Environmental Services.—The closing of the monasteries by Henry VIII resulted at the time of Queen Elizabeth in there being no organization to provide for the relief of the poor, so the parish, which was the most active survival of the early English system, was adopted as the unit of administra- tion under the Poor Relief Act of 1603. Each vestry appointed an overseer and poor rates were instituted, the activities of the vestry and the parish officers being super- vised by the local Justices of the Peace. There was at that time little local representation. Chartered towns existed with their local self-government ; the vestry in each parish was subject to the control of the Justices, the nominees of the Crown.
Local government then was largely controlled by the Crown. Following the disturbances in the times of the Stewarts, by the time of the revolution of 1688 it had become an accepted principle that there should be no interference in local affairs by the central government, so local government developed its independence. Throughout the eighteenth century local government was not very active, and many even of the larger towns had no civil organization other than local vestries and the county Justices of the Peace. Their powers even in London were inadequate to ensure the pro- vision of local services, even when judged by the standards of the times. Recourse was therefore had to the appointment of various bodies which were semi-private concerns with powers to carry out particular duties over very limited areas, having the power to levy a rate for the purpose. In this way commissioners for sewers, commissioners for paving, trustees for the management of streets, etc., were set up. In some localities, poor relief was dealt with in the same way by the appointment of Poor Law Corporations with powers to build workhouses and to carry out other activities for the relief of the poor. The cholera epidemic of 1831 led to the creation of temporary local boards of health similarly established.
Up to the sixteenth century any measures for public health were limited to the control, by segregation and quarantine, of leprosy, plague, and the lesser infections. Up to the time of William IV there was no act of sanitary intention except that dealing with quarantine. The central government did not deal with public health. A few towns had Improve- ment Acts, but most local authorities did nothing. There was a National Vaccine Board concerned with vaccination, and Commissioners of Sewers to defend the land against flooding. In the towns there was some street paving, and a beginning had been made in sewerage and water-supply. Refuse and cesspools abounded, houses were ill-ventilated, and the food supply was uncontrolled.
The 1831 outbreak of cholera in England led to the establishment of a central consultative Board of Health. This step was followed by a recommendation for the forma- tion of local Boards of Health with powers to appoint inspectors and to remedy deficiencies in respect of food, clothing, bedding, etc. In 1832 all local authorities were advised to provide hospital accommodation. T h e central department took on additional powers and began to give orders. Certain places were instructed to establish local Boards of Health to which local medical practitioners were to notify cases of disease. Justices of the Peace were empowered to call on poor-law parochial authorities to abate nuisances injurious to public health.
In the latter part of the reign of William IV two Acts of sanitary significance were passed. T h e first was the Poor Law Amendment Act 1834, one result of which was the appointment of the Poor Law Commissioners, Edwin Chadwick being appointed Secretary to the new Poor Law Board. The other was an Act for the registration of births, marriages, and deaths.
The industrial revolution brought about such a marked change in the distribution of the population of the country that the ratio of urban to rural population once 1 to 2 became 2 to ι. Some of these aggregations were townships, though not necessarily boroughs ; the rest of the country was rural in character with groupings at most in villages. T h e newly created towns had their own needs for improved highways, street paving, lighting, and for better public health. To provide these the method in general was to set up a separate authority with powers over a special locality. This resulted in a confusing pattern of authorities with the levying of different rates and the creation of different electors.
In 1838 the Poor Law Commissioners drew attention to the relationship of poverty and disease, especially the infec- tious diseases. The Commissioners appointed three medical men to investigate the conditions of living of the London poor, this being the first use of medicine by the State. Their findings stimulated inquiries into the conditions of the labour- ing population which demonstrated the effect of bad housing, lack of sanitation, and the prolonged hours of sedentary work in causing sickness and mortality. In 1840 a Select Committee of the House of Commons was set up to inquire into the circumstances affecting the health of the inhabitants of towns. This led to the investigation of the causes instead of the mere alleviation of results, which is the characteristic difference between Public Health and Poor Law administra- tion. Two further Royal Commissions were set up. The Nuisance Removal and Disease Prevention Act was passed, followed by the Public Health Act of 1848. By this a General Board of Health was established, provided with powers of advice and inspection ; and local authorities, consisting of the Boards of Guardians in each union created by the 1834 Poor Law Act. The powers of the local authorities were restricted to searching out nuisances and reporting the offenders to the magistrates. The effect of the Act was that there was established against the chief health nuisances a system of summary jurisdiction exercisable by local justices on complaint of local authorities.
The next few years saw a volume of agitation for reform. Many voluntary associa- tions for widely different purposes were set up such as those for the promotion of sanitary reform, for the cleanliness of the poor, and for improving housing in London. Many towns wished for self-government, and numbers obtained local powers by making use of the various acts which could be adopted by towns, such as the Towns Improvement Clauses Act, the Markets and Fairs Clauses Act, and the Cemeteries Clauses Act. Liverpool, which in 1841 had Acts for dealing with water-supply, street improvement, better drainage and sewerage, was the first town to appoint a medical officer of health, Dr. W. H. Duncan filling this post in 1847. London soon followed, appointing Dr. J. (later Sir John) Simon, who laid the foundation of sanitary inspection. Inquiries set up by central departments led to a systematic investigation of the habitual diseases in the country. Snow showed the relationship of cholera and water, and Budd that of water, milk, and food and typhoid fever. This led to such sanitary measures as the examination of food supplies, house accommodation, physical surroundings, and industrial circumstances. Further widespread appeals for better sanitary legislation were helped by another cholera outbreak, which led to the passing of the Sanitary Act of 1866.
Under this it became for the first time the duty of the local sanitary authority to arrange for the inspection of the district and to proceed to the suppression of nuisances. The Commission set up in 1868, referring to the many bodies dealing with health, advised that ” the present fragmentary and confused sanitary legislation should be consolidated “, and recom- mended that : (a) There should be one local authority for all public health services in every place ; no place should be without one, nor any have more than one. (b) Centrally there should be one Minister for Public Health and for Poor Law. (c) Every local authority should have a medical officer of health and an inspector of nuisances.
Simplification came as a result of the creation in 1871 of the Local Government Board as a central department of State with general supervision of local government matters. By the Public Health Act of 1872 the country was mapped out into urban and rural sanitary areas. By the Municipal Corporations Act of 1882 the organization of the boroughs was reformed and their powers and duties re-adjusted. T h e Local Government Act of 1888 created county boroughs of the large towns, and administrative counties from the ancient counties, setting up popularly elected councils for each of these areas. The urban and the rural district councils were created in 1894 for the areas of the former sanitary authorities. London local government was reformed in 1899 DY t a £ crea- tion of the metropolitan borough councils.
In 1902 the organization of public education was simplified by the abolition of the former school boards, with the transfer of public education responsibility to the county councils and other local government authorities. The Local Government Act of 1929 transferred the Poor Law functions to county and to county borough councils, with the abolition of the Poor Law Guardians. Centrally the Local Government Board was abolished in 1919 and the Ministry of Health set up with the general duties of supervision over all local govern- ment authorities. This Ministry is the department of the Government through which central control of local govern- ment is mostly exercised. T h e Ministry of Education, however, as the central authority for educational services, exercises control over much of the school health services, while the Home Office supervises the conditions of work of those in factories.
The Ministry of Pensions deals with certain groups of persons, the Board of Trade with the health of the mercantile marine, while the Ministry of Agriculture and Fisheries has duties in relation to diseases of animals which can affect man. In addition the Admiralty, War Office, and Air Ministry are responsible for the health of the forces of the Crown. Apart from these central government departments, there are statutory bodies closely associated with the health services, such as the General Medical Council, the Dental Board, the General Nursing Council, and the Central Midwives Board, concerned with doctors, dentists, nurses, and midwives. There is, too, the Board of Control, a central authority under the Lunacy Acts, the Mental Deficiency Act, and the Mental Treatment Act.
A hundred years ago, then, the larger towns with their very low standard of sanitation were becoming active through their many Boards appointed to deal with different matters such as nuisances, highways, bridges, sewerage, etc. On the other hand over much of the country there was no body responsible for those matters affecting or associated with health.
The awakening of the health conscience of the country was reflected in the passing of many Acts of sanitary significance, culminating in the consolidating Public Health Act of 1875. The sanitary function of those authorities which had been set up included the prevention and suppression of nuisances, insistence on a pure water-supply, improved drainage and sewerage, and control of overcrowding. T h e 1875 Act was followed in the next few years by a spate of legislation dealing with such matters as infectious diseases, housing, food and drugs, control of river pollution, all relating to environmental hygiene. Even that for the hospitalization of the infectious sick had as its object not so much the care of the patient as the removal of an infective focus. These powers and duties were laid on the local sanitary authorities, the only bodies on whom they could be imposed, as the county councils as administrative bodies and county borough councils did not exist before 1888. T h e result of these activities and of the general raising of the standards of environ- mental sanitary conditions was a vast improvement in com- munal health. In 1838 the Commissioners had appealed to the Home Secretary for powers to deal with those nuisances which were causing diseases which in turn imposed such burdens on the rates. By contrast, at the end of the century the more spectacular outbreaks of such diseases as plague, cholera, small-pox, and typhoid fever had become a thing of the past. Environmental hygiene had been established on a firm basis.
Personal Services.—Although the environmental services had grown and had in general reached a high level fifty years ago, the only forms of public provision for the personal needs of the individual were elementary education, poor law, and a limited hospital provision for sufferers from infectious diseases and from lunacy. The personal health services are practically a growth of this century.
The public health services are but one section of those public social services provided by or financially assisted by local authorities aimed at enhancing the personal welfare of individual citizens. These have been classified as :
- a. The constructive communal services, such as education, the public health and medical services, the welfare of the blind, employment exchanges, etc.
- b. The social insurance services, such as national health insurance, unemployment insurance, etc.
- c. The social assistance services, such as non-contributory old age pensions, unemployment boards, the work of the public assistance authorities.
Practically every one of these services had its origin in some form of voluntary provision, the first phase in their development being the charitable urge to help those suffering or in distress. Next comes the social motive of setting minimum standards, as in education, hygiene, and medical treatment in the interests of the community. Then comes the democratic tendency towards reducing inequalities of status and opportunity ; and finally the self-help philosophy of encouraging or compelling people by schemes of organized thrift to protect themselves against the risks to which they are exposed.
The personal health services are provided for the benefit of selected classes of the community or for those suffering from specific diseases or abnormal states. Their growth has seemed to have been haphazard, as though for some reason it has been decided to concentrate attention on one service, and after a period of trial and development it evolves into another of those services available for those sections of the community. But the introduction of any service will have been preceded by a period in which beginnings on those lines will have been made, probably by voluntary organizations, and an increasing demand for their general application will have grown.
SCHOOL HEALTH SERVICES.
T h e first of the personal health services to be well established was that of school medicine. Partly the result of the findings of those examining recruits for the Boer War, in part the result of pioneer voluntary efforts and from a knowledge of what was being achieved elsewhere, the Education (Admini- strative Provisions) Act of 1907 was passed, laying the foundation of to-day’s school health services. To start with, the aim was the systematic medical inspection of all children attending the then-called elementary schools three times in their school lives. This examination revealed a vast amount of physical abnormality, acute illness, minor ailments, and disabilities. The intention was that those requiring treat- ment should obtain it through the medium of the existing machinery, local doctors and hospitals. It was very early apparent, though, that these resources were utterly inadequate to cope with the problem. There remained then nothing else but for the authorities themselves to step into the breach. They were therefore empowered to make provision, and in due course treatment schemes were available in most areas for a variety of services—minor ailments, dental treatment, removal of tonsils and adenoids, ophthalmic treatment, treatment of the physically defective, etc. Before this full development had taken place local authorities, instead of merely being permitted to make provision, had become obliged to. These growing activities of the authorities aroused the antagonism of a number of general medical practitioners and reference was made to * encroachment \ Actually there was little enough in this contention. T h e work had always been there to be done, but it was not being done either by the doctor or by the hospital, and the local authorities had found themselves forced into the position of having to make arrangements to meet a need not otherwise being met. Under the Education Act of 1944 local authorities are obliged to provide free of all cost treatment services, excluding domiciliary treatment, for those attending main- tained schools, so that this section of the population became entitled to thep~; very wide benefits some years before the rest of the community.
MATERNITY AND CHILD WELFARE.
The next of the personal services was maternity and child welfare. This, too, started as the result of voluntary activity and of copying something which was being done in France. In the first place premises were provided to which infants could be brought and their mothers advised on the way they should bring them up and feed them, the beginnings of the clinic services of to-day. Just as in the case of the school child, it was found necessary to make arrangements for the treatment of those found to be suffering from physical defects or abnormalities. It was necessary in addition that the mothers should receive advice in their own homes, so special visitors were appointed for this purpose, the fore- runners of the health visitor. In the meantime it was found it was not sufficient to deal with the child even just after it was born ; it was necessary to deal with its surroundings before that time, so the ante-natal service was started, in its inception for the sake of the child rather than the expectant mother, but since developed in her interests. T h e First World War revealed the need for special accommodation for maternity cases, so local authorities were urged to preside maternity homes. Later the 1936 Midwives Act imposed on certain authorities the obligation of ensuring that there were sufficient midwives practising in their districts to meet the needs of those mothers who were to be confined in their own homes.
TUBERCULOSIS.
Up to 1911 systematic provision for the tuberculous was limited and scattered. The National Health Insurance Act of 1911 obliged local authorities to make arrangements for the supervision of those suffering from tuberculosis and to provide institutions for those needing such care. In 1912 the Government first made grants to local authorities for the prevention of tuberculosis and for the treatment of those suffering from this disease.
MENTAL DEFICIENCY.
The 1913 Mental Deficiency Act provided for the ascer- tainment and care of the mentally defective and in 1918 the case of those suffering from mental affliction received special attention.
VENEREAL DISEASE.
During the First World War the incidence of venereal disease mounted rapidly, so in 1916 local authorities were required with the encouragement of heavy government contributions to make arrangements for the treatment of those suffering from these diseases.
THE BLIND.
The Blind Persons Act of 1920 obliged local authorities to establish schemes for the welfare of the blind, a group for whom no systematic provision had up to then been made by public authorities.
There was then a lull in this steady growth of the personal services being provided by local authorities until the 1929 Local Government Act transferred certain functions of the Boards of Guardians to the county and the county borough councils, which then became obliged to provide a general hospital service for their areas. Just before the Second World War the same authorities were made responsible for the creation of a scheme to deal with the early diagnosis and the efficient treatment of those suffering from cancer.
E.W Caryl Thomas, 1948
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