of an efficient force was not only made everywhere obligatory, but what was far more im- portant, the Government agreed to contribute one-fourth — after 1874, one-half — of whatever expense the locality incurred on its police force, provided that the Home Office was satisfied, after inspection, that the force was adequate and efficient. Under this combination of pressure and inducement, all the provincial police forces have steadily improved, rapidly rising, indeed, to a common level of adequacy and efficiency. At every inspection the defects have been pointed out in a way that could not be ignored. The mere in- timation that, unless these shortcomings were, somehow or another, remedied before the next annual inspection came round, the Secretary of State might have to consider the propriety of withholding a portion of the grant (now the certificate without which the Exchequer Contribution cannot be paid) has usually sufficed to induce the Local Authority — not necessarily next month, but gradually, in due course — to effect more or less of the necessary im- provements — not necessarily in exact compliance with any Government pattern, but with the fullest sense of local independence, exercising its own judgment in its own way, and often apparently on its own initiative. In the course of fifty years, though the official criticisms have been incessant, and though the Home Office has not been afraid, in, at any rate, one bad case of recent years, actually to withhold the Government contribution, it has seldom been necessary to take this course. Of legal GIVING AUTHOKITY TO CENTRAL CONTROL 421 proceedings, by Mandamus or otherwise, to compel a recalcitrant Local Authority to do what the statute re- quired, there has, in this matter of providing a constabulary force, been no question. Let us now examine the Grants-in-Aid of the expendi- ture of the English Boards of Guardians from this point of view. What authority does this sum of two and a half millions annually give to the suggestions, criticisms and orders made for the promotion of efficiency and economy by the Local Government Board ? We have to report that in practically the whole realm of Poor Law expenditure no use is made of the Grants-in-Aid as a means of affording the much-needed additional strength to the directions of the Central Authority. In this im- portant respect the existing Grants-in-Aid are — with the partial exception of the small sum in respect of teachers' salaries — entirely useless. The two fixed Grants (amount- ing to £1,350,000), and even the 4s. a week for lunatics and the trifling recoupment of school fees, are made in no way dependent on the Boards of Guardians fulfilling, as a whole, even their statutory obligations, let alone attending to any criticisms of the Local Government Board. A Board of Guardians may be flatly defying the Local Government Board — refusing to build a Poor Law In- firmary, when the mortality in the overcrowded insanitary Workhouse is excessive, retaining the children without segregation in the General Mixed Workhouse, giving or refusing Outdoor Relief against the whole spirit of the authoritative Orders, stinting the Medical Officer in salary and drugs, and appointing an altogether inadequate staff of nurses — and the Local Government Board has, never- theless, unquestioningly to watch a huge Grant being paid over, amounting often to half the total expenditure which is being thus incurred in the locality in defiance of its authoritative criticism and advice. Thus, the present Grants-in-Aid of the Boards of Guardians stand, in this respect, wholly condemned. We can see no justification whatever for the community as a whole having to provide this large proportion of the expenditure of Local Autho- rities who, as many Boards of Guardians do, deliberately 422 GRANTS-IN-AID and persistently disobey the instructions, or flout the authoritative recommendations of the Central Authority which Parliament has established in order to get carried out the policy decided on by the community as a whole. It has become axiomatic that, to ensure progress, Grants- in-Aid should in all cases be made dependent on efficiency of administration. A locality that, to the detriment of efficiency, rebelliously insists on its own autonomy, should, at least, be left to bear its own burdens. (b) The Metropolis In the Metropolis, the arrangements with regard to the Gran ts-in -Aid receivable by the Boards of Guardians are even less satisfactory than elsewhere. In addition to the two fixed grants, and the 4s. grant for lunatics and the grant for teachers that we have described, the Metropolitan Boards of Guardians receive also what are, in effect, two additional Grants-in-Aid, by the operation of the Metro- politan Common Poor Fund and the existence of the Metropolitan Asylums Board. By the former arrange- ment, the cost of certain specified parts of Poor Law administration in each Metropolitan Union (the salaries, etc., of officers, the net cost of lunatics in the county asylums, the maintenance of paupers other than children in the Workhouse or Infirmary to the extent of 5d. per day, the maintenance of children in Poor Law schools or " boarded out," the erection as well as the maintenance of the Casual Wards, and the whole cost of medicines and surgical appliances) was made chargeable to a common fund, which was provided annually by equal assessment according to the rateable value of each Union. This has a twofold effect. To every Union in the Metropolis, rich or poor, it amounts to the same thing as a Grant-in-Aid in respect of the particular services charged on the fund, each Board of Guardians being credited with more if it develops those particular services rather than other services. But as the fund is raised by precepts on all the Unions according to rateable value, the two-thirds of the Unions that are relatively poor receive an actual subven- THE METROPOLIS 423 tion of some £400,000 a year in aid of their general funds and in relief of their local rates. The total amount charged on the Common Poor Fund now approaches one and three-quarter millions sterling annually, being one- third of the total expenditure in the Metropolis under the Poor Law. Much the same financial effect is produced by the existence of the Metropolitan Asylums Board, an independent Poor Law Authority which maintains, not only asylums for pauper idiots, and schools for pauper children suffering from ringworm, ophthalmia, etc., but also hospitals for infectious diseases, maintenance in which is now, by statute, not deemed Poor Law Relief. As the expenditure of the Metropolitan Asylums Board, now exceeding a million a year, is now, in effect, all levied on the Unions in proportion to their rateable value, and not in proportion to the use that they severally make of its various institutions, these institutions are, in effect, open to Boards of Guardians gratuitously ; that is to say, no Union and no Board of Guardians pays more because it sends more cases. Thus, to the extent that they relieve each particular Board of Guardians of the cost of maintaining pauper idiots, pauper children, or patients in the infectious diseases hospitals who would otherwise be paupers, the existence of these virtually free institu- tions is equivalent to a Grant -in -Aid, though at the expense of the London ratepayers generally, to that Board of Guardians for these particular services. The effect of these elaborate, complicated and very ex- tensive Grants-in-Aid upon the finances of the Metropolitan Boards of Guardians can only be described as extraordinary. They amount, in the aggregate, to no less than 70 per cent of the total Poor Law expenditure of the Metropolis. (i.) The Relief to the Local Ratepayers Taking the various Grants-in-Aid together, the relief thereby afforded to the local ratepayer in the different Unions varied in 1907-8 from as much as 3s. 5d. in the £ in St. George's-in-the-East, 2s. 4d. in the £ in Bethnal Green, over 2s. in the £ in Stepney, and Is. 9d. in the £ 424 GRANTS-IN-AID in Poplar, down to practically nothing in Wandsworth and Hammersmith. On the other hand, the Grants-in- Aid to half a dozen of the Metropolitan Unions, whilst financially assisting certain forms of relief as compared with others, resulted (owing to the " equalisation " pro- visions) in a positive increase of the Poor Rate, which involved an additional charge of a few pence in the pound, and in the City of London Union of as much as 7d. in the £. The Boards of Guardians of St. Saviour's, Southwark, St. Pancras, and Bethnal Green find themselves bearing locally less than a quarter of what (apart from their fixed quota to the Common Poor Fund) they themselves spend in Poor Relief, whilst the Board of Guardians of the City of London Union bears a burden equal to the cost of all the Poor Relief that it dispenses. The Rate that has actually to be levied for the relief of the poor in the different Unions (in addition to a uniform 9d. in the £ for the Common Poor Fund, and 5d. in the £ for the Metro- politan Asylums Board) varies from less than 2d. in the £ in the Westminster Union and less than 4d. in the £ in the Paddington, St. George's, Hanover Square, and Hampstead Unions, up to as much as Is. 6d. in the £ in Hammersmith, Is. 8d. in the £ in Mile End Old Town and St. George's-in-the-East, and to as much as 2s. 6d. in the £ in Poplar — even after Poplar has been aided to the extent of Is. 9d. in the £. (ii.) Discrimination in Favour of Desii-able Expenditure Turning now to the influence exercised by these Grants in encouraging or discouraging particular services or forms of relief, we notice that the throwing upon the Metro- politan Common Poor Fund of the cost of all the Poor Law officers and fivepence per day per adult indoor 23auper, including those in the Poor Law infirmaries, and the omission of any similar subvention to Outdoor Relief, afford a considerable encouragement to Indoor as com- pared with Outdoor Relief. Whatever may be thought of this result in the abstract, we cannot avoid the conclusion IN FAVOUR OF DESIRABLE EXPENDITURE 425 that it is largely due to this peculiar arrangement of the Grants-in-Aid that the Metropolitan Boards of Guardians have been induced to incur enormous expenses for the erection and maintenance of gigantic Workhouses and Poor Law infirmaries, and that the whole cost of Poor Relief in London, however computed — whether per pauper, per head of population or per £ of rateable value — is proportionately far in excess of that incurred in any other part of the Kingdom. Similarly the placing upon the fund of the whole cost of maintenance of the Poor Law Schools, and refusing all subvention to children in the Workhouse, whilst distinctly discouraging the reten- tion of children in the General Mixed Workhouse, has greatly promoted the development in the Metropolitan Unions of the most costly of all the alternative methods of providing for the children, namely, the residential school. It is a minor consequence of the arrangement of the Metropolitan Grants-in-Aid that they actually dis- courage the provision of proper accommodation for children who are sick. As the Poor Law infirmaries are technically Workhouses, the establishment in these institutions of the most ideal ward for sick children brings no Grant, whilst if the sick children are sent to, or retained in, the Poor Law residential schools, where they ought not to be, the whole of their cost is borne by the Common Fund. Finally, we may observe that the effect of the Grants-in- Aid in actually restricting the contributions of relatives, that we have already described outside the Metropolis in the case of the Lunacy Grant, is seen in London to operate over the whole field of indoor pauperis7n. Instead of allowing each Board of Guardians to retain, for the benefit of its own ratepayers, whatever suras could be recovered from relations of paupers in the Workhouse, Poor Law infirmaries and residential schools — which would seem to be the course most calculated to encourage the exaction of such contributions — all such contributions have now to be credited to the Common Poor Fund, in which the pecuniary interest of any particular Union is small and scarcely noticeable. The result, we are told, is to check the efforts that the Boards of Guardians might otherwise make to 426 GEANTS-IN-AID exact contributions where these ought to be paid. The throwing upon the Fund of the whole expense of the Casual Wards and of the relief of Vagrants has the effect of discouraging any particular Board of Guardians from attempting, by the maintenance of a strict regimen, to deter persons from applying to its Casual Ward ; and at the same time does nothing to discourage any Board from maintaining so lax a regimen as to attract to its Casual Ward as many Vagrants as it will hold. The arrange- ments for persons of unsound mind amount, in effect, to relieving each Board of Guardians of the whole cost of this class of paupers, and throwing the cost upon London as a whole, provided they are sent, either as lunatics to the asylums of the London County Council, or as imbeciles or idiots to those of the Metropolitan Asylums Board. There is, accordingly, a great encouragement to get these paupers (and any others whom the doctors can be induced to certify as of unsound mind) out of the Workhouses, but no encouragement to any proper discrimination between those who should be sent to the institutions of the London County Council and those who should be sent to the institutions of the Metropolitan Asylums Board ; with the result that, whilst all Metropolitan Boards of Guardians get what seems to be an unduly large proportion of their Workhouse inmates certified as persons of unsound mind, some of them class these predominantly as lunatics and others predominantly as imbeciles or idiots. (iii.) Giving Authority to Central Control On the most important point of all, the extent to which the Grants-in-Aid enable due control to be exercised over the expenditure, the position in the Metropolis is, with regard to one of the Grants, a shade better than elsewhere. The fact that the approval of the Local Government Board is required to the charging of any item to the Common Poor Fund would seem, in theory, to give that Depart- ment an opportunity for exercising a really effective con- trol over all the branches of expenditure charged to the Fund. So far as the matter is uot governed by statute, it GIVING AUTHOEITY TO CENTRAL CONTROL 427 would seem as if, by refusing to sanction the charging to the Fund of officers' salaries otherwise than according to the scale which is prescribed, or of the cost of any Casual Ward not maintained in exact accordance with its regula- tions, or of the fivepence per day each for indoor paupers in any Workhouse that is overcrowded, the Local Govern- ment Board ought to be able, in the Metropolis, to attach a sanction to its instructions and suggestions that is else- where lacking. We cannot say that we are convinced that the Local Government Board has made the fullest use of the power which its control of the Metropolitan Poor Fund affords. However disobedient and recalcitrant during all these past forty years has been a Metropolitan Board of Guardians, however scandalously overcrowded and insani- tary its Workhouse, however gross the scandal of its " barrack school," however harsh or however lavish its policy of Outdoor Relief, however lax its Casual Ward, however deficient its arrangements for the sick poor, never once — as Sir Hugh Owen informed its — has the Local Government Board made use of the power entrusted to it hy statute of declaring the Board of Guardians to he in default, and of ivitliholding its share of the Common Poor Fund. Whether by reason of some defect in the regula- tions, or of some defect of organisation in the Local Government Board itself, it is clear that practically no use has been made of the potent instrument of Grants-in- Aid as a means of giving authority to the central control that, on paper, exists. On the other hand, the fact that so enormous a proportion of the expenditure of Metro- politan Boards of Guardians is borne otherwise than by the rates that they themselves impose, and that the conditions of most of the subventions received by them are so framed as to give no control to the Authority by which they are paid, will unquestionably have had an even greater effect in encouraging lavish expenditure than is elsewhere the case. On all counts, therefore, the present arrangements for the Grants-in-Aid of the Metropolitan Boards of Guardians — good as they were in their intention — must be condemned as nothing short of fantastic in their ab- surdities, and grossly inequitable in their results. 428 GRANTS-IN-AID (c) Scotland The Grants in Aid of the Parish Councils in Scotland, which amount to £244,000 a year, or nearly one-fifth of the total expenditure connected with the Poor Law, are, in many respects, analogous to those of Boards of Guardians in England and Wales. Grants in Aid of the Expenditure of Parish Councils IN Scotland Grant. Amount in 1907-8. Fixed Grant to Parish Councils in respect of the deficiency in the Poor Rates arising from the operations of the Agricultural Rates (Scot- land) Act, 1896. Relief of Rates Grant (total fixed) Poor Law Medical Relief Grant (total fixed) . Lunacy Grant (total fixed) ..... £58,500 60,000 20,000 115,500 Total £244,000 There is the same kind of fixed Grant in respect of the deficiency of revenue arising from the operation of the Agricultural Rates Act, a grant which, as in England and Wales, is now essentially one in aid of the expenditure generally. There is a second Grant of £50,000 made in relief of the local rates, and distributed among the Parish Councils, and thereby diff"eriiig from all the Grants in England, Wales and Ireland, partly in proportion to their valuation and partly in proportion to their population. This, too, so far as any relation to the Parish Council ex- penditure is concerned, is a fixed Grant. There are two other Grants, now received, like those of England and Wales, out of the Local Taxation Account, which, though fixed in total for Scotland as a whole, are allotted amonor SCOTLAND 429 the Parish Councils in proportion to their expenditure on particular services. Thus, the Poor Law Medical Relief Grant of £20,000 a year is annually distributed among such Parish Councils as have complied with the prescribed regulations, which include the appointment of legally qualified medical officers at fixed salaries, and the expendi- ture of at least. a prescribed minimum amount on Medical Relief. The Grant is distributed in such a way as first to defray practically half the cost of the trained sick-nursing in Poorhouses, and then to be shared pro rata according to the total expenditure of the various parishes on Medical Relief. This comes, in eflfect, to a Grant to each Parish Council of about one-quarter of its expenditure on that service. Similarly, the Lunacy Grant, fixed at £115,500, is shared among all the Parish Councils_pro rata, according to the total net expenditure incurred on the maintenance of pauper lunatics, not exceeding 8s. per week. This comes, in effect, to a Grant to each Parish Council of about two- fifths of its expenditure on pauper lunatics. We have now to consider what is the result of this system of Grants-in-Aid of the expenditure of the Scottish Parish Councils, in the three ways of reducing the burden on the ratepayer, encouraging one service rather than another, and strengthening the influence for efficiency of the Central Authority. (i.) The Relief to the Local Ratepayers We note, to begin with, the same extraordinary diver- sity and inequality in the relief afforded to the local ratepayers as in England and Wales, but carried even to greater extremes, as Lord Balfour of Burleigh has pointed out. " One Scottish parish may by some fortunate circum- stance have within its boundaries an amount of rateable property out of all proportion to its needs, while another may be composed of property which represents a taxable capacity inadequate for the barest needs of civilisation. For instance, the parish of Temple, in Midlothian, has a gross valuation of over £44 to each inhabitant, whilst Barvas, in Ross and Cromarty, has only 9s. per inhabitant, 430 GKANTS-IN-AID and a penny rate will, therefore, produce nearly 100 times as much per inhabitant in Temple as in Barvas." This inequality is frequently not mitigated, but actually in- creased, by the distribution of the subventions from the National Exchequer. To quote again Lord Balfour of Burleigh : " The parish of Ettrick, in Selkirk, which is almost wholly agricultural, has an assessable value of nearly £20 per inhabitant, and is, in this respect, one of the wealthiest parishes in Scotland. Its expenditure upon Poor Kelief is equal to 9s. 4d. per inhabitant, an amount which is considerably above the average for the whole of Scotland, but which, owing to the high assessable value, would involve a rate of less than 6d. in the £, even if it received no assistance from central funds whatever. Not- withstanding these circumstances it receives grants (in- cluding those under the Agricultural Rates, etc., Act) from the Local Taxation Account amounting in the aggregate to more than one-half of its expenditure, and representing 5s. Id. per inhabitant — one of the largest amounts, if not the largest amount, throughout Scotland. Of the total it appears that about one-quarter, or Is. 2d. per inhabitant, is derived from the ' grant in relief of parochial rates,* and with this and the other grants the Poor Rate is reduced to less than 3d. in the £. " The parish of Old Monkland (Lanark), which is partly within the burgh of Coatbridge, has less than one-quarter of the assessable value per inhabitant possessed by Ettrick, and administers its Poor Relief much more economically, having an expenditure equal only to 4s. 2d. per inhabitant, or less than one-half of the amount spent in Ettrick. But notwithstanding the more restricted resources and greater economy in Old Monkland, the parish only receives grants amounting to 8d. per inhabitant, a sum which is only just over one-half of the amount granted to Ettrick under the head of * relief of rates ' alone, and is left with a rate of 8fd. in the £." Since the date of Lord Balfour of Burleigh's Report, the inequalities seem to have become even more extreme. There are more than fifty parishes in Scotland to-day in which the result of the Government Grants, quite irrespec- RELIEF OF LOCAL RATEPAYERS 431 tive of parish property or " mortifications," church collec- tions or voluntary contributions, is to relieve the local ratepayer of more than one-half of the burden of Poor Relief — in nearly a dozen cases going so far as to enable a Poor Rate on occupiers to be entirely dispensed with. On the other hand, the ratepayers of the little parish of Glendevon (Perthshire) only got, in 1906-7, £1 in Govern- ment Grants towards their expenditure of £32 ; those of Stranraer (Wigtownshire) only £126 towards an expendi- ture of £1283 ; those of Blantyre (Lanarkshire) only £492 towards an expenditure of £4720 ; whilst those of Glasgow, Leith and Aberdeen on the one hand, and Polwarth (Berwickshire), Dalziel (Lanarkshire) and Kirkintilloch (Dumbartonshire) on the other, found themselves relieved only to the extent of one-seventh or one-eighth of their respective burdens. As a consequence it may occasionally happen that, in a particular year, a fortunate Parish Council may need to levy no Poor Rates at all, either on owners or occupiers, as was actually the case with the Dunsyre (Lanarkshire) Parish Council, though without either ** mortifications " or voluntary collections, in 1906-7, whilst nine other parishes had no rate on occupiers and only a fraction of a penny on owners ; and whilst hundreds of other parishes found their Poor Rates reduced to only a few farthings or a few pence in the £, the Parish Council of Barra (Inverness-shire) had a Poor Rate of 9s. 6d. in the £ (4s. 2d. on owners and 5s. 4d. on occupiers) ; that of Lochs (Ross and Cromarty) one of 12s. 3d. in the £ (5s. 9d. on owners and 6s. 6d. on occupiers) ; that of Barvas in the same county one of 13s. 8d. in the £ (5s. 8d. on owners and 8s. on occupiers). Such stupendous inequali- ties, dependent as they are on the assessable value of the parishes, bear no relation to the relative population, area or industrial character of the parish — still less to the economy or efiiciency of the Parish Council — and need only to be stated to be condemned. 432 GRANTS-IN-AID (ii.) Discrimination in Favour of Desirable Expenditure With regard to the encouragement of particular services or particular forms of relief rather than others, we may note that, in Scotland, a much larger proportion of the total Grants -in -Aid of the expenditure of the Parish Councils is framed so as to achieve this end than is the case with the Boards of Guardians in England and Wales. Of the total sum of £244,000, more than half is accounted for by the Lunacy Grant of £115,500 and the Medical Relief Grant of £20,000. The Lunacy Grant, which began in 1875, is so framed as to encourage the certifica- tion of paupers as being of unsound mind, as the larger the proportion of lunatics among its paupers, the larger is the Grant-in-Aid that the Parish Council receives. It is not without significance that the lunatic poor, who, between 1868 and 1875, had remained nearly stationary at between 1*8 and 1*9 per 1000 of the population, have, since the year in which the Lunacy Grant was first pay- able, increased by leaps and bounds, the proportion rising from 1-9 in 1875 to no fewer than 31 in 1907 per^lOOO of the population. Whereas in 1875 only 64 out of every 1000 paupers were certified as of unsound mind, there were in 1907 no fewer than 139 out of every 1000 so certified. This Lunacy Grant is not, as it is in England and Wales, payable only for such persons of unsound mind as are main- tained in lunatic asylums, but is payable for all persons of unsound mind maintained by the Parish Councils, whether in asylums, in Poorhouses, or ''boarded out," with regard to whom the General Board of Lunacy are satisfied that proper care and treatment are afforded. Notwithstanding this payment of the Lunacy Grant for lunatics still retained in the General Mixed Poorhouse, to which there is so much objection, we must, in fairness, record that the General Board of Lunacy insists on there being separate " licensed wards," and that a much smaller proportion than in England and Wales of the pauper lunatics — in fact only 782 out of the 15,031 — are so retained in Scotland, partly, perhaps, because 2771 are "boarded out." We may entirely accept the evidence IN FAVOUR OF DESIRABLE EXPENDITURE 433 that has been given that " the result of the Grant," under the watchful supervision and the incessant suggestions for amendment of the General Board of Lunacy, " has been a great improvement in the care of the insane." But we think it objectionable that, owing to the selection of this one section of the pauper host for a heavy Grant-in-Aid, there should be so great a temptation offered to Parish Councils to get poor persons certified as of unsound mind. The Medical Relief Grant has less equivocal features. Here, indeed, as in the English Police Grant, we have an example of a Grant-in-Aid operating — because framed upon sensible lines — in such a way as enormously to increase the efficiency of the service selected for encourage- ment. By means of the deliberately contrived scale of minimum expenditure on the medical service, as well as the requirement (which had not been embodied in any statute as to Poor Relief) that there should be a salaried doctor, which alone entitled a Parish Council to partici- pate in the Grant, its distribution was prevented from being merely a dole to the ratepayer. By making the Grant to each Parish Council, not in proportion to its population or valuation but directly proportionate to its own actual expenditure on Medical Relief, with an addi- tional bonus for the provision of trained sick nursing in the Poorhouses, the Central Authority effected " an imme- diate and lasting improvement in the administration of Poor Law Medical Relief, outdoor and indoor," from one end of Scotland to another. " By means of the Grant, a system of trained sick nursing has been established in Poorhouses ; schools of training Poor Law nurses have come into existence ; and recently the system has culmin- ated in State Certification of Poorhouse Nurses after three years' training and a high-class examination. The whole system of Indoor Medical Relief has thus been greatly improved." It is interesting to find the Local Govern- ment Board for Scotland itself making it a matter for congratulation — very natural, if rather prematurely optimistic — " that the best Poorhouse sick wards are now as well staffed as the wards of any first-class general hospital." VOL. I 2 F 434 GRANTS-IN-AID Unfortunately, the Medical Relief Grant has one accidental defect. In 1889, when this Grant was, with others, merged in the Local Taxation Account, it was pro- vided that it should be distributed according^ to the scale and regulations then in force. This statutory enactment has had the unintended effect of stereotyping the regula- tions of twenty years ago, so that certain parishes are now unfairly excluded from participation in the Grant, and, moreover, it has not been possible to enlarge its scope so as to encourage such new developments as salaried nurses for the Outdoor poor and probationer nurses in the Poor- houses, or to amend certain technical defects which experi- ence has revealed. What is required is merely to enable the Local Government Board for Scotland to revise the scale and the regulations from time to time. It is to be regretted that in no other branch of the Scottish Poor Law than Lunacy and Medical Relief have the Gran ts-in- Aid been made to work an equally benefi- cent improvement. Thus, there is no financial encourage- ment to the Scottish Parish Councils, as there is to the London Boards of Guardians, to provide for their pauper children otherwise than in the General Mixed Workhouse or Poorhouse. The result is that notwithstanding the prevalent belief that Scottish pauper children are nearly all " boarded - out," there are to be found in the Poor- houses of Scotland at any time a very large proportion of children under sixteen, numbering, indeed, on 31st March 1906, no fewer than 1845; whilst in London, with a greater population and a greater amount of pauperism, but under the operation of financial encouragement of the removal of children from the Workhouse, there were on 31st March 1906, only 174 children under sixteen in the Workhouses (other than sick), and only 965 in the sick wards of Workhouses, making only 1139 in the General Mixed Workhouses altogether. GIVING AUTHORITY TO CENTRAL CONTROL 435 (iii.) Giving Authority to Central Control Passing now to the third effect of Grants-in-Aid, the extent to which they strengthen, in the interests of efficiency and economy, the influence of the Central Authority, we need add little to what we have already said. Half the total Grants are, as we have seen, flung out in such a way as to do nothing to improve the relation- ship of the Local Government Board for Scotland with the Parish Councils. The Lunacy Grant gives the General Board of Lunacy the power to see that the care and treat- ment of the pauper lunatics are up to a minimum standard, and thus lends a certain amount of weight to its criticisms and suggestions. The Medical Relief Grant has enabled the Local Government Board to get a salaried Medical Officer appointed to attend to the poor of nearly every parish, and to get trained nurses appointed in many Poorhouses, including all the larger ones, but the accidental stereotyping of the regulations of 1889 has prevented the making of further requirements. But, for the most part, the beneficent influence of these Grants has operated automatically from the conditions under which they are payable, rather than from any increased weight that they have given to the influence of tlie Central Authority. (d) Irelaml The Grants in Aid of the expenditure of Boards of Guardians in Ireland, which amount to £528,000 a year, being no less than 40 per cent of the total expenditure, offer few points of diff'erence from those in England and Scotland. [Grants 436 GRANTS-IN-AID Grants in Aid of the Expenditure of Boards of Guardians IN Ireland Grant. 1907-8. Fixed (Agriculture) Grant to Boards of Guardians in respect of the deficiency arising from the operation of Clause 48 of the Local Govern- ment (Ireland) Act, 1898 , One-half of Estate Duty Grant (Sec. 3 of Probate Duties (Scotland and Ireland) Act, 1888) ; total not varying in any way dependent on Boards of Guardians, and allocation among Unions fixed on basis of 1886-87 Medical and Educational Salaries Grant £316,731 126,055 85,996 Total £528,782 There is the same kind of fixed Grant in respect of the deficiency caused by the relief afforded to the owner of agricultural land, a Grant which, as in Great Britain, is now essentially one in aid of expenditure generally. There is a second Grant in aid of expenditure generally, varying in total amount according to the yield of the Estate Duties, but in no way dependent on any action of the Board of Guardians, and allocated among the various Unions in a ratio that was fixed, once for all, in 1886-7, and has now ceased to bear any relation to the relative expenditures. These two Grants, amounting to no less than £442,786, or 86 per cent of all the Grants-in-Aid, have thus the effect of lump sum subventions in aid of the local expenditure, of which they amount, on an average, to as much as one- third. The third Grant, that in aid of medical and educational salaries, is now limited in total ; but, as with the Medical and Lunacy Grants in Scotland, this fixed maximum sum is allocated among the Boards of Guardians in proportion, to some extent, dependent on their own expenditure. The Boards of Guardians may claim for recoupment one-half the duly approved salaries of their medical officers of Workhouses and dispensaries ; IRELAND 437 one-half the cost of medicines and of medical and surgical appliances, obtained in accordance with the regulations ; half the salary of one trained nurse in each Workhouse ; one -half the remuneration of substitutes of doctors or nurses absent on vacation ; and the whole of the duly approved salaries of schoolmasters and schoolmistresses in Workhouses. But, by a provision of the Local Govern- ment (L'eland) Act of 1902, the maximum sum to be received by any Board of Guardians under these heads was fixed at what it actually paid under these heads in 1901-2, so that an enterprising Board, which had then already attained the low minimum standard imposed, may presently find that it has little or no financial encourage- ment to effect further improvements. Moreover, under the Local Government (Ireland) Act of 1898, it was provided that if the total sum provided for this Grant proved insuificient to meet the claims, the Grants payable to each Union were to be proportionably abated. This, in fact, happens now every year, so that the amounts payable to each Union (like the Scotch Medical and Lunacy Grants) bear each year a smaller proportion to the Guardians' expenditure on the services which it was desired to encourage. It should be added that the maintenance of persons of unsound mind in lunatic asylums is, in Ireland, entirely divorced from the Poor Law and from pauperism. There is a Grant of £160,000 made direct to the County Councils in aid of this service at the rate of 4s. per week per lunatic, or one-half the net cost if this is a smaller amount. (i. ) The Relief to the Local Ratepayers Coming now to the results of these Grants in Aid of the expenditure of the Irish Board of Guardians, we find them, in respect alike of the relief to the ratepayer, of the encouragement of particular services, and of the strengthen- ing of the influence for efficiency of the Central Authority, almost exactly parallel with what we have already described for England and Scotland. There are the same heedless inequalities in the extent of the relief afforded 438 GRANTS-IN-AID to the ratepayers of different Unions, entirely irrespective of their circumstances ; whether the test be population, area, poverty, amount of pauperism, efficiency of service, or economy of administration. These inequalities between the relief thus afforded to the Irish occupiers appear all the more inexcusable when we realise that it is the unfortunate districts of the West, where it may almost be said that chronic starvation prevails, which are most unfairly dealt with. Throughout the whole of Ireland the Government Grants are arranged almost as if it had been deliberately designed that those districts which needed help most should receive the least assistance, whilst those which required the least aid had this aid heaped upon them in profusion. We have worked out the figures for six of the richest and six of the poorest Unions in Ireland : — t^'r •c) »-^ ■3-S i2»r Union. County. 05 IS .a •-' 2 B<0 p He u SB n l1 £ £ £ £ £ £ s. d. g. d. Dunshaughlin Meath . . 399 332 2,383 3,114 7,979 105,242 13 4 7 9 Trim . . . Meath . . 485 408 3,568 4,461 13,973 109,054 7 16 6 4 Celbridge . . Kildare , . 579 456 2,122 3,157 14,225 106,057 7 9 4 5 Delvin . . . Westmeath 316 250 1,717 2,283 8,477 53,200 6 6 5 4 Crooni . . . Limerick . 597 402 2,677 3,676 10,806 63,836 5 18 6 9 Kilmallock . Limerick . 1,477 757 6,104 8,338 25,551 140,273 5 10 6 1 Glenties . . Donegal 669 539 1,059 2,267 33,191 22,314 13 1 4 Dunfauaghy . Donegal 364 194 392 850 15,781 12,036 15 1 BelmuUet Mayo 504 304 765 1,573 13,845 10,942 16 2 3 Oughterard . Galway . . 393 366 921 1,680 17,732 16,053 18 1 10 Swinefoid . . Mayo 758 490 2,123 3,371 44,162 42,374 19 1 6 Clifden . . Galway . . 507 370 1,020 1,897 18,768 19,010 1 2 In the Dunshaughlin Union, amid the rich grazing lands of Meath, where the valuation amounts to no less than £13 :4s. per head of population, the Government relieves the occupier from his burden of local expenditure to the extent of as much as 7s. 9d. per head. In the Dun- fanaghy Union, amid the bare rocks of Donegal, the Government relieves the occupier of his local burden to the extent of no more than Is. per head. There are unfortunate Unions in the West, in which the inhabitants RELIEF TO LOCAL RATEPAYERS 439 are habitually unable to earu a living (such as Glenties, Swineford and Caherciveen) where the total of Govern- ment grants in aid of the expenditure of the Board of Guardians on Poor Relief does not amount to a third of its cost — these Unions being aided no more than is flourishing Belfast. On the other hand, in some of the districts of Ireland where the valuation per head is highest (such as Dunshaughlin, Delvin, Groom and Celbridge), the fortunate Board of Guardians finds that it has to bear only one-fifth of the amount that it chooses to spend. Nor have these enormous inequalities any relation to the policy, to the efficiency, or to the extravagance of the different Boards. Among the Unions where pauperism is relatively high, and the numbers on Outdoor Relief are most considerable, we find the names of those (such as Kilmallock, Navan and Groom) in which the Government Grant is relatively the largest. The result is that whereas some Unions, richly endowed by the Government Grant, and spending in Poor Relief two or three times the average for the whole country, escape, whatever their extravagance, with a Poor Rate on occupiers of 6d. or 8d. in the £ ; others — by what seems almost like a bitter irony, those where the soil is poorest — have (like Bel- mullet and Dingle) to bear a burden, notwithstanding a starved administration costing only a third or a fourth as much per head as that of some other Unions, of between 3s. and 4s. in the £. We can find no excuse for the continuance of so anomalous and so unfair a distribution of the Government Grants, to which pointed attention was called in 1902 by Lord Balfour of Burleigh, Sir E. W. Hamilton and Sir G. Murray, without any reform being effected; and to which renewed attention has now been called by the Vice-Regal Commission on Poor Law Reform in Ireland. (ii.) Discrirtiination in Favour of Desirable Expenditure In the matter of the encouragement of particular services, the expansion of which is considered desirable, the Grants-in-Aid of the expenditure of the Irish Boards 440 GRANTS-IN-AID of Guardians are so arranged as to have the very minimum of effect. Four -fifths of the sum thus paid by the Government has no such discriminating effect at all. The remaining fifth — the Medical and Teachers' Grant — had originally a considerable influence in the improvement of the Medical and Educational staffs of the Union. But owing to what seems to have been a wholly mischievous change in 1902, when the expenditure of that year was stereotyped as the limit of the grant which no Union might hereafter exceed, however much it subsequently developed its medical and educational services, the bene- ficial effect of the Grant in this respect has diminished, though it still serves as a stimulus to prevent the most backward Unions from sinking below the minimum. There is no financial encouragement given to the Irish Boards of Guardians to provide for their pauper children otherwise than in the General Mixed Workhouse, where they are usually taught as well as boarded and lodged ; there is, for instance, no Grant paid in respect of children boarded out or placed in certified schools ; there is no financial encouragement to them to provide more than the minimum of nursing in the Workhouse ; there is no financial encouragement to them to give relief to the sick, the widows, or the aged and infirm in one way rather than another. (iii.) Giving Authority to Central Control On the last, and in some ways the most important feature of Grants -in -Aid, the extent to which they are arranged so as to strengthen the influence for eflGiciency of the Central Authority, the Grants to the Irish Boards of Guardians are always wholly useless. Four-fifths of the grants are made unconditionally in lump sums. Thus, an Irish Board of Guardians may go to the utmost limit of contumacy ; it may violate in the spirit, if not actually in the letter, all the commands of the law, and all the injunctions of the Local Government Board for Ireland ; it may be as extravagant in its expenditure and foolishly lavish in its Outdoor Relief as it chooses ; it may set at GIVING AUTHORITY TO CENTRAL CONTROL 441 naught all the advice of the Inspectors ; its members may be grossly partial, politically biased and virtually corrupt in their administration — nevertheless the Local Govern- ment Board for Ireland must, by law, unquestioningly hand out, year after year, the funds which provide one- third or one-half — sometimes even four-fifths — of what the Guardians are playing with. Such a position needs only to be stated to be condemned. Nor is the matter much better with regard to the remaining fifth of the total Grants, that in aid of the medical and educational salaries, etc. Here the conditions secure that the appointments and salaries shall have had the approval of the Local Government Board, and that the medicines, etc., shall have been procured in accordance with its regulations. But the Grant is not in any way dependent on the efficiency of either the medical service or the Workhouse school. The doctor may have got very old or taken to drink ; the teacher in the AVorkhouse school may have got worn out in the service and be utterly incapable of keep- ing the school apace with educational progress — never- theless the Local Government Board for Ireland must go on paying the Guardians the Grant towards the salaries of officers whom its Inspectors report to have become wholly inefficient. (e) What should be the Terms of the National Suhveyition We attribute the present chaotic condition of the Grants -in -Aid of the expenditure of the Destitution Authorities mainly to the lack of consideration with which the several Grants have, from time to time, been made. The desire merely to relieve the local ratepayer, or to bring new sources of revenue to the aid of rates on occupiers, has sometimes obscured the object of effecting a greater geographical equalisation of burdens and the still greater importance, as it seems to us, of strengthening the control of the community as a whole over local parsimony or local extravagance. Moreover, it does not seem always to have been borne in mind that, apart from the particular 442 GRANTS-IN-AID monetary necessity which led to the concession, each Grant-in- Aid necessarily ajffected, by its amount, its geo- graphical allocation and its conditions, the psychological and financial effects of all the Grants to the same Local Authority that were already in existence. But without dwelling further on these points, we have to observe that part of the evil appears to us to be inherent in the very nature of Grants -in -Aid of the expenditure of Local Authorities charged merely with the " relief of destitu- tion." So long as it could be said that the business of Boards of Guardians in England, Wales and Ireland, and of Parish Councils in Scotland, was merely to relieve " destitution," it followed that the policy of the Central Authority tended to be one of seeking to diminish their total expenditure ; the " best " Local Authority was the one which contrived to spend the least ; and any Grant- in-Aid was apt to be looked upon as mischievous en- couragement of the unnecessary and positively harmful expenditure that resulted from lax administration. It is, therefore, natural that, the Grant being regarded as wholly evil in its tendency, uo consideration should be given by the Department concerned to the conditions of its dis- tribution. Where the Grant-in -Aid is made to Local Authorities charged with the performance of a specific service, which it is wished to encourage, as is the case with the Education Grant and the Police Grant, in England and Wales, and the Poor Law Medical Grants in Scotland and Ireland, we see the Departments concerned framing elaborate regulations for making the Grant not merely relieve the ratepayer, but also promote the effici- ency of the service. We doubt whether it is possible to frame similar conditions for a Grant-in- Aid of the ex- penditure of a Destitution Authority generally, which would be really efiective in promoting efficiency and discouraging a lax administration of Poor Relief. If, therefore. Destitution Authorities continue to exist, there is much to be said for the view that all general Grants-in- Aid of their expenditure ought, as tending, in their hands, merely to local extravagance and inefficiency, to be with- drawn, or, as wc should rather say, diverted to other TERMS OF NATIONAL SUBVENTION 443 Local Authorities administering services, tlie development of which it is desired to encourage. But the very great variations in the weight of the rate-burden imposed upon localities by their administra- tion of the service of Poor Relief, which was declared by the Royal Commission on Local Taxation to be predomi- nantly national in character, render it absolutely necessary that Parliament should speedily make provision for the re-arrangement of the incidence of this burden. Such a re-arrangement involves the existence of some central or national fund ; and it is not, therefore, practicable to dissociate the present expenditure of Destitution Authori- ties (to whomsoever it may be transferred) from any scheme of Imperial subventions in aid of local expendi- ture. In any case, those evils of distribution which, so far from mitigating, even increase the burdens of poor districts, should promptly be reformed. We have, however, already seen that the administration of the Poor Law is becoming more and more differentiated into its constituent services, such as the education of the children and the curative treatment of the sick. We have seen, moreover, that, even within the range of the Poor Law, it is the Grants-in-Aid of specific services, such as the Lunacy Grant and the Medical Grant, which have had the most satisfactory results. We think it is clear that, whatever subventions from national revenues may from time to time be accorded in relief of the local ratepayers, these should always take the form, not of general grants, but of Grants-in-Aid of the expenditure on particular services or particular methods of administration that it is considered desirable to encourage, relatively to other services or other methods of administration. (i.) It should he a Grant, not merely an Assignment of Revenue We have carefully weighed the relative advantages of Grants-in-Aid, as compared with the assignment to the Local Authorities of specific branches of revenue, or the proceeds of particular taxes. For reasons which will have 444 GRANTS-IN-AID become sufficiently clear in our preceding analysis of the existing subventions received by the Destitution Authorities we object altogether to the latter plan. For Parliament to assign specific sources of revenue to the Local Authorities, or dedicate to their use the proceeds of particular taxes, is to deprive the community as a whole of part of its public resources without securing to the National Government, in return, any practical means of enforcing upon the Local Authorities that minimum of efficiency which the interests of the community require ; and without giving to the National Government that eff'ective backing of its super- vision and control, and that efi'ective strengthening of its counsel and advice, without which it is powerless to check local extravagance and local waste. The psychological effect upon the Local Authorities of assigned revenues instead of Grants-in-Aid, is, moreover, wholly to the bad. To a Local Authority, the proceeds of assigned revenues soon become regarded as its own property, which it ought to be able to spend at its will, as freely as the rates which it levies upon its constituents, or even more so, and yet without the check to extravagance that is supplied by the consciousness of having to face, at the elections, those from whom the money has been raised. In fact, as things are, " the Local Authorities enjoying the Grants are said to spend them without consideration, and with a recklessness which would be absent if they were dealing with moneys directly provided out of their own pockets. . . . Experience shows that Grants do not reduce the rates, these being, as a rule, as high now as before such Grants were in operation. Grants should be given for special purposes, and not in aid of rates generally. ... At present they are too much given to regard these grants in the light of doles." Whilst it is desirable, in our view, that considerable aid should be afforded to the local ratepayers, both for the sake of equalising local burdens, and for the sake of strengthening the influence for efficiency of the National Government, we regard it as of the highest importance, both as a check upon extravagance, and as a means of securing effective popular assent and control, that the Local Authorities, while receiving general assistance from the Exchequer in GRANT, NOT AN ASSIGNMENT OF REVENUE 445 respect of National burdens they cannot avoid, should feel that the results of their own actions seriously affect the amount of a definite local rate, varying from year to year. With regard to the aid that they get from the National Exchequer, it is desirable that they should feel that it comes as a recognition of the fact that the local service thus aided is one which is performed, not for the locality alone, but, in part at least, in furtherance of the interests of the community as a whole ; and that accordingly the community as a whole has a right to satisfy itself, by the inspection of the expert officers of the central departments concerned, that the service is performed at least up to the extent, and with at least the degree of efficiency, that the community may, in its own interests, from time to time prescribe. We do not think that it is within our province to suggest what should be the total amount of the subventions to be made to the Local Authorities, or the proportion that they should bear to the local expenditure. It is only for the sake of convenience that we assume that, at any rate, the present annual subvention of between three and four millions sterling received by the Destitution Authorities will not be withdrawn from the ratepayers, and that definite parts of it will continue to be allocated to England and Wales, to Scotland, and to Ireland respectively. Before, however, we proceed to consider in what way, and upon what conditions some such amount should be issued to the Local Authorities, a question may arise whether the sum now payable to the Destitution Authorities, in respect of the deficiency arising under the Agricultural Rates Act — commonly called the Agricultural Rates Grant — can pro- perly be included in the re-distribution. We are decidedly of opinion that it can and should be dealt with exactly like the other Grants-in-Aid. We are supported in this contention by the high authority of Lord Balfour of Burleigh, Sir George Murray, and the late Sir Edward Hamilton, whose lucid argument on the subject we now append. " The circumstances which we have thus briefly indicated," they state in their Minority Report (Ireland) of the Royal Commission on Local Taxation, " point with 446 GRANTS-IN-AID irresistible force to the desirability of a re-distribution of the aid to Local Taxation given from the Imperial Exchequer. With regard to most of the existing grants, such a proposal would meet, we believe, with ready concurrence. But the case of the Agricultural Grant, which is by far the largest item, may appear at first sight more doubtful, and needs careful consideration. " In the provisions of the Irish Local Government Act, 1898, as to the Agricultural Grant, there is no limit of time, and consequently it might be supposed that any modification of the whole arrangement would be a sort of breach of faith. We think it is possible to draw some distinction. " The feature of the Act, which was of the nature of a bargain, and which is irrevocable, was this : That, whereas landlords had hitherto paid half the Poor Rate, they should, in future, be relieved of that liability. . . . This relief was given for various reasons, but more especially in consideration of the risks which a more representative system of Local Government in Ireland would undoubtedly bring to them. Consequently, all rates in rural districts (as well as most urban rates) are to be henceforth paid by occupiers, and this arrangement is admittedly beyond alteration. "At the same time it was provided by the Local Government Act that the rates in respect of agricultural land should be relieved to the extent of the Agricultural Grant. We do not consider that it is desirable or prac- ticable to depart from the general policy of that Grant; but we do not think it can be assumed that the arrangements as to the aggregate, and especially the distribution of the Grant, are fixed to the last penny for all time. Indeed, demands have already been made for the increase of the Grant, in order to bring it up to date. And, while the distribution is not, in our opinion, satisfactory at present, it may, owing to various possible changes in local finance, become grossly absurd. For instance, if the valuation of any district was considerably increased or diminished — as it probably should be in some cases — the rate in the £ would be altered, and the Agricultural Grant, based on the GRANT, NOT AN ASSIGNMENT OF REVENUE 447 standard year, 1896-7, might become very anomalous. A considerable increase of buildings or railways might have a similar effect, or such a result might follow from changes of administration. Thus, if a Union which has hitherto been very profuse in poor relief were to change its policy, it is not outside the bounds of practical possibility that the Agricultural Grant might be enough to cover more than the whole charge on the land. Or, if the other sub- ventions in any district were varied, the rate would vary, and the Agricultural Grant would again become anoma- lous. Again, if it is held impossible to vary the distribu- tion of the Agricultural Grant, it would seem equally impossible to alter the distribution of any other Grant, for the effect on the ratepayers would be just the same. "Now, we are of opinion that, as between ratepayers, the relief afforded to the occupier of agricultural land by the Local Government Act was equitable, and should be continued, on the ground that the ability as measured by the occupation of the land is less than the ability repre- sented by the occupation of other property of equal annual value. We, therefore, propose that henceforth, as at present, the rate on agricultural land should be in each area less than the rate on other property by half the standard rate. If the position of the agriculturist be thus safeguarded, we hope that this further proposition may be admitted, viz., that the Agricultural Grant ought not to be regarded as an inalienable endowment of particular districts and particular ratepayers, but that equitable revision from time to time, as fairness and administrative policy demand, is legitimate and necessary." Similar considerations, it is clear, apply with equal force to the Agricultural Rate Grants in England and Wales, and in Scotland. Whether or not it is just and proper to continue the beneficial arrangements as to the assessment of agricultural land at only half its value, or the payment by the occupier of only half-rates upon it, whichever system is found most convenient, there is clearly no obligation on the part of Parliament to continue to pay, in one ivay rather than in another, the Grant 448 GRANTS-IN-AID which it made to Local Authorities in 1896-7 in respect of the deficiency thus arising. (ii.) It should he Dependent on Local Efficiency We think it essential, in the interests alike of economy and efficiency, that the present arrangement of making to the Destitution Authorities definitely fixed lump sum Grants, irrespective of the use that is being made of them, should be promptly and completely brought to an end. Such an arrangement operates almost as an encouragement to extravagance and laxity of administration, and makes the National Government a helpless accomplice in the crime. Such a system has, to recommend it, only the advantage that it affords to the Chancellor of the Ex- chequer of knowing in advance exactly how much the total sum to be provided in aid of the Local Authorities will amount to. We recognise the advantage of thus separating the fluctuations of local expenditure from those of the National Exchequer. But this object can be com- pletely attained without sacrificing the other important advantages of making Grants-in-Aid vary according to efficiency of service. There is no objection to the aggre- gate total of the Grants-in-Aid being fixed in advance, for England and Wales, Scotland and Ireland respectively, either permanently or for a term of seven or ten years. This total could then be distributed among the Local Authorities according to certain fixed principles, leaving the amount to be allotted to each to vary according to the amount or the efficiency of the service. Thus, the total amount of Grant receivable by the Scottish Parish Councils in respect of their expenditure on Lunatics is definitely fixed, but the proportion which each Parish Council receives varies according to the number of lunatics provided for to the satisfaction of the General Board of Lunacy for Scotland in each particular parish. APPLIED TO SELECTED SERVICES 449 (iii.) It should he Applied to Definite Deliberately Selected Services Of the several distinct services at present aggregated together under the Destitution Authorities, that of pro- viding for the aged in their homes will henceforth be, to a large and, we may believe, an increasing extent, borne by the National Exchequer in the form of Old Age Pensions. The provision to be made for the Able-bodied, including the Vagrants on the one hand, and the Unem- ployed on the other, must necessarily, as we shall show in Part 11. , be undertaken, at least in some of its forms, by the National Government. We do not think it desirable, therefore, that any part of the expenditure of the Local Authorities in providing for the maintenance of the Aged in their own homes or in providing any form of relief or maintenance for able-bodied men in health, should be aided by Government Grants. A third service, that of providing for the children of school age, including, when necessary, maintenance as well as schooling, should, we recommend, become part of the work of the Local Education Authority, which has its own elaborate system of Grants -in- Aid ; and with this system, notwithstanding the enlargement of sphere of the Local Education Authority, we do not suggest any interference ; unless, indeed, it should be thought desirable, in accordance with the recommendation of the Royal Commission on Local Taxation, to add a specific new Grant in respect of the maintenance of the children for whom more than schooling has to be pro- vided. A fourth service, that of provision for the Mentally Defective of all ages, kinds and grades, will, we may assume, in accordance with the recommendations of the Royal Commission on the Care and Control of the Feeble- minded, be undertaken, exclusively and entirely, by the Local Authority for the Mentally Defective, in succession to the present Local Lunacy Authority, which receives its own simple grant of so much per head per patient suitably provided for. We agree with the Royal Commission that this grant should become payable equally for all kinds or grades of the Mentally Defective. We think that it would VOL. I 2 G 450 GRANTS-IN-AID be an advantage if it could be arranged on the same basis as the Grant to be made towards the cost of other inmates of institutions, whatever that basis may be, so as to avoid any financial encouragement to certify patients as mentally defective. Thus, there remains for consideration, out of all the several services at present entrusted to the Destitution Authorities, only those that we propose should become part of the work of the Local Health Authority, namely, the provision for the sick poor of all ages, the provision for birth and infancy, the provision for the infirm under pensionable age, and the whole of the institutional pro- vision for the aged. All this, as we have indicated, should become part of the ordinary work of the local Health Authority, which, vital as it is to the community as a whole, receives, at present, the stimulus and assistance of practically no Grants -in -Aid, and (we may almost say, consequently) no systematic inspection or supervision. We recommend, therefore, that a sum equal to at least the whole amount now received in Grants-in-Aid by the Destitution Authorities (apart from what is now received in respect of lunatics) should be received in future by the Local Health Authorities ; and that it should become ^available, under suitable conditions, not for specific items, but for the whole expenditure of these Authorities upon the services which include all those matters which we propose should be transferred to their jurisdiction. (iv.) It should he Conditional It follows from our whole argument that the Grants- in-Aid of specific services should be administered by the Departments of the National Government charged with the supervision of those services, and that, in order to emphasise, year by year, the conditional character of the Grants, they should be paid by, or on the instructions of, these Departments direct to the Local Authorities con- cerned. The conditions on which the Grants are to be payable should not (as the examples of the English Poor Law Teachers Grant and the Scottish Medical Grant SHOULD BE CONDITIONAL 451 emphatically warn us) be stereotyped in a statutory en- actment, but should be formulated and revised from time to time by the Department concerned. It would, of course, be essential that the accounts of all Local Authorities receiving Grants-in-Aid should be duly audited by District Auditors, who should, in Scot- land, as is already the case in England, Wales, and Ireland, be ofiScers specially appointed for the purpose, and giving their whole time to the work. We shall later draw attention to the importance of definite qualifications (as to age, experience, and competency in financial and adminis- trative knowledge) being required from candidates for this important appointment, and to the desirability of the auditor's report (though not his disalloivances) extending to more than the bare question of the legality of the ex- penditure. No grant should be payable unless a certificate is given by the Department concerned that the Local Authority is administering the service to be aided in general accordance with the law and with the authoritative regulations of the Department ; that the service, alike in adequacy of supply and degree of efiiciency — taking into account all the cir- cumstances of the locality — reaches at least what may be considered the National Minimum ; and that the Local Authority is applying itself to remedy any shortcomings according to its means. We recommend that immediately the Department has reason to anticipate, owing to a report from its Inspector or otherwise, that it may not be in a position at the proper time to give this certificate, it should send instant warning to the Local Authority concerned. Finally, where the certificate cannot be given, the Depart- ment concerned should be empowered to withhold, after due warning, either the whole Grant or any portion of it, and, if thought necessary, to require that the deficiency should be made good by the levy of a special additional rate, before any future Grants will be paid. 452 GRANTS-IN-AID (v.) It should he based on a Scale of Distribution according to Need and Ability We think it desirable, on the whole, that (assuming the requirement of general efficiency to be made) the Grants should not be allocated on any basis of the number of persons treated, or the number of officers engaged, at so much per head or at such a proportion of the salaries paid. The simplicity of. calculation gained by any such arrangement is outweighed, in our opinion, by the impossibility of doing justice to the special circumstances of particular localities, by the difficulty of securing any approach to an equalisation of local burdens, and by the danger of estab- lishing a basis which becomes rapidly obsolete. The pro- vision of a service adequate in extent to the local needs, and yet not unnecessarily expensive, can, we think, be better secured by appropriate regulations, compliance with which is enforced by a Grant, than by offering what comes to be a standing bonus on further extensions. Similarly, we think that a rising standard of efficiency, and the intro- duction of new improvements in service, can be better secured by advisory Circulars and a periodical revision of regulations, coupled with a Grant varying with the total amount of service, than by specific grants for teachers, nurses, drugs, etc., which can never be made to cover all the various improvements that are being made by one Local Authority or another. It is to be noted, moreover, that the adoption of the County and County Borough as the unit for administra- tion, which (subject to due consideration of the position of, and possible sharing of services with, the Non-County Boroughs and populous Urban Districts of England, Wales, and Ireland, and the smaller Burghs in Scotland) we have throughout assumed, will greatly facilitate both the com- plete remodelling and the future administration of the Grants-in-Aid. Instead of having to deal with 1679 separate Destitution Authorities, the Local Government Boards for England and Wales, Scotland and Ireland will be dealing only with about 210 County and Borough Councils. ACCORDING TO NEED AND ABILITY 453 We recommend, after carefully considering all the alternatives, that, subject to a fixed aggregate total, the Grants for each service should be allocated among the Local Authorities concerned in amounts varying in pro- portion to the total expenditure (apart from loans) of each such Authority upon the whole of the particular service. Thus, the Local Health Authorities would, subject to com- pliance with all the other conditions, share among them- selves the aggregate Grant allotted to the Public Health service, in proportion to their several expenditures, on '* maintenance " or " rate " account, on all the various branches of their work. But, unless it is thought to be too complicated, we would go a step further. We feel that it is very desirable to afford some special encouragement to poor districts, and to make the Grant-in-Aid for each service to each Local Authority vary, not only in proportion to the expenditure of that Authority on the service, but also in proportion to its poverty, as measured by the assessable value of its area per head of population. We agree on this point with the Royal Commission on the Care and Control of the Feeble- minded, though with a wider application of their words. "As matters now stand," they say, "it is, we think, impossible for counties with a low assessable value, and many claims on the County Rate, to make a provision that, in our opinion, is absolutely necessary in the interests of the community . . . and the mere fact that the subsidy of the Exchequer is increased, even largely increased, will not, of itself, meet the difficulty. On the other hand, by the application of definite standards to administrative finance, the methods which we recommend would further economy." In fact, " so long as the burden of the necessary expenditure upon national services falls with greater severity upon one district than another, it is difficult to insist upon general administrative reforms." That Commission accordingly recommended for adoption, with regard to the Grant for all the Mentally Defective, the plan submitted to the Royal Commission on Local Taxation by such high Authorities as Lord Balfour of Burleigh, Sir George Murray, and the late Sir Edward 454 GRANTS-IN-AID Hamilton. This plan proceeds on the basis of fixing what we may call a "National Minimum" rate of ex- penditure per head of population — taking something like the minimum which experience shows to be anywhere necessary for efficiency — and a Standard Rate in the £ — taking, we suggest, something like the average of the rates of the country as a whole. If the product of the Standard Rate does not produce, in the area of any Local Authority, the "National Minimum" of expenditure for its population, the deficiency might be made wholly good by what we should call the Primary Grant. The actual expenditure of the Local Authority would, however, practically always be in excess of the National Minimum rate of expenditure per head of population — this neces- sarily having to be at the lowest customary standard — and towards the excess the National Government should contribute, as the Secondary Grant, a moderate proportion only — an amount which, we suggest, should be whatever can be aff"orded from the balance of the fixed total aggregate Grant (after deducting the sum of all the Primary Grants), in exact proportion to the actual expenditures of the several Local Authorities over and above the standard expenditure per head of population. The amounts of the Primary and Secondary Grants to each Local Authority would be added together, and paid over as a single block Grant. It must, however, be borne in mind that any scheme of Grants-in-Aid depending wholly or partially upon the factor of rateable value can be fairly or properly administered only if steps are taken to bring to a common standard the various methods of assessment now prevailing in different parts of the country, otherwise equity in distribution will be impossible. The necessity of this reform as a condition precedent is in- sisted on by all the members of the Royal Commission on Local Taxation in their first Report on Valuation. Another factor, too, requires more frequent revision in this connection than is possible under existing law, namely, the factor of population. A Census Bill will doubtless be passed through Parliament in the Session of 1909 ; and we suggest that (as repeatedly urged by the ACCORDING TO NEED AND ABILITY 455 Eoyal Statistical Society, the Institute of Actuaries, the Society of Medical Officers of Health, and the London County Council) the opportunity should be taken to provide for an enumeration of the population — a much less expensive business than the regular census — in 1916, and, thereafter, midway between the dates of the decennial censuses. If the Grants-in-Aid to the Local Health Authorities and the Local Authorities for the Mentally Defective were made somewhat on this basis — the exact figures being worked out according to the circumstances of England and Wales, Scotland and Ireland respectively — the poorest and the most backward localities would — provided that they brought their administration up to a reasonable standard of efficiency — receive larger Grants in proportion to their assessable value, as well as a larger proportion of their expenditure, than the richer and more progressive districts. We do not object to this result. We agree with Lord Balfour of Burleigh that "so long as the poorer districts are not treated with greater liberality than the richer ones, it will be almost impossible to secure reforms in administration, which would entail an additional burden upon the rates, without constant appeals to the Central Government for assistance, such appeals mainly coming from the poorer districts in which the burden is already very high. If the rich and poor districts were once placed, so far as possible, upon the same footing . . . these demands upon the State would be less frequent and persistent, and . . . adminis- trative reforms would be more easily effected." It is, in fact, practically impossible to press upon a Local Authority the adoption of a higher standard of efficiency of service - — essential as it may be in the interests of the community — if the improvement would, owing to the poverty of the district, involve a rate actually higher than that of the average of the country as a whole. It appears to us a most valuable feature of the plan of distribution advocated by Lord Balfour of Burleigh that it ensures, even to the poorest district of the United Kingdom, the ability to attain, at any rate, the " National Minimum " of efficiency 456 GRANTS-IN-AID in its local services, at no greater rate in the £ than that which is the average for the country as a whole. On the other hand, even the richest and most progressive Local Authorities, on whose continued experimenting in improved methods of treatment all further advance in efficiency of Local Administration will depend in the future, as it has depended in the past, will (whilst retaining full autonomy to make whatever experiments they choose) receive Grants which will, subject to the sanction of the Depart- ments concerned, vary with the amount of their expen- diture on the services of Public Health in which the community as a whole has so vital an interest. (f) Conclusions We have accordingly to report : — 1. That alike in England and Wales, Scotland and Ireland, the Grants -in -Aid of the expenditure of the Destitution Authorities are urgently in need of revision. In return for the sum of three and a half millions annually, which is being contributed to Boards of Guardians and Parish Councils, the various Departments of the National Government, which are charged with the supervision and control of the Local Authorities, now obtain the very minimum of power to prevent either extravagance or inefficiency, or of influence towards a greater efficiency of service. The relief afforded to the local ratepayer is so unequal and so arbitrarily distributed as to amount to a gross injustice, which is all the more intolerable in that, especially in Ireland, the poorest districts and those most heavily burdened often obtain the least relief. And the conditions of the Grants, whilst seldom, so framed as to cause a wise discrimination in favour of the more desirable methods of expenditure rather than others, sometimes result in positively encouraging extravagance, laxness, and refusal to carry out the policy desired by the Legislature. 2. That, in our opinion, in view of the large share of the cost of providing for the aged in their homes now borne by the National Exchequer under the Old Age Pensions Act of 1908, and of the share which we think CONCLUSIONS 457 it necessary for the National Government to take in the administration of the provision for the Unemployed and Able-bodied, we consider that no Grant-in- Aid should be made to the Local Authorities in respect of these two services. 3. That when all grades of the mentally defective are placed in the hands of the proposed new Local Authorities for the Mentally Defective, a Grant should be made to those Authorities in respect of all the persons satisfactorily provided for by them. It would be desirable that this Grant should be made on the same basis as that to the Local Health Authorities. 4. That a Grant-in- Aid should be made to the Local Health Authorities in respect of all the work now done by them, or to be hereafter entrusted to them. 5. That it is essential that all Grants-in-Aid should be administered by the particular Government Departments concerned with the particular services to be aided; and paid direct to the Local Authorities. 6. That all Grants should take the form of Grants-in- Aid of local services ; that they should be conditional on the efficient performance of the services ; that they should be governed by detailed regulations, and accompanied by systematic inspection and audit ; and that they should be withheld, wholly or in part, on failure to comply with the law and the regulations in force. 7. That they might, for the convenience of the Chan- cellor of the Exchequer, be fixed in aggregate total, which might remain unchanged for a term of seven years ; but that the allocation of the total among the several Local Authorities should be proportionate to their several ex- penditures from time to time on the services to be aided, subject to such expenditure being allowed by the Depart- ment to count for this purpose, as not being extravagant or improper. If not considered too complicated, the scale of distribution proposed by Lord Balfour of Burleigh, determined jointly by expenditure and by the poverty of the district, might advantageously be adopted. CHAPTER XI SUPERVISION AND CONTROL BY THE NATIONAL GOVERNMENT It was an essential feature of the recommendations of the Report of 1834 and of the Poor Law Amendment Act of that year, that there should be established a strong, well-informed, and ably-administered Central Poor Law Department ; and that this Department should, in the interests of National Uniformity and of a sound Poor Law policy, prescribe the general lines of administration of the Boards of Guardians, prohibit any misguided deviations from the policy so prescribed, and by means of Orders having the force of law and specific approvals of appoint- ments and salaries, together with a system of inspection and audit, exercise a close supervision and control over every act of the local authorities. This was the most novel feature of the new Poor Law, and it was the one on which the reformers placed the most reliance. When the Poor Law was extended to Ireland (1838), and remodelled in Scotland (1845), powers of central supervision and control, essentially on the English model, were expressly provided for, though in the case of Scotland with some significant and suggestive variations of detail. The Local Government Board in each of the three countries has inherited all these powers of supervision and control of the administration of the Local Destitution Authorities ; and has even acquired, by successive statutes, new and additional authority over these bodies. Never- theless, as our survey has revealed, the minute supervision and authoritative control of the Local Government Board in England and Wales does not prevent, in one district or 458 SUPEEVISION AND CONTROL 459 another, the most gross and persistent divergence from its declared policy, either on the side of laxness, or on that of harshness ; it has failed completely to secure the National Uniformity that the reformers of 1834 thought of such importance ; it does not, as we have seen, secure the proper treatment of any class of the poor ; and it has not prevented either an almost unmeasured extravagance or, in a few bad cases, widespread and long-continued corrup- tion. In Scotland and Ireland the Local Government Boards seem more seldom to have initiated changes of policy — a fact which serves somewhat to conceal their lack of control over the vagaries of the Local Authorities. But, as far as we have been able to judge, the criticism that we have to make, with regard to the failure of the Local Government Board for England and Wales to secure a National Uniformity of policy, is applicable also to Poor Law administration in Scotland and Ireland. (a) The Orders We take, as the chief exemplar, the Local Government Board for England and Wales, from which, as we have said, the corresponding Departments for Scotland and Ireland differ only in details. Here we have, as the principal foundation of its authority over the Boards of Guardians, a voluminous code of " Orders," which have the force of law, prescribing in minute detail how the Workhouses and other institutions shall be managed ; what officers each Union shall have, at what salaries and under what conditions of appointment ; and what classes of persons shall be alone eligible for this or that kind of relief, and under what conditions it shall be granted. These Orders, some of them " General," or applicable to two or more Unions, whilst others are " Special," or applicable to a single Union only, but all alike having the force of law, exist in bewildering and literally uncounted numbers. They extend over the past seventy-five years ; and they are nowhere collected or published in a complete series. The principal Orders alone are dealt with in the legal text-books which private enterprise has provided, some of 460 SUPERVISION AND CONTROL which extend to over 1000 pages. Many witnesses have complained to us of the impossibility under these cir- cumstances of any Poor Law Guardian being able to find out what it was that the Local Government Board required him to do or not to do ; and they have suggested to us that the Orders should be codified into a single new " General Consolidated Order," containing the whole law. We are unable to concur in this suggestion. The three main Orders, upon which the whole fabric depends — the General Consolidated Order of 1847 as to Indoor Relief, the Outdoor Relief Prohibitory Order of 1844, and the Out- door Relief Regulation Order of 1852 — are all of them more than half a century old. They were prepared for a state of things essentially unlike that of the present day. They embody a policy which has, for all the several classes of persons to be relieved, been virtually repudiated by Parliament in successive statutes. So far as concerns the various classes of the non-able-bodied, they are dia- metrically at variance with the later policy of the Local Government Board itself, as expressed in its subsequent Orders and Circulars. We gather from all official docu- ments issued since 1890, and from the evidence given on behalf of the Department, that the Department, at any rate for the vast majority of the non-able-bodied poor, wholly disapproves of the General Mixed Workhouse, and of indiscriminate, unconditional and inadequate Outdoor Relief — a disapproval in which we concur. Yet when a zealous clerk or conscientious member of a Board of Guardians, anxious to carry out the policy of the contem- porary Local Government Board, turns to the authorita- tive text-book supplied to him, he finds that the General Consolidated Order of 1847 actually prescribes the General Mixed Workhouse, with all its hideous detail of un- specialised management, uniformity of deterrent discipline for all classes, and, notwithstanding the nominal classifica- tion system, practical promiscuity of intercourse in work. And if, seeking direction as to the Outdoor Relief to the non-able-bodied, he turns to the Outdoor Relief Orders, by one or other of which his Union must be regulated, he discovers, to his surprise, that they do not deal with the THE ORDERS 461 subject at all. Although all but an insignificant fraction of the three or four millions sterling of Outdoor Relief that is annually granted by the Board of Guardians in England and Wales is distributed among the sick, the aged and infirm, the mentally defective, the widows, the deserted wives, the mothers of illegitimate babies, and the children of non-able-bodied fathers, there are no Orders of the Local Government Board stating whether Outdoor Relief should or should not be given to such persons, or, if given, under what conditions. There is no prohibition of relief to persons of disorderly lives, or living in insanitary conditions positively dangerous to the public health. There are no conditions prescribed as to the way the infants on Outdoor Relief shall be reared, or the children placed out in the world. Thus, whilst the Guardians find themselves unable to dismiss a porter, give a £5 rise of salary, or open a doorway between two rooms without the express consent of the Local Government Board, on the question of administration of Outdoor Relief to the non- able-bodied, the most difiicult and dangerous of all their tasks, the whole of the tens of thousands of General and Special Orders from 1834 down to the present day are dumb. And even where the Orders give precise instruc- tions, our zealous Clerk or inquisitive Guardian will know that they are often neither observed nor capable of exact observance. With regard, for instance, to the structural accommodation required, it will suffice to say that, of all the Workhouses that we have inspected, we have never seen one in which all the requirements of the General Consolidated Order of 1847, devised as they were for Workhouses in the abstract, were fulfilled in every detail, or could possibly be fulfilled in the particular building which, with the approval of the Board itself, is being used as a Workhouse. When we come, in Part 11. of this Report, to describe the relief of able-bodied men, as actually carried out by the Destitution Authorities, we shall show that, in direct disobedience to the Outdoor Relief Prohibi- tory Order and the Outdoor Relief Regulation Order, some Boards of Guardians give, continuously, week by week, Outdoor Relief to able-bodied men, without any labour 462 SUPERVISION AND CONTROL test; some Boards carry on what are essentially Relief Works for the Unemployed ; whilst others maintain town labourers on farms with the avowed object of training them to take up small agricultural holdings. In short, the three principal General Orders, though purporting to have actually the force of law, are, both in the letter and in the spirit, whoUy out of date ; and they are accordingly, to a large extent, ignored or evaded by all concerned. Any expenditure of money or time on their codification — a task of colossal magnitude — would, in our judgment, be wholly wasted. Quite apart from their particular contents, however, the Orders of the Local Government Board appear to us unsuited for modern administration, owing to their failure to distinguish in form between peremptory laws which have to be applied judicially and inflexibly, and administrative injunctions serving as ideals and patterns which can only be carried out with such modifications as local circumstances require. We may illustrate this distinction by some examples. As an instance of the first type, we may cite the " rules " made by the Home Secretary under the Factories and Workshops Acts, w^liich are in every detail as binding on every person concerned as the statutes themselves ; which have to be strictly construed by the judiciary ; and non - compliance with which is punishable by fine or imprisonment. In the realm of the present Poor Law there are subjects appro- priate for Orders of this sort ; such, for instance, as the definition of the classes of persons liable to contribute towards the maintenance of other persons, or the defini- tion of the classes of persons to whom pensions are to be awarded, or even the conditions in the absence of which no allowance at all (other than on " sudden or urgent necessity ") is to be granted to persons living in their own homes. Such Orders are useful instruments for formu- lating, in more minute detail than is possible in an Act of Parliament, those imperative commands which are to be enforced by judicial procedure of one kind or another ; which must, therefore, be expressed with the same pre- cision and construed with the same continuous and con- THE ORDERS 463 sistent strictness as if they were statutes. To permit deviations from these formal Orders by private letters to particular Authorities, or by the oral sanction of an Inspector — still more, to advise, by published Circular, wholesale evasions or violations of the spirit or the letter of these Orders (and this, as we shall presently describe, has been the practice of the Local Government Board) — is to destroy the moral authority, and prevent the enforce- ment of the Orders themselves. On the other hand, the day -by -day administration of institutions, or the domi- ciliary treatment to be aflPorded to particular cases — and it is these things which make up the bulk of the existing Orders, and nine-tenths of the business of the Destitution Authorities — is not work which can properly be prescribed in detail by legally binding " Orders," any more than it can by Acts of Parliament. This administrative work does not consist of a series of judicial decisions as to whether a case falls within one category or another ; and it is not to be accomplished by even the most minute and persistent torturing of the terms of a statute or mandatory Order. Administrators must be free to make the most of the actual material with which they have to deal, and to act as seems best in all the complex circum- stances of each case ; whilst if there is to be any social progress they must be perpetually devising new ways, undreamt of before, of coping with the new needs that from time to time emerge. It is exactly this day-by- day administration of specialised institutions that is the sphere of the representative body — a sphere in which the " many-headed " and mutable membership of such a body is actually an advantage. To cope with all the varied difficulties, unthought of by the bureaucrat at his desk, which actual administration has to face, to meet the new issues that the changing environment is always producing, and to keep the whole Government in necessary touch with the public opinion of the moment, we need the representatives of every social grade, of every kind of training, and of every variety of opinion. Above all, what is essential to successful administration is the common consent of the community, which the local representative 464 SUPERVISION AND CONTROL body brings from its dependence on popular election. To attempt, by peremptory Orders, meticulous in their detail, having the force of law, to convert the thousands of repre- sentatives of the ratepayers, in all this work of administra- tion, into mere mechanical agents of a Central Government Department is, in our opinion, at once to court failure and to destroy Local Government. It is highly significant that, in this criticism of the whole machinery of Orders, we are but expressing the present practice of the Local Government Board itself. The great General Orders of 1844-52 have had no successors. It has not even been thought worth while, obsolete as they have become in so many respects, systematically to revise them. The Special Orders, each equivalent in law to an amendment of the General Orders, by means of which the circumstances of particular Unions used to be met, have, for many years, become compara- tively infrequent, and have ceased to be of significance. When new developments have had to be provided for, such as Poor Law Schools or Infirmaries, nursing or boarding -out, they have been dealt with by separate General Orders, which have silently thrown into the background (though without expressly repealing) large sections of the earlier code. But even this has not sufficed to give to the clumsy machinery of mandatory Orders the elasticity necessary to any administrative work. In our investigation of the actual administration of the Destitution Authorities, we have been struck by the fact, in Union after Union, that things were being done in flagrant contravention of the General Orders that were supposed to be legally binding. We assumed, at first, that these experiments had been authorised by Special Orders of equal validity. But we discovered, in case after case, that no such legally authoritative instrument had been issued. What had happened was that the Board of Guardians, by persistently arguing the matter with the Local Government Board, had so far con- vinced that authority of the desirability of the experiment that — ignoring its illegality under the Orders — some sort of permission had been given for it to continue, in some THE ORDERS 465 cases orally by the Inspector, but more usually by an official letter (not generally promulgated) from the Local Government Board itself. And even when — often as the result of such illegal but privately permitted experiments of Boards of Guardians — it has been thought right by the Local Government Board to promulgate generally some new development of Poor Law policy, this new policy has often not been embodied in any new Order, nor in any amendment of the great General Orders of 1844-52, but has been pressed on the Boards of Guardians by way of Circular Letters, which cannot, of course, in law, supersede or vary the formal Orders, and have, indeed, no legally binding authority. This was the course adopted, for instance, between 1871 and 1879, when the Local Govern- ment Board was in favour of a general restriction of Out- door Relief to the non-able-bodied. This, too, was the course adopted when, in 1886, 1892, 1895, and 1904, the Board instructed the Destitution Authorities to co-operate with the Municipalities in providing, for the able-bodied and unemployed workmen, the " work at wages " which had been, and continued to be, prohibited by the Orders. The same course was followed in 1895-1896 and 1900, when, with regard to the deserving aged, the Local Government Board reversed its policy of non-discrimina- tion by past character in the relief of destitution, and, in flat contradiction of the General Consolidated Order of 1847, directed the provision of the special quarters for the deserving aged which had been aimed at by the Report of 1834. This perpetual nibbling away of the General Orders by Special Orders, and of both kinds of Orders by oral or written " permits," and by official Circulars, makes both useless and impracticable any codification of the General Orders. It has, in fact, been found, by the Local Government Board itself, impossible to frame any code of legally binding Orders on all the manifold subjects of administrative business, which should permit the inevitable variety and the desirable elasticity of Local Government, whilst securing, by means of such Orders alone, the neces- sary central control. It is in the main because the existing Orders of the Local Government Board mix up, in one and VOL. I 2 H 466 SUPERVISION AND CONTROL the same instrument which purports to have the force of a statute, what are essentially mandatory commands or pro- hibitions, such as forbidding any expenditure on setting up destitute persons in trade, or granting Outdoor Relief to able-bodied men employed for wages, with what are essentially advisory injunctions, such as the method of allocating the different classes of inmates of an institution among the different rooms in the building, the selection of the classes to serve other classes, and the detailed speci- fications of the duties of minor officers, that the whole authority of the Orders has fallen into disrepute, and that they are neither respected as having the force of law, nor sympathetically received as advice to be acted on if possible. The reorulative instructions of the Local Government Board for Scotland, with regard to the whole realm of administration, as distinguished from judicial procedure under law, seem to us preferable in form to those of the Local Government Board for England and Wales. The Scotch Board has no power to issue Orders having the force of law. Each Parish Council having a Poorhouse is required by statute to frame rules and regulations for its management, which have to be approved by the Local Government Board. That body issues model rules, with such amendments from time to time as experience dictates. The Parish Councils adopt, as their own, these model rules, with whatever modifications are required by the size, situation, or structure of their Poorhouse, the staff at their disposal, the numbers and distinct classes of poor to be provided for in each institution, the Council's own organi- sation for business, and any other local circumstances. The rules so framed are, if considered suitable, approved by the Board. This procedure has the advantage of allowing variations from place to place, and from time to time, without the commission of any illegality. It leaves it open to the representative body which will have to obey the rules to suggest in what way they need to be varied from the general model. On the other hand, it enables the Central Authority to understand what exactly the local body is aiming at, and affords an opportunity for THE ORDERS 467 timely criticism and argument. In the last resource the Central Authority can refuse its sanction to any regula- tions which represent any falling below the National Minimum of efficiency of service, which has to be enforced from one end of the kingdom to the other, or to any regulations which are otherwise against public policy. If the Local Government Board for England and Wales had chosen, instead of prescribing by Mandatory Orders all the details of administration, to require all Boards of Guardians to submit for its approval suitable By-laws with regard to Outdoor Relief, it might have secured the essential "National Uniformity" which the Report of 1834 so strongly advocated, whilst not resisting the variations and experiments required by local circumstances and local initiative. We should, at any rate, have been saved the " Babel of Principles " and the demoralising inequalities between Union and Union that we have described in our analysis of the local By-laws ; where, to cite only one instance, one Board of Guardians prescribes what are virtually Old Age and Invalidity Pensions of 5s. a week, and its next-door neighbour ordains that even the most deserving aged and infirm person shall be relieved only in the General Mixed Workhouse. (b) Audit An essential auxiliary of any organisation of central control is an official audit of the accounts of the Local Authorities. The systematic audit of the accounts of the Boards of Guardians was one of the most . important features of the new Poor Law. It has since been greatly improved and extended not only to Scotland and Ireland, but also to other branches of Local Government. This audit has a double object. It aims, on the one hand, at preventing and revealing all peculation, fraud, or corrup- tion in the dealings of the officers or members of the local body. On the other hand, by surcharging any expendi- ture not legally authorised, the audit seeks to prevent the local body not only from travelling outside its sphere, but also from disobeying the law or the mandatory iustruc- 468 SUPERVISION AND CONTROL tions of the Central Authority. We cannot say that the audit of the accounts of the Destitution Authorities, whether in England and Wales, Scotland or Ireland, appears to us to be completely successful in attaining either of its objects. Recent official investigations into certain Unions, and the criminal proceedings to which they have given rise, prove that, under the present audit, gross peculations by Relieving Officers and others, corrupt dealings in the matter of contracts, and fraudulent prac- tices by individual members of the Local Destitution Authority may occur, and may remain undiscovered for years. How far this is due to imperfections in the audit itself, and how far to defects in the official regula- tions — especially in the General Order as to accounts which is more than forty years old — we have not had time to determine. We cannot, for instance, see how any audit can prevent or discover frauds by Destitution Officers, so long as one and the same person, as is the practice in many districts, " controls the case from start to finish " — receives the application, visits the home, advises on the relief, com- municates the decision, and pays the money week after week to the helpless applicant — without at any stage being automatically checked by the intervention of some other officer, by any obligation to prove that the recipient is still living, or even by the necessity of obtaining a receipt or other documentary voucher. Nor does the audit appear to us to be any more successful in preventing con- tinued expenditure disapproved of by the Central Authority. The Board of Guardians of one London Union, for instance, has adopted a costly administrative policy with the repeated approval of its constituents, which, whether it was right or wrong, intended by Parliament or not intended, has at any rate been strongly condemned and objected to by the Local Government Board. This policy has continued for years, to the knowledge of the Local Government Board, and is still being continued, notwithstanding the official inquiry, without being brought to an end by the official audit. And when the disobedience of the Destitution Authority takes the form, not of expenditure considered improper, but of a refusal to incur expenditure considered AUDIT 469 imperative — when a Destitution Authority refuses for years to build a new Poor Law Infirmary or Poor Law School, and persists, notwithstanding injunctions from the Central Authority, in retaining the sick and the children in a General Mixed Workhouse which is overcrowded and in- sanitary, the audit, as a means of enforcing the control of the Central Authority, is powerless. We do not, however, undervalue the importance of an efficient and authoritative audit of the accounts of Local Authorities. Though such an audit will not, in itself, either ensure honesty or give effective central control, experience has shown that it is both a valuable adjunct and ally of good administration. Though it cannot make good any deficiency in the regulations for the conduct of business or the absence of a technically qualified Inspector- ate — still less the lack of a carefully thought-out and consistent policy of the Central Authority — such an independent and external audit may be of the highest value, not only by preventing and discovering fraud, but also by calling attention to administrative deficiencies and financial mistakes. For this purpose it is necessary that the Auditors should not be permitted to confine themselves to peremptory disallowances of payments that are actually contrary to law. It is or should be their duty to call attention to any shortcomings in the regulations, or the system of business of the Local Authority whose accounts they are auditing — such, for instance, as the automatic checks on peculation or waste, or the procedure with regard to the acceptance of tenders for supplies — and also to report as to any grave errors in financial policy ; not with any view of peremptory interference by the Central Authority in matters which must be left to the discretion of the representative body, but merely for the information of the Local Authority itself and, if necessary, of its constituents. We cannot say that we are satisfied that the fullest advantage has yet been afforded to the Local Authorities and to the ratepayers by the Local Government Board's system of audit. Here, as in the analogous case of the Orders, there seems to have been no clear distinction drawn between the intervention in local administration 470 SUPERVISION AND CONTROL which should be mandatory, and that which should be advisory only. A District Auditor, under the Public Health Act, 1875 (England and Wales), has power to dis- allow and surcharge any payment made by the Local Authority ultra vires, or any payment that is contrary to law ; but he has no power to disallow and surcharge any payment that the Local Authority is legally authorised to make, however mistaken, or extravagant, or financially disastrous he may consider such payment, or the policy or administration of which it is a part. The District Auditor may also charge " against any 'person accounting " the amount of any deficiency or loss incurred by the negligence or misconduct of that person. This does not warrant him in individually charging any member of the Local Authority, not himself, individually, being " a person accounting,^' for any negligence or misconduct whatsoever, least of all for participation, merely as a member of the Local Authority, in any corporate act of that Authority or its committees which the District Auditor may think to amount to negligence or misconduct. In both these cases — that of extravagant or financially unwise policy within the powers of the Local Authority, and that of negligence or misconduct of members of the Local Authority in their corporate acts, or of any person not being himself " a person accounting " — to which the District Auditor may quite properly take exception, his criticism must, under the law, be confined to reports for the information of the Local Authority, the Local Govern- ment Board, and the ratepayers. Unfortunately, just as the Local Government Board includes much in its manda- tory Orders which should be only matter of advice, so the District Auditor in his sphere has bee a tempted to stretch his legal powers, so as to disallow and surcharge in questions of policy and administration, when he ought only to report. Thus there have been cases in which District Auditors have disallowed and surcharged pay- ments of Outdoor Relief, and many in which they have threatened to do so, because, as they alleged, the Guardians ought to have adopted more frequently the policy of " ofi'ering the House." There have been cases in which AUDIT 471 District Auditors have disallowed and surcharged relief granted to persons who have had relations, not legally liable to maintain them, but in a position to do so. There have been cases in which District Auditors have, at any rate, threatened to disallow and surcharge the expenses incurred by Guardians in visiting pauper children in certified schools and homes, on the ground that no such inspection was necessary. There have even been cases in which District Auditors have surcharged members of Local Authorities because they have not accepted the lowest tenders for supplies, or because they have thought fit to pay what the District Auditor thought unduly high rates of wages. In all these cases it was open to the District Auditor, by way of report, to have called attention to what he considered financially unwise policy or administra- tive acts on the part of the Local Authority. Unfortu- nately, this part of the function of the Local Government Audit has been too much neglected. As a consequence of this neglect, the District Auditors have sometimes assumed to themselves an authority and a jurisdiction by way of disallowance and surcharge which has created resentment, and really impaired the efficiency of their service. Fortunately, the Court of Appeal in a recent case has definitely laid it down that the District Auditor's power of disallowance and surcharge is confined to "a checking of accounts, not a checking of policy " ; though his duty to report may be of much wider scope. We think it indispensable, in view of our proposals for an extension of the work of the District Auditors, that this limitation of their power of disallowance and surcharge, and this distinction between items which they may dis- allow and items as to which they ought to report, should be authoritatively specified and scrupulously observed. We may add that we are not altogether satisfied with the qualifications of some of the District Auditors for their important task. We find that no limits of age and no technical qualifications are prescribed for the office. It is not necessary that a person, before being appointed a District Auditor, should have had any experience in administration or finance, or should possess any economic 472 SUPERVISION AND CONTROL knowledge, or should even have passed any examination in accountancy. Under these circumstances, as with the Relieving Officers, the absence of any prescribed qualifica- tions inevitably leads sometimes to the appointment of persons on other grounds than that of fitness for the particular office. We recommend, therefore, that there should be prescribed some definite qualifications without which no person should be eligible for appointment as District Auditor. (c) ^ Court of Ajppeal We find established in Scotland an interesting instru- ment of control over the Destitution Authorities in the form of an appeal against their decisions. To this, in England and Wales, or in Ireland, there is scarcely anything corresponding. In Scotland, a person totally refused relief has a right of summary appeal, without delay and without formality, to the Sheriff" ; and this right is exercised in hundreds of cases annually, especially by those who have been refused because they are deemed able-bodied. More- over, if relief in any form has been given, the recipient has a right of appeal against the inadequacy of the relief to the Local Government Board for Scotland ; and this right is exercised, on an average, in eight or nine cases every month. We have taken much evidence as to the working and the results of this system of appeal. We find that the appeal to the Sheriff against a total refusal of relief has many unsatisfactory features. This officer, who, in Scot- land, is a legal stipendiary, engaged in multifarious civil and criminal business, has usually no specialist experience or knowledge of Poor Law, Public Health, or Education, either as to the law or as to the administrative practice. He has no officers at his command to investigate the physical state or the economic and domestic circumstances of the appellant. He receives no Report from the Public Health or Education Authorities, nor even from the Inspector of Poor. He hears, in fact, no other evidence than the quite informal, uncorroborated statement of the appellant himself, which there is no opportunity of A COURT OF APPEAL 473 disproving. If the appellant has been refused relief on the ground that he is able-bodied, he often comes to the Sheriff armed with a certificate obtained from a " sixpenny doctor " that he is suffering from some ailment or another. It is, therefore, not to be wondered at that most Sheriffs make it a practice to give the appellant the benefit of every doubt ; and, in fact, to order "interim relief" in all but glaring- cases of imposture. Once the Sheriff has given his decision, the Inspector of Poor must instantly give the " interim relief" ordered. He may then, if he chooses, lodge with the Sheriff a written statement of the grounds of his original refusal of relief. The Sheriff then directs it to be answered, and appoints an agent to act on behalf of the appellant, when the case comes in due legal form before his Court for final judgment. But all this involves the Desti- tution Authority iu expense, so that, as we are informed, " in very few cases is a formal deliverance given by the Sheriff. When the Inspector of the Poor finds that the Sheriff takes the view that the applicant has a prima facie claim, he usually acquiesces and grants relief." The Inspector of Poor prefers to settle the matter, without lodging a statement, by withdrawing his refusal, and offering the appellant immediate admission to the poor- house. He even tends to anticipate the Sheriff by giving relief in all cases in which he fears an appeal. After carefully considering all the evidence, we have come to the conclusion that the right of appeal to the Sheriff has been, and still is, injurious to Poor Law administration in Scotland. Its only practical advantage is that it serves as one of the many methods by which the legal prohibition of relief to the able-bodied has had to be evaded. We can see no advantage in it over the English and Irish practice of offering admission to the Workhouse or Casual Ward in the first instance to any one who persists in claiming relief and alleges that he is destitute. There is, perhaps, more to be said for the right of any recipient of relief to appeal to the Local Government Board on the ground of its inadequacy. Such an appeal, which may be either as to the amount, the character, or the description of the relief ordered, has to be made on a 474 SUPERVISION AND CONTROL prescribed form, through the local Inspector of Poor. The Board is bound, without delay, to investigate the nature and grounds of the complaint. If the complaint is found to be justified, and if the evil is not remedied by the Parish Council, the Board issues a minute declaring that the pauper has a just cause of action against the Parish Council, and such a minute enables the pauper to take legal proceedings to enforce his right to adequate relief. But the case hardly ever gets thus far. Out of an average during the past five years of 111 appeals per annum, half are summarily rejected as disclosing no valid ground of complaint, and half of the others are dismissed after a satisfactory explanation from the Parish Council. The remaining quarter drop owing to the ground of complaint having, in the meantime, been removed by the Local Authority. In these latter cases, averaging two or three per month, the appeal must be considered as having resulted in improvement of the administration, and possibly in the removal of some real grievance. Only in two cases in the last five years has it been necessary for the Local Government Board to issue a Minute stating that the pauper has a just ground of complaint. In the whole sixty-two years that the system has been in operation such a Minute has been issued in thirty-five cases only. We see no objection, in principle, to this formal right of appeal to the Local Government Board virtually against what is alleged to be improper treatment of the poor by the local Destitution Authorities. We understand that, in its practical working, this form of the Scotch system of appeal amounts to little, if anything, more than actually prevails in the practice of the Local Government Boards for England andWales and for Ireland, as, indeed, in that of other public departments. If a letter is received from any person, pauper or otherwise, making specific allegations of improper treatment of any sort by any Local Authority, and disclosing in the allegations what would, if they were accurate, be a valid ground of complaint, the Department concerned does not refuse to make the matter the subject of inquiry, usually referring it for report to the Local Authority concerned. As in Scot- A COURT OF APPEAL 475 land, the vast majority of such letters either disclose no real ground of complaint, or the complaint is found, on inquiry, to be unfounded. In nearly all the remaining cases, we trust that, as in Scotland, the Local Authorities, on their attention being drawn to the grievance, will have promptly removed any real ground for complaint. If this is not done, we think that in these cases of rare occurrence, the Central Authority, whether in England and Wales, Scotland or Ireland, after due inquiry by its own Inspectors, and after further consultation wdth the Local Authority, ought to have power, without any expensive legal proceed- ings, peremptorily to require the Local Authority to remedy what will have been proved to be a genuine grievance. We may mention here another type of decision by the Central Authority, by w^hich its view is made to prevail over that of the Destitution Authorities, namely, Arbitra- tion between two such Authorities, in cases voluntarily submitted to it. This device has been made use of both in England and Wales and in Scotland, as a means of reducing the heavy expenses formerly incurred over disputes as to which particular Local Authority was liable to bear the burden of maintaining particular paupers. In England and Wales it has for more than half a century been open to any two Boards of Guardians to agree to refer any disputed " settlement" of a pauper to the Local Government Board, whose decision is, under such agreement, binding on the Unions concerned. There is a similar provision in Scotland, under which any two Parish Councils differing as to the settlement of any poor person, but agreed as to the facts, may refer the case to the Local Government Board for Scotland for determination. This provision is freely made use of, to the great saving of litigation. In Scotland, other cases of dispute between Parish Councils are voluntarily submitted to and habitually decided by the Board. More- over, a peculiar feature of the Scottish Law is the appeal of the pauper against removal to his parish of settlement. Under the Poor Law Act of 1898 any person who has continuously resided for one year in the parish from which he has to be removed, may appeal against being removed. The Board decides, according to all the circumstances of the 476 SUPERVISION AND CONTROL case, so as to avoid harshness or injury to the poor person. If the appeal is allowed the Board determines also which Parish Council shall be liable for the maintenance. We consider that all these experiments in the direction of using the Central Authority as an arbitrator in disputes between two Local Authorities have worked well, and have resulted in a great saving of time and expense. We agree with a large number of our witnesses in thinking that the practice should be extended to any case of disputed settle- ment on the application of any Local Authority concerned, whether or not both Local Authorities agree to such arbitration, and whether or not the facts are agreed. We think that it would be an advantage if some similar arrangement could be made to settle by arbitration other disputes between Local Authorities in each country as to relief, and also disputes between such Authorities in the different parts of the United Kingdom. (d) The Inspectorate The control exercised by a Government Department over Local Authorities, whether it be by regulative Orders or advisory Circulars, financial audit or jurisdiction in appeal, powers over the local officials or Grants-in-Aid conditional on compliance with central advice, depends always for its efficiency on the existence of a staff of peri- patetic agents of the Department concerned, who can keep the local administration constantly under observation, help the Department to form its judgments, and convey to the Local Authorities the advice and instructions in which the policy of the Department is from time to time embodied. This condition of successful central control was recognised by the reformers of 1834. For the first time in English administration there was established, as a link between the National Executive and Local Governing Bodies, an organised salaried stafi" — called at first Assistant Commis- sioners, and now General Inspectors — to serve as the eyes, hands and voice of the Poor Law Department. The present General Inspectors of the Local Government Board have inherited, so far as the Destitution Authorities are THE INSPECTORATE 477 concerned, a unique position and exceptional powers. Unlike the Inspectors of other Government Departments, they are not only empowered to visit and inspect the work of the Local Authorities, but they are also authorised and required to attend the meetings of the Boards of Guardians whenever they think fit, and (without voting) to take part in the proceedings. They are, in fact, so far as the Poor Law is concerned, not merely the Inspectors, but also the appointed Counsellors of the Local Authorities. This is true of Ireland as of England and Wales. In Scotland, the Inspectors — designated General Superintendents of the Poor — do not enjoy either the salary or the status of their English colleagues. This Inspectorate has, in the past, achieved remarkable successes. In England and Wales, for instance, between 1834 and 1847, it was very largely due to the tact and ability, the knowledge and conviction of the Assistant Commissioners that the new Poor Law was brought success- fully into operation all over the country. Between 1869 and 1885, again, the Inspectorate, as a means of counter- acting an evil laxity which had become prevalent, created a new ideal of Poor Law administration, to which the progressive and enlightened Boards of Guardians tended everywhere to approximate. But for the last twenty years, during which, as we have seen, the control of the Local Government Board in England and Wales has been very far from effective, the Inspectorate has lost much of its former influence over the Destitution Authorities. Regarded as an instrument of central control, it has, in fact, of late years, been wholly unsuccessful. It has failed to get carried out the older policy of the Central Authority, which is still embodied in the General Orders. It has not succeeded in formulating any systematic and consistent new policy in substitution for the old. It has failed to get adopted, with any thoroughness or uniformity, the authoritative views on the treatment of the sick, the children, and the deserving aged, to which the Local Government Board has, since 1895, given repeated utter- ance. It has failed even to prevent the persistent defiance of the instructions of the Central Authority ; a defiance 478 SUPERVISION AND CONTROL resulting, on the one hand, in continued refusals to provide the new buildings deemed to be requisite, and, on the other, with a few urban Unions, in a rising tide of extravagance and corruption. Meanwhile the Local Government Board, for what reason we do not understand, has allowed to continue without any inspection at all what amounts to one-third of the total Poor Law expenditure, and probably to more than one-third of the work of the Guardians, namely : — (i.) The administration of Outdoor Relief in accordance with* the Orders. (ii.) The whole activities of the 3700 officers of the Outdoor Medical Service. (iii.) The Poor Law Dispensaries. (iv.) The 6000 children "boarded-out within the Union " ; and (v.) The 3000 others placed, with the approval of the Local Government Board, in uncertified homes. No part of this extensive range of Poor Law work, costing more than £4,000,000 annually, has, to this day, the advantage of any official inspection whatever. We do not attribute the general failure of the Inspectorate during the past two decades to any short- comings of the existing staff. There are among the Inspectors of to-day, as there have always been, men of great ability, belonging to the best type of English administrators, combining detailed knowledge of the technique they were appointed to control with wide views of policy, an understanding of general principles, and con- siderable capacity for handling men. We attribute the present ineffectiveness of the Inspectorate, as an instru- ment of central control, to the fact that, almost without its being observed, the duties imposed upon it have been changed. Inspection, to be efficient, must always be per- formed by a person technically expert in that which he inspects. The Assistant Commissioners of 1834-47, and the Poor Law Inspectors of 1869-85, had a single function to supervise, and a single technique to invent or acquire, namely, the relief of destitution in such a way as to render the relief deterrent. Dispauperisation was, in fact, their THE INSPECTORATE 479 sole aim. For this tliey devised and made themselves masters of an appropriate technique — the General Mixed Workhouse of the General Consolidated Order of 1847, and the penal task of the Outdoor Labour Test Order of 1852; the Able-bodied Test Workhouse, the grant of Medical Relief on Loan, and the application of the Work- house Test to the Aged, that were characteristic of 1869-85 — which they could press on Boards of Guardians with all the power that comes from knowledge and conviction. But this elaborate machinery of Clogs and Deterrents on relief, applied to all applicants alike, has, as we have seen, been swept out of the minds of the Guardians by the newer policy vaguely demanded by Parliament and public opinion, and actually prescribed by the Local Government Board. The more enlightened and the more progressive Guardians of to-day find themselves not merely admin- istering "relief" under deterrent conditions, but building and equipping hospitals for the sick, lying-in homes for young mothers, institutions for the epileptic, sanatoria for the phthisical, comfortable almshouses for the aged, homes and schools for children, nurseries for infants, farm colonies for the able-bodied unemployed, and what not. We have already drawn attention to what may be called the anarchic and uneven hypertrophy of the Destitution Authority — its virtual transformation from an ad hoc to a "mixed" Authority — as the fundamental cause of its failure. The same transformation has put it out of touch with the Destitution Inspector. The General Inspector of the Local Government Board — as the Poor Law Inspector is now designated — is, in fact, without fault of his own, in a hope- less position. The old technique, of which he was fully possessed, has been repudiated with regard to one class after another, by Parliament and public opinion, and even by the Presidential Circulars of his own Department. The task that he is now supposed to perform would demand a mastery, not of one technique, but of many techniques. It would be impossible for any man, however versatile his natural talents, and however varied his pro- fessional training, to be an authority alike on the medical treatment of the sick at home or in institutions : on the 480 SUPERVISION AND CONTROL rearing of children whether by their own mothers or by others ; on the education and starting in life of boys and girls ; on the rescue of fallen women and the nurture ot their infants ; on the management of imbeciles and idiots ; on the ameliorative treatment of the crippled ; on the provision of almshouses for the aged — not to mention such nascent services as the training of the unemployed and the penal detention of the wastrels. Every Board of Guardians embarking on one or other of these enterprises finds in the Inspector either amiable tolerance or silent disapproval, but never the guidance, the suggestiveness, and the effective control that come only with superior knowledge. In short, with the transformation of the service, the General Inspector of the relief of destitution — like the Destitution Officer and the Destitution Authority itself — has become an anachronism. The transformation of the duties of the Inspector has gone even further. With the designation " General In- spector" have come duties unconnected with the Poor Law, duties relating to Public Health By-laws and hospitals and drains and sewage, for which he has no pretence of knowledge or qualification. Medical Officers of Health have remarked to us on what seemed to them the anomaly of their Annual Reports being referred to " General Inspectors " who were merely laymen. The very idea of having " General Inspectors " of Local Government in the abstract is, we need hardly say, diametrically at variance with the conception of an Inspectorate supplying to the Local Authorities the counsel and guidance, together with the supervision and control, that can come only with specialised expert knowledge. The " mixed " character of the duties of the General Inspectors has had a subtle influence on the recruiting of the staff. As the work which the Inspector has now to supervise is so enormously varied that no man can be professionally qualified to discharge the duties, there is no prescribed qualification at all for the appointment. Successive Presidents of the Local Government Boards for England and Wales, Scotland and Ireland respectively, finding that no particular professional training could be THE INSPECTORATE 481 said to be essential, and latterly, not even any particular conviction as to " Poor Law principles," have, not un- naturally, felt themselves free to appoint any person in whose integrity of character they placed reliance. We have already described how, on a lower plane, a similar absence of any definite professional requirements results in persons being appointed as Relieving Officers and Masters of Workhouses on other grounds than that of fitness for the office. We have referred to the same tendency in the case of the District Auditors. We cannot refrain from the inference that, in some cases, persons have been appointed as General Inspectors in England and Ireland, and as General Superintendents in Scotland, for reasons of personal favour or political service. This will, we fear, always be the case, with the highly paid inspectors as with the lowly paid Relieving Officers or Workhouse Masters, so long as the duties of these important posts remain so " mixed " as to make it impossible to insist on any professional qualification. It would be unfair not to record that these essential disadvantages of such a "mixed" office as that of General Inspector have already been noticed by the Local Govern- ment Board for England and AVales, and to a lesser extent by the Boards for Scotland and Ireland. It has been recognised, for instance, in England, that it was absurd to rely on the General Inspectors, who naturally can know nothing about educational technique, as the only official source of information about the condition and progress of the Poor Law Schools and the Certified Schools. The duty of inspecting these schools, so far as their educational work is concerned, has accordingly been transferred to the Board of Education, to be carried out by its Educational Inspectors. It was plainly impossible for the General Inspectors, if only because of their sex, properly to super- vise the boarded-out children ; and for this work the Local Government Boards for England and Ireland have now the advantage of lady Inspectors, whose specialist know- ledge and experience has kept this branch of Poor Law work, so far as their inspection has been allowed to extend, up to a high standard. The steady expansion of the VOL. I 2 I 482 SUPERVISION AND CONTROL "hospital branch "of the Poor Law has made necessary also the appointment, in England, of two Medical In- spectors of Poor Law infirmaries and Workhouse sick ^ards — who, unfortunately, are not charged generally with the inspection of all treatment of the sick poor — to whose professional training and specialist knowledge we attribute the very marked improvement which has taken place in that part of the work of the Boards of Guardians that they have been permitted to supervise. It appears to us desirable that further developments should be made in this direction. It is, we believe, a necessary condition of any efficient administration that each kind of treatment, involving a separate technique, requires to be supervised, not by a General Inspector knowing none of the techniques, but by a professionally trained specialist. (e) The Poor Law Division of the Local Government Board No mere perfecting of the instruments of central control can result in efficiency of Local administration, unless the Department from which the control emanates is itself organised on such a basis of efficiency as will enable it to formulate a definite and consistent policy, and to apply it in its dealings with the Local Authorities, with the authority of wider experience and superior technical knowledge of the service concerned. In 1834, when there existed no Government Departments for the supervision and control of the Local Authorities, the authors of the New Poor Law, feeling it essential that there should be such Central Control, were necessarily driven to the establishment of a new Department, that of the Poor Law Commissioners, from which the existing "Poor Law Division" of the Local Government Board is the direct descendant. There was at that time no Local Education Authority, no Local Health Authority, no Local Unemployment Authority, and no Local Pension Authority. All the forms of public assistance which then existed were necessarily grouped together under the new Local Authorities at that time established, the Boards of THE POOR LAW DIVISION 483 Guardians, and were covered by the single term of relief of destitution. The fact that the new Central Authority was also a " Destitution Authority," regarding all forms of public assistance as constituting essentially a single service — the relief of destitution — kept it in close touch with the Local Authorities of the time. The Poor Law Commissioners of 1834-47 had their own definite and consistent policy, for which, with the aid of the Assist- ant Commissioners, they developed their own specialist technique, and imposed it, with great success, upon the Boards of Guardians. But, as we have abundantly shown, the administration of the Poor Law has, in the course of the last genera- tion, ceased to constitute a single service with a single technique. In place of the mere relief of destitution, with the constant aim at " dispauperisation," Parliament and public opinion — indeed, the very nature of the case — have compelled the Local Government Board to advocate, and have led the Boards of Guardians to start, nurseries and schools, and hospitals and sanatoria, and farm colonies and homes for the aged, each of them involving its own technique, demanding its own expert policy, and neces- sitating, in the Central Authority as in the Inspectorate, its own kind of specialised knowledge. We have already seen how inadequate the Destitution Authorities have proved, just because they are Destitution Authorities, successfully to discharge so many different kinds of duty. From the General Inspectors, just because these are "Destitution Inspectors," the Local Authorities can get neither helpful suggestiveness nor effective control in these heterogeneous services. Unfortunately the Central Authority has failed equally to keep pace with the grow- ing diversification of the services actually undertaken by the Boards of Guardians. The treatment of the sick is not dealt with by one branch, the education of children by another, the provision for the able-bodied by a third, and the treatment of the aged by a fourth. The Local Government Board, so far as the supervision and control of the "relief of the poor" are concerned, has remained a single undivided unit. Its " Poor Law Division," to 484 SUPERVISION AND CONTROL which comes all Poor Law business, and from which must emanate all Poor Law control, remains to-day, like the Poor Law Commissioners of 1834-47 and the Poor Law Board of 1847-71, essentially a "Destitution Authority," grouping together all the varied activities of the Boards of Guardians as " relief of destitution," and regarding this still as having a single technique of its own, to be guided by one simple policy, which can only be of a negative and restrictive character. Thus, when the progressive Boards of Guardians of the present day strive to improve the education of the children committed to their care, or to make more efficient the hospital service which they maintain for the sick, their aspirations and proposals do not get the advantage of the specialist know- ledge and professional criticism of the Board of Education or of a Public Health Department respectively. What happens is that they are dealt with exclusively by the " Poor Law Division," which, by its very nature, neces- sarily lives and moves and thinks in terms, not of educa- tion or of public health, but of the relief of destitution, just as it was started to do in 1834. It follows, from this unfortunate failure of the Local Government Board to develop specialised departments for the different social services under its control, that the business heaped upon its " Poor Law Division " is of the most heterogeneous kind. The 30,000 letters which it has annually to dispose of deal not only with " the ad- ministration of Indoor and Outdoor relief," and " the appointment, qualifications, remuneration, duties and resignation or dismissal of all the more important officers of Boards of Guardians," but also with the management of " schools and grouped or scattered homes for pauper children," and their " education and employment." It approves the plans of schools and the equipment provided. It decides how many teachers shall be allowed in each school and what their qualifications shall be. It has to supervise the administration of " infirmaries " and " district sick asylums," and " the medical care and nursing of sick and mental patients," and the "practice as to surgical operations and midwifery." It approves the appointment THE POOE LAW DIVISION 485 of medical officers and the arrangements for the supply of drugs. It has to settle the " tasks of work to be per- formed by vagrants and able-bodied paupers " and also decide on " emigration." It deals with the " reports of the Lunacy Commissioners " on the treatment of the in- sane. It advises when new infirmaries are required, and approves the plans in accordance with the latest hospital science. It watches over the "boarding-out of pauper children." It supervises the small-pox and scarlet fever hospitals of the Metropolis, though these are non -pauper institutions ; and it settles what staff of doctors and nurses shall be employed in each of them, and the salaries that these professional officers shall receive. We think it will be clear that no one officer and no one department can possibly be the possessor of expert knowledge, or the exponent of consistent policy — and, therefore, the source of successful central control — for such a hotch-potch of services. The head of the Poor Law Division, Mr. J. S. Davy, C.B., who is both Chief Inspector and Assistant Secretary, is an officer of great ability and wide experience. He is assisted by a staff which has acquired an efficiency of its own. But Mr. Davy would be the first to avow that, assuming it is desired that the schools and hospitals and other specialised services of the Boards of Guardians should each be as wisely economical as it is possible for schools and hospitals to be, and at the same time should be efficient in its own line, neither he nor any one in his Division is qualified to judge or to advise what is the right policy or what are the right methods of attaining this end. He has himself explained to us how completely his Division has failed, notwith- standing its absolute power to refuse to sanction extrava- gant plans, to prevent the most extraordinary variation of capital cost of schools and hospitals ; and how, in consequence, the expenditure on many of these buildings has run up to an immense, and altogether disproportionate figure, without, as we have already mentioned, the build- ings thus provided by Destitution Authorities, with the approval of a Destitution Department, being at all well suited to their use as schools or hospitals. We attribute 486 SUPERVISION AND CONTROL no blame for this failure either to Mr. Davy or to the Poor Law Division, As he has explained, it is almost impossible for an unspecialised Department, having no continuous experience, and no expert knowledge of schools or hospitals, to cope successfully with the medical and architectural experts who are advising the Boards of Guardians. When " the two architects and the Board of Guardians cannot agree . . . the administrative part of the [Local Government] Board is," to use Mr. Davy's own words, " rather helpless." We think it is clear that no mere General Department, attempting simultaneously to supervise and control such entirely distinct services as education and the treatment of the sick, the provision for the imbeciles and that for the able-bodied, the care of maternity hospitals and of asylums for the senile, can possibly acquire the technical experience or possess the specialised knowledge necessary either for the formulation and enforcement of a consistent policy, or for the exercise of any effective control over expenditure. (f) The Need for Specialised Central Control We have accordingly to report that the existing organisation of the Local Government Board for England and Wales, the Central Authority in Poor Law administra- tion, is, from the stand-point of efficiency of central control, wholly unsatisfactory. It is, in our opinion, a necessary preliminary to any improvement that the so-called *' Poor Law Division," which professes to instruct and control the Local Authorities in such entirely different services as education and the cure of the sick, the relief of able-bodied workmen and the management of imbeciles, the provi- sion for the aged and the care of newly - born infants, should be broken up, and its duties allocated to depart- ments having knowledge and experience of the several services. It is significant that the need for some such specialisation of function has already been recognised by Parliament, by Royal Commissions and Departmental Committees, and by the Local Government Board itself. The Poor Law Division, in fact, no longer deals either NEED FOR SPECIALISED CENTRAL CONTROL 487 with all the work of the Boards of Guardians or with all the public provision for the destitute. When, under the Unemployed Workmen Act of 1905, a new service of public assistance for the able-bodied was established, this was placed under the guidance and control of another division of the Local Government Board — leaving, how- ever, the guidance and control of the relief of the other sections of the able-bodied still with the Poor Law Division. When, in 1906, the provision made for another section of the able-bodied — the vagrants — was inquired into by a De- partmental Committee appointed by the President of the Local Government Board, and including two of the principal officers of that Department, the cardinal recommendation of that Committee was that the guidance and control of this service should be taken away from the Poor Law Division and transferred to a Department (the Home Office), which could specialise upon the able-bodied man " on tramp." The same tendency has manifested itself with regard to other classes of the poor. When, under the Old- Age Pensions Act of 1908, a new service of public assistance for the aged was established, this was placed, not under the guidance and control of its own new divi- sion of the Local Government Board, nor yet under that having the guidance and control of the provision for the rest of the aged, but under the Division having to deal with Public Health By-laws, motor-cars and the Unem- ployed. With regard to the children the process of dis- integration has gone on in several ways ; not only has the Board of Education undertaken the guidance and control of the Local Authorities in the provision of medical in- spection and treatment, and the feeding of destitute children at school, but also the Local Government Board itself has, in tardy accordance with the recommendation of the Departmental Committee on Metropolitan Poor Law Schools, voluntarily ceded to the Board of Education the duty of inspecting and reporting upon the education of pauper children. Finally, even whilst we were con- sidering the subject, the Royal Commission on the Care and Control of the Feeble-Minded has recommended that the guidance and control of the Local Authorities, in 488 SUPERVISION AND CONTKOL respect of the large proportion of the pauper population who are in any way mentally defective, should be wholly transferred from the Poor Law Division of the Local Government Board and placed under a separate specialised Department (the Board of Control). In fact, as we have seen to be the case with regard to the Local Authorities, we have now, for each separate class of destitute persons, rival Central Departments promulgating conflicting policies and each purporting to exercise guidance and control — the Poor Law Division of the Local Government Board still assuming to supervise all relief to the destitute, in respect to their destitution ; whilst other Departments or Divi- sions of Departments deal with the public provision made for the several classes in respect of the cause or character of their needs. We think it is clear that there should be, for each class for which public provision is made, a single Central Depart- ment or Division, from which should emanate the policy to be recommended, and from which should be directed the necessary inspection and control of the Local Authori- ties concerned. Only in this way is it possible to secure for the Local Authorities the assistance of any consistent or helpful guidance in the development of their several services. Only in this way is it possible to secure such an administration of Grants-in-Aid of particular services as will promote good local administration and give the neces- sary strength to the Central Authority. Only in this way is it possible to exercise over local expenditure of the rates and taxes any effective supervision and control. With regard to the children of school age (not being actually sick or mentally defective) we consider it essential that the whole duty of supervision and control of the provision made by the Local Authorities for this class — whether for their schooling or for their feeding — should be exercised by one Department, which cannot be other than the Board of Education. The present arrangement, under which the policy, the supervision and the control of children of school age for whom public provision is made, are divided among three different Departments (the Board of Education, the Home Office, and the Local Government Board) — each NEED FOR SPECIALISED CENTRAL CONTROL 489 having its own Grants-in-Aid and its own staff of In- spectors, who in some cases visit the same institutions, without even conferring with each other — is hopelessly- inefficient and extravagant. In particular, the peculiar arrangement by which the Poor Law Division of the Local Government Board continues responsible for inspecting the board and lodging of the children in the Poor Law schools, whilst the Board of Education is responsible for inspecting the schoolrooms and the instruction provided for these same children, is one which cannot possibly be continued. This has been forcibly brought to our notice in the first General Report on the schools made by the Inspectors of the Board of Education. Nor can it be justified that the Home Office, a Department having no other work con- nected with education, should pay Grants to, and should keep an Inspector to visit, industrial schools which are sometimes provided by Local Education Authorities, con- temporaneously in receipt of Grants from the Board of Education, and sometimes inspected also by the Inspectors of the Local Government Board, which certifies them as fit for use by the Destitution Authorities. The arguments for the transfer, from the Poor Law Division of the Local Government Board and the Home Office to the Board of Education, of all matters relating to children of school age, whether such children are in schools of one designation or in schools of other designations, will become even more overwhelming in strength when, as we have recommended, the actual provision for all necessitous children in each locality, not being actually sick or mentally defective, including industrial and reformatory schools, and " board- ing-out," is made by a single Local Authority (the Local Education Authority). We anticipate much advantage to the Board of Education itself in this enlargement of its functions. It has been suggested to us that the Inspectors of the Board of Education, confined as they are at present to the scholastic instruction of the children, are apt to take too exclusively a literary view of education. We think that the widening of view which must come from having to deal, not merely with schooling, but with all the needs of the child, and the experience of those who in 490 SUPERVISION AND CONTROL industrial and reformatory schools and in Poor Law schools have had always to consider the whole up-bringing of the children, their industrial training, and the actual starting them out in the world, will be of special value in correcting the " defects of the qualities " of a mere Educa- tion DejDartment, apt to think only of what can be taught in class. We do not, of course, suggest that the same Inspector would deal with all the different aspects of the child's life and the child's needs. There will, it is clear, be a much greater differentiation and specialisation among the Inspectorate than has heretofore existed. In particular, the transfer to the Board of Education of the specialised Inspectors of boarded-out children, with their intimate knowledge of the interaction of the school and the home, would add a valuable element to the educational staff. The same general arguments support the placing of the whole central control of the local medical services and of the public provision for the sick in the hands of a single specialised Department. We have seen how necessary it is that the present Poor Law Medical Service and the Public Health Service in the several localities should be merged in a unified Local Medical Service on Public Health lines. It is, in our judgment, equally essential that this unified Local Medical Service should have the guidance and control of a single Central Department, having the supervision of everything relating to the public health. We have even received representations in favour of the establishment of a separate Ministry of Public Health with a representative in the Cabinet. Leaving aside, however, this larger question, we were surprised to find that, notwithstanding the strong recommendation of the Sanitary Commission of 1869, there does not exist to-day even a self-contained Division of the Local Govern- ment Board dealing with the subject. The supervision and control of the public provision for the prevention and cure of disease — a service on which the nation is spending altogether many millions sterling annually — is scattered among no fewer than five Divisions or Departments of the Local Government Board, each having its own staff, its own experience of administration, its own expert consult- NEED FOE SPECIALISED CENTKAL CONTROL 491 auts, its own views of policy, and its own permanent head responsible for advising the Permanent Secretary and the President of the Board. Thus, all questions relating to the Poor Law Infirmaries and the Isolation Hospitals of the Metropolis go to the Poor Law Division ; and about these the Secretary and President are advised as to policy by Mr. J. S. Davy, C.B. The Isolation Hospitals everywhere else, and the vaccination business of the Boards of Guardians (though not their administration of the Infant Life Protection Act) are dealt with by quite another Division ; and the Secretary and President are advised as to policy by Mr. J. Lithiby, C.B. But this Division, called the " Public Health, Local Finance and Local Acts Division," also deals with Public Libraries and Canal Boats, and is encumbered, curiously enough, with the entire subject of Local Finance, including rates, assess- ments, loans, and the accounts of Municipal Corporations. It is also responsible, moreover, for the supervision of water-supply, rivers pollution and the purity of food and drugs. Nevertheless, the whole activity of Local Authori- ties under the Public Health Acts and the Gas and Water Facilities Act is looked after by yet another Department, the " Sanitary Administration and Local Areas Division," which also deals with Housing, Drainage, Roads, and Burial ; and on all these matters the Secretary and Presi- dent are advised as to policy by Mr. N. T. Kershaw, C.B. On the other hand, the vital question of By-laws under the Public Health and other Acts, and of regulations as to water-supply and milk, as well as those relating to motor- cars — together with the whole administration of the Unemployed Workmen Act of 1905, and, curiously enough, also of the Old- Age Pensions Act of 1908 — is in the hands of yet another Division, under Mr. H. C. Monro, C.B., who has the responsibility of advising the Secretary and President as to the policy to be pursued with regard to these heterogeneous services. Apart from all these Divisions, with a department of a dozen or more doctors and inspectors, stands the Chief Medical Officer of the Board, Dr. A. Newsholme, who, as we have learned from the complaint of his distinguished predecessor. Sir John 492 SUPERVISION AND CONTROL Simon, may or may not advise the President with regard to these health matters, according to whether or not the other Divisions, which are charged with one or other of the fragments of the Public Health service, send the papers to his Department. We are satisfied that there can be neither adequate control of expenditure nor efficiency of service, whether on the side of the Poor Law Medical Service or on that of the Public Health Medical Service, so long as this illogical and demoralising distribution of the central control among five rival divisions or departments of the Local Government Board continues to prevail. To-day, as it was authorita- tively stated in 1869, "the causes of the present insuffi- ciency of the central sanitary authority are obvious : — "(1.) The want of concentration .... ** (2.) The want of central officers, there being, for instance, no staff whatever for constant, and a very small one for occasional, inspection. " (3.) The want of constant and official communi- cation between central and local officers throughout the kingdom. A new statute, therefore, should constitute and give adequate strength to one Central Authority .... not to centralise administration, but, on the contrary, to set local life in motion — a real motive power, and an Authority to be referred to for guidance and assistance by all the Sani- tary Authorities for Local Government throughout the country." In short, we cannot help attributing to the scattering of the knowledge, the power and the responsibility among five different heads of Departments, all offering advice to the Permanent Secretary and to the President of the Board, and all having other matters to attend to besides the Public Health, the lack of any strong and con- sistent policy with regard to the public provision for the prevention and treatment of disease, the disabling lack of co-ordination among the several parts of this service, the failure even to keep the work of the Local Authorities under supervision by any systematic medical inspection of the various public hospitals and infirmaries, the absence of medical statistics of their work, and the lack of guidance NEED FOE SPECIALISED CENTEAL CONTEOL 493 and control of the manifold activities and frequent omis- sions of the Local Authorities in the whole domain of Public Health, with which, as we have seen, the work of the Boards of Guardians is so closely connected. We recommend that the responsibility for the supervision, guidance and control of the Local Authorities in all their action in the prevention and treatment of disease, including the administration of the Gran ts-in -Aid in respect of this service, should be placed upon a single Public Health Department, whether that Department be represented by a Minister of its own, or form one of several Divisions of the Local Government Board. To this Public Health Department — which should be self-contained and complete in itself, with its own specialised legal and architectural experts — there would naturally fall the supervision of all public hospitals and infirmaries, whether now administered by Boards of Guardians or by Town Councils, etc.; of all domiciliary medical inspection and treatment, whether by the District Medical Officers or the Medical Officers of Health ; of all developments of vaccination and the use of anti-toxins ; of all the provision made for infants under school age, including the administration of the Infant Life Protection Act, now re-enacted in the Children's Act, 1908 ; of all the institutional pro- vision made for the aged ; of the measures taken to secure the wholesomeness or purity of milk, meat and other food, and of drugs ; of the bylaws and regulations relating to matters of health ; and of water-supply, drainage and house sanitation. The Department would, of course, have its own staff of qualified Inspectors ; among which there would, no doubt, be developed a Hospital Inspection Branch, dealing systematically with all the institutional provision for the sick, to which the present " Medical In- spectors for Poor Law Purposes " would bring their valuable experience. Such a Public Health Department would, of course, need more than one Assistant Secretary ; would have, as its immediate permanent head, an officer combining administrative with public health experience, and would include among its administrative staff (and not merely as consultants) men of medical qualifications. We think, in 494 SUPERVISION AND CONTROL fact, that the office of Chief Medical Officer should be combined, if not with that of the permanent head, at all times with that of one of the Assistant Secretaries (just as the office of Chief General Inspector is now combined with that of Assistant Secretary for the Poor Law Division), in order that — as is already the case in Scotland and Ireland, to the great advantage of the Public Health Service — the Chief Medical Officer may, on the one hand, be in direct communication with the Local Authorities, and on the other, be directly responsible for advising the Permanent Secretary and the President of the Local Government Board as to policy in all matters relating to Public Health. We do not presume to suggest whether any of these Departments should be placed under Ministers of their own, by whom they would be directly represented in Parliament. But for such of them as remain associated together in the Local Government Board we recommend that a proper organisation for conference and co-ordination should be pro- vided. We have been much impressed by the arrangements in this respect of the Local Government Boards for Scot- land and Ireland. These Boards are real boards of consulta- tion, composed of the permanent heads of the several Divisions with the permanent head of the office as Vice-Presi- dent. We may cite as other examples the Army Council at the War Office and the Board of Admiralty. We think that if the responsible permanent heads of Departments, each administering a single service, met weekly in formal con- ference with the Minister (or in his absence the permanent head of the office) in the Chair, it would secure, on the one hand, full opportunity for bringing to notice the urgent needs of each service, and on the other, that automatic co-ordination of policy which is as requisite for the wisest economy as for the fullest efficiency. In the case of the large class of the mentally defective — whether lunatics, idiots, inebriates, epileptics, or merely feeble-minded — we are relieved from thenecessity of arguing in favour of the concentration in a single specialised Depart- ment of the whole of the central control, by the emphatic recommendations just made by the Royal Commission on the Care and Control of the Feeble-minded. AVhether that NEED FOR SPECIALISED CENTRAL CONTROL 495 Department be designated the Board of Control, as recom- mended by the Commissioners, or whether it be given some more expressive title, we think it indispensable that it should be a self-contained Department, administeriDg all the Grants-in-Aid of the service under its control, directly responsible to whichever Minister of the Crown may be entrusted with its supervision, and in direct communication with all the Local Authorities making provision for any class of the mentally defective. We think that this Department should have its own specialised legal and architectural advisers, as well as its own medical officers and inspectors. The administration of the service of national pensions for the aged is so inchoate, and the character of the local organisation is as yet so vaguely determined, that, whilst it necessarily impinges upon our subject, we hesitate to make definite recommendations in the matter. The present situation is anomalous. The orders and regulations are made by the Local Government Boards for England and Wales, Scotland and Ireland respectively. The executive officers representing the Government in the different localities, and actually doing the bulk of the work of inquiry and determination, are not officers of these Depart- ments, but of the Commissioners of Inland Revenue, whose sphere extends to the whole of the United Kingdom. The Inspectors who are to see that these executive officers carry out the orders and regulations, not of their own department, but of the three Local Government Boards, are at present responsible only to the Commissioners of Inland Revenue. The Pension Committees of the Local Authorities are in correspondence, not with the Com- missioners of Inland Revenue, but with the Local Govern- ment Boards for England and Wales, Scotland and Ireland respectively, to which the appeals are to be made. These appeals will have to be determined severally by these three Local Government Boards ; and there does not seem to be any provision for ensuring that the appeals from England and Wales, Scotland and Ireland respectively will be decided on uniform principles. We presume that this curious arrangement is only a temporary one. We regard it as essential that there should be a single, 496 SUPERVISION AND CONTROL self-con tained Central Department for this pension service, having its own executive staff and its own Inspectorate, supervising and controlling the Local Pension Authorities and determining all appeals from the local decisions. In view of the necessity of securing uniformity in the decisions on these appeals, and having regard to the fact that the whole of the funds are provided directly from the National Exchequer, we do not see how the Central Pensions Authority can be other than national in its scope, dealing directly with the whole of the United Kingdom. This consideration appears to exclude it from the Local Govern- ment Boards for England and Wales, Scotland and Ireland respectively, and to point to its administration as a sub- ordinate Department of the Treasury. There remains the class of the Able-bodied, for whom provision is now made as paupers or vagrants by the Destitution Authorities, and as unemployed by the Distress Committees of the Town Councils, etc. The central control is exercised, so far as England and Wales are concerned, in part by the '* Poor Law Division " of the Local Government Board under Mr. J. S. Davy, C.B., and in part by the " Legal and Order Division " of that Department, under Mr. H. C. Monro, C.B. A further disintegration of the central control with regard to the able-bodied has been recommended, as we have mentioned, by the Departmental Committee on Vagrancy, in the transfer to the Home Office of all supervision of the action of the Local Authorities in regard to the able-bodied who are relieved outside their own parishes. We shall deal with the whole subject of the provision for the Able-bodied in Part II. of the present Report. It suffices here to say that we regard it as absolutely essential to economy and efficiency that one Central Department, and one Central Department only, should be responsible for the supervision and control of the treatment of able-bodied persons in receipt of public assistance ; and that this Central Department should be self-contained and distinct from those Departments of the National Government which have to lay down a policy, and to guide the Local Authorities, in the treatment of the various classes of the non-able-bodied. CONCLUSIONS 497 (g) Conclusions We have therefore to report : — 1. That the Local Government Board for Enghxnd and Wales — and in a lesser degree the Local Government Boards for Scotland and Irehmd — have failed to secure the national uniformity of policy with regard to the relief of the poor which was aimed at in the establishment of a Central Authority upon the Keport of 1834. 2. That this failure has contributed to the extraordinary variations in Poor Law administration in different districts, and to the present demoralised state of the majority of the Destitution Authorities. 3. That we attribute the failure, not to any short- comings in the persons concerned, but to the obsolete character of the administrative machinery with which they have had to work ; and notably to their not having been able to keep pace with the virtual transformation of the Destitution Authorities, from bodies set to " relieve destitution" under a deterrent Poor Law, into Local Authorities which, in response to public criticism, have started to provide, for this or that class of their patients, not deterrent relief, but curative and restorative treatment. 4. That the "Poor Law Division," with its General Inspectors, adhering to the old technique of a deterrent " relief of destitution," is unqualified to secure the efficient and economical administration of the different kinds of nurseries, schools, hospitals, asylums, custodial homes, farm colonies, and what not, that are now being run by the hypertrophied Destitution Authorities. 5. That each of the separate services — such as educa- tion, public health and care of the insane — administered by the Local Authorities imperatively requires the super- vision, guidance and control of a distinct and self-contained Department or Division of a Department, having its own regulative orders, its own technically qualified Inspectorate, and its consistent line of policy ; and that just as the Local Destitution Authorities should be broken up and merged in the several Committees of the County or County Borough Council dealing with the several services, VOL. I 2 k 498 SUPERVISION AND CONTROL so the Poor Law Division of the Local Government Board should be abolished, and its work distributed among the several Departments or Divisions of Departments to which may be entrusted the supervision and control over the Local Education Authorities, the Local Health Authorities, and the Local Authorities for the Mentally Defective, respectively. 6. That we cannot refrain from animadverting on the fact that, notwithstanding the enormous importance and steady expansion of the Public Health work of the Local Authorities, there exists, in England and Wales, no Depart- ment, and not even a distinct and self-contained Division of a Department, responsible for their supervision, guidance and control in this important service, and for maintaining in it a definite and consistent policy — the work of dealing with the questions as they arise being intermixed with the business of other services and scattered among five different Divisions of the Local Government Board ; none of them having, under its control, any staff of inspectors for the systematic visitation of all the Local Health Authorities, or the administration of any Grant-in-Aid of the services of those Authorities ; and none of them being charged with the duty of formulating and maintaining a consistent policy for the service as a whole. CHAPTER XII THE SCHEME OF REFORM The state of anarchy and confusion, into which has fallen the whole realm of relief and assistance to the poor and to persons in distress, is so generally recognised that many plans of reform have been submitted to us, each represent- ing a section of public opinion. In fact, throughout the three years of our investigations we have been living under a continuous pressure for a remodelling of the Poor Laws and the Unemployed Workmen Act, in one direction or another. We do not regret this peremptory and insistent demand for reform. The present position is, in our opinion, as grave as that of 1834, though in its own way. We have, on the one hand, in England and Wales, Scotland and Ireland alike, the well-established Destitution Authorities, under ineffective central control, each pursuing its own policy in its own way ; sometimes rigidly restricting its relief to persons actually destitute, and giving it in the most deterrent and humiliating forms ; sometimes launching out into an indiscriminate and unconditional subsidising of mere poverty ; sometimes developing costly and palatial institutions for the treatment, either gratui- tously or for partial payment, of practically any applicant of the wage-earning or of the lower middle class. On the other hand, we see existing, equally ubiquitous with the Destitution Authorities, the newer specialised organs of Local Government — the Local Education Authority, the Local Health Authority, the Local Lunacy Authority, the Local Unemployment Authority, the Local Pension Authority — all attempting to provide for the needs of the 499 500 THE SCHEME OF REFORM poor, according to the cause or character of their dis- tress. Every Parliamentary session adds to the powers of these specialised Local Authorities. Every Royal Commission or Departmental Committee recommends some fresh development of their activities. Thus, even while our Commission has been at work, a Departmental Committee has reported in favour of handing over the Vagrants and what used to be called the " Houseless Poor," to the Local Police Authority, as being interested in " Vagrancy as a whole," apart from the accident of a Vagrant being destitute. The Royal Commission on the Care and Control of the Feeble-minded has recommended that all mentally defective persons now maintained by the Poor Law should be handed over to the Local Authority " specially concerned with mental deficiency, whether in a destitute, or in a non-destitute person. The increasing activities of these specialised Local Authorities, being- only half-consciously sanctioned by public opinion, and only imperfectly authorised by statute, are spasmodic and uneven. Whilst, for instance, the Local Education Authorities and the Local Health Authorities are provid- ing, in some places, gratuitous maintenance and medical treatment, for one set of persons after another, similar Authorities elsewhere are rigidly confining themselves to a bare fulfilment of their statutory obligations of school- ing and sanitation. Athwart the overlapping and rivalry of these half-a-dozen Local Authorities that may be all at work in a single district, we watch the growing stream of private charity and voluntary agencies — almshouses and pensions for the aged ; hospitals and dispensaries, con- valescent homes and " medical missions " for the sick ; free dinners and free boots, country holidays and " happy evenings " for the children ; free shelters and soup kitchens, " way tickets " and charitable jobs for the able-bodied, together with uncounted indiscriminate doles of every description — without systematic organisation and without any co-ordination with the multifarious forms of public activity. What the nation is confronted with to-day is, as it was in 1834, an ever-growing expenditure from public and private funds, which results, on the one hand, SCHEMES WE HAVE REJECTED 501 in a minimum of prevention and cure, and on the other in far-reaching demoralisation of character and the con- tinuance of no small amount of unrelieved destitution. (a) Schemes that we have Rejected We may distinguish, amid the various proposals for reform that have been brought before us, three main policies to be carried out by new legislation in England and Wales, Scotland and Ireland alike. These all con- template the continuance, under one constitution or another, of an Authority specifically charged with the relief of destitute persons, and of destitute persons only. As each of these policies has received substantial support, we think it expedient to state briefly what they involve, and our reasons for not adopting them. (i.) The Continuance of a Denuded Destitution Authority alongside of other Local Authorities Providing for the Poor The easiest policy to pursue, by way of bringing the chaos into some sort of order, would be to restrict the Destitution Authorities to a "deterrent" and "less eligible" relief of actual destitution, whilst giving free play to the other Local Authorities to develop assistance out of the rates and taxes on their own specialised lines of prevention and treatment. This policy has not been explicitly recommended to us as a definite scheme of reform. But it is implied in many of the fragmentary proposals that have been laid before us ; as, indeed, it is by much of the legislation of the last few years. It was this policy which seems to have inspired the momentous Circular of 1886, by which Mr. Chamberlain, when Presi- dent of the Local Government Board, inaugurated the Municipal Relief Works for the Unemployed, and the same policy is plainly embodied in the Unemployed Workmen Act of 1905. "Any relaxation," said Mr. Chamberlain, of the ordinary deterrent tests in Poor Law Relief, "would be most disastrous." But another 502 THE SCHEME OF KEFORM form of public assistance of men who would otherwise have been relieved by the Poor Law was to be provided by another Local Authority. Similarly, as an explanation of the Unemployed Workmen Act of 1905, we were in- formed by Mr. Walter Long, that, in his view, *' the object of the Poor Law," in respect of the able-bodied, was " to check " the manufacture of paupers " by imposing upon those who are thriftless, idle or intemperate the strictest possible regulations," in which he desired no relaxation whatsoever. But for "strong, healthy, industrious men," who are " by force of circumstances " in distress, " some fresh powers and new machinery are required. The same idea lay at the root of the persistent advocacy, by Mr. Charles Booth, of a national scheme of pensions for the aged. A wise system of non-contributory pensions for the aged, together with municipal hospitals for the sick, would, he held, enable the Poor Law to be made wholly deterrent. The same idea has been embodied in nearly all the legislation on these problems of the last few years ; and it has inspired the recommendations of nearly all the Royal Commissions and Committees of Inquiry, in favour of providing, outside the Poor Law, milk depots and school dinners for the infants and children, municipal hospitals for all sorts of diseases, "custodial homes" for the feeble-minded, and pensions for the aged. This policy offers to-day the attraction of requiring no reversal of recent legislation, and no discouragement of municipal efforts to raise the standard of life. It in- volves, however, the denudation of the English Boards of Guardians and the Scottish Parish Councils of all the forms of specialised provision for the children, the sick and the aged that we have described ; and the rigid curtailment of the activities of these Destitution Authorities to the maintenance of a deterrent Workhouse. This means in England and Wales, the abrogation of nearly all the Orders and Circulars of the Local Government Board since the date of the General Consolidated Order of 1847 and the Outdoor Relief Prohibitory Order of 1844, It would, by depriving the elected members and the ofhcials of all the interest of managing educational, curative and SCHEMES WE HAVE REJECTED 503 philanthropic institutions, take the heart out of Poor Law administration ; and make it more difficult than ever to induce men and women of zeal and integrity to devote themselves to what would be nothing but a hateful service. Moreover, experience with regard to vagrants and the " Ins-and-Outs " has shown that the most deterrent Work- house does not prove continuously deterrent, unless its administrators can apply powers of compulsory detention. To grant such powers would be to make the Destitution Authorities very nearly akin to the Prison Authorities. It was on such grounds that the Departmental Committee on Vagrancy was constrained to recommend that the Vagrants should be taken out of the Poor Law, and entrusted to the Police Authorities, and that a penal colony for their detention should be provided by the Prison Department under the Home Office. Indeed, it is difficult to discover what class of destitute persons would, under this scheme, be found, in practice, to re- main under the jurisdiction of the denuded Destitution Authority, after all those who require curative treatment, all those for whom honourable maintenance ought to be provided, and all those subjected to penal detention had been withdrawn. Meanwhile, the other Local Authorities, specialising on particular services, would be free to go ahead in their several ways, increasing the municipal debt in all directions, and relieving whole classes of persons and whole forms of destitution, without any check against overlapping, without any insistence on charge or recovery, without inquiry into economic circumstances before the grant of food or money in the home, and without, in fact, any safeguards against developing afresh all the evils of an unregulated Poor Law. On the other hand, as rigid deterrence is found to leave much destitution unrelieved, and as the other Local Authorities would have no re- sponsibility for preventing starvation, we should have, in some districts, practically the evil of there being no relief of distress ; whilst nowhere would the Local Authorities be under any obligation to make whatever provision they chose to develop, in any one service, adequate to the needs of the poor. 504 THE SCHEME OF REFORM (ii.) The Monopoly of Public Assistance hy a Deterrent Destitution Authority The idea of limiting all assistance out of rates and taxes to the operations of a Deterrent Poor Law was unreservedly advocated, with regard to the Able-bodied, by the Royal Commission of 1834, and put into practice by the Poor Law Commissioners of 1834-1847. Some students of the 1834 Report consider that this policy was also intended to be applied to the non-able-bodied. But the application of this policy to the " Disabled " was re- served for the talented Inspectorate of 1869-86. It was then argued that just as under the Act of 1834 the intro- duction of a Deterrent Poor Law had ".obliged the Able- bodied to assume responsibility for the able-bodied period of life, an application of the principle to the other re- sponsibilities would produce equally advantageous results." To ensure the maximum of deterrence, it was suggested that the " Workhouse Test " should be universally applied, so that the only relief offered to any class, " the Disabled " as well as the Able-bodied, should be bare subsistence in a disciplinary Workhouse, combined with the humiliation and disgrace that — so it was argued — should be attached to " living upon funds that have been raised by com- pulsion." This policy, it was fervently believed by its advocates, would, by reason of its very harshness to the aged, to the sick and to the children, so stimulate private charity and voluntary agencies, and so encourage parental and filial, brotherly and cousinly feeling, that every aged person, every sick person and every child, who was at all " deserving," and many even of those who were not deserving, would be maintained without "pauperism," and without cost to public funds. The uniform enforcement of this policy throughout the country has been advocated by many of our witnesses, including some having great experience of the actual administration of the Poor Law. The official representa- tives of the Poor Law Officers' Association, for instance, presented this policy to us as embodying " the funda- mental principles of the English Poor Law " which were SCHEMES WE HAVE REJECTED 505 " as sound as tliey were well understood." They laid it down that the principles upon which we ought to insist, with regard to all assistance from public funds, were that " the condition of the person relieved should not in any respect be better than that of the lowest class of inde- pendent labourer ; and the next, that it is essential to associate with the receipt of relief such drawbacks as will induce the poor, so far as lies in their power, to make provision for the future." We find some difficulty in estimating the exact changes that would be required for universal adoption of this policy, owing to the fact that its advocates are not clear whether they really desire it to be applied to all classes of paupers. Mr. Crowder, for instance, whose long and devoted service as a Poor Law Guardian in St. George's-in-the-East is so w^ell known, emphatically declared to us that all relief of distress from public funds should be through the Poor Law, and that all such relief should be " less eligible," should be " deterrent," and should be subject to " the stigma of pauperism." But it subsequently appeared that Mr. Crowder was unprepared to apply this policy to the not inconsiderable section of the paupers who are children, nor yet (except " to some extent ") to the still larger number who are sick. Some witnesses, however, were more consistent. Mr. T. Mackay, for instance, would have us boldly apply this historic policy to the aged and to the sick, as well as to the Able- bodied. One important witness, the Rev. Canon Bury, who was so long mainly responsible for the Poor Law administration of Brixworth, frankly advocated the appli- cation of the same principles even to the children, for whom he recommended residence in the General Mixed Workhouse, as the only way of making their condition less eligible than that of the children of the lowest grade of independent labourer. " I think," said Canon Bury, " the child must bear, as it were, the sins of the father . . . and I should not like Poor Law relief to interfere with that." Thus, we have maintenance in the Workhouse advocated as the sole form of public assistance to be afforded to any class. The only alternative appears to 506 THE SCHEME OF REFORM such reformers to be a grant of Outdoor Relief which cannot be made either adequate or conditional. For " it is evident," remarks one of the Inspectors, " that if out- relief were granted in sufficient amount to afford adequate relief (which may be defined as relief which would place the recipient in reasonable comfort) it would raise the pauper class to a better condition th^-n the independent person in a similar position of life (miserable as that position may be in the estimate of more favoured sections of society) and would offer a premium to dependence upon the rates. Besides, no out-relief can teach cleanliness and decency (again, according to a higher standard), or can prevent persons in great poverty from parting with any article they can turn into money." The adoption of this policy would involve the repeal of the various Acts of recent years enabling the Local Educa- tion Authorities to feed necessitous children, and to provide medical treatment for those who need it. It would involve, not only the abandonment of all this activity by Local Education Authorities, but also their closing their resi- dential schools for defective children, and their day industrial schools. The Local Health Authorities would have either to close their 700 hospitals, or else — what indeed, the Legislature seems originally to have intended — make such a substantial charge for admission to them as would automatically throw back on the Poor Law every destitute person stricken with fever. Similarly the most progressive of the Local Health Authorities would have either to close their Municipal Milk Depots, and dismiss their Health Visitors ; or else make such charges for these services as would render them self-supporting, and, at the same time, leave to the Destitution Authority the monopoly of public assistance in the poorest districts. We should have to ignore the recommendations in favour of specialised provision for particular classes, which have emanated from every Royal Commission, every Select Committee of the House of Commons, and every Departmental Committee which has, during the last twenty years, been set to consider any one of these problems. We should, in particular, have to neglect the recommendations of the SCHEMES WE HAVE KEJECTED 507 Departmental Committee on Vagrancy and those of the Eoyal Commission on the Care and Control of the Feeble- minded. Finally, we should have to repeal the Unem- ployed Workmen Act of 1905 and the Old- Age Pensions Act of 1908. The Destitution Authorities themselves would have to be revolutionised. The Poor Law Division of the Local Government Board would have to revert to the policy and the Poor Law technique of the Inspectorate of 1869-86 ; and this would involve the reversal of nearly all the official Orders and Circulars of the last sixty years with regard to the children ; of all those of the last forty years with regard to the sick ; and of all those of the last twenty years with regard to the aged. The Boards of Guardians of England and Wales would have to give up their Cottage Homes and Scattered Homes, their Infirmaries and Sanatoria. The Parish Councils of Scot- land would have to give up their Parochial Homes and pensions for the aged, and their roll of widows with children on exceptional home aliment, far above what is enjoyed by the wives of the lowest class of independent labourers. We do not think that any such revolution is possible or desirable. What, indeed, has become apparent is that the con- dition of the lowest grade of independent labourers is unfortunately one of such inadequacy of food and clothing and such absence of other necessaries of life that it has been found, in practice, impossible to make the conditions of Poor Law relief "less eligible" without making them such as are demoralising to the children, physically injurious to the sick, and brutalising to the aged and infirm. Nor do private charity and Voluntary Agencies suffice as a substitute or as an alternative for the public provision for the destitute. It is not merely that private charity has at least as many evils of its own, and at least as many dangers, as the public provision has. What has been abundantly demonstrated is that, without State action, private charity and Voluntary Agencies nowhere fit the need — they are in most places and for most pur- poses demoralisingly superabundant. Finally, they never rise above the individual hard case. With such problems 508 THE SCHEME OF REFORM as the excessive infantile mortality of a whole district, the wide prevalence of tuberculosis, or the preventable illnesses of school children, it never occurs to them to attempt to cope. (iii.) The Extension of Public Assistance by a Disguised and Swollen Poor Law We pass now to the recommendations of the majority of our colleagues in respect of the functions and constitu- tion of the bodies which they suggest should take the place of the Boards of Guardians in England and Wales. We confess to some difficulty in discovering or under- standing what it is that they propose. They sweep away all existing Poor Law Authorities — doing, as it seems to us, grave injustice in the terms they apply to the existing Guardians — but they recommend the creation of a new Poor Law Authority under another name. They are emphatic in laying down the principle that '* the responsi- bility for due and effective relief of all necessitous persons at the public expense should be in the hands of one and only one Authority." Moreover, they declare that they *' do not recommend any alteration of the law which would extend the qualification for relief to individuals not now entitled to it, or which would bring within the operation of assistance from public funds classes not now legally within its operation." So far we might be dealing with the plan of "a Monopoly of Public Assistance by a Deterrent Destitution Authority " that we have just described. But our colleagues reject that plan. They carefully avoid any recommendation in favour of a return to the "principles of 1834." These principles, hitherto acclaimed as the basis of any sound policy, are left aside as antiquated and inapplicable. " The administrators of the present Poor Law," we are told, " are, in fact, endeavouring to apply the rigid system of 1834 to a condition of affairs which it was never intended to meet. What is wanted is not to abolish the Poor Law, but to widen, strengthen, and humanise the Poor Law." The SCHEMES WE HAVE REJECTED 509 new Poor Law Authority is therefore no longer to be confined to dealing with '* the destitute " ; it is to provide for the much larger class of "the necessitous." Its work is no longer to be "relief," but to be concentrated mainly on curative and restorative treatment of the most varied kind. This policy, it will be perceived, involves not only the continuance of the array of specialised institutions which a few Boards of Guardians in England have latterly established, but their multiplication in every district and the development of new varieties. Besides the Poor I^aw residential Schools (or Cottage Homes, or Scattered Homes), there is to be established in every populous district a Poor Law day school, providing meals for the children of widows on Outdoor Relief, as well as an improved form of education, better adapted than that given in the Public Elementary Schools for the prepara- tion of pauper children for industrial careers. There are to be also Poor Law almhouses or Cottage Homes for the deserving aged, and Poor Law Rescue Homes for necessitous young women of immoral life. What puzzles us is how the new Poor Law AuthorityA can provide all these things for " the necessitous," without enormously increasing its present costly overlapping and rivalry with the Local Education Authority and the Local Health Authority. For it is very far from being true that, under the plan to which our colleagues have committed themselves, there would be " one and only one Authority " administering public assistance. Some classes which have lately been withdrawn from the Poor Law are it is true, to be thrust back. The respectable mechanic temporarily out of a job, who is now obtaining " Employ- ment Relief" from the Distress Committees under the Unemployed Workmen Act, is again to come under the jurisdiction of the Poor Law Authority. The necessitous child, now being fed at school, or medically treated under the newly -constituted organisation of the Education Authority, is once again to depend on the Poor Law Authority, and on the Poor Law Authority alone. We gather that in England the phthisical patients who are now being treated in Municipal Hospitals are to be i 510 THE SCHEME OF REFORM transferred to the Inj&rmaries of the Poor Law Authority. These changes will involve the repeal of the Unemployed Workmen Act 1905, the Education (Provision of Meals) Act 1906, and the Education (Administrative Provisions) Act 1906. On the other hand our colleagues concur with the recommendations of the Royal Commission on the Care and Control of the Feeble-minded in advocating that all mentally defective persons, however destitute, shall cease to be paupers and be transferred to the Local Lunacy Authority. They also repeat (though whether or not with approval we are unable to ascertain) the recommendations of the Departmental Committee on Vagrancy, in favour of divorcing the whole provision for this section of the Able- bodied from the Destitution Authority, and of entrusting it to the Watch Committees of Borough Councils and (outside the Metropolitan area) to the Standing Joint Committees of County Councils. With regard to these not inconsiderable portions of the destitute — amounting to at least one -fifth of the entire pauper host — our colleagues are proposing, to use their own condemna- tory words, to break up into sections " the work pre- viously performed " by the Boards of Guardians, and to transfer it "to existing committees of County and County Borough Councils." We fail to understand the reason- ableness of a change, involving great expense and dis- turbance, which withdraws the Vagrant, the Lunatic, the Epileptic, and the Feeble-minded person from the Poor Law, and throws back into the hands of the Poor Law Authority the respectable artisan in want of work, the child found hungry at school, and the phthisical patient requiring isolation, who are now being dealt with by other Authorities. Nor do the recommendations of our col- leagues even approach, still less attain, their own ideal of there being " one and only one Authority," dispensing Public Assistance. We should still have the overlapping between the hospital provision made by the 700 institu- tions of the Local Health Authorities, in diseases other than phthisis, and the sick wards and infirmaries of the Poor Law Authorities ; between the residential schools, day feeding schools, and " boarding -out " of the Local SCHEMES WE HAVE REJECTED 511 Education Authorities and the exactly similar schools and boarding-out of the Poor Law Authorities. But it is with regard to the Able-bodied that our colleagues depart most widely from their principle of having " one and only one Authority." Besides the vaguely suggested Local Police Authority, for relieving such of the Able - bodied as are vagrant, and the new Poor Law Authority for such of them as are stationary, there are to be, in every district, a Labour Exchange managed by the Board of Trade, providing Migration Relief in the form of railway tickets at the expense of the Treasury for such of the Able-bodied as are Unemployed ; a Local Insurance organisation, of uncertain constitution, dispensing Treasury subsidies as Unemployment Relief to insured workmen ; and a Detention Colony giving " Con- tinuous Treatment " at the expense of the Home Office to those " who will not work, or whose recent character and conduct are an insuperable bar to their re-entering in- dustrial life." The situation is to be further complicated by the existence of a semi-statutory Voluntary Aid Com- mittee, which is evidently intended to direct the opera- tions of all the other authorities ; for, we are told, " a first application for assistance will naturally be made to the Voluntary Aid Committee," to be dealt with at its discretion. If it decides to refuse its own aid, it is to be a principle that the Poor Relief afforded " shall be in some way less agreeable than " what the Voluntary Aid Committee would have given. Thus, the Voluntary Aid Committee is to set the standard, which the new Poor Law Authority is never to exceed. " In course of time," we are told, " the practice of the committees would be so well known in the district that the applicants for assist- ance themselves would know to which of the two com- mittees they ought to apply," But so far as we have been able to follow the maze of Authorities to be set up, there will be, not two but six different Authorities more or less supporting the Able-bodied of any one district. We fear that we must agree with our colleagues when, in another part of their Report, they say that "it is difficult to conceive any system in which different public 512 THE SCHEME OF REFORM Authorities have power simultaneously to administer relief to much the same class of applicant in the same locality which will not result in overlapping, confusion and divergence of treatment and practice." Our colleagues seem to us to be even less successful in carrying out, in their detailed recommendations, their axiom that they do not desire " to bring within the operation of assistance from public funds classes not now within its operation," We have already alluded to the pro- posed substitution, for the classic, narrow category of " the destitute," of the far wider category of " the necessitous." The same desire, as they express it, " to widen, strengthen and humanise the Poor Law," is shown, we think, in an almost morbid wish to alter the names of things, in order to give a flavour of generosity, if not of laxness, to the new Poor Law. Their new Poor Law Authority is to be euphemistically designated the " Public Assistance Authority " ; its Relief Committees are to be " Public Assistance Committees " ; the Able-bodied Test Workhouse is to be known in future as the " Industrial Listitution " ; the Outdoor Labour Test is described under " Outdoor Relief" ; and simple Outdoor Relief, far from being abolished, obtains consecration in the official phraseology of the future as " Home Assistance." The good old- fashioned term " detention " is deemed " infelicitous," and whenever the new Poor Law Authority wishes to detain a pauper against his will, the instrument will be disguised as an " Order for Continuous Treatment." But passing from these innocent devices of " illusory nomenclature," we find, in some of the proposals — not, as the "principles" would lead us to expect, a restriction of the area of pauperism, but actually an extension of its area, and an increase in its amenities. With regard to the sick in particular, the new Poor Law axiom is to be " Investigation should follow upon Treatment." Whether the medical treatment is to be peremptorily terminated whenever the inquiry discloses pecuniary resources, is not stated. But being necessitous is not always to be the condition of eligibility under the new Poor Law. It is expressly recommended that institutional treatment, including maintenance, should be provided by SCHEMES WE HAVE REJECTED 513 the Poor Law Authorities without charge and without disfranchisement, for all persons who are members of Provident Dispensaries and are recommended by their own doctors for such treatment ; apparently in rivalry with the Local Health Authorities, and equally whether or not the patients have sufficient means to obtain such institutional treatment for themselves. This extension of entirely gratuitous treatment to persons who are not necessarily destitute, and from whom the cost of this treatment is not to be recovered, involves a serious exten- sion of the area of Public Relief, and of the work of the new Poor Law Authority, and no inconsiderable increase of expenditure. What seems to us even more extra- ordinary is the proposal to grant to every destitute sick person the privilege of a free choice among the doctors of the town, exactly as if such sick persons had belonged all their lives to a well-organised Provident Dispensary. If it is desired to make relief less desirable than mainten- ance by individual exertion and foresight, we should have thought that " free choice of doctors " was exactly the privilege to be withheld from the person coming on the rates for treatment. The proposal seems to us all the more dangerous, as it is plain that the poor patient will tend to choose the doctor who interferes least with his habits, and whom he finds most sympathetic in ordering *' medical extras " ; from which, it must be remembered, food and even alcoholic stimulants are not excluded. We cannot but agree with our colleague, Dr. Downes, who states in his Dissent that " the scheme . . . appears . . . to offer what amounts to a large measure of free medical relief without adequate safeguard either to the medical profession generally or to the ratepayer." The promoters of this scheme seem not unnaturally to feel that the present Boards of Guardians in England and Ireland, and the present Parish Councils in Scotland, would not be equal to the administration of so multifarious an array of services, each having its own technique. The failure of the present Destitution Authorities to cope with the difficulties presented by the existing mixture of classes with which they have to deal makes it clear, in fact, that VOL. I 2 L 514 THE SCHEME OF REFORM to administer the new congeries of functions would demand instruments of " high finish and fine temper," which cannot, it is contended, be ensured by popular election. Thus the new Poor Law Authority, though in form a Committee of the County or County Borough Council, is to have its own autonomy, even as to the rate to be levied or the capital outlay to be made ; and is not to be subject to the control of the Council. Though Councillors will sit upon it, it is to consist largely of co-opted and nominated members, who are to be drawn from amongst men and women of greater experience, wisdom and local knowledge than popular election can supply. The powers and duties of the new Poor Law are not even entrusted to this packed Poor Law Committee disguised under a new name, but are to be distributed among a whole series of '* Public Assistance Committees " and " Medical Committees," the bulk of the work devolv- ing upon these nominated local committees, each with its own dilution of non-elected members — the Medical Com- mittees largely composed of the doctors who are going to be selected by their pauper patients, and paid their fees out of the rates ; and the Public Assistance Committees made up to a great extent of persons nominated by volun- tary charitable agencies. But this is not all. What might seem the generous laxness of the whole terminology of the proposed new Poor Law, if not also of some of its provisions, is to be counteracted by statutory *' Voluntary Aid Committees " ; constituted on the lines of the Charity Organisation Society ; eligible to receive grants from the Public Assistance Authority out of the County Rate ; but in no way under public control. To these irresponsible committees of benevolent amateurs all applicants will apply in the first instance; and in case of refusal of aid, the Public Assistance Committee is to be bound to assist the applicant, if at all, "in some way less agreeable" than the Voluntary Aid Committee would have done ! We have found some difficulty in unravelling the complicated details of the constitution recommended in this scheme for the administration of an annual expenditure from the rates and taxes of, in England and Wales alone, at least SCHEMES WE HAVE REJECTED 515 £15,000,000 sterling. What is clear is that the un- concealed purpose of constructing this elaborate and mysterious framework, With centric and eccentric scribbled o'er. Cycle and epicycle, orb in orb, is to withdraw the whole relief of distress from popular control. But apart from this undemocratic constitution, which, in our judgment, makes the scheme politically quite im- practicable, we consider the whole conception of a Swollen Poor Law, under whatever name disguised, unsound in principle. The experience of the past, as shown by the analysis contained in the preceding chapters of this Report, demonstrates, we think, beyond possibility of doubt, that when a Destitution Authority departs from the simple function of providing bare maintenance under deterrent conditions, it finds it quite impossible to mark off or delimit its services from, those which are required by, and provided for, the population at large. The function of preventing and treating disease among destitute persons cannot, in practice, be distinguished from the prevention and treatment of disease in other persons. The rearing of infants and the education of children whose parents are destitute does not differ from the rearing of infants and the education of children whose parents are not destitute. The liability of persons to be compulsorily removed from their homes, because they have become a public nuisance or a source of danger, must surely be the same whether or not they are technically " destitute." The exercise of the power of compulsorily adopting the children of parents who are leading a vicious life, or who are cruelly treating them, has no reference to the " destitution " of such parents. In short, if we are going to provide preventive and curative treatment — if the treatment of each class, and of each individual within that class, is to be governed not by the fact of their destitution but by the conditions surrounding the particular class and the particular in- dividual of the class — the category of the destitute be- comes an irrelevancy. What is demanded by the 516 THE SCHEME OF KEFOKM conditions is not a division according to the presence or absence of destitution, hut a division according to the services to be provided. Each public service requires its own "machinery of approach" of the population at large, its own technical methods of treatment of the class [ entrusted to it, its own specialised staff, and its own \ supervising committee, bent upon the performance of the ! particular service. Those from whom the cost of their I treatment ought to be recovered can be effectively made to pay without vainly trying to separate the treatment of the destitute from the treatment of the poor. To seek to withdraw from the elaborate specialised public services already in existence for the population at large the 5 or 10 per cent of each class who are technically " destitute," and to set up duplicate services for their separate treat- ment under the Poor Law, even if disguised under the name of Public Assistance, would be both injurious to themselves and unnecessarily costly to the public. (b) The Scheme we Recommend "We have now to present the scheme of reform to which we ourselves have been driven by the facts of the situation. The dominant exigencies of which we have to take account are : — (i.) The overlapping, confusion and waste that result from the provision for each separate class being undertaken, in one and the same district, by two, three, and sometimes even by four separate Local Authorities, as well as by voluntary agencies. (ii.) The demoralisation of character and the slackening of personal effort that result from the un- necessary spreading of indiscriminate, unconditional and gratuitous provision, through this unco-ordinated rivalry. (iii.) The paramount importance of subordinating mere reUef to the specialised treatment of each separate class, with the object of preventing or curing its distress. (iv.) The expediency of intimately associating this THE SCHEME WE RECOMMEND 517 specialised treatment of each class with the standing machinery for enforcing, both before and after the period of distress, the fulfilment of personal and family obhgations. We have seen that it is not practicable to oust the various specialised Local Authorities that have grown up since the Boards of Guardians were established. There remains only the alternative — to which, indeed, the con- clusions of each of our chapters seem to us to point — of completing the process of breaking up the Poor Law, which has been going on for the last three decades. The scheme of reform that we recommend involves : — (i.) The final supersession of the Poor Law Authority by the newer specialised Authorities already at work. (ii.) The appropriate distribution of the remain- ing functions of the Poor Law among those existing Authorities. (iii.) The establishment of suitable machinery for registering and co-ordinating all the assistance afibrded to any given person or family ; and (iv.) The more systematic enforcement, by means of this co-ordinating machinery, of the obligation of able-bodied persons to support themselves and their families. (i.) The Supersession of the Destitution Authority We think that the time has arrived for the abolition of the Boards of Guardians in England, Wales and Ireland ; and, so far as any Poor Law duties are con- cerned, of the Parish Councils in Scotland. We come to this conclusion not from any lack of appreciation of the devoted public service gratuitously rendered on these Boards of Guardians and Parish Councils by tens of thousands of men and women of humanity, ability and integrity, which, we feel, has never received adequate recognition. But it has become increasingly plain to us in the course of our inquiry — it is, in fact, recognised by many of the members of these bodies themselves — that 518 THE SCHEME OF REFORM the character of the functions entrusted to the Poor Law Authorities is such as to render their task, at best, nugatory ; and, at worst, seriously mischievous. The mere keeping of people from starving — which is essentially what the Poor Law sets out to do — may have been useful as averting social revolution : it cannot, in the twentieth century, be regarded as any adequate fulfilment of social duty. The very conception of relieving destitution starts the whole service on a demoralising tack. An Authority having for its function merely the provision of maintenance for those who are starving is necessarily limited in its dealings to the brief periods in each person's life in which he is actually destitute ; and has, therefore, even if it could go beyond the demoralising dole — too bad for the good, and too good for the bad — no opportunity of influencing that person's life, both before he becomes desti- tute and after he has ceased to be destitute, in such a way as to stimulate personal effort, to strengthen character and capacity, to ward off dangers, and generally to keep the individual on his feet. As regards the effect on individual character and the result in enforcing personal and family responsibilities, of the activities of the Destitution Authority on the one hand, and those of the Local Education Authority and the Local Health Authority on the other — even where these latter give food as well as treatment — there is, as all our evidence shows, no possible doubt on which side the advantage lies. Yet if a Poor Law Authority attempts to do more than provide bare subsist- ence for those who are actually destitute, for the period in which they are destitute ; if it sets itself to give the neces- sary specialised treatment required for birth and infancy ; if it provides education for children, medical treatment for the sick, satisfactory provision for the aged, and specialised compulsion for the able-bodied, it ceases to be an " ad hoc " Authority, with a single tradition and a single pur- pose, and becomes a " mixed " Authority, without either the diversified professional staff, the variety of technical experience, or even a sufficiency and continuity of work in any one branch to enable it to cope with its multifarious problems. Moreover, as has been abundantly demon- THE SCHEME WE RECOMMEND 519 strated by experience, every increase in the advantageous- ness of the " relief" afforded by the Destitution Authority, and every enlargement of its powers of compulsory removal and detention, brings it into new rivalry with the other Local Authorities, and drags into the net of pauperism those who might otherwise have been dealt with as self- supporting citizens. If, as it seems to us, it has become imperative to put an end to the present wasteful and demoralising overlapping between Local Authorities, it is plain that it is the Destitution Authority — already denuded of several of its functions — that must give way to its younger rivals. Besides this paramount consideration, there are two incidental reasons which support our recommendation for the abolition of the Boards of Guardians in England, Wales and Ireland, and, so far at any rate as their Poor Law work is concerned, of the Parish Councils in Scotland. These are : — (a) The grave economic and administrative incon- veniences of the existing Poor Law areas ; and (b) The unnecessary multiplication of elected Local Authorities. In the great majority of cases the population dealt with by the Destitution Authority is too small to permit either of economical administration or of proper provision being made in separate institutions for all the various classes of paupers. Out of the 1679 districts into which the United Kingdom is divided for Poor Law purposes, four-fifths have populations which do not amount to 20,000 families each. Even in England and Wales more than two-thirds of the Unions include fewer than 10,000 families ; and 81 of these Unions actually have populations of fewer than 2000 families each. In Ireland, out of the 130 Unions, there are only 9 having as many as 10,000 families; and there are 12 having fewer than 2000 families. In Scotland, where this morcellement is carried to an absurd extent, a population smaller than that of London is dealt with by 874 separate Poor Law Authorities, nearly three-eighths of which rule over fewer than 200 families each. Any proper provision of specialised institutions for such small groups 520 THE SCHEME OF REFORM of people is absolutely impossible. In short, even apart from any other considerations, there are not more than about 100, out of all the 1679 Poor Law districts of the United Kingdom, in which it would be possible to make decent provision for the many separate classes which have to be differentially dealt with. We have received a large amount of evidence demonstrating conclusively that, if any new area is adopted for administration and rating, it cannot, on all sorts of grounds, practically be any other than that of the County and County Borough. On this point, which we think needs no further argument, we are glad to find ourselves in agreement with the majority of our colleagues. If the new area adopted be that of the County and County Borough, the Local Authority to be entrusted with the work cannot, we are assured by those best acquainted with local administration, be any other than the County Council and County Borough Council acting through its several committees. " You could not have two Authorities in the County area," declared to us a prac- tical County administrator, " we should always be clash- ing." " It would have to be done by the County Council," Mr. "Walter Long informed us. " Would you contemplate," he was asked, " setting up a new ad hoc Authority in the county area for any purpose whatsoever?" To this he replied emphatically, " None." The same testimony was given by Lord Fitzmaurice, who has so long worked in County government, and who declared himself opposed to any new County Authority for Poor Law purposes only. The setting up in London or in the County Boroughs of any separately elected body, for the same area, and levying rates on the same occupiers, appears equally impracticable. We therefore come inevitably to the proposal to transfer the duties of the Boards of Guardians to the Councils of the Counties and County Boroughs. In favour of this course there are many different argu- ments. We think that it will be generally recognised that the mere reduction in the number of separate Local Authorities, having separate powers of expenditure of the rates, and making separate demands on the time and ser- vice of the citizens willing to stand for election, is an THE SCHEME WE RECOMMEND 521 advantage in itself. It fortunately happens that, at any rate in the County Boroughs of England and Wales, which comprise one-third of all the population of that country, the various rivals to the Poor Law — the Local Education Authority, the Local Health Authority, the Local Pension Authority, the Local Unemployment Authority, the Local Police Authority and the Local Authority for the Mentally Defective — have one and all become committees of the Town Council. In the Metropolis, and in the counties, the several Committees of the County Council already deal with the same services, though they may share their administration, so far as local duties are concerned, with corresponding committees of minor local authorities. The abolition of the Boards of Guardians, and the adoption of the area of the County and County Borough would, in England and Wales at any rate — with appropriate arrange- ments to meet the cases of the Metropolitan Boroughs in London and of the Non-County Boroughs and Urban and Rural District Councils in the other Counties — enable a very desirable unification of Local Government to be carried out. In this proposal to make the County and County Borough Councils financially responsible for all the duties at present performed by the Boards of Guardians, we are glad to find ourselves in agreement with a majority of our colleagues. We difi'er from them in this matter in the extent to which they seek to withdraw the new services from the control of the County or County Borough Council itself, and in the way in which they attempt to determine by what machinery of committees and sub-committees the Councils shall carry out the work entrusted to them. We cannot help thinking that these are matters which, in prac- tice, the Councils will decide for themselves. We doubt whether any provision of Parliament will prevent a Town or County Council exercising whatever measure of control it chooses over a service entrusted to one of its committees for which it has to find the money. And we cannot help thinking that in adopting as their own the proposal that the unit of area should henceforth be the County and County Borough, and that the supreme authority should be the County Council and County Borough Council, the 522 THE SCHEME OF REFORM majority of our colleagues have rendered inevitable the adoption of the principle of distributing the Poor Law services among the committees already concerned in those very services. We cannot imagine, for instance, the Education Committee of the Manchester Town Council handing over to the tender mercies of any new statutory Poor Law Committee the residential schools for defective children, the Day Industrial Schools, or the provision of dinners for hungry children, in which the Councillors take so much pride ; or the Health Committee handing over to the new Poor Law Committee the exact contingent of the patients in its Isolation Hospitals and Phthisis Wards who are declared to be destitute. If the responsibility for the administration of the various services of the Poor Law is imposed on the Manchester Town Council at all — if it has to levy the Poor Rate to support the Poor Law Schools at Swinton and the Poor Law Infirmary at New Bridge Street — it may confidently be predicted that it will make its own Education Committee and its Director of Education answerable for the one, and its own Health Committee and Medical Officer of Health answerable for the other. (ii.) The Distribution of the Services of the Destitution Authority We have satisfied ourselves that, in England and Wales at any rate, and we think also in Scotland — Ireland pre- senting a somewhat different problem — there would be no serious difficulty in all the various functions of the Poor Law being undertaken by the several committees of the existing Local Authorities. AVe prefer to reserve for subsequent examination, in Part II. of this Report, the whole class of the Able-bodied, whether Vagrants, Paupers or the Unemployed, for whom we shall propose a national organisation. If, however, it were decided to leave this class also to Local Authorities, there would be no difficulty in entrusting this branch of the work to its own appro- priate Committee of the County or County Borough Council, in which the existing Distress Committee under the Unemployed Workmen Act would be merged. THE SCHEME WE RECOMMEND 523 (a) The Duties to he Transferred to the Local Education Authorities Witli regard to the children of school age at present dealt with under the Poor Law, the course is easy. We believe that public opinion is wholly in favour of the transfer, in England and AVales, of the entire care of the pauper children of school age to the Local Education Authorities, under the supervision of the Board oi Educa- tion. We need not recapitulate the manifold advantages of dissociating, once for all, the whole care of the children from any connection with pauperism. Up and down the country the Local Education Authorities, as we have seen, are already providing not only schooling but also mainten- ance for many thousands of children ; they have actually, in some cases, their own residential schools and their own arrangements for " boarding-out " ; they have their own machinery for searching out cases where the children are being neglected, and for the systematic medical supervision of practically the whole child population. Already, throughout Great Britain, there has been transferred to the Local Education Authorities the whole schooling of nine- tenths of the children under the control of the Destitution Authorities, and to the Board of Education for England and Wales the inspection of the remaining Poor Law schools, etc., in that country. The Local Education Authorities already deal with so many children that the addition to their work involved by this transfer is proportionately small. The Education Committee of the Gloucestershire County Council, for instance, has about 50,000 children under instruction. The dozen or so of Boards of Guardians in the corresponding area of the County have among them all scarcely 1000 children of school age in their charge, and of these only between one and two hundred receive institutional care. The thirty-one Boards of Guardians of the Metropolis have in their charge perhaps as many as 25,000 children of school age, of whom some 15,000 receive institutional treatment. The super- vision of this number would make no great difference to the work of the Education Committee of the London 524 THE SCHEME OF REFORM County Council, which deals already with nearly 1,000,000 children. Where educational administration is shared between the County Education Committee and a Minor Authority — as, for instance, where the Council of a Non- County Borough or of an Urban District administers its own elementary day schools — the responsibiUty for the custody and care of the children at present under the Board of Guardians would naturally pass to the County Education Authority, which might use the day schools of the Minor Authority just as the Board of Guardians does. (h) The Duties to he Transferred to the Local Health AuthoHties The duties to be transferred from the Board of Guardians to the Local Health Authorities — the provision for birth and infancy, the treatment of the sick and the incapacitated, and the institutional provision for the aged — cannot be disposed of so simply as those relating to children of school age. Let us begin with the case of the County Boroughs, which now include one-third of the whole population of England and AVales. Here there is already a Health Committee of the Town Council, which has its own Medical Officer of Health, its own staff of doctors and sanitary inspectors, often also of Health visitors and nurses. It usually has its own hospital or hospitals, and sometimes its own sanatorium. If it were made responsible for all the treatment of the sick, domi- ciliary as well as institutional, the addition of the Poor Law Medical Officers to its staff, and of the care of the pauper sick to its work, would involve practically no difficulties. Similarly the provision for birth and infancy and for the institutional treatment of the aged could easily be added to the existing duties of the Health Committee. Outside the County Boroughs the functions of the Local Health Authority are at present everywhere shared between the County Council, with its County Medical Officer, and a Minor Health Authority, which may be (in the Metropolis) a Metropolitan Borough Council or the Corporation of the City of London ; or (in other Counties) THE SCHEME WE KECOMMEND 525 the Council of a Non-County Borough, or that of an Urban Sanitary District, or that of a Kural Sanitary District. We have received much evidence in favour of the abolition of the smaller Minor Health Authorities, and of the exten- sion of the Public Health functions of the County Council. But assuming the existing organisation in this respect to remain undisturbed, at any rate so far as the larger Local Health Authorities are concerned, it would, we think, not be difficult to divide the duties now performed by the Boards of Guardians in respect of Birth and Infancy, the treatment of the sick and incapacitated, and the institu- tional treatment of the aged, appropriately between the County Health Authority and the Minor Health Authority. To the former would fall, along with the general supervision of the Public Health of the County as a whole, the admin- istration of all the institutions transferred from the Boards of Guardians, or established in order to provide for the classes of patients hitherto dealt with by the Poor Law Authorities. The advantages of a unified and properly graded institutional organisation for the County as a whole, together with the financial saving of such an organisation to every part of the County, appear to us so great that this unified County service should, at all hazards, be insisted on. In the Non-County Boroughs having over 10,000 population, and in the Urban Districts having over 20,000 population, we should be inclined, with regard to the Outdoor Medical Service of the Poor Law, to follow the precedent set by the Education Act of 1902 with regard to elementary day schools, and to allow these Minor Health Authorities, if they so desired, to take over the present District Medical Officers, and to undertake, under the general supervision of the County Medical Officer, the domiciliary medical service for their respective districts — provided always that they were prepared to organise, out of these officers and the present Public Health staff, a unified medical service under the direction of an adequately salaried, qualified Medical Officer devoting his whole time to the work. With regard to the Non-County Boroughs of less than 10,000 population, the Urban Districts of less than 20,000 population, and the Kural Sanitary Districts, 526 THE SCHEME OF REFORM whatever their size, we are satisfied that these Authorities have neither the means nor the ofiicial staff that are requisite for the performance of the duties already assumed by them under the Public Health Acts. For them to bring their sanitary services, and especially their drinking- water supply and their drainage systems, even up to the National Minimum, would involve, in many cases, a local rate of crushing weight. To expect them to equip their little districts adequately with hospital accommodation for scarlet fever, let alone for tuberculosis, is, for the most part, hopeless. We cannot recommend the transfer to such Authorities of any part of the work now done by the Boards of Guardians in this department. This work should, in respect of their districts, be wholly assumed by the Health Committee of the County Council, under the direction of the County Medical Officer. The small Non- County Boroughs and Urban Sanitary Districts should be encouraged (as the former have been in the matter of their autonomous police forces) to cede even their present Public Health services, in whole or in part, to the County Council, in order that they may be merged in the unified establish- ment under the County Medical Officer. They should, for instance, receive no part of the proposed new G-rant-in-Aid of the expenditure of the Local Health Authorities, pay- able as this would be in order to enable the larger Health Authorities to undertake new services which will not devolve upon these smaller Health Authorities. The same lines should be followed with regard to the Rural District Councils ; unless, indeed, these can be, on their ceasing to be also the Boards of Guardians, altogether abolished, and their duties with regard to road maintenance, sanitation, etc., shared between the County Council and the Parish Councils. In the Metropolis, pending a more complete re- organisation of Local Government, the transfer should proceed on analogous lines, all the Poor Law institutions, including the hospitals and special schools of the Metro- politan Asylums Board, passing to the Health Committee of the County Council ; whilst the District Medical Officers in each Metropolitan Borough would become part of a unified medical service for street and house sanitation and THE SCHEME WE RECOMMEND 527 domiciliary treatment, directly under a qualified Borough Medical Officer, and subject to the general supervision of the County Medical Officer. (c) The Duties to he Transferred to the Local Pension Committee Even whilst we were considering the matter there has been established, by every County and County Borough Council under the Old Age Pensions Act of 1908, a Local Pension Committee, charged with the confirmation of the pensions to be granted to more than half the poor persons over seventy years of age. We propose that this Com- mittee should deal also with those aged who are for one reason or another not entitled to National Pensions, but for whom Local Pensions are recommended. The practical convenience of there being one and the same Committee to deal with both classes of aged — those whose pensions will be payable from the National Exchequer and those whose pensions will be payable from Local Funds — is so obvious that we do not think the point needs further discussion. {d) The Duties to he Transferred to the Local Committee for the Mentally Defective The Report of the Royal Commission on the Care and Control of the Feeble-minded makes it clear, we think, that there should be transferred to a new Local Committee for the Mentally Defective — virtually the existing Asylums Committee of the County or County Borough Council — the care of all persons legally certified to be of unsound mind, whatever their age or physical condition, whether these be lunatics, idiots, imbeciles or epileptics ; whether they be certified under the Inebriates Act ; or whether they be registered as feeble-minded, or as morally defec- tive, under the proposed extended classification. This conclusion, which we entirely accept, involves the transfer, to an enlarged Asylums Committee of the County or 528 THE SCHEME OF KEFORM County Borough Council, of the institutions established by one or two such Councils under the Inebriates Act, of the special institutions here and there established for epileptics, of the special schools for mentally defective children, and of those inmates of Poor Law institutions — estimated, for England and Wales alone, at 43,000 in number — who may in due course be certified as feeble- minded. It involves also, in London, the transfer of the asylums for imbeciles, etc., of the Metropolitan Asylums Board to the new Mentally-Defectives Committee of the London County Council, in which its present Asylums Committee would be merged. (iii.) New Machinery for the Co-ordination of Public Assistance At the present time, whilst much distress goes wholly untreated, some families are in receipt, at one and the same time, for one or other of their members, of regular Outdoor Relief from the Board of Guardians, school meals for the children from the Education Committee, milk below cost price, medical advice gratis, and maintenance in hospital from the Health Committee, and, in some towns, even gratuitous clothes from the police — besides a flow of doles from religious and charitable agencies. Whether or not any of the public assistance given to one family by the various agencies will be charged for, and whether or not the charge will be enforced, is, as we have seen, almost a matter of chance. One family may be getting everything free, even free of inquiry. Another family, in receipt of relief on account of its destitution, may find its head suddenly removed to gaol for not refunding the cost of the maintenance of his child in an industrial school. To abolish the Board of Guardians, and merge its duties in those Committees of the County or County Borough Council who are already dispensing their own forms of public assistance, will diminish the present overlapping, but will not, of itself, end it. Some systematic co-ordination, within each local area, of all forms of public assistance, and, if possible, of all assistance dispensed by Voluntary THE SCHEME WE RECOMMEND 529 Agencies, is essential, if we are to put an end to the present demoralisation. (a) The Registrar of Public Assistance The first condition of co-ordination is a centre of information about all the public assistance that is being dispensed in a given locality. We therefore recommend the appointment, by the County or County Borough Council, of one or more responsible ofiicers, each having jurisdiction in a district of suitable area and population. For the less-populous County Boroughs and the smaller Counties, one such ofiicer, sitting on successive days in different parts of the district, would probably sufiice. For the most extensive Counties, as for the Metropolis, there might have to be half a dozen, sitting weekly in as many as thirty different localities. We propose that these officers, who might be designated Registrars of Public Assistance, should have a threefold duty. They should be responsible for keeping a register, with " case papers " of the most approved pattern, of all persons receiving any form of public assistance within their districts, including treatment in any public institution. They should have the duty of assessing, in accordance with whatever may be the law, the charge to be made on individuals liable to pay any part of the cost of the service rendered to them or their dependants or other relations according to their means, and of recovering the amount thus due. Finally, we propose that these officers should have submitted to them any proposals by the several Committees of the Council for the payment of what is now called Outdoor Relief, but what should in future be termed Home Aliment, in connection with the domiciliary treatment of cases in which such treatment was deemed preferable to institu- tional treatment. The Registrar should also determine, in case of need, to which Committee of the Local Authority any neglected or marginal cases belonged for treatment. VOL. I 2 m 530 THE SCHEME OF REFORM (h) The Public Register To the first of these duties, the keeping of one common Register of all the various forms of assistance given in the locality, we attach great importance. This registration should be automatic and continuous, without regard to status or means, or the kind of treatment given. All public Authorities should be required to forward, daily or weekly, full particulars of every case in any way dealt with, whether it were that of a rich man admitted as a paying patient to the County Lunatic Asylum, or that of a poor man whose child was being fed at school, or whose wife was receiving milk at a nominal charge ; whether it were a County Bursary to Oxford or compulsory admission to an industrial school. We should earnestly invite all voluntary hospitals, dispensaries and other institutions regularly to send in similar information. In course of time, we should hope to get recorded in this Register the persons assisted by every public or private agency within its district. The Registrar would thus be able to see, at once, whether different members of the same family were receiving assistance without this being known, or whether different Authorities, in ignorance of each other's doings, were simultaneously aiding the same person. In this branch of his duty, he would confine himself to communi- cating the information to the various Local Authorities, to the Registrars of other districts where necessary, and to such voluntary organisations as had affiliated themselves. (c) Charge and Recovery The second function of the Registrar would be to put on a systematic and impartial basis the recovery of the cost of the public assistance rendered, where any legal liability existed for its repayment, and where the recipients or other persons liable were really able to pay. We have already described the unutterable confusion that at present exists in this respect — a confusion in which the Local Health Authority and the Local Education Authority have their shares, no less than the Destitution Authority. THE SCHEME WE RECOMMEND 531 We do not here discuss the question as to which public services should be charged for, to what extent relations of different degrees of kinship should be made to pay for those to whom they are akin, and what amount of earn- ings or income should be held to constitute ability to pay. These points must be determined by Parliament, in a con- sistent code. But, as we have seen, clearness and con- sistency of the law will not bring about impartiality and consistency in the practice, so long as the matter is left to the haphazard decisions of irresponsible committees of shifting membership. It is, we think, essential that the charge to be made in each case should be assessed, accord- ing to the exact terms of the law and the definite evidence as to means, after systematic inquiry, by a single officer dealing with the cases judicially. His decisions might, of course, be made subject to appeal. We regard it as a special advantage of this proposal that, under it, the question of chargeability and recovery of cost is altogether removed from the consideration of the officers and Committees who are responsible for the decision of whether or not a case is in need of treatment, and of what kind of treatment. At present, some Local Authorities refuse to treat a person, who is admittedly in need of treatment, because they choose to think that he or his relations could pay for what he needs. The result is that, to the grave injury of the community, many cases remain untreated. Other Local Authorities go on the plan of treating all who need treatment, on the assumption that any one found to be in actual need of treatment has not the pecuniary resources to enable him to get it at his own expense. The result is that many persons who might fairly pay something escape all contribution. If we desire that all those should be treated whom it is important, in the public interest, not to leave untreated, and that, in the interest of public economy and personal independence, all those should pay who can afford to do so, we must separate the two processes. If it is thought right to segregate all the different grades of the mentally defective, to leave no child uneducated, to prevent disease and restore as quickly as possible the sick to health, and to 532 THE SCHEME OF REFORM provide decent maintenance for the aged, we ought not to allow the Local Authorities responsible for the treat- ment to be hampered in their work by considerations as to whether or not the individual, or any of his relations, ought, according to the law of the land, to pay for what is required to be done ; and whether or not he or they are of sufficient ability to do so. On the other hand, if we wish to put a check to the practice of getting gratuitously from the public what the individual is quite well able to pay for, and to restrict to the really necessitous cases the spread of gratuitous treatment by the Local Authority, we ought not to let those who are charged with the recovery of contributions be hampered by considerations of whether it will not be dangerous to let the case remain untreated, or by the natural desire of the managers of institutions to make them as widely useful as possible. The Registrar of Public Assistance, having nothing to do with the treatment of the cases, would deal with them exclusively from the standpoint of legal liability to pay, and economic ability to do so. In whatever branches of public service Parliament decided that a charge should be made — for instance, maintenance in the County Lunatic Asylum — the Registrar would automatically investigate all cases reported to him ; and would assess the charges on the patients' estates, or on their legally liable relations, exclusively according to the law and to the evidence of means, exactly as the Inland Revenue officers deal at present with the assessed taxes. For this purpose, the Registrar would be provided by the County or County Borough Council with a suitable staff of Inquiry and Recovery Officers, dealing impartially and on like prin- ciples with rich and poor. We feel no doubt that the additional revenue which would thus be obtained, from patients and from the relations legally liable for their maintenance — even after exempting all those who were not of sufficient ability to contribute — would be very large, and would more than cover the entire expense of the Registrar and his establishment. The existence of such an officer would, if it were desired, enable effective measures to be taken to stop THE SCHEME WE KECOMMEND 533 what is called "hospital abuse." It is complained that, among the crowds of patients of the voluntary- hospitals and dispensaries of the Metropolis, and of some other large towns, there are many persons well able to pay the whole or part of the cost of the treatment or main- tenance that they are obtaining from the benefactions of the charitable. The hospitals, absorbed in the desire to treat cases, especially those that are instructive or inter- esting, and without any effective machinery for ascertain- ing the resources of their patients, have hitherto failed to cope with this problem. If the hospitals and dispensaries choose to make it a rule that the names and addresses of all persons whom they are benefiting should be forwarded daily to the Registrar of Public Assistance, he would be able, by means of his staff of Inquiry and Recovery Officers, to discover their economic circumstances. He might even, at the request of the hospital, be authorised to present a bill for the whole or part of the cost of the treatment, to such persons as might be found to be able to pay. Payment of this bill, under the present state of the law, would be optional ; but we have been informed by trustworthy witnesses that in many cases such patients would willingly discharge their debt, if a bill were sent in. It might be a matter for further consideration by Parlia- ment, whether the practice of charge and recovery for treatment in voluntary hospitals and dispensaries might not, with advantage, be put on the same legal footing as treatment in the hospitals and dispensaries of the Local Authority. (d) Sanction of Home Aliment So far as institutional treatment is concerned, there would be no harm in letting all the various Authorities — for instance, the Health Committee, the Education Committee, and the Asylums (or Mentally-Defectives) Com- mittee — admit, to the several institutions in their charge, all the persons whom they deemed in need of the particular treatment of these institutions, without any other co-ord- inating machinery than that of the Public Register and 534 THE SCHEME OF REFOKM the automatic recovery of the cost when legal Hability aud sufficient ability were found to exist. But in the great majority of cases — at present three out of every four — it is not necessary or desirable to incur the great expense of institutional treatment, especially as, in many instances, the cases can actually be more efficiently treated in their, own homes. To permit the same freedom in the granting of Home Aliment to all the various committees of the County or County Borough Council, each one merely con- sidering the needs of the particular member of the family — the child, the mother and infant, the sick father, the aged grandmother — might easily result, as it frequently does at present, in one family obtaining more than the current income of a respectable artisan. Nor will the establishment of a common register do more than mitigate this evil. What is required is that, before any (beyond temporary) public assistance is given in the home, there should be due consideration, not merely of the need, in respect of treatment, of any individual, but of the circum- stances of the family as a whole. We cannot afford to have the Education Committee granting Home Aliment for the children of an admirable widow, who is living in an altogether insanitary home ; or the Committee for the Mentally-Defectives deciding, for the sake of economy, to pay for the retention at home of a feeble-minded girl without regard to the consequences to the young children in that home. And it would never do to let all the several Committees be granting Home Aliment without a common standard of economic necessities, and due regard for the possible effect in subsidising wages. The only way to ensure that the family shall always be regarded as a unit, and that all the circumstances — educational, moral, sani- tary, and economic — shall be taken in due proportion into account, is to make each Committee submit its proposals as to Home Aliment to an authority external to them all. For this purpose, the Registrar of Public Assistance, him- self an officer of the County or County Borough Council, necessarily in constant communication with every depart- ment through his Public Register and his proceedings for charge and recovery, equipped with his own staff of THE SCHEME WE RECOMMEND 535 income assessors, and able to hear evidence from the educational and sanitary officials of the various treating Committees, seems the ideal arbiter. We propose, there- fore, that (apart from the provision for " sudden or urgent necessity") it should be necessary for any Committee thinking the domiciliary treatment of a case desirable, and proposing to grant Home Aliment, to submit the case for sanction to the Registrar of Public Assistance, who would be charged to satisfy himself that the circumstances of the family as a whole warranted the grant, and that the amount proposed was neither inadequate nor excessive. If the grant was sanctioned, we propose that the case should come up automatically before the Registrar for revision every three months, or even every month, whichever may be thought preferable. If sanction were withheld, it would still be open to the Committee to admit the patient to the appropriate institution ; and where the need was urgent, it would be their duty to do so. But there should be an opportunity of appeal, hy the Committee responsible for treatment, against the decision of the Registrar ; an appeal which, in view of the importance of securing uniformity of practice throughout the kingdom with regard to Home Aliment, we think should lie, following the successful pre- cedent of the present appeal to the Local Government Board for Scotland, to a Central Department ; which (in order to keep it apart from Education, Public Health, etc.) might conveniently be that supervising Local Finance. An incidental advantage of the distribution, among the various committees of the County and County Borough Council, of the different services now aggregated together under the Destitution Authorities, would be that it would thus enable us to bring uniformity and judicial impartiality into the grant of what is now called Outdoor Relief As we have seen, it is impossible to expect to get either uniformity or impartiality in decisions on successive cases, if these decisions are arrived at, without automatic check or guidance, by such a many-headed tribunal, of such mutable membership, as is presented by a representative committee. There is no reason to think that the several committees of the County or County Borough Councils, 536 THE SCHEME OF REFORM subject as they would be, though possibly to a lesser extent, to the same influences, would, if they had to per- form exactly the same duties as a Board of Guardians, be able to arrive at much greater uniformity or impartiality between case and case, than the members of the Destitu- tion Authority. Merely to transfer the work of the Board of Guardians to a single Poor Law Committee of the Town Council would, therefore, in this respect, produce no sufficient reform. Nor could the Outdoor Relief be withdrawn from their jurisdiction. So long as it can be assumed that all the members of the same family — the infant, the child of school age, the sick adult, and the helpless aged person — will all be treated by one and the same Committee, it will never be practicable to withdraw from that Committee the duty of considering all the economic and other circumstances of the family as a whole, and the right to decide according to its own view of what is desirable, how much Outdoor Relief should be granted. But when the services are divided among several com- mittees the case is obviously altered. The Education Committee will admit that it is impossible to allow the Health Committee, the Mentally -Defectives Committee and the Pension Committee — not to mention the possible Local Committee for Unemployment — all to be giving Home Aliment to the different members of one and the same family, without the proposals being made subject to some co-ordinating control. Thus, for the first time it will become possible, whilst leaving to representative com- mittees, directly responsible to the ratepayers, the whole treatment of the cases, whether in the institutions or in the home, and even the full responsibility for proposing the grant of Home Aliment, to secure the advantage of a judicial consideration, case by case, of the economic and other circumstances involved. (e) The Registrar s Receiving House for Omitted Cases Under the scheme we propose, each treating Committee would have its own arrangement (as, indeed, exists at present wherever the service is well organised) of Receiving THE SCHEME WE KECOMMEND 537 Homes, or Observation or Probation Wards, into which it would take its patients, on their way to one or other of its institutions. But there are " mixed " cases, in which several Committees may be concerned ; there are the cases of persons without known abode, who have not been dis- covered by the searching officers ; there are the cases of persons found " on the road " by the police, or reported by neighbours to be in distress without the nature of the distress being ascertained ; there may even be cases in which treatment has been refused, and is alleged to have been wrongfully refused, by one or other of the Local Authorities. Moreover, if we are to distribute the various forms of public assistance among three or four specialised Committees, it will be necessary that there should be, in each district, one well-known public office where immediate relief can be obtained, in cases of sudden or urgent necessity, or when it is not known to which Department application for treatment should properly be made. We propose, therefore, that there should be in each district, under the immediate direction of the Registrar, a small and strictly temporary Receiving House, which might often be com- bined with some other public office, and which should be always open. The number and extent of such Receiving Houses would naturally differ from county to county. It should be rigidly insisted on that no person should be allowed to stay in them for more than the few days required for the adjudication of his case. In London and other populous places each Receiving House would have to be sufficient to accommodate all the cases coming in during, say, one week. In rural counties the number would be governed more by geographical considerations. But with a complete use of telegraph and telephone and a motor ambulance, it is suggested that very few Receiving Houses would be needed. With every police-station, every medical practi- tioner, and every county officer in telephonic communica- tion — presently, we may assume, with every village post- office on the telegraph, if not even on the telephone — and with a motor ambulance at call that would take a person 20 miles in an hour — the area that might be effectively 538 THE SCHEME OF REFORM served by a centrally placed Receiving House in a rural district might be (even assuming only a 30 miles' radius) as much as 2800 square miles, which is much larger than most counties. With the general specialising of institu- tions, it would be possible to set aside some of the smaller Workhouses as Receiving Houses. It would be part of the function of the Registrar, on his daily or weekly visit to each part of his district, to "deliver" the local Receiving House of all the persons who had drifted in there since his last visit ; allocating them, and directing their conveyance, to the Receiving Departments of the institutions appropriate to their state. It would be obligatory that the Registrar's instructions in this respect should be obeyed ; but the Committees con- cerned would be free to bring the cases before him at a subsequent sitting and to show cause why they should be transferred to the care of some other Committee, or placed on Home Aliment, or summarily discharged as not needing treatment. (f) The Registrar as National Pension Officer We think that the Registrar of Public Assistance — associated as he would be with all forms of public service, those enjoyed by persons in easy circumstances as well as those taken advantage of only by the poor — would be an ideal officer to adjudicate, on behalf of the National Government, on applications for Old-Age Pensions. He would have at his command his own permanent staff of Inquiry and Recovery OflSicers, who would possess an unrivalled knowledge of the economic circumstances of the great majority of the families of the district. After the first award of pensions has been made in 1909, the number of applications to be dealt with annually will be only about one-tenth of the numbers of that year ; and, spread as they will be over the whole twelve months, will be insufficient to occupy the whole time of even one officer in each locality. Nevertheless, it would be very in- convenient to all concerned not to have Pension Officers available in each locality. We cannot help suggesting THE SCHEME WE RECOMMEND 539 that there would be positive advantages in making the Registrar of Public Assistance act also as National Pension Officer ; and in placing the Local Pension Committee — at any rate in respect of the Local Pensions which we propose that it should grant — in the same sort of relation to him as the Local Education Committee and the Local Health Committee will be when they propose to grant Home Aliment as an adjunct of their domiciliary treatment. (g) The Status of the Registrar We propose that the Registrar of Public Assistance should be an officer of high status and practical permanence of tenure. We would leave the appointment freely in the hands of the County and the County Borough Councils, relying on their choosing officers of tried experience in administration (especially in connection with the Poor Law), and preferably of some kind of legal training. As it is essential that the Registrar should be entirely in- dependent of the committees concerned with the grant of Home Aliment, we propose that he and his staff, and his Receiving House, should be placed under the General Purposes Committee of the County or County Borough Council. If the Registrar were made use of, as we suggest, by the National Government, as the adjudicator of claims to Old-Age Pensions, this would have the great advantage of enabling the Treasury to contribute a portion of the salary and expenses of his office ; an arrangement which, whilst affording some financial relief to the County and County Borough Councils, would, of course, entail the concurrence of the Treasury in the appointment and dismissal, and thus secure, in the least invidious manner, that practical security of tenure which seems desirable. (c) Conditions of Eligibility for Public Assistance In describing the overlapping and confusion of spheres between the Destitution Authority on the one hand, and the Local Health Authority, the Local Lunacy Authority, the Local Education Authority, the Local Police 540 THE SCHEME OF REFORM Authority, the Local Pension Authority, and the Local Unemployment Authority on the other, we found the posi- tion obscured by two rival and inconsistent conceptions — not explicitly stated or clearly realised — of what exactly constituted " destitution," or the condition in respect of which the public assistance was rendered. Under the Poor Law, whether in England or Wales, Scotland or Ireland, no one, it is asserted, can be relieved who is not in a state of destitution, and this term has a technical meaning. " Destitution," as we were authoritatively in- formed, " when used to describe the condition of a person as a subject for relief, implies that he is for the time being without material resources (1) directly available ; and (2) appropriate for satisfying his physical needs (a) whether actually existing, or {h) Hkely to arise imme- diately. By physical needs in this definition are meant such needs as must be satisfied (1) in order to maintain life ; or (2) in order to obviate, mitigate or remove causes endangering life, or likely to endanger life, or impair health, or bodily fitness for self-support." It will be seen that, to the Destitution Authority, it is not the actual mental or physical condition of the patient, but the absence of material resources, that is the governing consideration. Thus, if a child is, in fact, suffering in health, or is even in danger of death, from lack of food, clothing or medical attendance, or from a total absence of home care, but the responsible parent, being present, has himself £2 a week coming in, and food actually in the house, the Destitution Authority cannot legally relieve the child. There is no lack of the necessary " material resources," and therefore, in the Poor Law sense, the child is not destitute. Similarly, the Destitution Authorities are advised that they can take no action in cases of disease, so long as the disease has not as yet interfered with a man's earning his livelihood, and that, in fact, he has money in the house. It is even doubtful whether a Board of Guardians can lawfully intervene when a miserly and half-imbecile old woman is lying alone in her cottage, in a state of filth, disease and neglect likely to lead to early death, and yet, to the knowledge of the Relieving CONDITIONS OF ELIGIBILITY 541 Officer, has a bag of gold under her bed, and bread in the house. There is no absence of material resources, and therefore, in the Poor Law sense, no destitution. And, as our analysis of the Bylaws and practice of the Boards of Guardians shows, it is held not to be necessary that these economic resources should belong to the applicant, if he has, in fact, access to them. " Destitution," states the Clerk of Dudley Union, " is always a question of fact, and the Guardians are bound to take into consideration all sources of income or assistance which affect the applicant." There are two remarkable statutory exceptions which, by their very existence, confirm this accepted interpreta- tion of " destitution " under the Poor Law. In the case of the lunatic, the Relieving Officer intervenes whether or not there are material resources. But this action of the Poor Law Authorities required special legislation. Similarly, when it was thought expedient to give Poor Relief to members of Friendly Societies, in spite of the fact that they possessed definite incomes, it required an Act of Parliament. Thus, in the absence of special legislation, the view taken is that Poor Relief is only for those who are pecuniarily destitute. This view it is, whether or not legally correct, which has dominated the Destitution Authorities and coloured all their activities. Very different is the standpoint of the other Authorities. Under the various statutes which the Local Education Authority, the Local Health Authority, and even the Local Unemployment Authority carry out, the condition which sets them in motion is not destitution in the sense of the absence of material resources, but the existence in the person dealt with of conditions which, without the intervention of the Public Authority, would produce consequences inimical to the common weal. This we must designate, for lack of a better term, " personal destitution " or " physiological destitution." The necessary conditions may or may not co-exist with the presence of material resources — a consideration which may affect the pecuniary charge to be made in return for the services of the public Authority, but not the rendering of the services them- 542 THE SCHEME OF REFORM selves. Thus, in the case of a child found destitute of education, of a person suffering from small-pox destitute of proper treatment and facilities for isolation, of a boy running wild in low company, destitute of proper parental control, the presence or absence of material resources is wholly irrelevant to the rendering of the appropriate service. Moreover, these specialised Local Authorities are not required to wait, and do not, in practice, wait, until the injury to the community has actually begun. Thus, the School Attendance Officer registers the child long before it actually attains school age, and advises the mother which school it should presently attend, so that there may never be any " personal destitution " in respect of his service. The Health Visitor counsels the mother, and even tenders municipal milk, before the infant is ill, deliberately in order that it may not become ill. The Medical Officer isolates " contacts," though they are not ill, and though there is no known contagion, merely out of precaution. But Boards of Guardians in England, Ireland and Wales, and Parish Councils in Scotland, take the view that they have no power to intervene until the state of destitution — however broadly they may choose to interpret this term — has been actually entered upon. "It is certainly not the duty of the Guardians to anticipate it." This contradiction between the two versions of the conditions of eligibility for Public Assistance has a large share in producing the confusion and overlapping that we have described. Moreover, a lack of appreciation of the exact contrast has, we think, on both sides, stood in the way of a proper exercise of the powers of Charge and Recovery. We think it important that this confusion of thought should be cleared up. It is essential, for the attainment of the very objects for which the several "treating" Authorities are constituted, that they should continue to adopt, so far as their treatment is concerned, the definition that we have designated " personal " or " physiological " destitution. These Authorities must, in order to prevent injury to the community, take action whether or not there are material resources. We propose CONDITIONS OF ELIGIBILITY 543 that they shall act on the same principles in the enlarged sphere that we assign to them. We consider that it is the maintenance of the contrary view by the Destitution Authorities — the insistence on pecuniary destitution — which has excluded them from the whole domain of preventive work, and has given to their operations, humane and philanthropic though they are, their char- acteristic barrenness. On the other hand, after the appropriate service has been rendered to the person in need of it, the question may quite properly be raised whether a Special Assessment ought not to be made upon him in repayment of the cost. At this point what is relevant is not whether he needs the service (" personal " or " physiological " destitution) ; but whether he or any one responsible for him has sufficient means to warrant a charge being made upon him. In our chapter on "Charge and Recovery " we have described the chaos into which this realm has fallen. It is one of the advantages of the Scheme of Reform that we advocate that, under it, the " treating " Authority — acting on what we have called "personal" or "physiological" destitution — is entirely divorced from the official machinery for Charge and Recovery, the Registrar of Public Assistance acting according to " pecuniary destitution," at whatever level of means Parliament may decide. We pass now to the question of the degree of need — that is, of " personal " or " physiological " destitution — which should set the several "treating" Authorities in motion. The Legal Adviser of the Local Government Board informed us a person was entitled to have satisfied, at the expense of the Poor Rate, if he was without the means of satisfying them, " such needs as must be satisfied (i.) in order to maintain life ; or (ii.) in order to obviate, mitigate or remove causes endangering life or likely to endanger life or impair health or bodily fitness for self- support." This would seem to entitle an artisan or small shopkeeper, able to maintain himself and his family, but needing, to save his life, an expensive surgical operation, not merely to have this performed at the expense of the Poor Law, but even to have provided for him whatever 544 THE SCHEME OF REFOKM was necessary — expensive treatment, mechanical ap- pliances, and maintenance in convalescence — to restore his " bodily fitness for self-support." It is clear that the Local Government Board's definition would involve a great increase in Poor Law expenditure in respect of specialised hospitals, convalescent homes and " medical extras." We are disinclined to go as far in the provision of Public Assistance as is involved in Mr. Adrian's words. We accept as a better working definition of the conditions under which PubHc Assistance should be granted, that given by the Royal Commissioners on the Aged Poor, when they said that "Destitution might be taken in practice to mean a want of the reasonable necessaries of life, such as food, lodging, warmth, clothing and medical attendance according to the normal standard of the times." The "normal standard of the times" impHes a changing standard, increasing with the customary expendi- ture of the ordinary man. This is a less alarming proposition, and one well within our means. As a matter of fact, we do not find that the expenditure on sanitation, education, etc., even keeps pace with the rise in personal incomes ; still less does the total of all forms of Public Assistance keep pace with the growth of the public revenue of the country. Our whole expenditure on the poor, great as it is, bears a much smaller proportion to the aggregate revenue of the nation than it did a century (d) Disfranchisement It is, we think, one of the advantages of our Scheme of Reform that, with the break-up of the Poor Law and the abolition of Poor Relief, the whole apparatus of electoral disfranchisement, of persons who have the resi- dential qualifications for the franchise, will fall to the ground. We can see no practical advantage in disfran- chising a person because he has received the treatment which Parliament has provided for his case. The evidence goes to show that, so far as disfranchisement has any efiect at all, it is a " Test " of the very worst kind ; deterring DISFRANCHISEMENT 545 the good and self-respecting, and in no way influencing the willing parasite. Moreover, the present position is so illogical that it could not, in our opinion, anyhow, have been maintained. There is no disfranchisement for the person convicted of crime, even of the most shameful kind. There is even, contrary to the common opinion, nothing to prevent a pauper voting if he is on the electoral register ; and many of them actually do vote. Moreover, although the Statute does forbid paupers in England and Wales to vote at an election of Guardians, no means are usually taken to prevent those paupers who happen to be on the electoral register from exercising their franchise at an elec- tion of Guardians ; and there is nothing on the face of the register to hinder their votes being received. What does happen is that, once a year, when the register is being- revised, those persons (usually men only) whom the Clerk to the Guardians reports as having received Poor Relief (other than Medical Relief) at any time during the pre- ceding twelve months are struck off, whatever may have been the cause or occasion, or the momentary character of the destitution to which they were reduced. This does not prevent them from voting, although they are paupers, during the two or three months that the old register re- mains in force ; and it does prevent them from voting, even if they have long since ceased to be paupers, during the ensuing twelve months that the new register will be in force. In strict law the disqualification is absolute, even if the whole cost of the relief be immediately repaid ; and even if the pauperism be actually forced on the election by law, as when a dependent is, by magistrate's orders, com- pulsorily removed to the County Lunatic Asylum. On the other hand. Medical Relief only does not disqualify, and Revising Barristers differ from place to place how far treatment and maintenance in the sick "ward of the Work- house, or the Poor Law Infirmary, is merely Medical Relief. Where the patient is sent by the Board of Guardians to the Municipal Hospital, or to a voluntary institution, he may or may not find his name struck off the register according to the form in which the Board of Guardians takes the cost of his treatment out of the Poor Rate. If VOL. I 2 N 546 THE SCHEME OF REFORM he is paid for at so much per case per week, he will lose his vote, because this is (by local Government Board instructions) entered as Outdoor Relief 1 If (as is more usual) he is paid for in a lump sum, he will not lose his vote. Nor will he be disqualified (even for voting for the Home Secretary who has let him out of gaol !) if he has been maintained in prison at His Majesty's expense ; and if he is a free-holder or a University graduate, he will not even lose his qualification for next year's register by his enforced residence in prison. Nor will he be disqualified (even for voting for the Town Council which provides his relief) if he is admitted to the Municipal Hospital by the Medical Officer of Health, or given relief under the Unem- ployed Workmen Act ; or if his eldest son is maintained in a Reformatory School, his younger son in an Industrial School, and his feeble-minded daughter in a Custodial Home, or if his infant gets milk at the Municipal Milk Dis- pensary, or if his other children are medically treated and provided with spectacles out of the Education Rate ; or even if they are regularly fed at school. The absurdities of the present position are, indeed, so gross that no Minister of the Crown would think of proposing, and no House of Commons would dream of entertaining their explicit re-enactment. (e) The Sphere of Voluntary Agencies It is one of the advantages of the proposed distribution of the various services at present aggregated together under the name of Poor Law that it affords the oppor- tunity for initiating a really systematic use of voluntary agencies and personal service, to give to the public assist- ance that touch of friendly sympathy which may be more helpful than mere maintenance at the public expense, and to deal with cases in which voluntary administration may result in more efiective treatment than can be given by public authorities exclusively. It is a drawback of the Destitution Authority, which increases with its hyper- trophy, that it is constantly becoming the rival of these voluntary agencies. Relief Committees have never known SPHERE OF VOLUNTARY AGENCIES 547 how to use volunteer helpers, and they seem even to look upon philanthropic institutions as interlopers, because they are not managed by the Board of Guardians itself. We think that it should be a cardinal principle of public administration that the utmost use should, under proper conditions, be made of voluntary agencies and of the per- sonal service of both men and women of good will. But it is, in our opinion, essential that the proper sphere of this voluntary effort should be clearly understood. In the delimitation of this sphere, a great distinction is to be drawn between the use of voluntary agencies in the visita- tion of the homes of the poor, and the use of these agencies in the establishment and management of institutions. In the one case there should be absolutely no finding of money. In the other case, the more private money the better. With regard to the whole range of charitable work in connection with the home life of the poor, there is, in our judgment, nothing more disastrous, alike to the character of the poor and to the efhciency of the service of public assistance which is at their disposal, than the alms dis- pensed by well - meaning persons in the mere relief of distress. This distribution of indiscriminate, uncondi- tional and inadequate doles is none the less harmful when it is an adjunct of quite kindly meant " district visiting," the official ministrations of religion, or the treatment meted out by a " medical mission." Even when such gifts are discreetly dispensed by the most careful visitor, they have the drawback of being given without knowledge of what the other resources of the family may be, without com- munication to other agencies which may be simultaneously at work, and without power to insist on proper conditions. We are definitely of opinion that no encouragement what- ever should be given to any distribution of money, food, or clothing in the homes of the poor by any private persons or charitable societies whatsoever. The only exception to this rule should be a regular pension to a particular person ; and this ought, in all cases, to be notified to the Registrar of Public Assistance. It is not that we undervalue the utility of the personal visits of sympathetic and helpful 548 THE SCHEME OF REFORM men or women. On tlie contrary, we wish to see much more use made of this devoted service, which could, we think, be greatly augmented, if it were called for by public authorities. But this service of visitation, to be effective, must be definitely organised, under skilled direction, in association with a special branch of public administration. Such specialisation of home visitation is the only means of keeping at bay the mere irresponsible amateur, and of ensuring that the volunteer has been sufficiently in earnest to undergo some sort of technical training. The utility of such a service of specialised visitation has already been demonstrated in many directions. Thus, there are now a thousand or two of unpaid Health Visitors, acting under the direction of the Medical Officers of Health. Another example is afforded by the members of the Children's Care Committees, established in connection with the public elementary schools, and the analogous committees of the special schools of the London County Council. We see no reason why some such voluntary assistance should not be organised in connection with the Local Health Authority and the Local Education Authority in every district. We think, too, that similar voluntary assistance could be use- fully employed in connection with the work of the Local Pension Authority and the Local Authority for the Men- tally Defective. Such a band of volunteer helpers, acting within the framework of a specific municipal service, forms, in the densely populated districts of the great towns, an almost indispensable supplement to official activity. Such volunteers, able to devote to each case as much time as it requires, and bringing to bear a wider experience of everyday life than the specially trained and hard- worked official can do, may not only " search out " those who need public assistance, but may keep them con- stantly under observation before and after the treatment afforded at the cost of the rates, and may ensure that nothing is overlooked by which they may effectively be helped, and that, when restored to self-support, no relapse occurs without its being noted. It is, however, we repeat, essential that such domiciliary visitors should not have the distribution of money or relief in the homes, whether this SPHERE OF VOLUNTARY AGENCIES 549 be from public or private funds, their own or other people's. On the other hand, there is still enormous scope for beneficent gifts of money, to be administered under volun- tary management. There are many kinds of institutional treatment which the various public Authorities are not likely themselves to initiate ; and there are others that they are almost debarred from conducting. There is room for many pioneer experiments in the treatment of every type of distressed person. The whole tendency of modern applied science is to subdivision and the breaking-up of old categories into newer specialisations. We cannot expect our County and County Borough Councillors to launch out into experiments of this kind. Such private experiments in Industrial and Reformatory Schools, Technical Insti- tutes, Farm Colonies, Inebriate Retreats, Rescue Homes, and what not, have already greatly advanced the technique of these services. In this field of initiating and developing new institutional treatment — whether it be the provision of perfect almshouses for the aged, or the establishment of vacation schools or open-air schools for the children ; whether it be the en'veloping of the morally infirm, or of those who have fallen, in a regenerating atmosphere of religion and love, or some subtle combination of physical regimen and mental stimulus for the town-bred "hooligan" — very large sums of money can be advantageously used, and are, in fact, urgently needed. And not the financing alone, but also the management of such institutions aff'ords a sphere for unofficial work. Just as no public Authority can hazard the ratepayers' money in these experimental institutions, so no public Authority can assume responsi- bility for the desirable unconventionality of their daily administration. We should wish to see the several Com- mittees of the County and County Borough Councils make full use of these voluntary institutions, entrusting to their care the special types of cases for which they aff'ord appropriate treatment. But in this use there should be invariably two conditions. Any voluntary institution receiving patients from the Local Authority must place itself under the regular inspection both of that Local 550 THE SCHEME OF REFORM Authority and of the National Department having the supervision of the particular service. And if payment for the treatment is required, even without other subsidy, the Local Authority must be given the opportunity of placing its own representatives on the actual governing body of the institution. (r) The Practical Application of the Scheme It is, of course, more easy to devise a scheme of reform on paper than to be sure that it can be applied in practice. We have, therefore, individually taken means, not only by special investigation, but also by specific personal inquiry of Poor Law Guardians and County and County Borough Councillors, of still more experienced Clerks to Boards of Guardians, Masters of Workhouses, and Relieving Ofiicers, and of various ofiicers of County and County Borough Councils, to satisfy ourselves that what we are proposing could actually be put into opera- tion without serious difiiculty. Those practically con- cerned in the working of the existing machine whom we have consulted on this point have given us very favour- able opinions. We are accordingly convinced that what we are proposing is practicable as well as desirable. It is, in fact, a great advantage of the scheme that it does not involve the creation of any novel area, or the estab- lishment of any new Authority. In fact, in all the County Boroughs it amounts only to the transfer of all the powers of the Boards of Guardians to the Town Council ; though, instead of handing them over en hloc, it provides for their distribution among the Education, Health, Asylums, Pension and General Purposes Committees of that body, thereby greatly lightening the additional burden of work to be imposed on the Councillors, whose numbers might, of course, be increased if desired. As with the duties of education and lunacy at present, we propose that all business relating to the several duties should automatically "stand referred" to the appropriate Committees for con- sideration and report, the Councils being left free to give to their Committees as much or as little delegated PRACTICAL APPLICATION OF THE SCHEME 551 authority as they choose (except as to actually levying the rate or raising money on loan), and subject to such conditions as they think fit. The troublesome readjust- ment of areas, too, would be reduced to a minimum. The merging in the County or County Borough of all the Unions wholly within each of them would involve the minimum of readjustment of property and liabilities. The only alterations of area required would be in those cases in which Unions at present cut County or County Borough boundaries. These, which in England and Wales are 197 in number, would be required in any adoption of the County as the new area. Moreover, the scheme involves the minimum of expense for compensation of dispossessed officers. It would, of course, be necessary to give to all officers whose posts were abolished the usual generous treatment that Parliament in such cases accords. But many of the Clerks to Boards of Guardians would make admirable Registrars of Public Assistance, and could be offered these appoint- ments. The best of the Masters of Workhouses could be found places in the various specialised institutions (in- cluding the Receiving Houses). Most of the Relieving Officers would become the Inquiry and Recovery Officers of the Registrars of Public Assistance. The District Medical Officers would be simply made part of the unified Medical Service under the Local Health Committee, at their existing emoluments, etc. The existing Workhouses, Casual Wards, Poor Law Schools, etc., would, of course, be utilised for the various specialised institutions that would be required, being divided up among the various committees as might l)e found most convenient. The scheme could be applied gradually. England and Wales, Scotland and Ireland could be separately dealt with. There would be no great difficulty in the transfer of the administration from the Boards of Guardians to the County and County Borough Councils taking place in one locality after another, on " appointed days " to be fixed as the arrangements made by the Executive Commission (which would in any case have to be appointed) were completed for the particular localities. We can even 552 THE SCHEME OF KEFOKM imagine tlie scheme being applied to one service after another ; the functions of the Boards of Guardians with regard to the children or the sick or the mentally defective being successively dealt with, and the final abolition of the Destitution Authority being deferred until the last remnant of its duties could be handed over. (i.) Tlie Rural Counties In the application of the scheme to the counties of England and Wales, the only serious difficulty appears to be the division of the medical service between the County Council and the existing minor sanitary authorities (the Councils of Non-County Boroughs, Urban Districts and Rural Districts) ; and for this we have ofiered specific suggestions. The establishment of the Registrar of Public Assistance, visiting once a week or so every part of the County — which should, we suggest, be divided into dis- tricts at least as small as the present Unions — would go far to relieve the members of the County Council of the most burdensome part of the work. There could, of course, be local visiting committees of volunteers chosen from among the local residents attached to the several institutions. (ii.) The Metropolis In the application of the scheme to London, a similar division of the medical service would be necessary between the Health Committee of the London County Council and the Health Committees of the Corporation of the City of London and the Metropolitan Boroughs. The asylums for imbeciles and idiots of the Metropolitan Asylums Board would naturally pass to the new Committee for the Mentally Defective (virtually the present Asylums Com- mittee of the London County Council), and the isolation hospitals to the Health Committee of that body. If there were appointed, say, half a dozen Registrars of Public Assistance for the whole of the Administrative County, they would be able to sit for an entire day in each week in districts somewhat smaller than the present thirty- PRACTICAL APPLICATION OF THE SCHEME 553 one Unions. But an even prompter " delivery " of the Receiving Houses could easily be arranged if required. In London, too, there could easily be special local visiting Committees for the several institutions. The scheme is not dependent on any general reform of London Local Govern- ment, or on any enlargement of the Administrative County, though it would fit in easily with either of these proposals. (iii.) Scotland In the application of the scheme to Scotland, we speak with less assurance. We do not feel that our knowledge of Scottish Local Government warrants us in doing more than suggest that, so far as we can learn, the same principles of reform are applicable. The enlargement of the unit of area is — with 874 separate Parish Councils distributing relief — even more urgently necessary than in England. The new area can hardly be any other than that of the County and, perhaps, those of the larger Burghs. There are the same advantages to be gained by the distribution, among the existing specialised com- mittees, of the various services now aggregated together in the Poor Law. With regard to the provision for all grades of persons of unsound mind, we can accept the recommendations of the Royal Commission on the Care and Control of the Feeble-minded, which adopt and con- tinue the existing Lunacy Authorities ; or, on the other hand, these might be simply reconstituted as Committees of County and Burgh Councils. In the one-third of Scotland which is in the large towns, the care of the children would naturally pass to the School Boards. We assume that the other services would pass to the County and principal Town Councils, with a division of the medical service between the District (Health) Committee of the County Council and the Health Committees of the smaller Burghs within the County similar to that suggested for the English Counties. This District (Health) Committee, or perhaps the County Committee of a District constituted under the Education Act of 1908, might take over the care of the children. Whether it would be desirable to 554 THE SCHEME OF REFORM continue in existence the Parish Council in Scotland, any more than the Rural District Council in England and Wales, once all the Poor Law functions had been assumed by other Authorities, we do not venture to decide. (iv.) Ireland In the application of the scheme to Ireland, we wish to speak even more tentatively than with regard to Scotland. Yet Ireland has already progressed further in the direction of breaking up the Poor Law, and distri- buting its services among the other Authorities, than either England or Scotland. The whole provision for persons of unsound mind, for instance, even for those who are destitute, is already entirely outside the Poor Law, and in the hands of the County Councils. The medical service of the public dispensaries, too, is not deemed to be Poor Law relief, and could apparently easily be reorganised as a County Medical Service on Public Health lines. The provision of a complete system of hospitals by the County Councils, admitting all patients requiring hospital treat- ment, whatever their diseases, is one of the recom- mendations of the Vice-Regal Commission on Poor Law Reform in Ireland. And, though that Commission did not recommend the abolition of the Boards of Guardians, we feel that our own scheme proceeds almost entirely on the same lines as their proposals, and that the establish- ment of the Registrar of Public Assistance would probably make it easy to adopt our recommendations almost in their entirety. The one exception lies in the case of the children. Ireland has, at present, no Local Education Authority to which the care of the children could be transferred. We agree with the Vice-Regal Commission in recommending that the children for whom the com- munity has to find maintenance should, wherever possible, attend the existing day schools under the National Ele- mentary Education Board. We suggest that their further care should be entrusted to new " Boarding -Out Com- mittees" of the County and County Borough Councils, on which women members should be co-opted, charged to PRACTICAL APPLICATION OF THE SCHEME 555 find suitable homes for these children, either in the duly- inspected cottages of foster-parents, or in institutions under voluntary management, properly certified by the Local Government Board for Ireland. The two existing Poor Law schools could probably be most advantageously utilised as schools for some special kinds of children who cannot be suitably dealt with by boarding-out. (v. ) TJie Departments of the National Government Whilst the scheme relates mainly to local administra- tion, no reform of the Poor Law can be effected without, in England and Wales at any rate, considerable changes in the central departments. We have already described how important it is, for efficiency and economy alike, that the Local Authorities should have the assistance, in each of the various services they undertake, of the supervision of a Department of the National Government charged solely with that service. We feel that the confusion and inefficiency into which so much of Local Government has fallen is to be ascribed in some degree to the absence of this specialised central supervision and control. Incredible as it seems, forty years after the Report of the Royal Commission on Sanitation in 1869, there is to-day no Department, and no Division of a Department, charged solely with Public Health as such. Even the Education Departments of England and Wales, Scotland and Ireland, find, at present, a great deal of the public provision for children of school age outside their control. With the abolition of the Destitution Authorities, the existing " Poor Law Division " of the Local Government Board would, of course, come to an end ; and a redistribution of functions and ofiicers would be necessary. We do not presume to make any recommendations as to how the duties of the several Departments should be allocated among the Ministers who would be responsible to Parlia- ment for their policy and administration. Nor need we consider which of the Divisions (each being self-contained and complete in itself) can conveniently l^e grouped together, under the name of the Local Government Board 556 THE SCHEME OF KEFORM or otherwise, with the Permanent Heads of the Divisions (as in Scotland and Ireland) sitting at a Board or Council under the presidency of the responsible Minister. We are, however, convinced that it is of the highest import- ance that there should be separately organised and com- pletely self - contained Departments, — each having the supervision and control of all the local services falling within its subject-matter, — not only for Education, but also for Public Health (including all the services entrusted to the Local Health Authorities) ; for all the provision for the Mentally Defective (including the feeble-minded and the inebriates, as well as the lunatics and idiots) ; for the National Pensions for the Aged ; and (as we may here add) for the whole provision for the Able-bodied, the Vagrants, and the Unemployed. Each of these five separate Depart- ments or Divisions of Departments should issue its own regulative orders, and have the administration of all the Grants-in-Aid that may be made in respect of the services with the supervision of which it is charged ; and all such Grants-in-Aid should be conditional on proper efiiciency in local administration, and proportionate partly to the local expenditure and partly to the local poverty, according to some such scale as we have suggested. Each such Depart- ment or Division of a Department would, of course, have its own specialist Inspectors, who should be chosen, in the first instance, from the technically qualified members of the present staffs. The existing General Inspectors of the Local Government Board would, we suggest, form a suit- able nucleus for the new Inspectorate that will be required by any Department dealing with the Able-bodied Un- employed — a service in which no technique has yet been worked out, and in which the General Inspectors would start with greater knowledge than any one else possesses. Alongside these five separate Departments, or Divisions of Departments, there must, we think, be another, distinct and apart from them all, charged with the supervision of the audit, the sanctioning of loans, and local finance generally, and to this might be entrusted also the supervision of tlie Home Aliment sanctioned by the Registrars of Public Assistance. PRACTICAL APPLICATION OF THE SCHEME 557 In Scotland and Ireland, whilst the same principles are applicable, the local circumstances will require some modifications of these proposals. Where England and Wales need separate Departments, Scotland and Ireland may be able to do with separate Divisions of one Depart- ment, especially if, as we think advisable, the Permanent Heads of the several Divisions sit in a Board or Council under the presidency of the responsible Minister. It may, in conclusion, be noted that any scheme of reform will involve the appointment of an Executive Commission to adjust areas and boundaries, and assets and liabilities, and to allocate buildings and officers according to the new organisation. (g) Some Theoretical Objections Ansivered We have, of course, not failed to weigh carefully the various objections that have been made to our proposals. These objections, it need hardly be said, are theoretical. There is the objection that the breaking-up of the Poor Law involves the breaking-up of the family. There is the objection that the proposed scheme would lead to the harass- ing of the poor in their homes by a multiplicity of officers, each bent on enforcing his own conditions. There is the objection that the transfer to specialised committees of the Local Authority of the obligation to relieve the destitute may lead to an extravagant extension of gratuitous treat- ment at the cost of the rates. Finally, there is the objection, in exact contradiction to this fear of increased collective provision, that the abolition of the Destitution Authority may, somehow or other, abrogate the existing statutory right to relief. (i.) Tlie Integrity of the Family There are conditions under which the transfer of the functions of the Board of Guardians to the County or County Borough Council will undoubtedly cause more separation of the members of families than prevails at present. In our 558 THE SCHEME OF REFORM chapter od " The General Mixed Workhouse of To-day " we have described how all the members of a destitute family are now usually admitted simultaneously, by one gate, into one institution. These "mixed" institutions have undoubtedly the advantage — if it be an advantage — of keeping all the members of a family under the same roof, and even of permitting, especially in the smaller and less rigidly administered Unions, continued intercourse between husband and wife, and parent and child. In visiting some of the Workhouses in the wilds of Ireland, we have been struck by the homeliness of the arrange- ment by which a whole family, rendered destitute by an eviction, will be found crouching round the peat fire of the one common day-room ; the able-bodied father smoking his pipe, the mother suckling her infant, the children playing around, and an aged grandparent dosing in the one armchair. When this domestic interior is supervised by a group of kindly nuns, visited by the parish priest, and illuminated by the dignity of agrarian martyrdom, the public assistance afforded has doubtless a charm of its own ; though we may question, not only its deterrent, but also its curative and restorative effects. But in the well- regulated English Workhouse, still more in the mammoth Poor Law establishments which now characterise the great towns of England, Scotland, and Ireland, the inclusion under one roof, or within one curtilage, of a whole family — ^the able-bodied man, the ailing woman and infant, the children of school age, the feeble-minded girl and the aged grandparent — means a promiscuous intercourse, not between the members of that family alone, but between all ages and different sexes, which is anything but edify- ing. It certainly does not conduce to the integrity of family relationships. And when the Destitution Authority, responding at last to the constant pressure of the Local Government Board, consents so far to " break up the family " as to treat the different members of it in different institutions — as the 1834 Report so strongly advised — it often nullifies the very improvement at which the Reform has aimed. In a desire, we suppose, to treat the family as a unit, at any rate at the moment of admission and the THEORETICAL OBJECTIONS ANSWERED 559 moment of discharge, the Guardians at present summon the wife and her infant from the Infirmary, the children from the Cottage Homes in the country, and the feeble- minded daughter from the laundry, to meet, at the lodge of the Able-bodied Workhouse, the husband and father who has claimed his discharge because he is tired of test work. It is this insistence on dealing with the family as a unit which gives the gravest aspect to the terrible problem of the " Ins-and-Outs." Let the man determine to take his discharge, — however evil his character, how- ever notoriously vicious his habit of life, however homeless he may be, — all his dependents are at present summoned, from the specialised institutions at which they are being treated at great expense, as if to his death-bed ! The children are brought in by an officer from the country boarding-school, clean and even smart in their neat clothes, and handed over to him at the Workhouse lodge, with the almost certain prospect that " the family," after unspeakable experiences, will be readmitted within a few days, in a state of filth and demoralisation. In common with every experienced Poor Law Adminis- trator, we accept the responsibility of so far " breaking-up the family " as to insist (with the authors of the Report of 1834) that, if there is to be institutional treatment at all, it shall be treatment of the different members of a family, according to age, sex, and physical state, in separate specialised institutions, under distinct ma7iagement and supervision. We do not see any reason for imagining any greater dissolution of the family when these institu- tions are administered by difi'erent committees of a Town Council than when they are administered by different committees of a Board of Guardians. But we o-q further. In common with, we think, the majority of experienced Poor Law administrators, we recommend that no sick dependent should be discharged from the Infirmary, and that no child should be brought back from the school to be handed over to its father, unless and until some reason- able assurance can be given that there is a home for them to go to, offering, at any rate, minimum conditions of decency and safety. It is one of the advantages of our 560 THE SCHEME OF REFORM scheme that the Education Committee and the Health Committee, under the advice of their own oJOScers, will certainly wish to satisfy themselves on this point before they forcibly eject any child or sick person committed to their charge. In our proposal of a Registrar of Public Assistance specially charged with the duty of proceeding against defaulting heads of families, we provide a far more effective means of enforcing parental responsibility than the present remarkable practice of casting out the wife and child whenever the man chooses to leave. A curious question has, in this connection, been asked of us. How, it is said, are the various members of a family, once sorted out into different institutions, under different committees of the Town Council, ever to get together again ? What seems to puzzle some naive objectors is the vision of the Health Committee's ambulance carrying off to its hospital the mother with puerperal fever, the Education Committee's officer conducting the children found wandering in the streets to the Industrial Schools, the Asylums Committee taking charge of the imbecile girl, the Unemployment Authority giving the man his railway ticket to the Farm Colony, whilst the police " run in " the hooligan son for commitment to a Reforma- tory School. The answer to this inquiry is that this very process is taking place daily under our eyes in any large city, without the difficulty arising. The existence of a Destitution Authority over and above all the existing specialised committees does nothing to bring these scattered members of the family together. In practice, they find each other without difficulty when they emerge from their several institutions, just as they would if they had gone at their own cost to school, to search for work, or to get medical treatment. But in so far as any difficulty may arise — as, for instance, with the feeble- minded or with truant children, or with parents wishing to evade their responsibilities — our scheme provides, for the first time, effective machinery for " reuniting " the family, either voluntarily or compulsorily. The Registrar of Public Assistance, advised daily of all admissions and discharges in every public institution, with an office at the THEORETICAL OBJECTIONS ANSWERED 561 Local Receiving House, always open to applicants, and with his Inquiry and Recovery Officers instantly in pursuit of husbands and fathers who have run away from their responsibilities, will, in fact, make it very difficult for families not to reunite. There is, however, a far more insidious " breaking up of the family" constantly going on to-day than any that could possibly be caused, whenever institutional treatment becomes necessary, by there being separate institutions for each sex, age-period and physical condition. Owing to the unfortunate limitation of the action of the Board of Guardians to the period of actual destitution, thousands of families are disintegrating to-day under our eyes, from lack of the timely strengthening which might have prevented their becoming destitute. But when the cost and trouble of providing for the several members of the family when destitute fall upon committees which have, as part of their ordinary duty and machinery, the periodical visita- tion of the home, irrespective of destitution, these committees will have the families continuously under observation. Is the child unfed at school ? A member of the Children's Care Committee calls to ascertain the cause. At every birth, at every death, at every occurrence of notifiable disease, the officer of the Health Committee becomes acquainted with the circumstances of the house- hold. Thus, the several Committees of the Town Council, as a mere measure of economy, so as not eventually to incur the cost of institutional treatment, with its con- comitant of " breaking up the family," will be perpetually doing whatever may be necessary to maintain the family intact, to encourage those members of it who are striving to keep the home together, and forcibly to restrain any member whose conduct is threatening it with ruin. (ii.) The Wiihdraival of the Destitution Officer The suggestion that the great expense to the rate- payer, and the " break up of the family," involved in the institutional treatment of the present Poor Law, can, in many cases, be obviated by friendly supervision and well- VOL. I 2 562 THE SCHEME OF REFORM informed advice before and after the crisis of destitution, rouses another set of theoretical objections. Under the scheme of reform now proposed, it is objected that there would be a great increase in the number of salaried officials, all " harassing " poor famihes with inquisitorial inquiries and officious advice. This, however, is an error. As a matter of fact there would, under the reform pro- posed, be actually fewer officials on the salary list, and each of them would ask fewer questions than is at present the case in any well-administered district. An efficient Town Council has already its staff of Sanitary Inspectors and Health Visitors, of School Attendance Officers and School Managers or members of Children's Care Com- mittees. These domiciliary agents at present investigate, not only questions of sanitation and the hygienic condition of the family, school attendance and the care of the children, but also — now that school meals, medical treat- ment, milk for the infant and so on, are being provided — find themselves compelled to inquire, however imper- fectly, into the economic circumstances of the household. Meanwhile, the family, in many cases, is obtaining, or asking for. Poor Law Relief. The well-administered Board of Guardians accordingly sends to the house, one after another, in order to make successive inquiries, the Reliev- ing Officer, the Cross Visitor, the Collector and Removal Officer, and, if the case presents any difficulty, also the Superintendent Relieving Officer. All the latter Destitu- tion Officers inquire into exactly the same facts as have been inquired into by the officers of the Local Health Authority and the Local Education Authority. It is true that their primary investigation is into the pecuniary resources of the family, but the Guardians expect them to report also on the sanitary state of the home, the health of all the members of the family, the attendance of the children at school, and even whether the mother can or will suckle her infant. On these points the Destitution Officers, whether one, two, three, or four in number, are unqualified to judge — a fact which does not make their inquiries less annoying. Incredible as it may seem to those unacquainted with the working of the conflict in THEORETICAL OBJECTIONS ANSWERED 563 Local Government to-day, this curious multiplicity of domiciliary visitors, all going, one after another, to the same house, unaware of each other's visits, and all inquir- ing indifferently into subjects in which they may be assumed to possess some professional competence, and into those about which they frankly know nothing, is actually the present practice of town after town. It may be seen, for instance, in Edinburgh or Paddington, Glasgow or Bradford. With the remodelling of the Poor Law that we are recommending, this overlapping and confusion will cease. The Sanitary Inspector or Health Visitor, the School Attendance Officer or the member of the Children's Care Committee, will still be found visiting the homes ; but their hygienic or educational inquiries and advice, like their information as to the available public assistance appropriate to the case, will no longer be hampered by vague questioning as to the total earnings coming into the home, or about the existence of relatives able to contribute. The three or four Destitution Officers, with their unsavoury hotch-potch of inquiries into all sorts of subjects, will be replaced, in each locality, by the one Inquiry and Re- covery Officer of the Registrar of Public Assistance. His business will be limited strictly to the ascertainment of the pecuniary resources of the family — not with any view of preventing the requisite treatment being afforded, for that will already have begun — but in order to ascertain what charge, if any, should be made for it, and upon whom it should be made. He, having no concern with the health or morals of the family, will have no more right than the agent of an insurance company or the Assessor of Income- Tax to do what in the Relieving Officer excites such resentment, namely, pry into the bedroom, cross-examine the woman as to her relation with the male lodger, or comment on the cough and expectoration of the delicate daughter — all in order to find a reason for refusing Out- door Relief and offering the Workhouse instead. Finally, this agent of the Registrar of Public Assistance will be in no sense a Destitution Officer. His visits will imply no pauperism. They will be paid alike to the family requir- 564 THE SCHEME OF REFORM ino- Home Aliment for its bread-winner, and to the family regularly paying the full charge for the maintenance of a member in the Tuberculosis Sanatorium ; to the old woman claiming a National Pension, and to the household which has distinguished itself by the gaining of a County Scholar- ship ; to the husband of the woman using the Maternity Hospital, as well as to the propertied lady who is paying for her husband's detention in the most luxurious villa of the County Lunatic Asylum. In fact, therefore, the pro- posed " sorting-out " of the present multiplicity of officers, and the restriction of each to his own sphere, will posi- tively diminish both their numbers and the multifarious- ness of their questions. And with the final abolition of the Destitution Officer, and his hateful combination of functions, any prejudice that the poor may have against domiciliary visitation as such will, we anticipate, disappear. (iii.) TJie Economy of Efficient Administration We pass now to what appears to us the most genuine of the objections made to our proposals, namely, that they will involve : — [a) A large increase of expense to the ratepayers ; and {b) An unnecessary multiplication of those for whom gratuitous service is provided. Our answer is that whilst our proposals involve in- creased expense in some directions, they bring great saving in others. What is even more important is that the increases in expenditure will tend to be temporary only, whilst the saving is calculated to be permanent and cumulative. To begin with the 230,000 infants and children on Outdoor Relief, we accept the responsibility (in common, we think, with a majority of Poor Law administrators) of proposing increased expenditure on those among them who — to use the words of our own Medical Investigator into their condition — are now suffering, definitely and seriously, from the circumstances of their lives. We do not think that it is possible, under any scheme, to continue to pre- tend to maintain children on a shilling or eighteenpence a THEORETICAL OBJECTIONS ANSWERED 565 week each. The chronic under-feeding, stunted growth, and premature death, to which we are at present con- demning many tens of thousands of Outdoor Relief children — children for whom the community has, by enrolling them in the register of paupers, definitely assumed responsibility — is surely the most wasteful and extravagant arrangement that could be devised. We admit that when the responsibility for these children passes into the hands of the Local Health Authority and the Local Education Authority, the reports from the Health Visitors and the Medical Officers, the mere sight of their condition in the school, and the reports as to their home circumstances by the members of the Children's Care Committees, will compel the proposal to the Registrar of Public Assistance, where the mothers are to be trusted, of Home Aliment much more adequate than a shilling a week, the provision of day industrial schools for many thousands more, and the adoption, and removal from their parents, of those found to be living in actually vicious homes. On the other hand, we may anticipate that the enormous capital outlay, and the high charge for maintenance, now incurred by some Boards of Guardians, for every child in their Cottage Homes, owing to their inexperience of the real requirements of efficient school buildings, will not continue under Local Authorities who are perpetually erecting such buildings for children at large, on more economical principles. We may, however, frankly admit that the net result of a transfer of destitute children from the present Poor Law to the Local Education Authorities — in common, we think, with all serious proposals for reform in this department — will be, during the next few years, an increase in the total spent on the children. But as it is exactly these children, brought up on insufficient food or in undesirable homes, who presently recruit the great army of pauperism, we think that it will be agreed that the expenditure is a good investment. Meanwhile, the Registrar of Public Assistance wdll be at work, enforcing payment from parents whose ill-treatment of their children proceeds not from lack of income, but from self-indulgence in drink, etc., or from mere inhumanity. It may well 566 THE SCHEME OF REFORM prove that whilst there will be more spent on the children who are really destitute, the number of claimants for school dinners or spasmodic relief, or of those who shovel their children into costly Poor Law schools, will, under the steady and impartial pressure of the new system of Charge and Recovery, actually be diminished. Much the same argument applies to the sick. We accept the responsibility of recommending the adoption of the Public Health principle of searching out disease in its incipient stages, in place of the Poor Law attitude of waiting until the disease has gone so far as, on the one hand, to produce destitution, and, on the other, to render the belated but costly treatment of no avail. This will mean, in the first years, an increased expenditure on domiciliary treatment, and, where really required, on the provision of hospitals. But seeing that no less than half of the present pauperism — that is to say, £9,000,000 a year out of the present Poor Law expenditure of £18,000,000 — is directly caused by the diseases of early or adult life, and that most of these are known to be ** preventable," we regard this expenditure also as a good investment. Let us assume, for a moment, that the United Kingdom and all its inhabitants formed the property of a great slave-owning company, much as whole districts in Russia used to belong to a great proprietor. With the modern knowledge of preventive medicine, it is clear that it would " pay " the slave-owner, not only to provide for his "hands" or his "souls" good sanitation and a supply of pure water, but also to train them in hygienic habits of life, and to take care that no incipient disease among them, more especially contagious or infectious disease, remained untreated. It is surely the worst of all forms of national waste to allow the ravages of preventable sickness to progress unchecked ; and this not merely because it kills off thousands of pro- ducers prematurely (burdening us, by the way, with the widow and the orphan), but because sickness levies a toll on the living, and leaves even those who survive crippled, debilitated, and less efficient than they would otherwise have been. There is even, by the taking of timely measures, an eventual decrease in the expenditure required THEORETICAL OBJECTIONS ANSWERED 567 to cope with a disease. To put up an Isolation Hospital is at first costly ; but when (as has been repeatedly found to be the case with smallpox) the disease has been stamped out, the hospital stands empty, and is available for other public use. And the treatment need not be gratuitous. As we have seen, there is at present great diversity of practice as to which diseases shall be treated gratuitously, and which shall be charged for. The tendency, under the present system, is to increase the range of gratuitous treatment ; and it is significant that even whilst we were enquiring into the matter, the responsibility for the gratui- tous treatment of phthisis (including maintenance in hospital when required) has been formally and explicitly assumed by the Local Health Authorities of Scotland, under the authority of Parliament and the Local Govern- ment Board. The whole question of the pecuniary basis of the public treatment of disease seems to us to need further consideration, with the object of secur- ing the maximum result from whatever expenditure the nation decides to afi"ord. But when charges are decided on by Parliament they ought to be impartially enforced ; and for this no adequate provision at present exists or has been included in any other proposals. We rely for this purpose on the establishment in every district of a Registrar of Public Assistance, unconnected with the medical service and bent on really enforcing whatever charges may be legally imposed on those for whom hospital maintenance is provided. This may well lead to an actual decrease in the area of gratuitous treatment, which, under the present system, is shovelled out, with the very mini- mum of inquiry, to all who ask for it. (iv.) Hie Right to Relief It is curious to notice that our insistence on treatment rather than relief, and the importance that we attach to enforcing payment from those who are legally liable and of sufficient ability to pay for what they receive, has raised an objection quite the opposite of that with which we have just dealt. It is feared by some that in the super- 568 THE SCHEME OF REFOEM session of the Destitution Authority by the more special- ised organs of Local Government the poor will lose their present statutory right to relief. Our answer is that whilst we recommend the repeal of the Poor Law Amend- ment Act of 1834, which created the Boards of Guardians, we do not advocate the repeal of the Statute of the 43r(i of Elizabeth. We propose that there should be no less legal obligation on the Local Authority, than there is at present, to provide the necessities of life to all those who are without them. Just as the Local Education Authority is under statutory obligation to provide schooling for all children within its district who are without schooling, so we propose that it should assume the statutory obligation (now imposed upon the Board of Guardians) of providing, for those children who are destitute, whatever other things are required. Just as the Local Health Authority is under statutory obligation to make certain sanitary provisions for its district, so we propose that it should assume the statutory obligations (now imposed upon the Board of Guardians) of providing for those of the sick who are destitute, whatever their necessities require. And similarly for the other sections of the present pauper host. The obligations which the Poor Relief Act of 43 EHzabeth, c. 2, embodied in our Statute law can be simply trans- ferred from the Board of Guardians to the County or County Borough Council. There remains to be noticed what may be considered the present safeguard of the poor in the liability of the Relieving Officers to criminal prosecution, even for man- slaughter, if any person is injured owing to their failure to afford relief when relief is requii-ed. This liability has the special characteristic of not being affected by any orders of the Destitution Authority under whom the Relieving Officer has been placed. Moreover, if a destitute person refuses the particular form of relief offered, the Relieving Officer still continues liable in case of any harm occurring, and is compelled therefore to provide relief in some other form. The majority of our colleagues propose to abolish all this criminal liability of the Relieving Officer. We do not think that this is either necessary or desirable. There THEORETICAL OBJECTIONS ANSWERED 569 is, we think, an advantage, in so important a matter as preserving human life, in there being, in each district, an officer who is definitely responsible, whatever other Authorities may be prescribing, for preventing deaths from starvation or neglect. We recommend that the present responsibility of the Relieving Officer should be transferred to the Registrar of Public Assistance and the keeper of the local Receiving House, together with some person in each parish or other convenient area whom the Registrar may appoint for this purpose and for the giving of relief in kind in cases of sudden or urgent necessity. Every such case would be automatically reported to the Registrar, who would place the case in charge of the officers of one or other of the committees concerned, or arrange for removal to the Local Receiving House pend- ing his decision. If the relief was refused, we recommend that the Local Health Authority should be empowered, in any case in which, through inanition or neglect, life might be endangered, or a public nuisance caused, to obtain a magistrate's order (to be granted only under careful safe- guards) for the compulsory removal of the person con- cerned to the appropriate institution. We think that, in cases of urgency, the Registrar of Public Assistance might be given power to make a similar order. In short, what our scheme of reform ensures is that, whilst the Right to Relief is fully maintained, the obligation to accept relief in its most appropriate form is, under penalty of com- pulsory removal in extreme cases, practically insisted on. (h) Summary of Proposals Deferring our proposals with regard to the whole of the Able-bodied until Part II. of the present Report, we recommend : — 1. That, except the 43 Elizabeth, c. 2, the Poor Law Amendment Act of 1834 for England and Wales, and the various Acts for the relief of the poor and the corre- sponding legislation for Scotland and Ireland, so far as they relate exclusively to Poor Relief, and including the Law of Settlement, should be repealed. 570 THE SCHEME OF REFORM 2. That the Boards of Guardians in England, Wales and Ireland, and (at any rate as far as Poor Law functions are concerned) the Parish Councils in Scotland, together with all combinations of these bodies, should be abolished. 3. That the property and liabilities, powers and duties of these Destitution Authorities should be transferred (subject to the necessary adjustments) to the County and County Borough Councils, strengthened in numbers as may be deemed necessary for their enlarged duties ; with suitable modifications to provide for the special circum- stances of Scotland and Ireland, and for the cases of the Metropolitan Boroughs, the Non-County Boroughs over 10,000 in population, and the Urban Districts over 20,000 in population, on the plan that we have sketched out. 4. That the provision for the various classes of the Non -Able-bodied should be wholly separated from that to be made for the Able-bodied, whether these be unemployed workmen, vagrants or able-bodied persons now in receipt of Poor Relief. 5. That the services at present administered by the Destitution Authorities (other than those connected with vagrants or the able-bodied) — that is to say, the provision for : — (i.) Children of school age ; (ii.) The sick and the permanently incapacitated, the infants under school age, and the aged needing institutional care ; (iii.) The mentally defective of all grades and all ages ; and (iv.) The aged to whom pensions are awarded — should be assumed, under the directions of the County and County Borough Councils, by : — (i.) The Education Committee; (ii.) The Health Committee ; (iii.) The Asylums Committee ; and (iv.) The Pension Committee respectively. 6. That the several committees concerned should be authorised and required, under the directions of their Councils, to provide, under suitable conditions and safe- SUMMARY OF PROPOSALS 571 guards to be embodied in Statutes and regulative Orders, for the several classes of persons committed to their charge, whatever treatment they may deem most appro- priate to their condition ; being either institutional treat- ment, in the various specialised schools, hospitals, asylums, etc., under their charge; or, whenever judged preferable, domiciliary treatment, conjoined with the grant of Home Aliment where this is indispensably required. 7. That the law with regard to liability to pay for relief or treatment received, or to contribute towards the maintenance of dependents and other relations, should be embodied in a definite and consistent code, on the basis, in those services for which a charge should be made, of recovering the cost from all those who are really able to pay, and of exempting those who cannot properly do so. 8. That there should be established in each County and County Borough one or more officers, to be designated Registrars of Public Assistance, to be appointed by the County and County Borough Council, and to be charged with the threefold duty of : — (i.) Keeping a Public Register of all cases in receipt of public assistance ; (ii.) Assessing and recovering, according to the law of the land and the evidence as to sufficiency of ability to pay, whatever charges Parliament may decide to make for particular kinds of relief or treat- ment ; and (iii.) Sanctioning the grants of Home Aliment proposed by the Committees concerned with the treatment of the case. 9. That the Registrar of Public Assistance should have under his direction (and under the control of the General Purposes Committee of the County or County Borough Council) the necessary staflf of Inquiry and Recovery Officers, and a local Receiving House for the strictly temporary accommodation of non - able - bodied persons found in need, and not as yet dealt with by the Committees concerned. 10. That the present national subventions in aid of the 572 THE SCHEME OF REFORM Destitution Authorities should be replaced by Grants-in- Aid of the expenditure on the whole of the services to be administered by the Health Committees of the County and County Borough Councils, subject to the administra- tion of these services up to, at any rate, a National Minimum of Efficiency ; the aggregate amount of such Grants-in-Aid for the United Kingdom and their alloca- tion as between England (including Wales), Scotland, and Ireland being fixed, and subject to revision only every seven years ; but the distribution of this total among the several County and County Borough Councils being made, according to the plan we have specified, in proportion to their several gross expenditures on these services, and at the same time in such a proportion to the poverty of their districts as will enable the National Minimum of Efficiency to be everywhere attained without anywhere exceeding the Standard Average Rate. 11. That the Local Authorities in England and Wales, in respect of the services administered by each Com- mittee, be placed under the supervision of a single Department or Division of a Department of the National Government, which shall itself administer the Grants-in- Aid of its particular services, issue its own regulative Orders, and have its own technically qualified Inspectors ; the Education Committees in England and Wales being thus responsible, for the efficiency of all their services, to the Board of Education ; the Mentally Defectives (or Asylums) Committees to the proposed Board of Control, in succession to the Lunacy Commissioners ; the Pension Committees to whatever Department is deputed to take charge of the administration of the Old-age Pensions Act of 1908 ; and the Health Committees, with regard to all their enlarged range of functions, to a separately organised and self-contained Public Health Department, whether this is organised as a separate Division of the Local Government Board or made a distinct Department. The determination of appeals from the decisions of the Registrar of Public Assistance, and whatever national supervision may be exercised over the grant of Home Aliment to the Non-Able-Bodicd. should, we suggest, be SUMMARY OF PROPOSALS 573 entrusted to another separately organised and self-con- tained Department or Division of a Department which, if it can be dissociated from the Local Government Board, might, with advantage, be placed, along with the Depart- ment or Division dealing with Audit, Loans and Local Finance generally, in close connection with the Treasury. 12. That a temporary Executive Commission be appointed to adjust areas, boundaries, assets and liabilities ; and to allocate buildings and officers among the future Local Authorities. SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS I. That the General Mixed Workhouses of England, Wales and Ireland, and the Poorhouses of Scotland, whether urban or rural, new or old, large or small, sumptuous or squalid, all exhibit the same inherent defects, of which the chief are promiscuity and un- specialised management. 2. That these institutions have a depressing, degrad- ing, and positively injurious effect on the character of all classes of their inmates, tending to unfit them for the life of respectable and independent citizenship. 3. That the institution of a General Mixed Work- house, whether large or small, was decisively condemned by the Poor Law Commissioners of 1834; that it has been repeatedly condemned since that date by a succession of competent critics ; that this condemnation has been confirmed by the evidence given before us, by the reports of our own Investigators and by the individual inspec- tions that we have been able personally to make in many different parts of the United Kingdom. 4. That the institution is everywhere abhorred by the respectable poor, and that, in our judgment, the con- tinued incarceration within its walls of the non-able- bodied or dependent poor, who are admittedly incapable of earning an independent livelihood, cannot be justified. 5. That the continuance of the General Mixed AVork- house as the main method of institutional treatment, alike by the Boards of Guardians of England, Wales and Ireland, and by the Parish Councils of Scotland, in spite of such long-continued and widespread condemnation, is 574 CONCLUSIONS AND RECOMMENDATIONS 575 to be attributed to the fact that these bodies are essentially Destitution Authorities, charged with the "relief" of persons of the most different ages, ailments and conditions, in respect only of their destitution. 6. That the abolition of Outdoor Relief to the non- able-bodied is, in our judgment, wholly impracticable, and, even if it were possible, it would be contrary to the public interest. There are, and, in our opinion, there always will be, a large number of persons to whom public assistance must be given, who can, with most advantage to the community, continue to live at home ; for instance, widows with children whose homes deserve to be main- tained intact, sick persons for whom domiciliary treat- ment is professionally recommended, the worthy aged having relatives with whom they can reside, and such ot the permanently incapacitated (the crippled, the blind, etc.) as can safely be left with their friends. Nor can the community rely on voluntary charity providing for these cases. In many places such charity does not exist, and in many others there is no warrant for assuming that it would ever be adequate to the need. Moreover, our investigations show that voluntary charity, in so far as it exists in the form of doles and allowances to persons in homes, has all the disastrous characteristics of a laxly administered Poor Law. 7. That so long as the alternative is admission to the General Mixed Workhouse, the policy of systematic refusal or restriction of Outdoor Relief to the non-able- bodied, pursued by a few Boards of Guardians in England, cannot be recommended for general adoption. We are unable to resist the evidence that this policy of " offering the House " even to the non-able-bodied, results, in not a few cases, in unnecessarily destroying the home and break- ing up the family, in separating child from mother, and in exposing young and innocent persons to the demoralis- ing atmosphere of the General Mixed Workhouse. Such a policy, moreover, by deterring the poor from applying for relief, leads, in far too many cases, to semi-starvation and physical and mental degeneration, from which the women and children especially suffer, and, in a small 576 CONCLUSIONS AND KECOMMENDATIONS number of cases, even to death from want and exposure. The proposal made to us by some witnesses that, in order to obviate this latter danger, the Destitution Authority- should be granted powers of compulsory removal appears to us — in view of the character of the General Mixed Workhouse in which these poor people would be incar- cerated — wholly out of the question. 8. That the present system of administering Outdoor Relief to the non-able-bodied in England, Wales and Ireland, and to a lesser degree, also in Scotland, is open to the gravest criticism. The large sum of nearly four millions sterling which is now expended in this way annually — a burden on the community that is steadily increasing — is being dispensed, without central inspection or control, in doles and allowances, awarded upon no uniform principle, and differing widely from place to place. This lack of common principle is observable even in the Bylaws or Standing Orders by which the best administered Unions in England profess to guide their action. But in the actual practice the diversity between one place and another, in large districts between one Relief Committee and another, and sometimes even between one meeting and the next, according to the accident of which members attend — a diversity applying alike to the persons to v^hom Outdoor Relief will be given, to its amount and to its conditions — is still more extreme. It can, in fact, be described only as a total absence of principle. 9. That amid all this diversity of principle and practice, we find certain evil characteristics practically universal. Except in an insignificant number of well- administered districts in England and Scotland, the doles and allowances given are manifestly inadequate for healthy subsistence. They are given, not in relief of destitution, strictly so-called, but in supplement of other resources that are assumed to exist. In many cases, such other resources — whether earnings, charitable gifts or the contributions of relations — do exist, but are insufficient. In some cases, on the other hand, the total income of the household is such as not to warrant any relief from the CONCLUSIONS AND RECOMMENDATIONS 577 Poor Rate. But no Destitution Authority that we have seen succeeds in ascertaining what other sources of income exist or whether any such exist ; and the majority of them do not seriously attempt to do so. The result is that there are a great many cases in which, whilst Out- relief is given on the assumption that other resources will be forthcoming, none such are found ; so that the dole of Poor Law relief — upon which thousands of old people, sick people, and even widows with young children are steadily degenerating — is a starvation pittance. 10. That an equally grave defect in the Outdoor Relief of to-day, at any rate from the stand-point of the nation, is the unconditional character of the grant. With a few honour- able exceptions, no attempt is made by the Destitution Authority even to ascertain how the household is actually being maintained upon the Outdoor Relief that is granted, still less to effect any necessary improvement in the home. The result, as we have grave reason to believe, is that a large part of the sum of nearly four millions sterling is a subsidy to insanitary, to disorderly, or even to vicious habits of life. The saddest feature of all is that no small proportion of the 234,000 children whom, in the United Kingdom, the Destitution Authority elects to bring up upon Outdoor Relief — in the course of a year probably as many as 600,000 different children — are to-day, without any interference by these Authorities, chronically under- fed, insufficiently clothed, badly housed, and, in literally thousands of cases, actually being brought up at the public expense in drunken and dissolute homes. 11. That we do not ascribe the disastrous social failure of the Outdoor Relief of to-day to any personal short- comings of the individual members of Boards of Guardians in England, Wales and Ireland, or of Parish Councils in Scotland. We have found no evidence that the corrupt and criminal practices which have unhappily occurred in certain places are at all frequent or widespread. Nor have we reasons to suppose that the evil influences of electoral or social pressure have been otherwise than ex- ceptional. We have, indeed, been impressed by the vast amount of zealous and devoted service, unremunerated VOL. I 2 P 578 CONCLUSIONS AND RECOMMENDATIONS and unrecognised, that is being rendered in all parts of the Poor Law Administration of the United Kingdom, hy- men and women of humanity and experience. We ascribe the defects and shortcomings of the present administra- tion of Outdoor Relief to the very nature of the Local Authority to which this duty is entrusted. 12. That we attribute the almost universal failure of the Boards of Guardians in England, Wales and Ireland, and of the Parish Councils in Scotland, in the matter of Outdoor Relief, in all districts, and in every decade, partly to an illegitimate combination, in one and the same body, of duties which can be rightly done by a board or com- mittee, and those which can be efficiently discharged only by specialised officers continuously engaged in the task. The "many -headed" body is exactly what is required, whether for Outdoor Relief or for the management of institutions, for arriving at decisions of general policy ; for prescribing the rules that are to be followed in determining particular cases ; and for examining grievances and pre- venting the abuse of their powers by the officers. But if the administration is to be democratic in its nature — if, that is to say, the will of the people is to prevail — it is absolutely necessary that the application to individual cases of the rules laid down by the board or committee should be determined evenly, impartially and exactly according to the instructions, by a salaried officer ap- pointed for the express purpose. We recognise this at once in the management of a school, a hospital, or an asylum, where the most democratic committee finds the best guarantee for the execution of its will in ordering its salaried officials to apply the rules that it lays down. But in the dispensing of Outdoor Relief, the same " many- headed " body that makes the rules has also attempted to apply them to individual cases ; and in doing so inevitably brings in personal favouritism, accident and the emotion of the moment, to thwart the will of the community as a whole. The relative success of the Outdoor Relief administration of some of the best governed parishes of Scotland is due, we think, to the fact that, whilst the Parish Council makes the rules, their application to indi- CONCLUSIONS AND RECOMMENDATIONS 579 vidual cases is not left to the chance membership of a particular meeting, but is in practice largely entrusted, as a judicial function, to the Inspector of the Poor. 13. That it is, however, not merely that " many- headedness " of the existing tribunal that is the cause of the failure of the Outdoor Relief administration of to-day. We ascribe that failure quite as much to the fact that the duty is entrusted to a Destitution Authority, served by subordinates who are essentially Destitution Officers. To entrust, to one and the same authority, the care of the infants and the aged, the children and the able-bodied adults, the sick and the healthy, maids and widows, is inevitably to concentrate attention, not on the different methods of curative or reformatory treatment that they severally require, but on their one common attribute of destitution, and the one common remedy of "relief," indiscriminate and unconditional. And just as this Destitution Authority tends always, in institutional organisation, to the General Mixed Workhouse, with its promiscuity and unspecialised management, instead of to the appropriate series of specialised nurseries, schools, hospitals and asylums for the aged that are needed, so it tends also, with its general *' mixed official," the Relieving Officer, to provide, alike for widows and deserted wives, the sick and the aged, infants and school children, one indiscriminate unconditional dole of money or food, instead of the specialised domiciliary treatment, according to the cause or character of their distress, that each class requires. 14. That the Boards of Guardians of England, Wales and Ireland, and the Parish Councils of Scotland have proved themselves to be, by their very nature as Destitu- tion Authorities, wholly unsuited to cope with the grave threefold problem as to Birth and Infancy with which the nation is confronted. Alike in the prevention of the con- tinued procreation of the feeble-minded, in the rescue of girl-mothers from a life of sexual immorality, and in the reduction of infantile mortality in respectable but necessi- tous families, the Destitution Authorities, in spite of their great expenditure, are to-day effecting no useful results. With regard to the first two of these problems, at any rate, 580 CONCLUSIONS AND RECOMMENDATIONS the activities of the Boards of Guardians and Parish Councils are, in our judgment, actually intensifying the evil. If the State had desired to maximise both feeble- minded procreation, and birth out of wedlock, there could not have been suggested a more apt device than the provision, throughout the country, of General Mixed Workhouses, organised as they now are to serve as un- conditional Maternity Hospitals. Whilst thus encourag- ing irregular sexual unions and the procreation of the feeble-minded, the Destitution Authorities are doing little to arrest the appalling preventable mortality that prevails among the infants of the poor. The respectable married woman, however necessitous she may be, can, with difficulty take advantage of the free food, shelter and medical attend- ance provided at great expense by the Destitution Authority for Maternity cases. In Scotland she is — if living with her own husband, he being in good health — absolutely debarred from relief by law. In England and Wales she is as far as possible deterred. 15. That in view of the fact that the Destitution Authorities of the United Kingdom have constantly on their hands more than 65,000 infants under five years of age, and that there is grave reason for believing the mortality among them to be excessive, alike among the 50,000 who are maintained on Outdoor Relief and among the 15,000 in Poor Law Institutions, careful statistical enquiry ought immediately to be made, in order to dis- cover where the mortality is greatest, and how this loss of life can be prevented. 16. That, in accordance with the recommendations of the Royal Commission on the Care and Control of the Feeble-minded, those unmarried mothers who come on the rates for their confinements, and are definitely proved to be mentally defective, should be dealt with exclusively by the Local Authority for the Mentally Defective. 17. That, whatever provision is made from public funds for maternity, whether in the way of supervision, or in domiciliary midwifery, or by means of Maternity Hospitals, should be exclusively in the hands of the Local Health Authority. CONCLUSIONS AND RECOMMENDATIONS 581 18. That, in accordance with the recommendations of the Vice-Regal Commission on Poor Law Reform in Ireland, the fullest possible use should be made, under the inspec- tion and supervision of the Local Health Authorities, of such Voluntary Agencies as Rescue and Maternity Homes, Midwifery Charities, and Day Nurseries. 19. That the system, which has already proved so successful, of combining the efforts of both salaried and voluntary Health Visitors with the work of the Medical Officer of Health and his staff, should be everywhere adopted and developed so as to extend to all infants under school age. 20. That the Local Health Authority should, in all its provision for birth and infancy, continue to proceed on its accustomed principles of — (a) The provision, free of charge, of hygienic information and advice to all who will accept it ; (b) The strict enforcement of the obligation im- posed upon individuals to maintain in health those who are legally dependent on them ; and (c) Where individual default has taken place in this respect, the immediate provision of the necessaries for health, and the systematic recovery from those responsible, if they are able to pay, of repayment according to their means. 21. That the Destitution Authorities of England and Wales, Scotland and Ireland have proved themselves — in spite of the devoted personal service of many of their members — inherently unfitted, by the very nature of their functions, to have the charge of the 237,000 children of school age for whom the State, in the United Kingdom, assumes the responsibility of whole or partial main- tenance. 22. That, as a result of this inherent unfitness of a Destitution Authority for the rearing of children, it has been demonstrated to us by our own expert investigators, and confirmed by other evidence, that certainly a majority of all the Outdoor Relief children — probably 100,000 boys and girls — are to-day suffering, definitely and seriously, in health and character, from the circumstances of their 582 CONCLUSIONS AND RECOMMENDATIONS lives — these circumstances being, in great part, the inade- quate and unconditional character of the Outdoor Relief upon which they are supposed to be maintained, and the lack of care and supervision exercised by the Destitution Authorities, and of inspection by the three Local Govern- ment Boards, to prevent the too frequent neglect and ill-treatment of these wards of the State. 23. That, in spite of almost universal condemnation, and notwithstanding a whole generation of efifort on the part of the three Local Government Boards to get the children otherwise maintained, there are in Great Britain three or four thousand, and in Ireland as many more, children of school age being brought up in the demoralis- ing atmosphere of the General Mixed Workhouse ; and we have found no evidence of any effective desire or inten- tion on the part of the Destitution Authorities to take steps to bring to an end this discredited method of pro- viding for children. 24. That the system of " boarding-out " the children with foster-parents, or placing them in certified institutions — a system which, under careful and continuous super- vision, and confined to a minority of suitable cases, has much to recommend it — is, at present, seriously prejudiced by the fact that the Destitution Authorities and their officers are, by the very nature of their functions, un- qualified to maintain an efficient inspection of the homes and institutions which they select for their children, let alone any continuous supervision of their welfare. In some cases it has even been deemed advisable to discourage or prohibit such visiting of the homes or institutions in order to avoid the connection of the children with the Destitution Authority which is supposed to look after them. 25. That the children in Poor Law Schools and Cottasfe Homes — the conditions of which have, for the most part, greatly improved — are, in many instances, maintained at an unnecessary cost ; an excessive expenditure sometimes directly attributable to the inexperience of a Destitution Authority in school management, and one which still leaves the children suffering, even in well -administered institutions, from — CONCLUSIONS AND RECOMMENDATIONS 583 (a) The difficulty of getting the best teachers in Poor Law Schools. (b) The impracticability of affording these " insti- tutionalised " boys and girls proper experience of life in a small home ; and (c) The educationally defective grouping together of children merely by the common attribute of their parent's destitution, instead of allocating them sever- ally to the particular types of school (e.g. mentally- defective schools, crippled schools, higher -grade schools, technical schools, etc.) that their individual characteristics require. 26. That owing to their lack of any appropriate machinery for the purpose, the Destitution Authorities fail to-day even to discover a large amount of the desti- tution that exists among children in the great towns, and this not merely in the matter of medical treatment urgently required, but even in the matter of actual inade- quacy of food, so that the powers entrusted to the Boards of Guardians for the prosecution of cruel or neglectful parents are hardly ever put in force, and many thousands of children are, for lack of the necessaries of life, growing up stunted, debilitated and diseased. 27. That, as a consequence of this failure of the Desti- tution Authorities to prevent or to relieve child destitu- tion. Parliament has been led, after many official investi- gations, to entrust to the Local Education Authorities the duty of providing meals for the children found at school unfed, at any rate on those days of the week, and those weeks of the year, when the elementary schools are open ; with the result that these Authorities are in England and Wales, during the present winter, feeding more than 100,000 children, and probably nearly as many children of school age as are being relieved, otherwise than in insti- tutions, by all the Destitution Authorities put together. 28. That these competing systems of relieving child destitution by rival Local Authorities in the same town — in many cases simultaneously assisting the same children — without any effective machinery for recovering the cost from parents able to pay, and for prosecuting neglectful 584 CONCLUSIONS AND RECOMMENDATIONS parents, are undermining parental responsibility, whilst still leaving many thousands of children inadequately fed. 29. That it is urgently necessary to put an end to this wasteful and demoralising overlapping by making one Local Authority in each district, and one only, responsible for the whole of whatever provision the State may choose to make for children of school age. 30. That the only practicable way of securing this unity of administration, and also the most desirable reform, is, in England and Wales, to entrust the whole of the public provision for children of school age (not being sick or mentally defective) to the Local Education Authorities, under the supervision of the Board of Educa- tion ; these Local Education Authorities having already, in their Directors of Education and their extensive staffs of teachers, their residential and their day feeding schools, their arrangements for medical inspection and treatment, their School Attendance Officers and Children's Care Committees, the machinery requisite for searching out every child destitute of the necessaries of life, for enforcing parental responsibility, and for obviating, by timely pres- sure and assistance, the actual crisis of destitution. 31. That in Scotland the whole of the public provision for children of school age might be entrusted, at any rate in the large towns, to the School Boards, and elsewhere, perhaps, either to the District Health Committee or to the newly-formed " County Committee of the District," under the supervision of the Scottish Education Depart- ment. 32. That in Ireland, where no Local Education Authorities exist, it should be considered whether the whole of the public provision for children of school age might not advantageously be entrusted to the County and County Borough Councils, acting through special " Boarding - out Committees," on which there should be women members, and sending the children to the existing day schools. 33. That the continued existence of two separate rate- supported Medical Services in all parts of the kingdom, costing, in the aggregate, six or seven millions sterling CONCLUSIONS AND RECOMMENDATIONS 585 annually — overlapping, unco-ordinated with each other and sometimes actually conflicting with each other's work — cannot be justified. 34. That the very principle of the Poor Law Medical Service — its restriction to persons who prove themselves to be destitute — involves delay and reluctance in the application of the sick person for treatment ; hesitation and delay in beginning the treatment ; and, in strictly administered districts, actual refusal of all treatment to persons who are in need of it, but who can manage to pay for some cheap substitute. These defects, which we regard as inherent in any medical service administered by a Destitution Authority, stand in the way of the discovery and early treatment of incipient disease, and accordingly deprive the medical treatment of most of its value. 35. That it has been demonstrated to us beyond all dispute, that the deterrent aspect which the medical branch of the Poor Law acquires through its association with the Destitution Authority causes, merely by preventing prompt and early application by the sick poor for medical treat- ment, an untold amount of aggravation of disease, personal sufi'ering and reduction in the wealth-producing power of the manual working class. 36. That the operations of the Poor Law Medical Service, being controlled by Destitution Authorities and administered by Destitution Ofiicers, inevitably take on the character of unconditional "medical relief" — that is, relief of the real or fancied painful symptoms — as distin- guished from remedial changes of regimen and removal of injurious conditions, upon which any really curative treat- ment, or any efiective prevention of the spread or recur- rence of disease, is nowadays recognised to depend. 37. That whilst domiciliary treatment of the sick poor is appropriate in many cases, it ought to be withheld — (i.) Where proper treatment in the home is impracticable. (ii.) Where the patient persistently malingers or refuses to conform to the prescribed regimen ; or (iii.) Where the patient is a source of danger to others. 586 CONCLUSIONS AND KECOMMENDATIONS It has become imperative in the public interest that there should be, for extreme cases, powers of compulsory removal to a proper place of treatment. Such powers cannot, and in our opinion should not, be granted to a Destitution Authority. 38. That where Destitution Authorities cease to abide by the limitation of their work to persons really destitute, or pass beyond the dole of " Medical Relief," their attempt to extend the range or improve the quality of the Poor Law Medical Service brings new perils. We cannot regard with favour any action which, in order to promote treat- ment, openly or tacitly invites people voluntarily to range themselves among the destitute ; or which tempts them, by the prospect of getting costly and specialised forms of treatment, to simulate destitution. Nor do we think that an Authority charged with the relief of destitution, what- ever its method of appointment or whatever the area over which it acts, or any Authority acting through officers concerned with such relief, whatever their official desig- nation, can ever administer a Medical Service with efficiency and economy. 39. That, with regard to the suggestion that the medical treatment of the sick poor should be left either to provident medical insurance or to voluntary charity, it has been demonstrated to us that these offer no possible alter- native to the provision for the sick made by the Public Authority. With regard to domiciliary treatment, the evidence as to medical clubs, "contract practice," Pro- vident Dispensaries and the out-patients' departments of hospitals, is such as to make it impossible to recommend, in their favour, any restriction of the services at present afforded by the District Medical Officers and Poor Law Dispensaries. Nor do we feel warranted in giving any support to the proposal made to us that the whole of this Outdoor Medical Service of the Poor Law should be super- seded by a publicly subsidised system of letting the poor choose their own doctors. Any such system would, in our judgment, lead to an extravagant expenditure of public funds on popular remedies and " medical extras," without obtaining in return for this enlarged "Medical Relief" CONCLUSIONS AND RECOMMENDATIONS 587 greater regularity of life or more hygienic habits in the patient. With regard to institutional treatment, we gladly recognise the inestimable services rendered to the sick poor by the hospitals, sanatoria and convalescent homes sup- ported by endowments or voluntary contributions. We approve of the use now made of these institutions by Public Authorities, and we think that many more suitable cases than at present might, on proper arrangements as to payment, be transferred from rate-maintained to voluntary institutions. But it is clear that such institutions provide only for a small fraction of the need, and that they leave untouched whole districts for some cases, and whole classes of cases everywhere, which there is no prospect of their being able or willing to undertake. 40. That the Medical Service of the Public Health Authorities, which now extensively treats disease, and actually maintains out of the rates a steadily increasing number of the sick poor, is based on principles more suited to a State Medical Service than that of the Poor Law. These principles, which lead, in practice as well as in theory, to searching out disease, securing the earliest possible diagnosis, taking hold of the incipient case, remov- ing injurious conditions, applying specialised treatment, enforcing healthy surroundings and personal hygiene, and aiming always at preventing either recurrence or spread of disease — in contrast to the mere " relief" of the individual — furnish in fact the only proper basis for the expenditure of public money on a Medical Service. 41. That such compulsory powers of removal in extreme cases, as have been asked for, are analogous to those already exercised, with full public approval, by the PubHc Health Authorities ; and that the proposed extension of such powers can properly be granted only to an authority proceeding on Public Health lines. 42. That we therefore agree with the responsible heads of all the four Medical Departments concerned — the Chief Medical Officer of the Local Government Board for England and Wales, the Medical Member of the Local Government Board for Scotland, the Medical Commissioner of the Local Government Board for Ireland, and the Medical 588 CONCLUSIONS AND RECOMMENDATIONS Officer of the Board of Education — in ascribing the defects of the existing arrangements fundamentally to the lack of a unified Medical Service based on Public Health principles. 43. That in such a unified Medical Service, organised in districts of suitable extent, the existing Medical Officers of Health, Hospital Superintendents, School Doctors, Dis- trict Medical Officers, Workhouse and Dispensary Doctors, and Medical Superintendents of Poor Law Infirmaries — the clinicians as well as the sanitarians — would all find appropriate spheres ; that one among them being placed in administrative control who has developed most adminis- trative capacity. 44. That we do not agree with the suggestion that the establishment of a unified Medical Service on Public Health lines necessarily involves the gratuitous provision of medical treatment to all applicants. It is clear that, in the public interest, neither the promptitude nor the efficiency of the medical treatment must be in any way limited by con- siderations of whether the patient can or should repay its cost. But we see no reason why Parliament should not embody, in a clear and consistent code, definite rules of Chargeability, either relating to the treatment of all dis- eases, or of all but those specifically named; and of Recovery of the charge thus made from all patients who are able to pay. In our chapter on " The Scheme of Reform," we propose new machinery for automatically making and recovering all such charges that Parliament may from time to time impose. 45. That the existing provision for the Mentally Defective persons maintained in the United Kingdom at the pubhc expense, probably approaching 200,000 in number, is far from satisfactory. 46. That the existence everywhere of rival Local Authorities maintaining the Mentally Defective, and the division of the supervision and control over their work among three (or even four) different Government Depart- ments, no one of which has full responsibihty, or combines in itself technical knowledge and financial control, involves — to use the emphatic words, formally given in evidence. CONCLUSIONS AND RECOMMENDATIONS 589 of the Local Goverument Board for England and Wales — " a large amount of unnecessary expenditure'' 47. That the continued detention in the General Mixed Workhouses of England, Wales and Ireland, and, to a lesser degree, those of Scotland, of no fewer than 60,000 Mentally Defective persons, including not a few children, without education or ameliorative treatment, and herded indiscriminately with the sane, amounts to a public scandal. 48. That the practice of Ireland, where the inmates of the County Lunatic Asylums are wholly unconnected with the Poor Law, and are not stigmatised as paupers, should be adopted for Great Britain. 49. That we concur with the Vice-Regal Commission on Poor Law Reform in Ireland in thinking that all persons of unsound mind, whatever their mental state, and whatever their age, should be everywhere wholly removed from the Workhouses. 50. That, in the words of the Royal Commission on the Care and Control of the Feeble-minded, it is "the mental condition of these persons, and neither their poverty nor their crime," that " is the real ground of their claim for help from the State." 51. That we, accordingly, concur with that Commission in the view that all grades of the Mentally Defective (including the feeble-minded, the epileptics, the inebriates, the imbeciles, the lunatics and the idiots) should, at all ages, be wholly withdrawn from the charge of the Destitu- tion Authorities, and from pauperism, as well as from the Local Education Authorities, and that the entire respon- sibility for their discovery, certification and appropriate treatment (whether institutional or domiciliary) should be entrusted in England, Wales and Ireland, to the County and County Borough Councils, acting by statutory Com- mittees for the Mentally Defective, in which the present Asylums Committees would be merged, and in Scotland to the County Councils and principal Town Councils, from which the District Boards of Lunacy are (with the excep- tion of six towns) selected. 52. That the whole duty of supervision and control of 590 CONCLUSIONS AND RECOMMENDATIONS the action of the Local Authorities in respect of the Men- tally Defective, including the administration of the Grants- in-Aid, should be concentrated, in England (including Wales), Scotland and Ireland respectively, in a single self- contained and fully equipped Division or Department concerned with the Mentally Defective alone, however that Division or Department may be grouped with others under a Minister responsible to Parliament. 53. That the inclusion, under the Poor Law, in one and the same category, of the congeries of dififerent classes known as " the Aged and Infirm " is fundamentally incon- sistent with any effective administration. 54. That the majority of Destitution Authorities of England, Wales and Ireland make no other provision for this aggregate of diverse individuals, of all ages and of different mental and physical characteristics, than the General Mixed Workhouse on the one hand, and indis- criminate, inadequate and unconditional Out -relief on the other — forms of Relief cruel to the deserving, and demoralisingly attractive to those who are depraved. 55. That some of the Parish Councils of Scotland and a few Boards of Guardians in England have honourably distinguished themselves by providing for aged persons of deserving conduct either comfortable quarters or pensions in their own homes ; though in the English Unions this provision has been unduly restricted by irrelevant conditions as to prolonged residence in one district, or as to the existence of relations not legally liable to contribute. 56. That no corresponding classification has been made among persons permanently, though prematurely, incapacitated, so that even the most deserving of these are very harshly dealt with. 57. That it is a necessary preliminary of any effective reform to break up the present unscientific category of " the Aged and Infirm," and to deal separately with distinct classes according to the age and the mental and physical characteristics of the individuals concerned. 58. That we concur with the Royal Commission on the Care and Control of the Feeble-minded that all CONCLUSIONS AND RECOMMENDATIONS 591 persons, whatever their age, who are certified to belong to one or other grades of the Mentally Defective — in- cluding not only the lunatics and idiots, but also the feeble-minded and those suffering from senile dementia — should be entirely removed from contact with any form of Poor Law, and should be placed wholly in charge of the Local Authority for the Mentally Defective. 59. That the establishment by Parliament in 1908 of a National Pension Scheme affords the proper provision for the aged who satisfy the necessary conditions in re- spect to income, residence in the United Kingdom, and conduct ; but that it will be requisite at the earliest possible date to lower the pensionable age to sixty-five, if not to sixty ; and that it is neither practicable nor desirable to make the previous receipt of any form of public assistance a ground for disqualification. 60. That, as there must always be a certain proportion of persons technically disqualified for a National Pension, for whom public provision must be made, and for whom institutional provision is neither necessary nor desirable, the Pension Committees of the Local Authorities should be empowered to grant out of the Rates, according to conditions settled by their Councils and approved by the Central Authority, pensions to persons of decent life, not being less than sixty years of age, who are not eligible for a National Pension. 61. That, whilst we anticipate considerable growth of voluntary agencies for securing, by insurance, supple- mentary pensions and provision for premature invalidity, we cannot recommend that the State should enter into competition for the workers' weekly pence with the Friendly Societies and Trade Unions, by any scheme of compulsory insurance ; which would, we think, provoke the strenuous opposition of these societies, if they were left outside the scheme ; and which must inevitably entail a national guarantee of their solvency, and Governmental control, if they were to be made part of the compulsory scheme. 62. That the responsibility for making suitable pro- vision, domiciliary or institutional, for the prematurely 592 CONCLUSIONS AND RECOMMENDATIONS incapacitated and the helpless aged, together with the necessary institutional provision for the aged to whom pensions are refused, should be entrusted to the Local Health Authority. 63. That the Local Health Authority should be granted compulsory powers of removal and detention similar to those which it now possesses in respect to certain infectious diseases, with regard to all aged and infirm persons who are found to be endangering their own lives, or becoming, through mental or physical incapacity to take care of themselves, a nuisance to the public. 64. That, whilst all the obligations to support aged and infirm relations that are imposed by law should be strictly enforced by the appointed officers, where there is proof of ability to pay, no attempt should be made by any public authority to exact contributions from persons not legally liable, by subjecting aged or infirm persons, or threatening to subject them, to any treatment other than that deemed most suitable to their state. 65. That the existing provisions of the law for charg- ing to, and recovering from, particular individuals, the cost of various forms of public assistance afforded to them, to their dependants, or to other persons for whom they are legally liable to contribute, are confused and incon- sistent with each other, and are based on no discoverable principle. 66. That the practice of the multifarious Local Authorities, with regard to charging or recovering the cost of public assistance, varies, for identical services rendered to persons in identical economic circumstances, from place to place, from case to case, and even from time to time in one and the same case, according to the idiosyncrasies of the members who happen to be present at successive meetings. 67. That the confused and uncertain state of the law, and the haphazard conflict of practice, lead to hardship and oppression on the one hand, and to demoralising laxity on the other ; the net result being that a serious loss of revenue is incurred, the law-abiding citizen paying, and the habitual "cadger" escaping scot-free; with the CONCLUSIONS AND RECOMMENDATIONS 593 additional absurdity that the patient for whom the cost is repaid is often classed as a pauper, whilst other patients suffering from the same disease get wholly gratuitous treatment and retain their status of citizenship. 68. That we recommend that a Departmental Com- mittee should be appointed to consider the whole question of what forms of public assistance can properly be made the subject of these " Special Assessments," and upon what persons these assessments should be made ; in order that the law may be amended on some definite principle, and consolidated by Parliament into a single statute. 69. That the duty of determining what Special Assess- ments are due according to the law, and from whom, together with the decision whether the person liable is of sufficient ability to pay, and the duty of enforcing payment by proper legal process, ought to be entirely separated from the work of administering the public assistance ; and it would be most suitably undertaken, for all the forms of public assistance afforded in a given district, by a salaried officer of adequate status, appointed by and acting under the County or County Borough Council, but unconnected with either the Health, Educa- tion, Mentally Defectives or Pension Committees. 70. That we wholly disapprove and condemn the practice of some Boards of Guardians in England of varying the treatment, or threatening to vary the treatment — offering the Workhouse, for instance, instead of Outdoor Relief — in respect of persons entitled to relief from them, with a view to extracting contributions from other persons, whether or not these are legally liable for the payment. We think that it should be definitely laid down that the kind and amount of relief or assistance granted in any case should be determined solely by a consideration of the circumstances of the applicant or patient himself, and ought never to be made dependent on whether somebody else fulfils, or does not fulfil, a legal or moral obligation. 71. That the existing Law of Settlement and Removal, wasteful in its cost and occasionally the cause of hardship to the poor, will, under the scheme of reform which we are VOL. I 2 Q 594 CONCLUSIONS AND KECOMMENDATIONS proposing, automatically cease to be applicable ; and all the statutes bearing on the subject should be definitely repealed. 72. That the assumption of the greater part of the charge for the aged by the National Government, and the proposed transfer to a Government Department of the provision for all sections of the able-bodied, will, in a large proportion of cases, obviate the necessity for raising the question of eligibility of an applicant for public assistance in respect of his previous residence. 73. That the reorganisation of the various services now included in the Poor Law on the lines of a County or County Borough administration under the several com- mittees concerned, with the County or County Borough as the unit for rating, will, in the great majority of cases, render it unnecessary to raise the question of past residence. 74. That with regard to services rendered by the Local Health Authority, it should be made a condition of the proposed Grant-in-Aid that no question of the past residence of any applicant should be raised, except only with regard to admission to any specialised institution ; and in the latter case admission may, if thought fit, be confined, except on terms to be prescribed, to persons who have resided in the district for one year — any other persons being, if thought fit, refused admission (except when such refusal would involve danger to life), and relegated to the General Infirmary, or removed, under proper conditions and safeguards, to the specialised institution of the County to which they belong. 75. That (beyond the retention of the power to con- tribute towards school accommodation for " boarded-out " children) there is no need for any question of past resid- ence to be raised in connection with the work of the Local Education Committee ; and this should be made a condition of the Government Grants. 76. That whatever provisions are made in this respect, there should be identical and reciprocal rights as between England and Wales, Scotland and Ireland. 11. That alike in England and Wales, Scotland and Ireland, the Grauts-in-Aid of the expenditure of the CONCLUSIONS AND RECOMMENDATIONS 595 Destitution Authorities are urgently in need of revision. In return for the sum of £3,500,000 annually, which is being contributed to Boards of Guardians and Parish Councils, the various Departments of the National Govern- ment, which are charged with the supervision and control of the Local Authorities, now obtain the very minimum of power to prevent either extravagance or inefficiency, or of influence towards a greater efficiency of service. The relief afforded to the local ratepayer is so unequal and so arbitrarily distributed as to amount to a gross injustice, which is all the more intolerable in that, especially in Ireland, the poorest districts and those most heavily burdened often obtain the least rehef. And the conditions of the Grants, whilst seldom so framed as to cause a wise discrimination in favour of the more desirable methods of expenditure rather than others, sometimes result in posi- tively encouraging extravagance, laxness and refusal to carry out the policy desired by the Legislature. 78. That, in our opinion, in view of the large share of the cost of providing for the aged in their homes now borne by the National Exchequer under the Old Age Pensions Act of 1908, and of the share which we think it necessary for the National Government to take in the administration of the provision for the Unemployed and Able-bodied, we consider that no Grant-in- Aid should be made to the Local Authorities in respect of these two services. 79. That when all grades of the mentally defective are placed in the hands of the proposed new Local Authorities for the Mentally Defective, a Grant should be made to those Authorities in respect of all the persons satisfactorily provided for by them. It would be desirable that this Grant should be made on the same basis as that to the Local Health Authorities. 80. That a Grant-in-Aid should be made to the Local Health Authorities in respect of all the work now done by them, or to be hereafter entrusted to them. 81. That it is essential that all Grants-in-Aid should be administered by the particular Government Depart- ments concerned with the particular services to be aided ; and paid direct to the Local Authorities. 596 CONCLUSIONS AND RECOMMENDATIONS 82. That all Grants should take the form of Grants-in- Aid of local services ; that they should be conditional on the efficient performance of the services ; that they should be governed by detailed regulations, and accompanied by systematic inspection and audit ; and that they should be withheld, wholly or in part, on failure to comply with the law and the regulations in force. 83. That they might, for the convenience of the Chancellor of the Exchequer, be fixed in aggregate total, which might remain unchanged for a term of seven years ; but that the allocation of the total among the several Local Authorities should be proportionate to their several expenditures from time to time on the services to be aided, subject to such expenditure being allowed by the Depart- ment to count for this purpose, as not being extravagant or improper. If not considered too complicated, the scale of distribution proposed by Lord Balfour of Burleigh, determined jointly by expenditure and by the poverty of the district, might advantageously be adopted. 84. That the Local Government Board for England and Wales — and in a lesser degree the Local Government Boards for Scotland and Ireland — have failed to secure the national uniformity of policy with regard to the relief of the poor, which was aimed at in the establishment of a Central Authority upon the Report of 1834. 85. That this failure has contributed to the extra- ordinary variations in Poor Law administration in different districts, and to the present demoralised state of the majority of the Destitution Authorities. 86. That we attribute the failure, not to any short- comings in the persons concerned, but to the obsolete character of the administrative machinery with which they have had to work ; and notably to their not having been able to keep pace with the virtual transformation of the Destitution Authorities, from bodies set to "relieve destitution " under a deterrent Poor Law, into Local Authorities which, in response to public criticism, have started to provide, for this or that class of their patients, not deterrent relief, but curative and restorative treatment. 87. That the " Poor Law Division," with its General CONCLUSIONS AND RECOMMENDATIONS 597 Inspectors, adhering to the old technique of a deterrent " relief of destitution," is unqualified to secure the efficient and economical administration of the different kinds of nurseries, schools, hospitals, asylums, custodial homes, farm colonies, and what not, that are now being run by the hypertrophied Destitution Authorities. 88. That each of the separate services administered by the Local Authorities — such as education, public health and care of the insane — imperatively requires the super- vision, guidance and control of a distinct and self-con- tained Department or Division of a Department, having its own regulative orders, its own technically qualified Inspectorate, and its consistent line of policy ; and that just as the Local Destitution Authorities should be broken up and merged in the several Committees of the County or County Borough Council dealing with the several services, so the Poor Law Division of the Local Govern- ment Board should be abolished, and its work distributed among the several Departments or Divisions of Depart- ments to which may be entrusted the supervision and control over the Local Education Authorities, the Local Health Authorities, and the Local Authorities for the Mentally Defective, respectively. 89. That we cannot refrain from animadverting on the fact that, notwithstanding the enormous importance and steady expansion of the Public Health work of the Local Authorities, there exists, in England and Wales, no De- partment, and not even a distinct and self-contained Division of a Department, responsible for their supervision, guidance and control in this important service, and for maintaining in it a definite and consistent policy — the work of dealing with the questions as they arise being inter- mixed with the business of other services and scattered among five different Divisions of the Local Government Board ; none of them having, under its control, any staff" of inspectors for the systematic visitation of all the Local Health Authorities, or the administration of any Grant-in-Aid of the services of those Authorities ; and none of them being charged with the duty of formulating and maintaining a consistent policy for the service as a whole. 598 CONCLUSIONS AND RECOMMENDATIONS Deferring our proposals with regard to the whole of the Able-bodied until Part 11. of the present Report, we recommend : — 90. That, except the 43 Elizabeth c. 2, the Poor Law Amendment Act of 1834 for England and Wales, and the various Acts for the relief of the poor and the corresponding legislation for Scotland and Ireland, so far as they relate exclusively to Poor Relief, and including the Law of Settlement, should be repealed. 91. That the Boards of Guardians in England, Wales and Ireland, and (at any rate as far as Poor Law functions are concerned) the Parish Councils in Scotland, together with all combinations of these bodies, should be abolished. 92. That the property and liabilities, powers and duties of these Destitution Authorities should be trans- ferred (subject to the necessary adjustments) to the County and County Borough Councils, strengthened in numbers as may be deemed necessary for their enlarged duties ; with suitable modifications to provide for the special circumstances of Scotland and Ireland, and for the cases of the Metropolitan Boroughs, the Non-County Boroughs over 10,000 in population, and the Urban Districts over 20,000 in population, on the plan that we have sketched out. 93. That the provision for the various classes of the Non- Able-bodied should be wholly separated from that to be made for the Able-bodied, whether these be unemployed workmen, vagrants or able-bodied persons now in receipt of Poor Relief 94. That the services at present administered by the Destitution Authorities (other than those connected with vagrants or the able-bodied) — that is to say, the provision for :— (i.) Children of school age ; (ii.) The sick and the permanently incapacitated, the infants under school age, and the aged needing institutional care ; (iii.) The mentally defective of all grades and all ages ; and (iv.) The aged to whom pensions are awarded — CONCLUSIONS AND RECOMMENDATIONS 599 should be assumed, under the directions of the County and County Borough Councils, by : — (i.) The Education Committee; (ii.) The Health Committee ; (iii.) The Asylums Committee ; and (iv.) The Pension Committee respectively. 95. That the several committees concerned should be authorised and required, under the directions of their Councils, to provide, under suitable conditions and safe- guards to be embodied in Statutes and regulative Orders, for the several classes of persons committed to their charge, whatever treatment they may deem most appro- priate to their condition ; being either institutional treat- ment, in the various specialised schools, hospitals, asylums, etc., under their charge; or, whenever judged preferable, domiciliary treatment, conjoined with the grant of Home Aliment where this is indispensably required. 96. That the law with regard to liability to pay for relief or treatment received, or to contribute towards the maintenance of dependants and other relations, should be embodied in a definite and consistent code, on the basis, in those services for which a charge should be made, of recovering the cost from all those who are really able to pay, and of exempting those who cannot properly do so. 97. That there should be established in each County and County Borough one or more officers, to be designated Registrars of Public Assistance, to be appointed by the County and County Borough Council, and to be charged with the threefold duty of : — (i.) Keeping a Public Register of all cases in receipt of public assistance ; (ii.) Assessing and recovering, according to the law of the land and the evidence as to sufficiency of ability to pay, whatever charges Parliament may decide to make for particular kinds of relief or treat- ment ; and (iii.) Sanctioning the grants of Home Aliment proposed by the Committees concerned with the treatment of the case. 98. That the Registrar of Public Assistance should aoo CONCLUSIONS AND RECOMMENDATIONS have under his direction (and under the control of the General Purposes Committee of the County or County Borough Council) the necessary staff of Inquiry and Recovery Officers, and a local Receiving House, for the strictly temporary accommodation of non-able-bodied persons found in need, and not as yet dealt with by the Committees concerned. 99. That the present national subventions in aid of the Destitution Authorities should be replaced by Grants-in- Aid of the expenditure on the whole of the services to be administered by the Health Committees of the County and County Borough Councils, subject to the administration of these services up to, at any rate, a National Minimum of Efficiency ; the aggregate amount of such Grants-in-Aid for the United Kingdom and their allocation as between England (including Wales), Scotland and Ireland being fixed and subject to revision only every seven years ; but the distribution of this total among the several County and County Borough Councils being made, according to the plan we have specified, in proportion to their several gross expenditures on these services ; and at the same time in such a proportion to the poverty of their districts as will enable the National Minimum of Efficiency to be everywhere attained without anywhere exceeding the Standard Average Rate. 100. That the Local Authorities in England and Wales, in respect of the services administered by each Committee, be placed under the supervision of a single Department or Division of a Department of the National Government, which shall itself administer the Grants-in- Aid of its particular services, issue its own regulative Orders, and have its own technically qualified Inspectors ; the Education Committees in England and Wales being thus responsible, for the efficiency of all their services, to the Board of Education ; the Mentally Defectives (or Asylums) Committees to the proposed Board of Control, in succession to the Lunacy Commissioners ; the Pension Committees to whatever Department is deputed to take charge of the Old Age Pensions Act of 1908; and the Health Com- mittees, with regard to all their enlarged range of CONCLUSIONS AND RECOMMENDATIONS 601 functions, to a separately organised and self-contained Public Health Department, whether this is organised as a separate Division of the Local Government Board or made a distinct Department. The determination of appeals from the decisions of the Registrar of Public Assistance, and whatever national supervision may be exercised over the Grant of Home Aliment to the Non-Able-bodied, should, we suggest, be entrusted to another separately organised and self-contained Department or Division of a Department which, if it can be dissociated from the Local Government Board, might, with advantage, be placed, along with the Department or Division dealing with Audit, Loans and Local Finance generally, in close con- nection with the Treasury. 101. That a temporary Executive Commission be appointed to adjust areas, boundaries, assets and lia- bilities ; and to allocate buildings and officers among the future Local Authorities. Printed by R. & R. Ci.ark, Limited, EdinlHruk, WORKS BY SIDNEY AND BEATRICE WEBB In the Press ENGLISH POOR LAW POLICY, 1834-1908 In this forthcoming volume, the authors of Industrial Democracy and English Local Government present what is practically a history of the English Poor Law, from the Eeport of the Eoyal Commission of 1832-4 down to that of the Eoyal Commission of 1905-9. For this work they have analysed, not only the statutes, but also tlie bewildering array of General and Special Orders, Circulars, Minutes, Inspector's exhortations, and unpub- lished letters, by means of which the Poor Law Commissioners, the Poor Law Board, and the Local Government Board have sought to direct the policy of the Boards of Guardians. No such history has before been attempted. For the first time the gradual development of policy can be traced, with regard to children, to the sick, to the aged and infirm, to vagrants, to the able-bodied, etc. The reader is enabled to watch the gradual and almost unconscious evolution, from out of the " principles of 1834," what may be called the " principles of 1908 " ; being the lines of policy to which the experience of the last three-quarters of a century has brought the Poor Law administrator of to-day. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA WORKS BY SIDNEY AND BEATRICE WEBB Demy 8vo, pp. xxvi and 664 (1907). Price 16s. net. ENGLISH LOCAL GOVERNMENT (THE PARISH AND THE COUNTY) FROM THE REVOLUTION TO THE MUNICIPAL CORPORATIONS ACT This work, the result of eight years' research into the manuscript records of the Parish and the County all over England and Wales — from Northumberland to Cornwall, from Cardigan to Kent — combines history and description in a continuous narrative of extraordinary interest. Avoiding the questions of the origin of English local institu- tions, and even of their mediseval development, the authors plunge at once into a vivid description of the Parish Officers and the Vestry Quarter Sessions and the Justices of the Peace, the Lord-Lieutenant and the High Sheriff, together with all the other authorities by which the internal administration was actually carried on. An entirely new view is presented of the social and political development of Parish Vestry and Quarter Sessions, of their relations to the Squire and the Incumbent, and of their attitude towards Parliament and the problems of their age. But the book is more than a contribution to history and political science. Practically all the counties of England and Wales, and literally hundreds of parishes, find place in this unique record of life and manners, in which are embedded not a few dramatic episodes of absorbing interest. It is a new picture of English life between 1689 and 1835 as it actually was in country and town, with graphic tracings of its results on national progress and on the social and economic problems by which we are now confronted. English Local Government— contd. CONTENTS THE PARISH Introduction. The Legal Framework of the Parish. («) The Area and Membebkhip of the Parish ; (t) The Officers OF the Parish ; {c) The Servants of the Parish ; (r/) The In- cumbent ; (e) The Parish Vestry ; (/) The Parish as a Unit of Obligation. Unorganised Parish Government. (a) The Parish Oligarchy ; {h) Government by Consent ; (c) The Uncontrolled Parish Officers ; [cV) The Rule of the Boss ; (c) The Turbulent Open Vestry. An Extra-legal Democracy. (a) The Organisation of the Public Meeting ; (6) The Control over the Unpaid Officers ; (o) A Salaried Staff ; {d) The Parish Committee ; (e) An Organised Democracy ; (/) The Recalcitrant Minority. The Strangling of the Parish. (ff) Eighteenth Century Legislation ; (6) The Sturges Bourne Acts ; (c) The Sturges Bourne Select Vestries ; {d) The Salaried Overseer ; (c) The Referendum ; (/) The Death of the Parish. The Legality of the Close Vestry. (a) The Close Vestry by Immemorial Custom ; (i) The Close Vestry by Bishop's Faculty ; (c) The Close Vestry by Church Building Act ; [d) The Close Vestry by Local Act ; (c) The Constitutions of Close Vestries. Close Vestry Administration. (a) Provincial Close Vestries ; (6) Metropolitan Close Vestries ; (c) Close Vestry Exclusiveness ; (o?) The Worst and THE Best. The Reform of the Close Vestry. (ff.) The Assaults that Failed ; (&) A London Movement ; (c) Opening the Close Vestry. THE COUNTY Introduction. The Legal Constitution of the County. (a) The Area and Divisions of the County ; (6) The Custos Rotulorum ; (c) The Sheriff and his Court ; (rf) The High Con- stable ; (c) The Coroner ; (/) The Commission of the Peace ; {g) County Service ; ijk) An Organ of National Government. English Local Government — contd. On some Anomalous County Jurisdictions, including the Counties Palatine. The Rulers of the County. (a) Number and Distribution of Justices ; {^) The Justice of Mean Degree ; (c) The Trading Justice ; {d) The Court Justice ; (c) The Sycophant Justice and Rural Tyrant ; (/) The Mouth- piece OF THE Clerk ; {g) The Clerical Justice ; (Ji) The Leader of THE Parish ; (i) Leaders of the County ; {j) The Lord- Lieutenant AND THE High Sheriff ; {k) Class Exclusiveness. County Administration by Justices out of Sessions. (a) The "Single Justice"; (&) The "Double Justice"; (c) The Special Sessions ; {d) Petty Sessions ; (e) The Servants of the Justices; (/) The Sphere of Justices "out of Sessions." The Court of Quarter Sessions. (rt) The Time and Place of Meeting ; (6) The Chairman of the Court ; (c) The Procedure of the Court ; {d) Administration by Judicial Process ; (c) The Grand Jury ; (/) The Hundred Jury ; (gr) Presentments by Constables ; (A) Presentments by Justices. The Development of an Extra-legal Constitution. L The County Executive. (a) The High Sheriff and his Bailiffs ; (fc) The High Con- stable ; (c) The Clerk of the Peace ; {d) The County Treasurer ; (c) The County Surveyor ; (/) Executive Makeshifts ; {g) Com- mittees of Justices. n. An Inchoate Provincial Legislature. IIL An Extra-legal County Oligarchy. The Reaction against the Rulers of the County. (ffi) The Breakdown of the Middlesex Bench ; (6) The Lack of Justices ; (c) The Restriction of Public Houses ; {d) The Justices' Poor Law ; (e) The Growth of County Expenditure ; (/) The Severity of the Game Laws ; {g) The Stopping up of Footpaths ; (Ji) The Stripping of the Oligarchy ; (i) Why the Justices Survived. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA WORKS BY SIDNEY AND BEATRICE WEBB Demy 8vo, pp. viii and 858, in 2 volumes (1908). Price 25s. net. ENGLISH LOCAL GOVERNMENT (THE MANOR AND THE BOROUGH) FROM THE REVOLUTION TO THE MUNICIPAL CORPORATIONS ACT In this second instalment of their English Local Government the authors apply their method of combined history and analysis to the fascinating story of the towns and the manorial com- munities, of which several hundreds find mention, belonging to all the counties of England and Wales. An interesting new account is given, from unpublished materials, of the organisation and development in the seventeenth and eighteenth centuries of the Manor and its several Courts, with picturesque glimpses of the hitherto undescribed part played by the Jury in the common- field agriculture. But the Manor is shown to be also the starting-point for a whole series of constitutional developments, passing through grade after grade of Manorial Borough, hitherto undescribed, into the complete Municipal Corporation. This, too, is analysed and described in a way never before attempted, so as to make the strangely interesting life of the towns live before us. A special chapter is devoted to the Boroughs of Wales, in which their national peculiarities are brought out. Their extensive study of the manuscript records enable the authors to set forth the inner working of the " Municipal Democracies " that existed alongside the chartered oligarchies, S English Local Government — contd. with their many analogies to modern American cities ; and to bring vividly to notice the conditions and limitations of succes- sive Democratic government. There is an interesting sketch of English hierarchies of town government, chief among them being the Cinque Ports, the constitutional position of which is presented in a new light. The anomalous history of the City of Westminster is explored by the light of the unpublished archives of its peculiar municipal organisation. An altogether novel view is presented of the constitutional development of the greatest municipality of all, the Corporation of the City of London, to which no fewer than 124 pages are devoted. The work concludes with a picturesque account of the " Municipal Kevolution " of 1835, and the Homeric combat of Brougham and Lyndhurst which ended in the Municipal Keform Act of 1835. CONTENTS Introduction. The Lord's Court — (a) The Lawyer's Vieav of the Lord's Court. (6) The Court Baron. (c) The Court Leet. The Court in Ruins — (a) The Hierarchy of Court.s. {h) The Court of the Hundred. (c) The Court of the Manor : (i.) The Bamburqh Courts. (ii.) The Court Leet of the Savoy. (iii.) The Court Leet and Court Baron of Manchester. (rf) The Prevalence and Decay of the Lord's Court. 6 E^tglish Local Government — contd. The Manorial Bokough — (a) The Village Meeting, (6) The Chartered Township. (c) The Lordless Court. (d) The Lord's Borough. (e) The Enfranchised Manorial Borouoh. {/) Manor and Gild. {g) Arrested Development and Decay. The City and Borough of Westminster — (a) Burleigh's Constitution. (6) Municipal Atrophy. The Boroughs of Wales — (a) Incipient Autonomy. (ft) The Welsh Manorial Borough. (c) The Welsh Municipal Corporation. The Municipal Corporation — («) The Instrument of Incorporation. (6) Corporate Jurisdictions. (c) Corporate Obligations. {d) The Area of the Corporation. (e) The Membership of the Corporation. (/) The Servants of the Corporation. (jr) The Chief Officers of the Corporation. (7i) The Head of the Corporation. {%) The Bailiffs. {j) The High Steward and the Recorder. {k) The Chamberlain and the Town Clerk. (/) The County Officers of the Municipal Corporation. {7?i) The Mayor's Brethren and the Mayor's Counsellors. («.) The Courts of the Corporation. (o) Courts of Civil Jurisdiction. (^) The Court Leet. {q) The Borough Court of Quarter Sessions. (r) Courts of Specialised Jurisdiction. (s) The Administrative Courts of the Municipal Corporation, (<) The Municipal Constitutions of 1689. Municipal Disintegration — (a) The Rise of the Corporate Magistracy. (6) The Decline of the Common Council. (c) The Establishment of New Statutory Authorities. (rf) The Passing of the Freemen. (e) The Mingling of Growth and Decay. 7 English Local Government — coritd. Administration by Close Corporations — (Penzance, Leeds, Coventry, Bristol, Leicester, and Liverpool). Administration by Municipal Democracies — (Morpeth, Berwick-upon-Tweed, Norwich, and Ipswich). The City of London — (a) The Legal Constitution of the City. (6) The Service of the Citizen to his Ward. (c) The Precinct. {d) The Inquest of the Ward. (e) The Common Council of the Ward. (/) The Decay of Ward Government. ((/) The Court of Common Hall. h) The Court of Common Council. {i) The Court of Aldermen. (./) The Shrievalty. (Jc) The Right Honourable the Lord Mayor. (Z) The Officers of the Corporation. (?n) A Ratepayers' Democracy. The Municipal Revolution— (rt) Towards the Revolution. (6) Instalments of Reform. (c) The Royal Commission. {(.i) An Alternative Judgment. (e) The AVhig Bill. (/) The Municipal Corporations Act. Index of Subjects. Index of Authors and Other Persons. Index of Places. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA WORKS BY SIDNEY AND BEATRICE WEBB To he puUished in 1909 Demy 8vo. 16s. net. ENGLISH LOCAL GOVERNMENT (STATUTORY AUTHORITIES) FROM THE REVOLUTION TO THE MUNICIPAL CORPORATIONS ACT This volume, completing the account of the constitutional structure of English Local Government, deals with a field hitherto even less explored than the Parish, the County, the Manor, and the Borough. Interspersed among these organisations there existed innumerable others, which might be termed, in the slang of to-day, " Ad Hoc bodies," formed for specific purposes. Among these were the Courts of Sewers, in town and country, the hitherto unexplored records of which yield an altogether new vision of local life in London and Lincolnshire, Somerset and the Fen country. The Turnpike Trusts give us two centuries of experience in roadmaking and road maintenance, which is not without its special interest for our own day. The Incorporated Guardians of the Poor of the eighteenth century are found to have anticipated many of the devices of those of the nineteenth and twentieth. The hundreds of bodies of Improvement Com- missioners, the records of none of which have been printed, or, indeed, hitherto scarcely glanced at, present us with a view of the real municipal administration of the towns, for which students have sought in vain in the Municipal Corporation archives. All these " Ad Hoc " bodies, like our own School Boards and Boards of Guardians, had their own constitutional life and development, from which much is to be learnt. LONGMANS, GKEEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA 9 SOME PRESS NOTICES OF ENGLISH LOCAL GOVERNMENT " A book of tlie deepest, even of fascinating interest. Here for the first time we have a real study of local life in England, in village and town and country. . . . Everywhere we follow the gallant fights of humane and just men whose stories are scattered through these pages, along with the sharp dealings of the astute. Familiar names meet us — a great-uncle of Cecil Rhodes making his ' Empire ' in St. Pancras ; the novelist Fielding cutting down the gains of the magistrate who preyed on the poor. . . . Noble figures stand out among the ignoble. As in the parish, the rulers of the county . . . found themselves left free ... to administer as they thought fit. They used the power fully ; governed, legislated, silently transformed their constitution, and showed themselves capable of the same extremes as the men of the parish, except that they never surrendered to the ' boss.' . . . We have only touched here on the tale the authors give, so absorbing in interest to any Englishman. . . . The best tribute to the writers of this most valuable work is the difficulty of turning away for comment or criticism from the subjects they present in such a vigorous and human form. . . . They have opened a new chapter in English history." — Mrs. J. R. Green, in Westminster Gazette. " Mr. and Mrs. Sidney Webb's monumental work on our local institutions must be a source at once of pride and of something a little like shame. Here at last we have a book which is more than worthy to be placed beside those of the great continental writers on the subject. . . . Mr. and Mrs. Sidney Webb are as learned as the Prussian, as lucid as the Frenchman, and as scholarly and careful as the Austrian. ... If it is literature to present a singularly vivid picture of a past stage of society, to render it real and lifelike by a careful selection and skilful grouping of illustrative details, and to explain its meaning with clearness, sound judgment, and not infrequent touches of quiet humour, then assuredly is this volume literary as well as learned. . . . Packed as it is with quotations and references, it is full of transcripts from life which one reader at least has found more fascinating than many of the efforts made to revivify the past through the medium of historical romance or romantic history. The story of the rise, the decline, and the fall of the parish autonomy and the old county oligarchy is in itself a sort of epic not wanting in the elements of adventure, and even of tragedy. . , . Here and there a remarkable personality emerges." — Mr. Sidney Low, in Standard. " Without exaggeration it may be said that this work will necessitate the rewriting of English history. . . . We are ushered into a new world, full of ea^er and heated interest. . . . The authors have contrived to make these dead bones live. Everywhere are peepholes into the lives of the people, and occasionally a connected story . . . throws a flood of light on English society. There is not a chapter which is not full of facts of general interest, while the whole volume . . . will be altogether indispensable to the serious English Local Government — contd. student. . . . There is a fascinating tale of the ' boss ' of Bethnal Green. . . A history of the English people, richer in local colour, more comprehensive in its survey of social affairs, and more truly human in its sympathies than any treatise hitherto given to the public." — Mr. R. A. Brat, in Daily News. " Mr. and Mrs. Sidney Webb continue their laborious and luminous studies of English local institutions. In the last two volumes we find the same charac- teristics as those already published respecting the parish and the county — a minute investigation conducted not in the spirit of the antiquary, but with an eye to realities which are of interest to the politician, the historian, and the economist ; an examination of the vast mass of printed matter on the subject, much of it practically inaccessible ; and exhaustive enquiry among unedited manuscript records, some of them probably never before read. A few lines in the text or in a footnote are the results of prolonged local in- vestigation ; a few unobtrusive words at the close of a sentence, or qualify- ing some general statement, are the fruits of a careful search among the muniments of some corporation. "We cannot speak too highly of the industry and patience which these volumes attest. They possess even rarer merits. The whole subject is set in a new light. We get away from traditional formulae and conceptions. We see the local institutions at work, and they appear very different from what they are represented by lawyers to be." — Tinus. " If it be true, as many deep thinkers maintain, that history affords the only sure key to a thorough knowledge of political institutions, then the work of which these two learned and elaborate volumes form a part is indis- pensable to every serious student of English Local Government, for the history of that subject has never yet been expounded with such completeness and so scientific an impartiality. ... A pioneer in a new way of writing the history of institutions, ... By the skill with which they present the general movement of institutional developments as the outgrowth of natural forces, and constantly illustrate it by particular points of actuality and human interest, these writers have given new life to a study too long neglected." — Scotsman. *' Closely packed tomes, crowded with detail, and exhibiting the result of a sum of research and investigation which leaves the indolent, irresponsible reviewer almost wordless with respectful admiration. . . . Such a collection of original material has been weighed and sifted as might move the envy of any German professor." — Evening Standard. " For years to come they will still be sifting, amassing, arranging, but their reputation as the foremost investigators of fact now amongst us is likely to be confirmed rather than shaken. Their work is as minute in detail as it is imposing in mass. In their patience they possess their intellect, and they remind us of the scholar with a magnifying glass in a picture by Jan van Eyck." — Observer. WORKS BY SIDNEY AND BEATRICE WEBB THE BREAK-UP OF THE POOR LAW BEING PART I. OF THE MINORITY REPORT OF THE POOR LAW COMMISSION Edited, with Introduction, by Sidney and Beatrice Webb Demy 8vo, xx and 604 pp. 7s. 6d net. Uniform with "English Local Government" Bluebooks, it has been said, are places of burial. The Report of the Royal Commission on the Poor Law and the Agencies dealing with the Unemployed is a ponderous tome of twelve pounds weight, crowded with references, footnotes, and appendices, impossible either to handle or to read. Mr. and Mrs. Webb have, therefore, rescued from this tomb the Minority Report signed by the Rev. Russell Wakefield, Messrs. Chandler and Lansbury, and Mrs. Webb herself. By omitting all the notes and references, and printing the text in clear type on a con- venient octavo page, they present the reader with something which he can hold with comfort by his fireside. This Minority Report is a new departure in such documents. It is readable and interesting. It is complete in itself. It presents, in ordered sequence, page by page, a masterly survey of what is actually going on in our workhouses and in the homes of those maintained on Outdoor Relief. It describes in precise detail from carefully authenti- cated evidence what is happening to the infants, to the children of school age, to the sick, to the mentally defective, to the widows with children struggling on their pittances of Outdoor Relief, to the aged and infirm inside the workhouse and outside. It sets forth the overlapping of the Poor Law with the newer Avork of the Education and Public Health Authorities, and the consequent waste and confusion. It gives a graphic vision of the working of the whole Poor Law machinery in all parts of the United Kingdom, Avhich is costing us nearly twenty millions sterling per annum. The volume concludes with a Scheme of Reform, of novel and far- reaching character, which is elaborately worked out in detail, involving the abolition of the workhouse, the complete disappearance of the Poor Law, and the transfer of the care of the children, the sick, the mentally defective, and the aged to the several committees of the County Borough Councils and County Councils already administering analogous services. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA 12 WORKS BY SIDNEY AND BEATRICE WEBB THE PUBLIC ORGANIZATION OF THE LABOUR MARKET BEING PART IL OF THE MINORITY REPORT OF THE POOR LAW COMMISSION Edited, with Introduction, by Sidney and Beatrice Webb Demy 8vo, xvi and 332 pp. 5s. net. Uniform with "English Local Government" The Problem of the Unemployed, which the Eoyal Commission on the Poor Law was incidentally set to solve, is the question of the day. Part II. of the Minority Eeport deals with it in a manner at once comprehensive and complete. The whole of the experience of the Poor Law Authorities, and their bankruptcy as regards the destitute able-bodied, is surveyed in vivid and picturesque detail. There is a brief account of the work of Voluntary Agencies. A lucid description is then given, with much new information, of the movement started by Mr. Chamber- lain in 1886, which culminated in the Unemployed Workmen Act of 1905. The story is told of the various experiments and devices that have been tried during the past twenty years, the Belief Works and the Farm Colonies, etc. This leads up to an altogether novel descriptive analysis of the Unemployed of to-day, who they actually are, and what they really need. The final chapter on Proposals for Eeform gives, in elaborate detail, the Minority's plan for solving the whole problem of Unemployment — not by any vague and chimerical panacea, but by a series of administratively practicable reforms, based on the actual experi- ence of this and other countries, which are within the compass of the Cabinet, and could, if desired, be carried in a single session of Parliament. LONGMANS, GEEEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA 13 WORKS BY SIDNEY AND BEATRICE WEBB THE HISTORY OF TRADE UNIONISM Post 8vo ; Eighth Thousand; New Edition, with New Introductory Chapter ; xxxiv and 558 pp. Price 7s. 6d. net. This work desmbes, not only the growth and development of the Trade Union Movement in the United Kingdom from 1700 down to the present day, but also the structure and working of the present Trade Union organisation in the United Kingdom. Founded almost entirely on material hitherto unpublished, it is not a mere chronicle of Trade Union organisation or record of strikes, but gives, in eflfect, the political history of the English working class during the last one hundred and fifty years. The opening chapter describes the handicraftsman in the toils of the industrial revolution, striving vainly to retain the mediaeval regulation of his Standard of Life. In subsequent chapters the Place Manuscripts and the archives of the Priory Council and the Home Office enable the authors to picture the struggles of the early Trade Unionists against the Combination Laws, and the remarkable Parliamentary manipulation which led to their repeal. The private records of the various Societies, together with contemporary pamphlets and working-class newspapers, furnish a graphic account of the hitherto undescribed outburst of "New Unionism "of 1830-34, with its revolutionary aims and subsequent Chartist entanglements. In the course of the naiTative we see the intervention in Trade Union history of Francis Place, Joseph Hume, J. R M'Culloch, Nassau Senior, William the Fourth, Lord Melbourne, Robert Owen, Fergus O'Connor, Thomas Slingsby Duncombe, John Bright, the Christian Socialists, the Positivists, and many living politicians. The hidden influence of Trade Unionism on English politics is traced from point to point, new light being incidentally thrown upon the defeat of Mr. Gladstone's Government in 1874. A detailed analysis is given of the economic and political causes which have, since 1880, tended to divorce the 14 The History of Trade Unionism — contd. Trade Union Movement from its tilliance with " official Liberalism." A new introductory chapter brings the story down to the last few years. The final chapter describes the Trade Union world of to-day in all its varied features, including a realistic sketch of actual Trade Union life by a Trade Union Secretary, and a classified census founded on the authors' investigations into a thousand separate Unions in all parts of the country. A coloured map represents the percentage which the Trade Unionists bear to the population of each county. A bibliography of Trade Union literature is appended (which, together with that given in Industrial Democracy, affords a unique index of almost every available source of information). CONTENTS Introduction to the New Edition. Preface. CHAP. I. The Origins of Trade Unionism. II. The Struggle for Existence (1799-1825). III. The Revolutionary Period (1829-1842). IV. The New Spirit and the New Model (1843-1860). V. The Junta and their Allies (1860-1875). VI. Sectional Developments (1863-1885). VII. The Old Unionism and the New (1875-1889). VIII. The Trade Union World. APPENDIX On the assumed Connection between the Trade Unions and the Gilds in Dublin— Sliding Scales — The Summons to the First Trade Union Congress — Distribution of Trade Unionists in the United Kingdom — The Progress in Membership of particular Trade Unions — List of Publications on Trade Unions and Combinations of Workmen. 15 The History of Trade Unionism — contd. " A masterly piece of work." — Times. " To the politician ... an invaluable guide." — Observer. " An admirably lucid presentation of a great mass of complicated facts. Its very footnotes display a wealth of material such as would have amply sufficed to turn each note into an article of considerable length. In the learning they exhibit, and the concise and decisive way in which they settle important subsidiary questions and side-issues, they remind us of the notes in such monuments of German industry and erudition as Zeller's Griechische Philosophie. . . . The result is a full, clear, and condensed history such as can have few parallels. . . . We may fairly repeat that the book is a master- piece of lucidity of knowledge. Every page is of value, and nearly every sentence contains a fact." — Speaker. " Readable every word of it. There is plenty of excitement and plenty of romance in the book." — Queen. *' As fascinating reading as a well-written novel." — Cotton Factory Times. " Infinitely painstaking, comprehensive, clear and acute, the first correct and scholarly history of Trade Unionism in England. . . . Marked by immense research. . . . The book must find a permanent place upon the shelf of every student of Economics. . . . Undeniably marked by the qualities of true history — fulness, accuracy, and clear connection in the presentation of facts." — Newcastle Chronicle. " It would not be easy to overestimate the value and importance of their admirable and masterly work . . . not likely to be superseded for some time to come." — Economic Review. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA i6 WORKS BY SIDNEY AND BEATRICE WEBB INDUSTRIAL DEMOCRACY Post 8vo ; Seventh Thousand ; New Edition in 1 vol., with New Introduc- tory Chapter (1902) ; Ixi and 929 pp., with Two Diagrams. Price 12s. net. ADVEETISEMENT In this work the authors of The History of Trade Unionism deal, not with the past, but with the present. They describe, with the systematic detail of the scientific observer, and in the same objective spirit, all the forms of Trade Unionism, Factory Legislation, and other regulation of industry to be found within the British Isles. The whole structure and function of Labour Organisations and Restrictive Legislation in every industry is analysed and criticised in a manner never before attempted. The employer in difficulties with his work- men, the Trade Unionist confronted with a new assault upon his Standard Rate, the politician troubled about a new project for Factory Legislation, the public-spirited citizen concerned as to the real issues of a labour dispute, will find elucidated in this work the very problems about which they are thinking. It is a storehouse of authenticated facts about every branch of " the Labour Question," gathered from six years' personal investigation into every industry in all parts of the Kingdom ; systematically classified ; and made accessible by an un- usually elaborate Index. But the book is more than an Encyclopedia on the Labour Question. Scientific examination of Trade Union structure reveals, in these thousand self-governing republics, a remark- able evolution in Democratic constitutions, which throws light on political problems in a larger sphere. The century-long experience of these working-class organisations affords unique evidence as to the actual working of such expedients as the Referendum, the Initiative, Government by Mass Meeting, Annual Elections, Proportional Repre- sentation, Payment of Members, and, generally, the relation between the citizen-elector, the chosen representative, and the executive ofiicer. The intricate relations of trade with trade have an interesting bearing upon such problems as Local Government, Federation, and Home Rule. Those who regard the participation of a working-class electorate in the affairs of Government as the distinctive, if not the dangerous feature 17 Industrial Democracy — contd. in modern politics, will here find the phenomenon isolated, and may- learn how the British workman actually deals with similar issues in his own sphere. The intricate constitutions and interesting political experiments of the thousand self-governing Trade Union republics are dissected and criticised by the authors in such a way as to make the work a contribution to Political Science as to the scope and method of which the authors, in describing their investigations, propound a new view. The analysis of the working of Trade Unionism and Factory Legislation in the various industries of the United Kingdom has involved a reconsideration of the conclusions of Political Economy. The authors give a new and original description of the working of industrial competition in the business world of to-day ; and they are led to important modifications of the views currently held upon Capital, Interest, Profits, Wages, Women's Labour, the Population Question, Foreign Competition, Free Trade, etc. The latter part of the work is, in fact, a treatise upon Economics. A new Introductory Chapter deals at length with Compulsory Courts of Ai-bitration and Wages-Boards in New Zealand and Australia. CONTENTS Preface. Introduction to the New Edition. PART I TRADE UNION STRUCTURE CHAP. I. Primitive Democracy. II. Representative Institutions. III. The Unit of Government. IV. Interunion Relations. PART II TRADE UNION FUNCTION CHAP. I. The Method of Mutual Insurance. II. The Method of Collective Bargaining. III. Arbitration. IV. The Method of Legal Enactment. V. The Standard Rate. VI. The Normal Day. VII. Sanitation and Safety. i8 Industrial Democracy — contd. CHAP. VIII. New Processes and Machinery. IX. Continuity of Employment. X. The Entrance to a Trade. {a) Apprenticeshii'. (5) The Limitation of Boy Labour. (c) Progression within the Trade. {d) The Exclusion of Women. XI. The Right to a Trade. XII. The Implications of Trade Unionism. XIII. The Assumptions of Trade Unionism. PART III TRADE UNION THEORY CHAP. I. The Verdict of the Economists. II. The Higgling of the Market. III. The Economic Characteristics of Trade Unionism. (a) The Device of Restriction of Numbers. (6) The Device of the Common Rule. (c) The Effect of the Sectional Application of the Common Rule on the Distribution of Industry. (d) Parasitic Trades. (c) The National Minimum. (/) The Unemployable. {g) Summary of the Economic Characteristics of the Device of the Common Rule. (A) Trade Union Methods. IV. Trade Unionism and Democracy. APPENDICES The Legal Position of Collective Bargaining in England — The Bearing OF Industrial Parasitism and the Policy of a National Minimum on the Free Trade Controversy — Some Statistics bearing on the Relative Movements of the Marriage and Birth-Rates, Pauperism, Wages, and the Price of Wheat— A Supplement to the Biblio- graphy OF Trade Unionism. "A permanent and invaluable contribution to the sum of human knowledge. . . . We commend to the public a book which is a monument of research and full of candour. . . . Indispensable to every publicist and politician." — Times (on day of publication). LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA 19 WORKS BY SIDNEY AND BEATRICE WEBB PROBLEMS OF MODERN INDUSTRY Post 8vo; Fourth Thousand ; New Edition, with New Introductory Chapter (1902) ; xx and 286 pp. Price 5s. net. CONTENTS Introbuction to the New Edition. Preface. CHAP. I. The Diary op an Investigator. II. The Jews of East London. III. Women's Wages. IV. Women and the Factory Acts. V. The Kegulation of the Hours op Labour. VI. How TO DO AWAY WITH THE SWEATING SySTEM. VII. The Reform op the Poor Law. VIII. The Relationship between Co-operation and Trade Unionism. IX. The National Dividend and its Distribution. X. The Difficulties of Individualism. XI. Socialism True and False. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA WORKS BY SIDNEY AND BEATRICE WEBB THE HISTORY OF LIQUOR LICENSING IN ENGLAND Small 8vo ; Seventh Thousand ; viii and 162 pp. Price 2s. 6d. net. CONTENTS CHAP. I, The First Century of Licensing. II. A Period of Laxness. III. Kegulation and Suppression. IV. Fbbe Trade in Theory and Practice. V. Legislative Repentance. APPENDIX — The Movement for the Reformation of Manners. " No book could be more opportune. The sale of alcoholic liquor has been under statutory regulation by means of licences for 300 years ; but the period which Mr. and Mrs. Webb have taken as their special study deserves the very careful examina- tion they give to it, for within those 130 years we find periods of regulation and suppression, of laxness and neglect in regard to the control of the liquor traflBc, equally instructive. There is during this period one brief six years wherein the magistrates, awaking to their responsibilities and compelled to a consciousness of the evil results of excessive gin-drinking, made a general effort to improve the condition of things through the one means in their power. To this remarkable episode the authors devote a valuable chapter. Strangely enough, it has hitherto not been noticed by historians, nor has it been mentioned in the voluminous literature of the temperance movement. Yet the effort of the magistrates during those six years was very far-sighted. It included — ' ' ' The deliberate and systematic adoption of such modern devices as early closing, Sunday closing, the refusal of new licences, the withdrawal of licences from badly conducted houses, the peremptory closing of a proportion of houses in a district over-supplied with licences, and, in some remarkable instances, even the establishment of a system of local option and local veto, both as regards the opening of new public-houses and the closing of those already in existence, all without the slightest idea of compensation.' All this in the closing years of the eighteenth century ! But what a contrast to this spasm of local statesmanship the earlier years of that drink-sodden century display ! Then, and not really till then, were sown the seeds of drunkenness in England. Contrasted with that reign of orgy the action of the magistrates in 1787 seems all the brighter, and the disappearance of the fact from public memory the more remark- able. Mr. and Mrs. Webb bring their detailed story to an end with the Drink Bill of 1830, which led to another outbreak of the drinking habit." — Guardian. " A valuable contribution to the history of the liquor traffic." — Political Science Quarterly. "This little book, with its abundance of newly discovered facts, is highly opportune." — Economic Review. " The book is of great interest, contains evidence of laborious investigation, and provides an admirably clear history of a matter of immediate practical importance." — Speaker. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA 21 WORKS BY SIDNEY AND BEATRICE WEBB LONDON EDUCATION By SIDNEY WEBB Small 8vo ; viii and 219 pp. Price 2s. 6d. net. A Description of the Educational Organisation of London, with a Survey of some of its Administrative Problems — avoiding both politics and religion. CONTENTS CHAP. I. The Evolution of an Educational System. II. The Organisation of the University. III. The Organisation op Commercial Education. IV. The Organisation of the Polytechnics. V. The Organisation of the Library Service. VI. The Lion in the Path. " This small but important volume. ... It is a noble idea.!."— Spectator. "Patiently and laboriously he has surveyed our educational equipment . . . and he presents a creditably clear and comprehensible picture of the whole field. It enables the administrator to see the various parts in their due proportion. It lays a much-needed emphasis on higher education ; it suggests some administrative improvements, and forms an indispensable starting-point for the far-reacliing schemes of co-ordination which it shows to be so sorely needed." — Speaker. " In dealing with elementary education, Mr. Webb is most practical ; in dealing mth the nascent London University he is most stimulating."— Pi7o^. "A debt of gratitude is due to Mr. Sidney Webb. . . . The book contains at once ideal and practical proposals for the attainment of this ideal."— Z)ai72/ News. LONGMANS, GREEN & CO. LONDON, NEW YORK, BOMBAY, AND CALCUTTA WORKS BY SIDNEY AND BEATRICE WEBB THE CO-OPERATIVE MOVEMENT IN GREAT BRITAIN By BEATEICE POTTER (Mrs. Sidney Webb) Crown 8vo ; Second Edition (1893) ; Fifth Thousand ; xii and 260 pp., with Coloured Map, Appendices, and Index. Price 2s. 6d. • CONTENTS CHAP. I. The Co-operative Idea. II. The Spirit of Association. III. The Store. IV. Federation. V. Association of Producers. VI. A State Within a State. VII. The Ideal and the Fact. VIII. Conclusion. APPENDIX Bibliography of the Industrial Revolution — List of Parliamentary Papers relating to Labour Question in this Century — Classified Tables of Associations of Producers — Extract from Letter from Mr. D. F. Schloss — Table of Percentages of Co-operative Sales per Hundred of Population — Table of the Relative Progress of the Co-operative Movement. "Miss Beatrice Potter's luminous and suggestive volume is not a mere bald, historical outline, but a thoughtful and pregnant study of tendencies, causes, and effects." — Times. ' ' The whole volume is full of suggestion, both to co-operators and politicians. ... It is without doubt the ablest and most philosophical analysis of the co-opera- tive movement which has yet been produced." — Speaker, SWAN SONNENSCHEIN AND CO., Limited HIGH STREET, BLOOMSBURY, LONDON 23 WORKS BY SIDNEY AND BEATRICE WEBB Published by Swan Sonnenschein and Co., Limited SOCIALISM IN ENGLAND By SIDNEY WEBB Crown 8vo ; Second Edition (1894), with New Introductory Chapter; xxii and 136 pp. Price 2s. 6d. " The best general view of the subject from the moderate Socialist side,"- Athe7i(eum. Published by Swan Sonnenschein and Co., Limited THE LONDON PROGRAMME By SIDNEY WEBB Crown 8vo ; Second Edition (1894), with New Introductory Chapter; viii and 214 pp. Price 2s. 6cl. "Brimful of excellent ideas." — Anti-Jacobin. Published by Walter Scott, Limited THE EIGHT HOURS' DAY By SIDNEY WEBB, LL.B., and HAROLD COX, B.A. Crown 8vo ; 280 pp. with Bibliography Price Is. " The unique value of this little book lies in its collection of facts. It is likely to hold the field as the handbook to one of the chief items in the social politics of the immediate future." — Pall Mall Gazette. Published by Vandenhoek und Euprecht (GOttingen) DER SOCIALISMUS IN ENGLAND. Geschildert von englischen Socialisten. Herausgegeben von SIDNEY WEBB 24 7 DAY USE RETURN TO DESK FROM WHICH BORROWED SOdAL WELFARE- CRIMINOLOGY LfBRARV This publication is due on tnexAST DATE BMX ^t''ii''i9i 8 »I>AY FEB 19 (3^ I 1 19bi nTii7 (;n«, 7 '«i^ General Library 1f57ys5^);if8 Universuy^of^glifornia U.C. BERKELEY LIBRARIES iliillllllll CD532M7b3a