339 W38p oo.l ' Digitized by the Internet Archive in 2016 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/charterofpoor13webb Cbc IRational Committee to promote tbc Breakup of tbe poor law The Poor Law Medical Officer and His Future. By M rs. Sidney Webb, D.Litt. PRINTED FOR THE NATIONAL COMMITTEE TO PROMOTE THE BREAK-UP OF THE POOR LAW 5 & 6, CLEMENTS INN, LONDON I 9°9 Price One Penny. Tbc National Committee to Promote the Break-up of tfoe Poor Laws, 5 and 6, CLEMENTS INN, STRAND, LONDON. The following Publications may be obtained at the above Offices: An Outline of the Proposal to Break up the Poor Law, 16pp. Price id., post free. The New Charter of the Poor: What is meant by the Break Up of the Poor Law, 8pp. Price id., post free. The Failure of the Poor Law, 8pp. Price id., post free. Seven Reasons for Supporting the Minority Report of the Poor Law Commission. By J. W. Willis Bund, Chairman of the Worcestershire County Council, 4pp. Price |-d.; or, post free, two copies for id. The Poor Law Medical Officer and His Future. By Mrs. Sidney Webb, 8pp., price id. post free. The Scheme of Reform. Part I. : The Poor Law, 8opp. Price 3d., post free. The Scheme of Reform. Part II. : Unemployment, 90pp. Price 3d., post free. The Care of the Children, 80pp. Price 3d., post free. The Treatment of the Sick, 88pp. Price 3d., post free. Birth and Infancy, 58pp. Price 3d., post free. The Disease of Unemployment, 86pp. Price 3d., post free. The Minority Report of the Poor Law Commission. Cheap Edition in two volumes. Part I. : The Break-up of the Poor Law. Price is. (postage 2d.) Part II. : The Unemployed. Price IS. (postage 2d.) The National Committee will be glad to arrange for public meetings, large or small, on the Minority Report ; also for drawing-room meetings, deputations to societies or talks to clubs to explain its proposals. Reading circles or study classes will be supplied with exponents or leaders. Debates can be opened at discussion societies. 2 3 ^ /M) . I The Poor Law Medical Officer and His Future. By Mrs. SIDNEY WEBB, D.Litt. I hope that I shall not be considered impertinent if I venture to say that of all the branches of the public service, that of the Poor Law Medical Officer seems to me to be, at present, the most hardly treated, the least appreciated, and the most depressed. Take first the remuneration. You are, unfor- tunately, only too well acquainted with the miserable pittances of ^50, ^Bo, or ^100 a year that the nation allows to thousands of fully qualified practitioners, for laborious duties of the highest importance to the public health, at a rate which often works out at a few pence per attendance. Consider the degradation of having to balance the cost of the drugs that ought to be used in any particular case against the prospect of having to spend on that case out of your own pocket far more than you are paid for it. Then consider the total absence of any professional stimulus, the lack of any encouragement by competent inspection, the absence df professional records, the complete indifference of Boards of Guardians and the Local Government Board to any results, as shown by their failure to ask for any reports, or to inquire whether the patients live or whether they die. Finally, think of the future of a Poor Law Medical Officer. Year after year he may go on in the same round of uncomfortable Poor Law practice, without prospect of promotion, usually without even an advance of salary, without the slightest chance of rising out of the narrow rut into which Fate has thrust him. Lias any mark of distinction or any sort of public honour — I do not say a baronetcy, but anything what- soever — ever been given to a Poor L,aw Medical Officer, as a Poor Law Medical Officer, even for the most meritorious, * A Paper read at the Conference of the Association of Poor Law Medical Officers, at the Guildhall, London, on July 6th, 1909. 3 * the most zealous, the most useful, and the most prolonged official service? In the course of my membership of the Poor Law Commission there was nothing with which I was more impressed than with the amount of devoted work, really quite unpaid for, that the Poor Law Medical Officers were, as a class, giving to the poor; or than the utter lack of official appreciation and encouragement which that work secured. What many members of the Poor Law Medical Service feel most is not the miserable pay that they get, nor the lack of official appreciation or encouragement, nor even the absence of honours and dignities ; but the extraordinarily narrow scope that, under the necessary limitations of the Poor Law, they find for useful work. It is not encouraging, for instance, to have through one’s hands (as the Poor Law Medical Officer does) one-third of all the deaths from phthisis; and yet, as several Poor Law doctors told us, never to have seen among them a single curable case. It breaks the spirit of a man who cares anything about his profes- sional work to have to go on year after year merely pretending to deal with cases, which have come to him only when destitution has set in, and therefore usually too late for any permanently remedial treatment, under structural and other conditions which he knows will prevent cure, but which he, as a mere Poor Law doctor, has no power to prevent. Meanwhile he sees the Medical Officer of Health, in go- ahead districts, advancing from point to point, starting this and that promising experiment, with municipal hospitals, bacteriological laboratories, Rontgen Ray treatment, milk dispensaries, school clinics, and what not, obtaining not only all the honour and glory but apparently unlimited scope at the public expense for really useful service of the State. Now the two Reports of the Poor Law Commission agree in recommending the prompt and complete destruction of the present Poor Law system, the abolition of the workhouse, and the abandonment of the well-known “ principles of 1834.” But they differ vitally in what they propose to construct. The Majority Report proposes that the Poor Law Medical Service shall continue in England and Wales separate from the Public Health Service, under a separate Local Authority; and that it shall remain rigidly restricted to attendance on paupers. It follows (as is inevitable under any Poor Law Authority) that the patients are not to be eligible even for medical treatment until they have become destitute, and that the treatment must cease as soon as they cease to be destitute. Moreover, it is proposed that there should be, alongside the work of the Poor Law doctor, a great extension of the contract practice of Provident Dis- pensaries, in which as many people as possible are to be enrolled. The fees from these enlarged Provident Dispen- saries are, however, not to be secured to the Poor Law Medical Officer. They are to be shared among all the doctors of the district, including any newcomers who may be attracted by this bait, according to the number of patients who honour them with their patronage; for everyone, even the pauper, is to have free choice of doctors. The District Medical Officer will thus find his professional work dwindling, for the competition will be increased, and it will often not be the “parish doctor 55 who is preferred; and the chance of any improvement in salaries will therefore not be great. Indeed, it is expressly contemplated in the Majority Report that the new Public Assistance Authority will find the duties of the District Medical Officer gradually dwindling away, his work being more and more taken from him, so that, after more or less lingering, he will be wholly superseded. The Minority Report proposes, on the other hand, that both the Poor Law Medical Service and the Public Health Service should be merged in a new County Medical Service, working under the supervision of an enlarged Health Com- mittee of the County or County Borough Council. Into that County Medical Service would come all the different branches of medical practice that are, or may be, maintained at the public expense — the isolation and other public hospitals, including the existing workhouse sick wards and the Poor Law infirmaries; the domiciliary or dispensary work of the District Medical Officer; the whole public supervision of, and whatever public provision is or may eventually be made for, maternity and infancy up to school age; the county homes for the aged needing institutional care, and whatever county institutions may be provided for the crippled and the incapacitated; the milk clinics, the bacteriological laboratories, and the elementary and public secondary school inspection and doctoring; the examination of candidates, the certification and the medical treatment required by all the public services in the country; and the general sanitation of the whole district. Only by some such unification into a County Medical Service, it is suggested, can we put a stop to the very serious overlapping and duplication between the different rate-supported medical services that are now so rapidly increasing. Only by some such unification can we prevent the Poor Law Medical Service from being more and more definitely restricted in the scope of its work, and from being more and more overshadowed by the growing Public Health Department. It is, I think, clear, that under such a County Medical Service, which sooner or later, is bound to come, there will be no question of all the work being done by one Medical Officer. There will be needed all sorts of medical practi- tioners, to say nothing of the subordinate staff of minor health officers and nurses which would be organised under medical supervision to the extent required by the circum- stances of each part of the county; there would be the domi- ciliary and dispensary practice which the community is bound to maintain for those who cannot pay a remunerative fee to the private practitioner. This would doubtless remain in the hands of the present District Medical Officers until the occurrence of vacancies permitted a re-arrangement of dis- tricts. There would be no disturbance of the rights or positions of existing officers. Probably as the existing District Medical Officers retire, or to the extent that they may choose to exchange their private practice for a salary and the prospect of a pension, the future will see the private practitioner relieved of all necessity for taking on the laborious and underpaid Poor Law work (like other contract practice) merely in order to keep out interlopers. We may contemplate the District Medical Officer of the future as invariably a whole-timer, absolutely debarred from private practice, properly salaried and pensionable, and provided with a county motor car to enable him to cover a large district, whenever he is summoned by telephone by the local nurses, dispensary attendants, and minor health officers whom 6 the county employs, leaving the private practitioner of the future free to monopolise all the paying practice. Along- side this domiciliary and dispensary service of the District Medical Officer, there would be an institutional branch of the County Medical Service, into which the District Medical Officers would be promoted, of Medical Superintendents, and Resident Medical Officers of the various kinds of public hospitals, convalescent homes, phthisis sanatoria, homes for the aged, institutions for the incapacitated and what not, into which the present Poor Law and Public Health insti- tutions of the county would be differentiated. This branch, of course, would be in the main — though not to the exclu- sion of consulting physicians and surgeons — a whole-time service, recruited largely from the District Medical Officers of all the counties, debarred from private practice, with adequate salaries and pensions. Alongside these two branches of the County Medical Service, there would be a third, the Special Sanitary Service, probably not localised, but visiting the various parts of the county as required, using the greater mobility now afforded by the motor car, and discharging such of the duties of the Medical Officer of Health as were not combined with the domiciliary practice of the District Medical Officer. Finally, there would be a head of all, in general charge of the whole medical staff and medical institutions of the county — -the County Medical Officer — probably aided in the larger counties, by one or more assistants, serving, so to speak, on his staff, and representing, probably, different branches of the County Medical Service. The County Medical Officer, who would hold a very highly-paid and responsible post, and his assistants, who would likewise be whole-timers of lifelong experience, would, in fact, be chosen indiscriminately from any of the three branches of the County Medical Service, the chance of promotion to the highest posts being thus open to any medical men, whether District Medical Officers or institution superintendents, clinicians or sanitarians, who developed not only professional but also administrative ability. For it is a great mistake to suppose that the County Medical Officer need be, or ought always to be, a sanitarian specialist. At present, it is true, the Medical Officer of Health with his D. P. H. is apt to 7 get all the plums, but this is just because the Poor Law Medical Service is kept outside as a separate Poor Law service, in which there is no possibility of advancement. I see no hope of improvement so long as this isolation con- tinues. But the sanitarian often has, from the standpoint of county administration, grave defects. From his lack of experience he sometimes forgets to allow for the difficulties of domiciliary practice. He is apt to leave out of account the very stubborn feelings and prepossessions of the average man, who will not be dragooned into health. Fie runs the risk of falling behind in his professional knowledge, so far as clinical work is concerned. On the other hand there are growing up in the Poor Law Medical Service many men who join high professional qualifications and great range of experience with administrative training as the superintendents of Poor Law infirmaries larger than most voluntary hospitals; or as conducting domiciliary and dispensary practices of greater range and extent than the majority of those who are only private practitioners; or as the resident medical officers of workhouses of gigantic size, in which they have to deal with every age, from infancy to senility, and with every pos- sible case, from childbirth to cancer, from tubercle to typhus. I venture to think that the part played by the Poor Law Medical Service in the future County Medical Service will be one of dignity and importance; and that the early creation of such a unified service, as is advocated in the Minority Report, offers the only practical means of putting an end to the very unsatisfactory position in which all sections of the Poor Law Medical Service now find themselves. Garden Cjty Press Ltd., Letchworth, Herts. 339 W36 no.£ Cbe National Committee to promote tbc Break-up of tbe poor Xaw The Minority Report in its Relation to Public Health and the Medical Profession. BY MRS. SIDNEY WEBB, D.Litt. PRINTED FOR THE NATIONAL COMMITTEE TO PROMOTE THE BREAK-UP OF THE POOR LAW 5 & 6, CLEMENTS INN, LONDON Price One Penny. 33 /?v0 . "V The Minority Report in its Relation to Public Health and the Medical Profession." The Minority Report of the Poor Law Commission proposes, so far as the provision for the sick is concerned, to put an end to the present duplication and overlapping be- tween the Poor Law Medical Service and the Public Health Service; to merge both services in a unified medical organisa- tion for each county and county borough (with due provision for the larger non-county boroughs and urban districts) ; and to place this unified service under the supervision, not of the Poor Law Division of the Local Government Board, but of a newly constituted Public Health Department, acting not through any Poor Law or “ Public Assistance 55 Authorities, but through the Public Health Committees of the directly- elected Town or County Councils. This far-reaching, but on the whole simple, scheme of reform emerged, during the three years’ investigation of the Poor Law Commission, from two streams of facts in the survey of the whole country that was made by the Commis- sioners. In town after town it was discovered that the old idea of the sphere of a Public Health Service — namely, that it confined itself to measures of general provision, and did not treat the individual patient — was no longer correct. The recent developments of the Public Health Service — its 700 municipal hospitals crowded with patients, opening their wards to one disease after another, and even adding out- patients’ departments and dispensaries; the growing staffs of “ health visitors ” (who are occasionally qualified medical * A paper read before the Society of Medical Officers of Health, Jan. 14, 1910. 3 practitioners), giving “ hygienic advice”; the organisation, here and there, of domiciliary nursing; the active supervision of midwives* the “ milk clinics ”; the medical inspection and treatment of school children; the official acceptance of the specifically pauperising disease of phthisis as part of the sphere of the Public Health Authority — were rapidly encroaching on the domain of the Poor Law doctor and the Poor Law infirmary, and were bringing about a hopeless confusion of principle as to what was the public and what the personal responsibility for sickness. Secondly, it had to be admitted that these developments of the Public Health Ser- vice were not to be ascribed merely to the over-zeal of local authorities or to the muddle-headedness of Parliament, but that they were the necessary outcome of a half-conscious realisation that the principles of the Public Health Depart- ment afforded a better basis for State medicine than those of the Poor Law Medical Service. This, as the Commission fully recognised, was not the fault of the Poor Law doctor himself. What appeared to the Commission the grave defect of the whole system of Poor Law medical relief — on which the community is spending something like five millions a year — was not any failure in skill or humanity on the part of the 4,000 Poor Law medical officers concerned, but the fact that they were condemned to stand helplessly by when their ministrations would have been most effective. They have to let the preventable disease occur, to see it develop and get worse whilst the patient is slipping slowly down the hill of poverty, and only come in towards the end when pecuniary destitution has set in. By the very nature of the Poor Law the ministrations of its medical service are inevitably confined to those persons in whom sickness has gone so far as to make them unable to earn their livelihood, and in which disease has reduced them to pecuniary destitution. By the very nature of the case the ministrations came, therefore, in the vast majority of instances too late to amount to much more than “ medical relief.” In short, what the Poor Law Medical Service was instituted for, what it still aims at, and what it secures is the diminution of individual suffering. It does nothing, and by its very nature can do nothing, to prevent the occurrence of disease. On the other hand, the Public Health 4 Service, whilst at least as effective in preventing individual suffering, aims at preventing the very occurrence of disease, or at any rate preventing its recurrence in the same or any other patient. The Public Health doctor can deal with the case in its incipient stage, irrespective of whether the patient is or is not too ill to go to work. Unlike the Poor Law Medical Service, the Public Health Service is not limited to the treatment of the individual patients, still less of such individual patients only as are so far gone as to have become pecuniarily destitute. It has at its command the devices of notification and searching out, of the provision of acceptable hospital accommodation and even in bad cases of compulsory removal, of house-to-house inspection and domiciliary nurs- ing, of a continuous supervision of practically all the infants and the school children, and of large measures of alteration of the sanitary environment. Above all, there is an important difference between the Poor Law and the Public Health Department in the psychological reaction. Here we come to the supremely important “ moral factor,” the effect on per- sonal character. The irony of the Poor Law Medical Service is that the better it gets the more harm it does to the character of those whom it seeks to benefit. For every increase in its efficiency, every growth of humanity in the Poor Law doctor, every expensive improvement in the Poor Law infirmary is a standing temptation to men and women to become destitute, or to pretend to be destitute, in order to qualify for the treat- ment which the State provides only for the most thriftless or the most unfortunate of the working class. And the tempta- tion is, in too many cases, irresistible. As a Northumbrian miner once put it, “ If you have owt you get nowt; if you have nowt you get owt, and a very gude owt too.” Apart from this, however, we have the fact that the Poor Law Medical Service, restricted as regards each patient to the period in which he remains destitute, can exercise no kind of moral pressure or disciplinary supervision before and after treatment. It can do nothing to induce the person who is just beginning to go down in health to adopt those habits of personal hygiene which alone would prevent him from becoming ill and therefore becoming destitute; it can do nothing, after the patient takes his discharge, to keep him 5 under observation and bring pressure to bear on him so to live as not to have the relapses that will bring him again and again to the workhouse, until he comes in for the last time to die. In this way, by making elaborate and comfortable pro- vision for the destitute sick, just because and just when they are destitute, without doing anything to prevent them from becoming destitute, the Poor Law Medical Service is in a cruel dilemma. For, by all the humane treatment that it provides for the girl about to have a baby, to the drunkard in his bouts of delirium tremens, to the prostitute in her attacks of venereal disease, to the wretched man or woman who comes in periodically to be fed up and cleansed from vermin, the very humanity and professional excellence of the Poor Law infirmary — divorced as it necessarily is from any preventive influence over the patients 5 lives before they become paupers and after they cease to be paupers — unfor- tunately constitute elements in the breaking down of personal character and integrity, and may even be said actually to subsidise licentiousness, feeble-mindedness, and disease. Now, the Minority Commissioners assert that this evil psychological reaction, characteristic of all the operations of the Poor Law — and of any Poor Law, whatever its designa- tion — is not a necessary accompaniment of public provision. It is, for instance, not seen in the operations of the Post Office or the public elementary school, or in the provision of scholarships to the universities. It is, in fact, inherent only in the operations of a “ Destitution 55 Authority. We know from actual experience that the Public Health Service, in its relation to sickness, not only has no “pauperising 55 effect, but on the contrary positively promotes physical self-control, stimulates self-maintenance and increases the consciousness of parental responsibility. No one is tempted to become destitute or to simulate destitution in order to obtain the valuable treatment (often including maintenance) afforded by the Public Health Department, any more than citizens are tempted to become destitute or to simulate destitution in order to enjoy the rate-maintained libraries, parks and pave- ments, the journeys in the municipal tramway, the water supply from the municipal reservoirs, the consumption of the municipal gas, or the education in the rate-provided schools. 6 This is the enormous psychological and sociological advance that has been made by “ taking out of the Poor Law 55 one service after another, and so getting rid of the qualification of “ destitution . 55 Moreover, the curative treatment of individual patients by the Public Health Service — undertaken as it is for the good of the community, and not merely out of a desire to relieve individual suffering — happens always to be accompanied by hygienic advice and requirements as to personal conduct, which (as seen, for instance, in infectious disease injunctions, health visiting, and the practice of “ milk clinics 55 ) amount to a constant stream of moral suasion, and,, where necessary, disciplinary supervision, to promote physical self-restraint and the due care of offspring. This is, indeed, admitted. The only complaint that is made against the Public Health Service, from the standpoint of those con- cerned for the maintenance of a sense of individual responsi- bility, is that this bracing influence on personal conduct is not always combined with a pecuniary charge. Here there seemed to the Minority Commissioners to be room for a deliberate reconsideration by Parliament, with regard to all branches of the public service, of the whole question of charge and recovery of cost, or, as it is more correctly designated, the propriety of “ special assessments 55 on individuals for services specifically rendered to them over and above the services enjoyed equally by all ratepayers. That gratuitous treatment is not necessarily connected with public provision for specific complaints, quite independently of the qualification of destitution, has been conclusively proved by the large amounts actually recovered year by year in respect of the maintenance of lunatics. The Minority Commissioners not only propose that Parliament should definitely prescribe which services should be made the subject of special assessments, and which should be done for all gratuit- ously, and what should be the scale of family income that should be deemed ability to pay; they have also devised, and for the first time promulgated, a carefully thought-out plan and the necessary machinery for enabling these special assess- ments to be made and enforced, wherever there is ability to pay, without hampering the Public Health Department in its preventive and curative work. 7 I proceed now to make clearer these proposals of the Minority Report by a summary description of what happens in the present chaos and what will happen in the order of the future, as regards birth and infancy, sickness and permanent invalidity. Birth and Infancy. At present it is not easy to say what public authority is responsible for enforcing parental obligation, for stopping gross neglect, and for ensuring as a minimum that at any rate such provision is made for maternity, and for the nurture of infants up to school age, as is imperatively required in the interests of a healthy community. The Poor Law Authorities are legally bound to give gratuitous treatment and main- tenance to any woman who is destitute and chooses at the time of child-birth to claim such aid. As a result, nearly 15,000 babies are born in the workhouses of the United Kingdom every year. The Poor Law Authorities, though they may provide costly maternity wards, are, by their very nature as Destitution Authorities, inherently and necessarily incapable of exercising any supervision over the health or the conduct of these women before they choose to come in to be confined, or after they choose to take their discharge. A girl may go out and let her infant quietly die; she may come in again a year hence, and let the second infant die; what is worse for the community, she may from poverty, ignorance, or wilful carelessness so neglect her infant in its earliest years as to saddle us with a rickety, stunted, and permanently diseased citizen; she may repeat this process as long as nature permits, without the Poor Law medical officer or the repre- sentatives of the ratepayers having any power to insist on or to ensure proper conditions for this torrent of babies brought into the world at the public expense. Against this mass of poverty and parental neglect the Public Health Authority is now bestirring itself to fight, and, with insufficient legal powers, and without practically any co-operation from the Poor Law Medical Service, is organising its service of health visiting and milk dispensaries. Meanwhile, the Local Education Authority, which has been tempted to subject infants of 3 to the discipline of the school-room, because 8 there was nowhere else for them to go, is beginning to exclude children under 5, and in doing this it is receiving the sanction of the Board of Education for England and Wales. But as the Consultative Committee of the same Department reported, “ There is no doubt that the absence of public provision for children under 5, so far as the poorest classes are concerned, is a crying evil. 55 * The Minority Report proposes that the whole responsibility for enforcing parental obliga- tions, preventing neglect and ensuring at any rate the necessary minimum of provision for maternity and infant nurture up to school age, shall be placed upon the Local Health Authority, which could combine for this purpose the present scattered services of birth notification, infant visita- tion, midwifery supervision, the milk dispensary and school for mothers, and the control over abortifacients. What it would take over from the Board of Guardians are birth registration, vaccination, and (outside the Metropolis) the inspection of baby-farming — all three anomalous excrescences on the Poor Law — together with the maternity ward, the workhouse nursery, and the pow r er to give domiciliary treatment (including the necessary home aliment) to mothers and infants. Under such a system the girl expectant mother (already presumably within the supervision of the health visitor under the chief medical officer), who might come into the maternity ward for her confinement, would remain under the same supervision after her discharge, and, in fact, throughout the infancy of her child, and would, if certifiable as feeble-minded, be reported to the Town or County Council Committee dealing with the mentally defective. On the other hand, the respectable married woman might obtain midwifery assistance in her own home, with or without pay- ment, according to scale of income, with no more stigma of pauperism than if she were a scarlet fever patient. Who can doubt that, if the chief medical officer of every town or county were empowered to organise such a systematic service for birth and infancy, on the lines of what is already being done in a partial way by the most progressive health authori- ties, the result would be a vast improvement in the conditions * Report of Consultative Committee upon Children Below Five, of 1908, p. 127. Cd. 4,259 9 of birth (including the virtual abolition of ophthalmia neonatorum ), and an almost incredible diminution of the mortality among new-born infants and children under 5, together with a most beneficent increase in the consciousness of parental obligation and in the performance of parental duties on the part of the mothers, and a far more general enforcement of pecuniary responsibility against the fathers — the whole at a cost to the community that would be more than saved in the diminution of the expense now so unwillingly incurred over the defective, the blind, the crippled and the diseased who result from our present neglect.* The Treatment of the Sick. In no branch of the subject is the question of overlapping of work and duplication of machinery between the Poor Law Medical Service and the public Health Department becoming more acute than in the actual clinical treatment of sick patients; and yet there exists, at the same time, a disastrous amount of untreated disease. There are, I believe, still some people, * An interesting example of the hopeless tangle into which we are getting through the overlapping and competition between the Poor Law and the Public Health Service is afforded by the position in England of the medical practitioner under the Midwives Act, administered by the Town or County Council. The medical man whom the law requires the midwife to send for in cases of difficulty is held by public opinion to be under a moral obligation to go ; and yet there is still, after a whole year’s delay, no provision for the payment of his fee. The Departmental Committee to which the question was referred could, under the inspiration of the Poor Law Division of the Local Government Board, find no better solution than to recommend the Board of Guardians to pay. Yet the Board of Guardians admittedly need not pay, and, indeed, cannot legally pay, unless upon inquiry they come to the conclusion that the woman (or rather the woman’s husband if living with her) was at the time “ destitute,” or at any rate “ poor,” according to the meaning of an obscure statute of 1848, which has never yet been construed by the High Court. At the same time, it is recommended that the Local Health Authority should be responsible for preventing collusion between midwives and doctors. Thus, the best arrangement the Local Govern- ment Board can suggest is that the doctor should go whenever he is called, but that his chance of getting his fee from the Poor Law Authority is to depend, not on the gravity of the case, or even on the absence of a fraudulent collusion between the midwife and himself, but on whether the Board of Guardians may subsequently choose, without possibility of appeal, to class the woman as desti- tute. Under the proposals of the Minority Report, both the control of the certified midwives and the payment of fees to medical men whom they are required to call in, would be in the hands of the Health Committee of the Town or County Council, and its chief medical officer ; whilst the recovery of the cost from the patient or her husband, in case of ability to pay according to t^e statutory scale, would be enforced by the special department of the Town or County Council entrusted with this duty. IO thinking themselves educated, who believe that the spheres of the two co-existing rate-maintained medical services are distinct and clearly defined — who believe, in short, that the Public Health Service has nothing to do with the clinical treatment of the individual patients. Such persons close their eyes to the 700 hospitals of the Public Health Service — actually having more beds than all the voluntary hospitals put together — treating at the present time, I suppose, some- thing like 100,000 separate patients every year; no longer confining themselves to small-pox and enteric, but taking in an ever-lengthening list of diseases — diphtheria, measles, all forms of tuberculosis and many accident cases — in two towns (Barry and Widnes) actually specialising exclusively in non- infectious cases. It is, in fact, now only a matter of chance and locality whether a sick person or a person who meets with an accident, will be removed to a voluntary hospital, a Public Health hospital, or a Poor Law hospital; and (whether or not he repays the cost of his maintenance) it will equally depend on chance whether or not he becomes thereby a pauper, and whether or not he or any of his relatives come under liability for repayment. This rivalry between the competing rate- supported hospitals and medical staffs is becoming daily more serious and more acute in the vast range of tuberculosis. The Local Government Board for England and Wales, like the Local Government Board for Scotland, is definitely rang- ing the provision of adequate treatment of tuberculosis within the sphere of the Public Health Department. In Scotland this has been done by explicit order. In England and Wales a phthisical man will now be alternately a pauper and a public health patient. Neglected and untreated whilst his disease is still curable, as soon as he becomes too ill to earn a living he can go into the workhouse whenever he chooses; as soon as he insists on taking his discharge, his case is officially notified to the medical officer of health, who thereby becomes responsible for looking after him and for preventing him infecting his family, but who is only here and there able to find him a place in a municipal hospital or sanatorium, and cannot in practice supply the necessary aliment for domiciliary treatment, or secure that the housing accommodation is adequate; then the man breaks down and 11 enters the workhouse again, passing thus alternately from the Poor Law to the Public Health Department, the present Public Health Service, just because of the existence of its older rival, being unable adequately to deal with the case : until eventually there ensues death in the workhouse and a widow and children on the rates. With all this overlapping of work and duplication of machinery, the amount of untreated sickness at any one time is plainly enormous. To take only that revealed by the Poor Law doctors themselves, we know now that one-third of all the two million persons who sought Poor Law relief last year did so on account of sickness, and the greater part of them on account of disease or infirmity, which, largely because it had not been treated when it should have been , had gone so far that the patient was unable to work. The sickness of the applicant for Poor Law relief is, in fact, nearly always a neglected sickness. But this is not all. The medical inspection of school children is revealing an almost incalcul- able amount of minor ailments going entirely untreated, either by the private practitioner or by any public doctor, and either by the Poor Law or by the Public Health Service. Thirdly, to revert again to tuberculosis, we have the fact that this disease, which in itself alone produces one-seventh of all our pauperism, and the greatest of all the deductions from the adult working life of the people, is at the present time, among the whole wage-earning class, hardly ever properly treated until its ravages have advanced too far to be curable. I need not instance the corresponding experience of cancer and of other diseases. “ Almost every disease , 55 Dr. McVail expressly told the Poor Law Commission, a can be dealt with from the standpoint of prevention; and whilst phthisis is specially important, yet the early stages of disorders of all organs of the body — heart, lungs, kidneys, digestive system, brain and the rest — often furnish indications for preventive measures , 55 which, if not applied in time, involve the com- munity in the waste and expense of subsequent incapacity and treatment. This neglect of early treatment is, of course, all the more grave in that in tuberculosis, and, as we are beginning to suspect, in many other cases, it means neglect of precautions against the spread of the disease to others. 12 In this administrative dilemma there are but two courses practically open to the statesman. In his able dissent from the Majority Report, Dr. Downes, the Local Government Board’s Medical Inspector for Poor Law purposes, sketches out one of them as his ideal. The whole of the public provision for the treatment of sick persons is to be relegated to the Poor Law. This means the transfer of the 700 Public Health hospitals to the Boards of Guardians (or the new Poor Law Authority); the reversal of all the arrangements now being made under the direction of the medical officers of health for the medical treatment of school children; the rescinding of the recent orders of the Local Government Board as to phthisis, and the transfer of all provision for tuberculous patients to the Poor Law medical officer. Dr. Downes does not tell us frankly that this policy involves also the abandonment of the public health principles of “searching out cases, and of treatment in the interest of the public health irrespective of pecuniary means ” — yet this necessarily follows, for no Poor Law Authority can possibly compel people to become paupers, or urge them to accept what cannot be other than parochial relief. Dr. Downes is, however, more candid on the obverse of the picture, for he makes it plain that he contemplates that the enlarged Poor Law, when it has swallowed up so much of the present work of the medical officers of health, is still to be “ deterrent 55 (as, indeed, any Poor Law or any Destitution Authority must inevitably be), and is still to bear the stigma of pauperism. I must leave you to judge what havoc any such policy would make of all the success so far achieved by the Public Health Service in combating infectious disease, and what sort of a service you would have when the medical officer of health had been reduced to the status that this highly placed official of the Local Government Board evidently regards as his proper sphere — of somewhere between the borough surveyor and the sanitary inspector. The other course, and, as it seems to me, the one to which Parliament every session more and more inclines, is to take the sick person altogether out of the Poor Law, and to make the Public Health Department exactly as responsible for the treatment of all cases of tuberculosis, cancer, and rheumatism 13 that would otherwise go untreated, as it is to-day for small-pox and enteric. This involves the transference to the County or Borough Council, acting through its Public Health Com- mittee, of the whole Poor Law Medical Service and its out- door patients, the Poor Law infirmaries and dispensaries, and the hospital treatment of the present inmates of the work- house sick wards. This is the solution officially recommended by the responsible medical chiefs of all the departments concerned — the Chief Medical Officer of the Local Govern- ment Board for England and Wales, the Medical Member of the Local Government Board for Scotland, the Medical Member of the Local Government Board for Ireland, and the Chief Medical Officer of the Board of Education for England and Wales. This, too, was the solution urged by the dis- tinguished medical man whom the Poor Law Commission specially appointed to investigate the very subject, Dr. McVail. Why, in face of this authoritative testimony against which no rebutting evidence was called, and of this remarkable concurrence of opinion among those practically concerned, the majority of the Poor Law Commissioners refused to adopt this solution I am still unable to understand. The minority of the Commissioners were more modest; they accepted the conclusions to which experience had led these authoritative witnesses, together with the medical expert to whom the Commission had deputed the examination of the problem. The recommendation of the Minority Report, based on this weighty expert evidence, is for a unified medical service in each county and borough of sufficient size, under the direction of the Public Health Committee of the elected Town or County Council; having in each case the necessary staff of whole-time salaried medical officers, including clinicians as well as sanitarians, institution superinten- dents as well as domiciliary practitioners; empowered, however, to give domiciliary treatment, and to make the necessary provision for home aliment and nursing wherever domiciliary treatment is judged expedient; adapting or increasing the existing buildings so as to provide (but only by way of supplement to whatever voluntary institutions there may be in each place) the necessary hospital and sana- torium accommodation for all diseases, including whatever 14 public provision is made for maternity, the care of infants under school age, and senile or other permanent infirmity; the whole work being nationally under the supervision of a separate Public Health Department at the centre, administer- ing (in order to prevent any increase in the local rates) a grant in aid of public health expenditure alone, and in substitution for the existing grants in aid to the Poor Law Authorities, of not less than five millions sterling. The Care of the Physically Defective and the Chronically Infirm. At present it is scarcely too much to say that we have no systematic arrangements for the crippled and the infirm. No small proportion of children suffer from grave physical defects of frame or limb or member. These go largely unattended to prior to school age, because no authority is responsible. Between 5 and 14 the child is within the sphere of the Local Education Authority, which in London and a few other places is providing most expensive schools in the hope of training these physically defective children to earn their own living. They pass out into the world and are again without the protection of any public authority, with the unfortunate result that whilst they intensify com- petition in many of the sweated industries, their infirmities often prevent them from earning any adequate livelihood. At last they pass into the hands of the Poor Law, to be either given a dole of outdoor relief, usually without any specialist examination and without supervision of their way of life, or to be merged with all sorts and conditions in the general mixed workhouse. Along with these unfortunates may be considered the later recruits to the same army of the invalidated — the prematurely broken-down man or woman, those rendered chronically infirm by rheumatism or heart disease, the sufferers from hernia or varicose veins, and the hundred and one others whose physical infirmities make them not worth a living wage. The great defect in our method of provision for all this great class, from infancy to old age, is, as it seems to me, the absence of any responsibility by the Local Health Authority. Seeing how helpless are these victims, and how grave is the financial burden that they place on the community, one would have thought it obvious that the Local Health Authority ought to know about every physically defective infant, in order to see that nothing was neglected in the early years which might prevent its becoming a cripple; one would have thought that the care of such children during school age was, again, primarily a matter of Public Health concern; one would have thought that when they became adult there ought to have been, again under the direction of the Health Authorities, the ministrations of the health visitor,* and for those who are friendless something in the nature of rural settlements in which they could be put to such non-competitive work as they were capable of. Those prematurely invalided men and women who, by reason of their physical infirmity, have to resort to public maintenance, ought surely to be the special charge of the Local Health Authority; to be treated from the medical standpoint in such a way as to stop malingering; to see that nothing was left undone by which the infirmity might be cured; to ensure that they did such work as they were capable of; and that, above all, they lived in such a way as not to aggravate their condition. The Minority Report recommends that the physically defective of all ages, who can be certified as unable by reason of their infirmity to earn a livelihood, should be the special charge of the Public Health Depart- ment of the County or Borough Council, which would find in the work a new and hopeful sphere. Safeguarding the Practitioner. And here I must break off to consider an objection which has been raised, though less to the Minority Report scheme than to that of the Majority, that any such proposed change in the Poor Law Medical Service would be seriously detri- mental to the interests of the private practitioner, if not of the medical profession as a whole. I do not mean that the * Some of these physically defective persons can and do earn good wages. I have heard of cases in which they have had to forgo earning these wages in order to qualify for medical treatment in the workhouse infirmary, when they might just as well have gone on earning their wages while under treatment in hospital, and thus paid back some of the cost. 16 doctors have put forward any claim that their private interests should be upheld at the cost of those of the whole com- munity. But it is necessary for the welfare of the com- munity that there should be a strong, competent, and adequately remunerated medical profession; and it is quite fair to point out that any change which was likely to injure a profession of so much value to the public must be, to say the least of it, very critically scrutinised. I am the more ready to say this because, in my own opinion, the medical profession in the United Kingdom stands at this moment in a position of grave danger. A very large proportion of its members earn incomes v/hich can only be described as scandalously inadequate, whilst many of those who now enter its ranks after a long and expensive education fail altogether to secure a footing. And for this evil, the uncon- sidered and piecemeal development of public policy, in connection with the Poor Law Medical Service, isolation hospitals, midwifery, some of the action with regard to infantile mortality and the treatment of school children, together with the wholesale extension of voluntary hospitals and dispensaries, may have been to blame. Now, the Minority Commissioners had very seriously in mind this consideration when they were drawing up their recommendations; they took care to fortify themselves by competent medical advice; and they did not proceed without satisfying themselves by very careful inquiry among practically all sections of the medical profession that their proposals would certainly inflict no injury on any part of the profession, and that they would, on the contrary, go far to avert the present dangers and set it up on a firm and durable base. What the private practitioner fears, to put it bluntly, is an extension of gratuitous doctoring, by which he will lose the poorer section of his present paying patients. It is, however, a mistake to assume that the work of a Public Health Department need necessarily be gratuitous. The most typical work of the Public Health Authorities — the enforcement of house drainage and the improvement of domestic sanitary conditions — has nowhere been done without charge; and nearly always the procedure has taken the form of compelling owners and occupiers to execute the necessary work at their own expense. All this development has certainly not been disadvantageous to the independent plumber and builder. In the same way, a rise in the standard of health — for instance, the general enforcement of a higher level of attention to minor ailments in children attending school — really increases the practice of the private doctors of all grades. What, indeed, is true is that, if we do not take thought about the matter , and go very deliberately into it as a matter of principle, we are only too likely to find that Parliament and local authorities, driven year by year to take up some new service that the health of the community requires — whether this be midwifery or the medical treatment of school children — and unable, so long as they deal with the subject in this fragmentary way, to devise any convenient machinery for charge and recovery, may slip unawares into free doctoring, without protecting the interests of the present generation of medical men. It is for this reason that the Minority Report elaborates a plan, and devises new machinery, for systematically charging an adequate fee to every person attended by the officers of the Local Health Authority, in every case in which that person is found to be able to pay, and for effectively recover- ing that fee by legal process. It is proposed that, instead of taking it for granted, as we now do, that several hundreds of thousands of persons are entitled to gratuitous medical attendance, and instead of leaving the option of making a charge, case by case, to the impulsive decision of the chance majority of a committee, there should be settled by Parlia- ment or by the Town or County Council a definite scale of incomes, according to number in family, which should con- stitute ability to pay. Such a scale is already in use by the Home Office in respect to children who are compulsorily removed to industrial and reformatory schools; such a scale is even now being framed by the London County Council with regard to medical treatment of school children. This scale is something very different from the wage limit so often suggested for dispensary or club practice. What the Home Office and the London County Council contemplate is a limit for gratuitous treatment of something like fifteen or twenty- 1 8 one shillings per week of family income, in country and town respectively. I do not think that any doctor makes much out of such people. His patients getting thirty shillings a week will certainly not be treated gratuitously. The duty of making the necessary inquiry as to incomes, assessing the charges according to the prescribed scale, and recovering the sums due for all the branches of the work of the Town or County Council, will be the work of a distinct department, under a new officer — the Registrar of Public Assistance — acting under the control of a separate committee of the Town or County Council, having nothing to do with the treatment of the cases. Under this system no one would be compelled to pay whose family income was found to be so low as to make it desirable in the public interest that he should be treated gratuitously. On the other hand, every person whose family income was such that he could properly afford even the smallest fee would, if he had accepted the services of the Public Health Department, whether by using the public hospital, the school clinic, or the domiciliary medical attend- ance of the district medical officer, find himself charged a substantial fee, in proportion to his means, which he would be as strictly compelled to pay as he has now to pay his rates, his payment for an inmate of the county lunatic asylum, or his contribution for a child at the industrial school. The medical man would meanwhile receive from the public authority the proper professional remuneration* for his work, whether or not this was recovered by the local authority. The primary object of this machinery for charge and recovery may well be financial, for it is a mistake to suppose that recovery is practically impossible. As a matter of fact more than half a million a year is even now recovered by the Poor Law and Industrial School Authorities. It all depends on how you go about it. I do not think there need be any fear that the new Registrars of Public Assistance, acting under a special committee, undisturbed by irrelevant considerations, having their own staffs, and fortified by express authority from the Town or County Council as a whole, would (whilst exempting all those falling below the scale minimum * This payment might take the form of a salary as in the county lunatic asylum, or as a fee as in the case of the police calling in a doctor to treat an accident. r 9 of fifteen shillings or a guinea a week) quite successfully compel every person to pay who could afford to do so. But an equally important object of this plan of charge and recovery is to confine the medical services of the Public Health Department to that section of the population which must, in the interests of the community as a whole, be provided with medical attendance at the public expense. Do you not see what a safeguard this systematic enforcement of payment would afford to the private practitioner? Every case would be automatically reported to the registrar and systematically investigated by his officers as to financial resources. The prosperous workman, or the stingy person of the lower middle class, who might be tempted to take advantage of the services of the Public Health Department because there was no stigma of pauperism, no relieving officer to face, and apparently nothing to pay, would promptly find himself served with a courteous but firm demand from the registrar for the payment of a substantial fee, exactly as he now receives the demand note for his municipal water rate or the municipal electric light. Finding that these services of the public doctor, though no longer guarded by a deterrent relieving officer, could not be obtained without this sub- stantial payment, all those who could afford to pay the private doctor’s fee would find no attraction in them. On the contrary, they would prefer, seeing that they had anyhow to pay, to choose their own doctors, to be attended to at their own homes, and to pay their own medical attendants. It is, I venture to say, this free choice of doctors that affords the most potent inducement, to all who can afford the fee, to consult the private practitioner. If payment has to be made anyhow, by all who can spare the money, even the most parsimonious of those who at present go past the private practitioner’s door will cease to find any reason why they should forgo this privilege of having their own doctor. Here, too, we see the real remedy for “ hospital abuse.” If the endowed and voluntary hospitals and other medical charities sent automatically to the Registrar of Public Assist- ance the names and addresses of all their patients, and if the registrar were empowered to make and enforce a prescribed charge upon all whose family resources were found on 20 inquiry to exceed the statutory minimum, we should no longer find the resources of these medical charities drained and the sphere of the private practitioner curtailed by the resort to gratuitous medical treatment on the part of those who can afford to pay their own doctor’s fee. And yet no sickness would go untreated. Hence the total income of the medical profession, in fees and salaries, would be largely increased. I venture very seriously to press this point on those who are concerned for the private practitioner. The Majority Report of the Poor Law Commission proposes a great exten- sion of “ provident ” dispensaries, to be subsidised out of the rates, membership of which, whether by paupers, or subscribers, is to entitle men, women, and children to the right to choose their own doctors, and to free institutional treatment — a proposal which I find one medical man has summed up as “ a public system, supported by public money, of free medical relief on a basis of contract practice.”* What the private practitioner should insist on is the maintenance, intact, of his monopoly of the practice of those who prefer a “ free choice of doctors.” Any suggestion that the State Medical Service, or any collective organisation, should be allowed to offer this attraction, should be instantly negatived. And, further, it should be insisted on that, whilst no one who needs the services of the public doctor should be turned away, there should be drawn a definite line of demarcation between those for whom the community will provide medical attendance without charge, and those from whom, if they take advantage of the State provision, the local authority will enforce repayment at such a rate as will encourage them to choose their own doctor. In the plan of charge and recovery by the Registrar of Public Assistance, the Minority Report furnishes for the first time an effective means of maintaining the safeguard of the private practitioner. The Relation of a Unified Public Health Service to National Character. In conclusion, I must again emphasise the urgency of this reform from the standpoint of the “ larger expediency ” of * “ The Poor Law Commissioners and the Medical Profession,” by a Medical Practitioner. (London : A. C. Fifield, 1909.) 21 improving not merely the health but the character of our race. However we may desire to safeguard the interests of this or that profession or section of a profession, the final decision will be based, or ought to be based, on whether or not the proposed reform will strengthen and ennoble the men and women who are subject to it. The Minority Report adopts this proposal of a unified and preventive medical service not only because it appears to offer the only practicable escape from the administrative dilemma into which the co-existence of two rival rate-maintained medical services has brought us, and not merely because, by extend- ing the Public Health principle of “ searching out 55 disease and dealing always with the incipient case, without the stigma of pauperism, it holds out the prospect of securing an incalculable improvement in public health and a pro- gressive diminution in the present annual waste through sickness. We advocate this reform because we believe that we shall thus curb physical self-indulgence, increase the care of the child by the mother, the concern of the husband for the wife, and positively heighten the desire and capacity of all persons to maintain themselves. To “ take the sick out of the Poor Law 55 is, as we now see, to put an end to what is inevitably a bad psychological reaction on personal character. The Poor Law Authority — constitute it as you please, call it by what name you will — must always, just because it is a Destitution Authority, fail altogether in the important matter of supervision of the lives of its patients before and after the crisis of destitution. Unless a person chooses to apply for relief, no Poor Law Authority can touch him, or bring him under inspection or moral pressure, or even know anything about him. Immediately he chooses to take his discharge, he disappears out of the ken of the Poor Law medical officer, he cannot be followed up, his home and method of life cannot be kept under observation, and no sort of influence can be brought to bear to prevent him getting into such a state as will inevitably bring him to the workhouse again. Take, for instance, the destitution brought about by drink. Under the Poor Law — under any Poor Law — the drunkard cannot be touched until he is in a state of destitution. A man may 22 be neglecting his children, leaving his wife without medical attendance, or maltreating a feeble-minded child, and yet no Poor Law Authority can do anything to prevent the destitu- tion that will probably ensue. It is only when the man is suffering from delirium tremens that he is taken into the workhouse, put into a clean bed with two attendants to look after him, dosed with the costly and agreeable morphia, and then, when he has recovered from his debauch and can return to his work, let out to begin his evil courses again. In fact, under the scheme of the Minority Report, with the Education Authority, the Public Health Authority, and the Lunacy Authority responsible for searching out the incipient destitu- tion of the neglected infant, the sick wife, and the maltreated feeble-minded child, the drinking head of the family would be called to book long before he found himself in the com- fortable quarters of the workhouse. Indeed, it seems apparent to me that once the Public Health Authority was responsible for searching out disease, one of the first diseases which would call for systematic prevention and cure would be alcoholism. With the treatment of sickness by the Public Health Authority there is, in short — through the machinery of the health visitors and sanitary inspectors, the municipal milk dispensaries and schools for mothers, the medical treatment of the children and the visits of the school nurse — no little opportunity for preventing, by inspection, by advice, by exhortation, by compulsory removal, and, where necessary, by prosecution, many of those practices of neglect and self-indulgence which now result in the waste and expense of disease. Note. — The Minority Report leaves unaffected the existing endowed and voluntary hospitals and other medical charities ; and (beyond affording to them, if they choose, an opportunity for stopping “ hospital abuse ”) in no way touches their interests. No Local Authority would set up new hospital accommodation except for the cases that any existing voluntary hospital could not or would not admit. 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The existence in our midst of men, women, and children actually without the primary necessaries of life is a manifesta- tion of social disease, which is a matter of shame to us all. The Destitution of To-day. The Poor-law Commission has laid bare, in its two reports, a vision of chronic destitution, degradation, and misery still existing in the midst of our wealth — a vision which, for a brief moment, stung the conscience of the ordi- nary citizen. More than two millions of separate persons in the United Kingdom were found to be driven to accept Poor-law relief in any one year. Nor can we dismiss this vast population as “ social wreckage,” or ne’er-do-wells. One-third of them are children ; one-third are sick ; and most of the remainder are either widows bereft of the family breadwinner, or the friendless aged, or the prematurely infirm, or the merely feeble-minded. Not one-tenth are able-bodied men in health. But outside this destitution, which is ascertained by the grant of poor relief — that is, outside official pauperism — there is, as we now know, a mass of persons who are destitute of the necessaries of life who do not claim, or who do not receive, poor relief — of unemployed men destitute of wages, “of sick persons destitute of medi- cal treatment, of little children needing food to enable them to benefit by teach- ing, of infants actually dying for lack of proper sustenance and care, of old people preferring to starve in cellars and garrets than go into the “House.” For all these people, whatever may have been the cause of their sinking to that condition, no civi- lisation, no proper fulfilment of the duties of parentage or citizenship, no really re- ligious or Christian life is possible so long as they are destitute. Now, destitution is not merely a matter of individual suffering, to be relieved by personal charity, but a social disease, to be remedied by appropriate changes in our social organism. These changes are already going on, but going on slowly and imperfectly. It was, in fact, the growing public con- sciousness of the mass of destitution that led successive Parliaments — Conservative and Liberal alike — to give new authorities supplementary powers to relieve destitu- tion — to Distress Committees to give re- lief work, to educational authorities to give medical treatment and food to school children, to Public Health authorities to give medical advice, and even milk, to mothers with infants. This successive grant of new powers to authorities other than those of the Poor Law has produced a costly and demoralising chaos of over- lapping and duplication of services whivh is fully described in the Minority Report of the Poor Law Commission. The Condemnation of the Poor Law. What we have now to do is to make up our minds to get Parliament to deal with the matter comprehensively on new lines. From the Poor Law Amendment Act of 1834 down to the present day, the paupers have been dealt with by boards of guar- dians on one of two principles. Some guardians, believing in “ the principles oi 1834,” have conscientiously sought tc “ deter ” persons from applying for re- lief. Other guardians, either from humans motives or out of carelessness, have tried to make the paupers comfortable, and thereby encouraged others to seek relief. The most remarkable result of the Royal Commission is the condemnation, by Majority and Minority alike, of both these schools of Poor Law opinion. The eighteen Commissioners unanimously re- pudiate and condemn the much-vaunted “ principles of 1834,” which they declare to be inapplicable to the present day. They all agree in recommending the abolition of the general mixed workhouse. The celebrated “ workhouse test ” is dis- missed in silence. On the other hand, the Minority concurs with the Majority in condemning mere indulgent or lax re- lief of destitution. 4 The Majority Proposals. But from this unanimity of condemna- tion of the existing Poor-law, the Royal Commissioners go on to divide sharply into two series of recommendations for the future, embodied in two separate reports. To use the words of Professor Bernard Bosanquet, “ the antagonism ” between the two reports “ cannot be put too strongly.” Their widely contrasted pro- posals for constructing the new adminis- trative machinery are rooted in a diver- gence not less wide as to the nature of the problem to be dealt with. What seems to the Majority to be necessary is to set up a new Poor-law authority under a new name — a complicated series of nomi- nated committees, under a so-called “ public assistance authority,” to be ap- pointed by the county or county borough council, but not to be subject to its criti- cism or control. These non-elective authorities, assisted by Voluntary Aid Committees, are to do the work now done by the guardians ; they are to do it, not on deterrent, but on “ curative and re- storative ” lines. But this new public assistance authority is, like its precursor the board of guardians, to be rigidly re- stricted to the relief of destitute persons. It is, in fact, merely a Poor-law authority disguised under a new name. The Futility of Any Poor Law. To this scheme the Minority object on many grounds, the most important being that no Poor-law authority , however designated , can ever he successful in preventing destitution, or even in curing destitution ; it can only relieve it. By the very nature of its being, a Poor Law authority is, and must always be, legally confined to deal- ing with a case, not at the outset of the disease when, in the incipient stage, it is still curable, but when the person has become destitute and is therefore usually incurable. More- over, if the relief is made deterrent, few will apply ; if it is made lax, many others will become destitute in order to qualify. What is now definitely proved is that a Poor Law authority can relieve destitu- tion, but as it is precluded from touching the causes of destitution — whether these be thought to be moral, or whether they are taken to be (1) sickness ; (2) neglected childhood ; or (3) unemployment — it cannot prevent its occurrence. By its methods of administration, a Poor Law authority may diminish pauperism, that is, Poor Law relief, but then it does nothing to diminish destitution. In short, a Poor Law authority, by bad ad- ministration, may increase destitution ; by wise administration, it may relieve destitution without increasing it ; but by no kind of administration can it prevent or even diminish the destitution that pre- cedes pauperism. The Minority Proposals. What, then, is the alternative to a new Poor Law ? The Minority Commissioners answer unhesitatingly, no Poor Law at all. We propose that the existing Poor Law should be simply abolished ; that the whole conception of merely relieving des- titution should be given up. We recom- mend in its stead that Parliament should cast the whole trouble and cost of main- taining each class of destitute persons — the infant and the child, the sick and the feeble-minded, the vagrant and the unem- ployed — on authorities having both the power and the machinery to remove the several causes of destitution. With one notable exception, these authorities already exist. In the Minority Report we describe how, up and down England, the local education authority, the local health authority, the local lunacy autho- rity, and the local pension authority are actually at work, ever more overlapping the sphere of the board of guardians, and dealing with the causes of destitution. We show, for instance, how successfully the education authorities are preventing the destitution of the neglected child by their residential and day industrial schools and the supervision of the teachers and school attendance officers ; and the public health authorities that of sickness due to epidemics by their “ search- ing ont ” of infectious disease, so as to treat it, not when destitution sets in, but long before, at the incipient stage. We propose to extend the responsibility of the education authority from school teaching and medical inspection to secur- ing for each child a due amount of food and proper home conditions. This, it need hardly be said, does not entail pro- viding either food or homes for all children. It may mean merely a syste- matic encouragement and, when neces- sary, enforcement of parental responsi- bility by the school attendance officer, the 5 school nurse, and the voluntary “ Child- ren’s Care Committees.” We propose to extend the responsibility of the public health authority from the provision of a main drainage system and the treat- ment of infectious diseases, to searching out other kinds of disease, with a view to prevention and cure. This does not en- tail that all diseases shall be treated free, any more than the public health super- vision of sanitation entails that bad land- lords shall have their house drainage pro- vided at the public cost. All the in- creased activity of the public health authorities in searching out and treating sickness may coincide with a systematic enforcement of personal responsibility in respect to personal hygiene and with re- gard to the maintenance in health of de- pendents. We concur with the recom- mendations of the Royal Commission on the Feeble-minded, and with those of our own colleagues, that the whole respon- sibility for the treatment of mentally de- fective persons, whether or not they be destitute, shall be cast on the lunacy authority. “ The mental condition of these persons,” it is now admitted, “ and not their poverty or their crime, is the real ground of their claim for help from the State.” In one case only do we propose a new authority. For reasons which are elabo- rately set forth in the Minority Report, we think that the prevention of involun- tary unemployment or voluntary idleness transcends the power of any local autho- rity. Hence we recommend the repeal of the Unemployed Workmen Act, and the establishment of a new national authority responsible for ascertaining all unemploy- ment, for so organising the labour market as to minimise it, and for adequately dealing with all classes of persons who are failing to maintain themselves and their dependents on account of want of work. Not Relief but Prevention ! Throughout all these recommendations of the Minority there is the fundamental conception that what is necessary is to prevent destitution by grappling with its causes. Each authority must apply itself to preventing the occurrence of destitu- tion ; to arresting, in the initial stage, each of its several causes whenever it ap- pears ; to stopping preventable disease ; to seeing that no child grows up without proper nurture ; and to preventing any man from becoming chronically unem- ployed. We of the Minority hold that this breaking up of the problem into its con- stituent parts will actually promote and preserve the integrity of the family ; its very object is, in fact, to get at the family before it actually reaches the state of destitution. This plan of getting at the family before it becomes destitute entails dealing with it for some specific Teason, e.g., the neglect of a child, the sickness of some member of it, the mental defect of some other member, or the unemployment of the breadwinner. Instead of the officer, or voluntary worker, concerned with the destitution of the whole family, and not coming until destitution has set in, we shall have the officer, or voluntary worker, of the education authority, the public health authority, or the unemployment authority, who will come into the home at a much earlier stage, with a specific purpose and with specific experience in respect to that purpose. We believe that such a person will be more capable of thinking out the problem of the family as a whole than a mere relieving officer, or a mere charity worker, who at pre- sent arrives at the eleventh hour, possibly well-informed as to how to relieve destitu- tion, but usually with no specific know- ledge or experience of how to grapple with the several causes of destitution ; and therefore concerned, mainly, to relieve the destitution which has overtaken the family for lack of the earlier preventive measures that we advocate. The Stopping of Overlapping. It has been said that this scheme of breaking up the Poor Law will bring about chaos and confusion in the whole sphere of public assistance — one member of a family getting relief from the education authority, another from the public health authority, and yet another from the national authority dealing with unemploy- ment. Our answer to this objection is that this chaos and confusion already exist ; and that under the present system and under the proposals of the majority of the Commissioners it will grow steadily worse. We have realised it, and have devised machinery for putting a stop to it. We propose that there should be a register of all forms of public assistance, and that the Registrar of Public Assist- ance should have certain definite func- tions in the co-ordination of all treatment given at the public expense. B 6 The Registrar of Public Assistance. The need for some such office as that of the registrar will be apparent to those who realise the demoralisation caused by the present chaos. This chaos, charac- teristic alike of town and country, pre- vails not only in the overlapping activities of the various public authorities, but also in their practice of enforcing payment of the cost of their assistance. The Com missioners themselves came across cases in which various members of the same family were simultaneously being relieved or treated, at the public expense, by the education authority, the health authority, the police authority, the lunacy authority, and the Poor Law authority, or some of them — not to mention voluntary agencies of different kinds — without any one of these authorities being aware of the action of the others. The result is, at present, side by side, many families whose destitu- tion is unrelieved, and others who are receiving, in the aggregate, more than the average labourer’s income. Even more startling was the discovery, fully described in the Minority Report, that* a similar chaos exists with regard to “ charge and recovery,” that is, the enforcement of re- payment. At present it depends entirely on the policy — more often the caprice — of particular meetings of particular com- mittees, the decision depending on which members happen to be present, and in what mood these happen to be, whether any, and, if so, what, charge is made for the assistance granted to or forced on the family, in respect of destitution, neglected childhood, lunacy, maternity, sickness or accident. We found many families in quite good circumstances getting public assistance from one or other authority without repayment of its cost, whilst other families, absolutely indigent, were being charged for assistance which they had sometimes been actually forced to accept. In one case the breadwinner of the family had been put in prison by the education authority for non-payment of its charge for an industrial school child at the very time that he and his family were so desti- tute as to be in receipt of outdoor relief from the board of guardians. We of the Minority regard it of vital importance to put an end to this unfair and demoralising inequality. The setting up of any new Poor Law authority, adopt- ing “ curative and restorative trea tment,” would only aggravate it. The abolition of the Poor Law authority would in itself not suffice. We see no other remedy than a common register of all forms of public assistance, in charge of a local officer to be appointed and controlled by the county or county borough council, but to be independent of the various treating com- mittees. To this officer, for the sake of securing a uniform administration of these “ special assessments,” we propose to en- trust also the whole work of whatever “ charge and recovery ” Parliament thinks fit to enforce. The Moral Factor. There are some critics of the Minority Report — usually, I think, those who have not troubled to read it— who complain that it ignores the “ moral factor ” of the problem of pauperism. I can only say that to me the “ moral factor ” — the question of the result on personal character — is virtually the whole of the problem. But we of the Minority came decisively to the conclusion that it is impossible even to begin to deal successfully with personal character until we dismiss the whole idea of relieving destitution, and until we go boldly for a definite policy of preventing each separate cause of destitution. Take, for instance, the destitution brought about by drink. Under the Poor Law — under any Poor Law — the drunkard cannot be touched until he is in a state of desti- tution. A man may be neglecting his children, leaving his wife without medical attendance, or maltreating a feeble- minded child, and yet no Poor Law autho- rity can do anything to prevent the desti- tution which will probably ensue. It is only when the man is suffering from de- lirium tremens that he is taken into the workhouse, put into a clean bed, with two attendants to look after him, dosed with the costly and agreeable morphia, and then, when he has recovered from his de- bauch and can return to his work, let out to begin his evil courses again. We main- tain that, under our system of making the education authority, the public health authority, and the asylums authority re- sponsible for searching out the incipient destitution of the neglected child, the sick wife, and the maltreated feeble-minded child, the drinking head of the family would have been called to book long be- fore he found himself in the comfortable quarters of the workhouse. Indeed, it seems apparent to me that, once the public health authority was responsible for searching out diseases, one of the first diseases which would call for systematic prevention and cure would be alcoholism. Take again the destitution brought about by unemployment. So long as this is relieved by a destitution authority, I see no chance of enforcing the responsi- bility of every able-bodied person to main- tain himself and his family. You may, of course, deter men from getting relief out of the rates, but you will not deter them from being parasitic on other people, or from allowing their dependants to sink into a state of destitution. If, however, you had an employment authority respon- sible for either finding a man a job or placing him in training, you could strictly enforce on every man and woman who were, as a matter of fact, failing to maintain themselves and their depend- ants the obligation to make use of this organ of the State. When the visitor from the Children’s Care Committee discovered an underfed child, or the health visitor discovered a woman about to be confined without proper nursing and medical at- tendance, it would be no excuse for the man to say he was out of work. It would be unnecessary to inquire why he was out of work, whether his unemployment was due to his own inefficiency or to the bank- ruptcy of his late employer. He would simply be required to be at the Labour Exchange, where he would either be pro- vided with a job or found the means of improving his working capacity while he was waiting for a job. If it were dis- covered that there was a moral defect, he would have to submit himself, in a deten- tion colony, to treatment which would be at once curative and deterrent in the old Poor Law sense. It is, in fact, exactly be- cause we think it impossible to grapple with the moral factor by merely relieving destitu- tion that we have turned away from the whole conception of a Poor law. We can Abolish Destitution ! Can this attractive programme of pre- venting destitution, instead of merely re- lieving it, be carried into practice? We may be unduly hopeful, but, after the most careful consideration and a gTeat deal of consultation with practical admin- istrators on all the different sides of the problem, we make bold to say that it can be done. We have satisfied ourselves that, even with our present imperfect hmman nature, this nation, if it choose®, can now drain the morass of destitution which is a shame to us all. It is now possible to abolish destitution , just as we have found it possible to abolish plague and typhus, negro slavery, and the labour of little children in cotton mills. We want, in short, to set on foot a systematic and sus- tained crusade against destitution. To do this we must induce Parliament to set going the forces, in every district, of the local education authority and the local health authority, in a way that they have never yet been set going; and we must bring to their aid the forces of a national authority dealing with unemployment. How to Join the Crusade. This new crusade against destitution has been taken in hand by a young and vigor- ous organisation — the National Com- mittee to Promote the Break-up of the Poor Law, of which I am acting as honor- ary secretary. Membership of that com- mittee entails no subscription and no lia- bility beyond an undertaking to do what is possible to help on its work. Subscrip- tion is entirely optional, but to members who contribute not less than half-a-crown a year we shall send valuable literature as fast as we can publish it. W e are organ- ising a band of devoted lecturers who will, next autumn, be speaking all over Eng- land, in church and chapel societies, and everywhere else that they can reach. We have able and enthusiastic writers who are giving their days to preparing our tracts and pamphlets. But we need in every town and parish a band of disciples and supporters. We have set before us the ideal of enlisting, to begin with, a hun- dred thousand members. This pamphlet alone ought to get us that number. We want to reach the heart of every m? f ’ and woman of good will, whatever the*r politics, whatever their religious opinions, whatever their position, and induce them to enrol themselves in this new crusade. And I make a special appeal to all who read these words to send me their names. Beatrice Webb. National Committee to Promote the Break-up of the Poor Law , 5 and 6, Clements Inn, Strand, London. [Mrs. Sidney Webb answers questions as to inter- pretation, application, propaganda, etc., of the proposals of the Minority Report, and gives useful facts and figures in “The Christian Common- wealth” every week. Of all Newsagents. Every Wednesday. One Penny.] B 2 8 WHAT THE MINORITY REPORT IS. An Inspiring Document The Revelation of a National Disgrace — A Message of Hope — Destitution can be Abolished as Surely as Typhus Has Been— A Call to Action. When it became apparent that the bulk of the members of the Royal Commission were going to follow the Chairman (Lord George Hamilton) in recommending the setting up of a new Poor Law authority, and in seeking to perpetuate the stigma of pauperism and all that it implies, Mrs. Sidney Webb and her three colleagues — the Rev. Prebendary Russell Wakefield, Mr. F. Chandler, and Mr. George Lans- bury — set to work to prepare an alter- native report to present to the King. This was no light task. It involved, not only the survey of the voluminous evidence and inquiries of the Commission itself (and these, it is said, fill forty volumes of printed Blue-book), but also the setting on foot of elaborate other investigations into matters which the Majority preferred to leave unexplored. It meant the writ- ing of a description, at once accurate and vivid, of “ How England is Governed,” in all the complications of our local ad- ministration, up and down the country. It required the bringing together of thou- sands of facts and figures gathered from all sources, the elucidation of these by the results of personal visits to hundreds of institutions, the marshalling of such a complicated mass of material as might well have daunted a whole Government department, let alone four busy indi- vidual Commissioners, without the help of any civil servants. But in this gigantic task, Mrs. Webb and her colleagues, in- spired by a burning zeal to remedy the evils that they had laid bare, spared them- selves no labour to construct such a re- port as should compel the attention of every serious-minded Englishman. This is the document which has now become celebrated all over the English- speaking world as “ The Minority Report.” Parliamentary papers do not usually be- come celebrated. Something like a quar- ter of a hundredweight of new Blue-books is issued every week, and they are gene- rally very dull reading, and quickly for- gotten. But the Minority Report is a new departure in such documents : it is complete in itself. It aims at presenting in ordered sequence, page by page, a sur- vey of what is actually going on in English workhouses and in the homes of those maintained on outdoor relief. It describes in precise detail from carefully authenticated 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 work of the education and public health authori- ties, and the consequent waste and con- fusion. Unlike most Blue-books it has style. It is an addition not only to politi- cal science, but also to English literature. For the first time it puts within the range of the plain man a vivid bird’s-eye view of the working of the whole Poor Law machinery in all parts of the United Kingdom, which is costing the nation nearly twenty millions sterling per an- num. Then it turns to the problem of the un- employed — the tragic riddle of the Sphinx — to our modern industrialism, and deals with it in a manner which, it is believed, is 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 detail. There is a brief ac- count of the work of voluntary agencies, in which justice is done to the remark- able efforts of the Salvation Army. A description is then given, with much new information, of the movement started by Mr. Chamberlain in 1886, which culmi- nated 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 relief works and the farm colonies, etc. This leads up to a wonderful description of the unemployed of to-day, who they actually are, and what they really need. No such searching analysis, no such illu- 9 minating vision, no such brilliant ac- count of the problem has ever been laid before the public. But the special interest for us in the Minority Report lies not in its presenta- tion of the prohlem, graphic and impres- sive as this is, but in the remarkable plan which it works out for grappling with it — a plan in which, we make bold to say, there is embodied something like real administrative genius, and one which., as will be seen from the articles we print below, has already secured the confidence and support of some of the most capable and experienced of our administrators. The first part of the Minority Report con- cludes, in fact, with a definite scheme of reform, which is elaborately worked out in detail, involving the abolition of the work- house, the complete disappearance of the Poor Law, and the transfer of the care of the children, the sick, the mentally de- fective, and the aged to the several com- mittees of the county borough councils and county councils already administering analogous services. Similarly, the second part of the report gives, in elaborate de- tail, 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 experience of this and other countries, which are within the compass of the Cabinet, and could, it is believed, be carried in a single session of Parliament. The two together constitute, in the judgment of some of those able to give an opinion, the most important scheme of social reform ever laid before the nation. What The Minority Report Proposes. The break-up of the existing Poor Law — the main feature of the Minority Report of the Poor Law Commission — is not a measure of mere destruction. It means in fact, just the opposite — a large scheme of social reconstruction based on a complete change in our way of looking at destitution. Here are the eight points of this New Charter of the Poor. The National Committee to Promote the Break-up of the Poor Law seeks I. — To abolish the Boards of Guardians; to get rid of pauperism, both the name and the thing ; and to sub- stitute for the parochial relief of the Poor Law an entirely different method of provision for those needing puklic aid. The verdict of all the members of tho Royal Commission on the Poor Law, 1905- 9, was, in effect, that the Poor Law had failed either to prevent destitution or to cure it ; that the administration, taken as a whole, was wasteful and demoralising ; that the Boards of Guardians, through no fault of their own, did not provide adequately or wisely either for the children or the sick, for the aged or the able-bodied ; and that neither the areas nor the methods, neither the aims nor the traditions of Poor Law administration were such as to be suitable in the twentieth century. This condemna- tion went beyond mere criticism of admini- strative machinery The Royal Commis- sioners of 1905-9 were unanimous in their conclusion that the “ principles of 1834 ” — notably the principle that the condition of the pauper should be made less eligible than that of the lowest grade of inde- pendent labourer, in order that as few as possible should be led to apply for relief — could no longer be adopted by a civilised community. II. — To set on foot a systematic Crusade against Destitution in all its ramifications s against the desti- tution caused by Unemployment, the destitution caused by Old Age, the destitution caused by Feeble- mindedness and Lunacy, the desti- tution caused by Ill-Health and Disease, and the destitution caused by Neglected Infancy and Neglected Childhood. The evidence and investigations of the Poor Law Commission revealed the existence, amid all our wealth, of a ter- rible morass of destitution, which the Poor Law only very imperfectly relieves, and which it does practically nothing to (prevent or cure. Into this morass of destitution there sink annually tens «>f thousands of our (fellow-citizens — of men thrown out of work and unable to get hack into regular employment, of per- sons smiitten with phthisis or chronic ‘rheumatism, of widows bereft of the family (breadwinner, of boys and girls 'growing up without proper nurture or 10 technical 'training, of wastrels refusing to work, or men and women of weak will succumbing to drink. No Poor Law authority — no authority restricted to the relief oi destitution — can ever arrest these causes of eventual destitution at the only time at which (prevention is really prac- ticable — namely, at the very beginning of the evil, long before destitution has set in. We want (to throw the responsibility of (maintaining each class of persons be- coming destitute upon those authorities which ought to have prevented the desti- tution — that is to say, upon the authori- ties having both the power and the machinery to arrest the several causes of destitution in their early stages. III. — To empower and require the Local Education Authority to search out all children within its district who are destitute of proper nurture, and to apply to them the appropriate treatment. The investigations of the PoorXaw Com- mission, like the inquiries into the physi- cal condition of the children in the elemen- tary schools and those of the Departmental Committee on Physical Degeneration, have proved beyond dispute that a large proportion of our children are growing up underfed, improperly cared for, and suffering from minor ailments which, be- cause they are neglected, become lifelong causes of impoverishment and disease. Neglected childhood is thus the cause not only of a vast amount of eventual desti- tution and personal suffering, but also of serious dam, age to our national prosperity. Parliament has already made the local education authority responsible for school feeding and medical inspection. ‘‘The least costly and most practical solution,” says Dr. Kerr, of the London County Council Medical Service, “ appears to be that any public provision for protecting and aiding growth and development of children during 'the years of school life — three to sixteen years of age — should be entirely committed to the education authority. This would allow such matters as the feeding, teaching, cleansing, medical treatment, or social protection of school children, when these duties become a public care, to be administered by the one authority, and by bringing all the various problems into a correct relation- ship and perspective would also effect considerable financial economy.” IV.— To empower and require the Local Health Authority to search out all sick persons within its district who are destitute of medical at- tendance, and to supply to them, either in their homes or in suitable institutions, whatever may be deemed the most appropriate treatment. This is already the policy of the Public Health Acts, which are as yet applied (and that only imperfectly) to some of the diseases deemed most dangerous to the community. By this policy of “ searching out ” disease we have practically exter- minated typhus and cholera, reduced smallpox to a vanishing point, and greatly diminished enteric fever. The same policy should now be applied to all cases of disease which are not being treated or at- tended to. Every such case is a loss to the community, and a potential cause of future destitution. We know now that a large proportion of the diseases from whicn we suffer can be obviated or arrested, if only the appropriate treatment and the appropriate regimen are applied at the very beginning of the complaint. At present, as the Minority Report aptly says, “ the young artisan, with the seeds of tuber- culosis 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.” In all diseases prevention is both more effective and less costly than cure. To the local health authority must fall also whatever public provision is made for maternity, the supervision of infants under school age, and the care of the in- firm, the physically defective, and the aged needing institutional provision. V. — To empower and require the Local Lunacy Authority to search out all feeble-minded or mentally defective persons destitute of proper care and control within its district, and to make appropriate provision for them. As to the mentally defective of all kinds there is practically universal agree- ment. The Poor Law Commission unani- mously concurred with the Royal Commis- sion on the Care and Control of the Feeble- minded that 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. . . . 11 There should be one authority in the county or county borough,” which should be responsible for securing appropriate treatment for all sections of those certi- fied as mentally defective. VI. — To empower and require the Local Pension Authority to search out all persons who are destitute from old age in its district, and to provide Old Age Pensions for such of them as are able and willing to live decently thereon. This is the policy with regard to the aged which the Local Government Board (through Mr. Chaplin’s Circular of 1896) has for the last thirteen years officially promulgated to boards of guardians, though hardly any of these bodies have granted these allowances either suffi- ciently freely or of adequate amount. Such local old-age pensions should, in order to prevent overlapping, clearly be administered by the same authority as dispenses to persons over seventy the national old-age pensions. They “ would be given and continued, not as of right, but at the discretion of the local autho- rity, only to such persons settled in the locality as the Pension Committee find could and would live decently by its aid.” VII. — To empower and require a new National Authority to search out all able-bodied persons destitute of employment, and to take the necessary steps both to diminish, as far as practicable, the social disease of Unemployment and to supply proper maintenance and training for those who are un- employed and unprovided for. To this, perhaps the gravest cause of eventual destitution and demoralisation, the Minority Report devotes a whole volume, and the complexity of the sub- ject prevents any intelligible summary in a few lines. The problem, whether we approach it from the side of the unem- ployed or from that of vagrancy, clearly transcends the powers of any local authority. There must be a department of the national Government to organise a system of labour exchanges, to promote trade union insurance, to regularise the national demand for labour, and suppress both excessive hours of work and the ille- gitimate use of boy and girl labour, to “decasualise” the casual labourer and regularise the employment of those en- gaged in seasonal trades, by “dovetail- ing ” different occupations, to open up new sources of livelihood by afforestation, small holdings, and land development generally, to provide appropriate training, with maintenance, for those for whom the labour exchange cannot find work, and to commit to reformatory detention colonies the “won’t works ” and the wastrels. VIII. — To empower and require all pre- ventive Authorities to enforce, by counsel and advice, by the sus- tained pressure of public opinion, and where needed by process of law, the obligation of all able- bodied persons to maintain them- selves and their families in due health and efficiency. Does not all this mean a, great increase in maintenance at the public expense and a serious diminution of personal re- sponsibility? In no wise. At present, amid the chaos of authorities and powers, and with the impossibility of demonstrat- ing to the justices that a man could pro- vide for his family if he would, it is practically impossible to enforce even, parental responsibility. The fathers of the hundred thousand children now fed at school are not, as a matter of fact, com- pelled to fulfil their responsibilities as parents. Infants and children are (at least up to the point of actual cruelty) neglected with impunity by careless or drunken parents. The Poor Law Authori- ties at present neither see that the wives and children are properly provided for nor prosecute the men for failing to do their duty. But once it was known that a man could, by applying to the Labour Exchange, either find employment or en- sure the proper maintenance of hi® family and (under training) also of him- self, it would rest only with the local education authorities and the local health authorities, acting through their Child- ren’s Care Committees and health visi- tors, their sanitary inspectors and teachers, to stop at once, by friendly counsel, by grave warning, and where necessary by criminal prosecution, every case in which a man was even beginning to fail in fulfilling his personal obliga- tions. Nor need the services always be gratuitous. Where Parliament decides that a charge should be made (as now for maintenance in asylums, industrial schools, etc), this should be assessed on the individual responsible, after careful inquiry as to his ability to contribute 12 without encroaching on the subsistence of his household ; and the contribution so fixed should be enforced with no less exac- titude and with no more stigma of pau- perism than the collection of income-tax. Nobody would wish to see any weakening of parental responsibility, but this, with other personal obligations, can be univer- sally enforced without hardship and with- out cruelty, only when the community 6ees to it that every man and woman has the opportunity of fulfilling them. What the Minority Report will do for the Poor. By GEORGE LANSBURY. Readers of this pamphlet will now have had a very good idea of the pro- posals of the Minority for the Break- up of the Poor Law and the Public Organisation of the Labour Market. How- ever clear these are, there will be some people who will repeat the question which is so often put to me — viz. : “ How will all these proposals really affect the poor?” I think that the case which happened only the other day in Shoreditch will show very clearly the essential differences be- tween what is now proposed to be done and what is now being done. The case concerned a child, and so far as I under- stand it, the facts are not in dispute. The relieving officer, when called in, considered that it was not a case of destitution, as there was a suspicion that the father was at work. Consequently no out-relief was given, and the child died of starvation. It will be noticed that the victim in this case was a child who was acknowledged by all parties to be very ill and in need of treatment. This treatment was denied to it because of some supposed defect in the father. Had the scheme of the Minority been in operation no questions would have been asked as to the character or means or position of the father. It would be enough for the Public Health Authority that the child was sick and in need of care and nourishment. This would have been provided straight away, in whatever form was deemed most appropriate, and *11 questions connected with the father’s ability or inability to pay would have been settled afterwards. The question of his destitution would not enter into the matter. Simply the need of the child would have been considered. It is said that this would result in neglect of chil- dren on the part of parents. I am not concerned to argue very much about this, as I think the facts of life are all against it. But I would repeat that in the case above mentioned a little child has been starved to death, and that up to the pre- sent nobody has been brought to book. This could not possibly happen under our scheme. If the father neglected his duty he would be prosecuted ; but meanwhile his child would not be starved. That is most of the difference between the two sys- tems. In my opinion our scheme would, for the first time, make real and effective the responsibility of the parent as well as of the State. If this man were out of work there would be a Labour Exchange for him to apply to, which would test his willingness to work by send- ing him to a situation, or in some other way putting him in a position to get his maintenance and the maintenance of those dependent upon him. He could then really be punished if he neglected his duty to feed his children. To-day there is no machinery for doing this, and the machinery proposed by the Majority of the Commission is quite hopeless for deal- ing with such cases. There is much more that I would have liked to say on these lines, but at the moment I am not able to give the necessary time. I should like to put it on record that the more I reconsider our Minority Report the more I believe that it does contain within it the means for really organising destitution out of existence. It is the children and the sick who make up the great bulk of the Poor Law problem of to-day. Let that problem be tackled in a scientific manner and much of the ineffi- ciency and pauperism which we see around will disappear. Unemployment still stalks abroad, and, so far, the Minority scheme holds the field. What readers have to do is to join our National Committee and get everyone else to do so, and to create such a public opinion as will compel Parliament not merely to discuss the proposals, but to get them — or a better scheme, if a better scheme can be got up — embodied in an Act of Parliament without delay. 13 THE URGENT NEED FOR REFORM. HOW WE WASTE OUR MONEY AND DEMORALISE THE POOR BY THE PRESENT CHAOS OF AUTHORITIES. By SIDNEY WEBB, LL.B., L.C.C. In 1834, when the old Poor Law was costing the United Kingdom about seven millions a year, its evil influence was thought to be bringing the nation to the brink of ruin. To-day, as the Minority Report brings out with impressive detail, the position is in many respects as serious as it was in 1834, though not exactly in the same way. Overlap and Confusion. Few persons realise that in the present year, and annually, a sum of nearly seventy millions sterling is being spent out of the rates and taxes of the United Kingdom in providing main- tenance, education, and medical treat- ment for the various sections of the poorer classes. This huge amount is being expended by all sorts of local govern- ing bodies, competing with each other, overlapping each other’s operations, and duplicating each other’s services. Their work is more or less supervised by half a dozen different departments of the national Government, acting on the most diverse principles, without consultation with each other, and often diametrically at variance with each other. The Poor Law authorities of the kingdom are spend- ing nearly twenty millions a year out of the total of seventy millions, and are usually quite without knowledge of what the other local authorities are doing in the same field. In London, for instance, the Board of Guardians are maintaining at this moment about 25,000 children of school age, three-fifths indoor and two- fifths outdoor. Meanwhile the London County Council was feeding last winter over 55,000 children of school age, or twice as many as were being maintained under the Poor Law. What is worse, in several thousand cases the two authorities are simultaneously providing, out of the rates, for the same children, without the one knowing of the other’s proceedings. The Poor Law authorities throughout the king- dom have about a hundred boarding- schools for poor children. It is not gener- ally known that the local education authorities are themselves maintaining already fifty other boarding schools for equally poor children. More- over, the Home Office is simultaneously maintaining out of the taxes, through philanthropic committees, a hundred and fifty more of these boarding-schools for other poor boys and girls. All these resi- dential schools deal with much the same class, and it is often a mere chance whether a child is under one authority or the other ; indeed, quite frequently brothers and sisters from the same household are in different institutions, under different authorities, and subject to entirely dif- ferent conditions, without one of the authorities knowing of the other’s action. In some cases the same institution is in- spected by the officers of the Board of Education, the Home Office, and the Local Government Board without the inspectors from the several departments knowing anything of each other’s visits, or criti- cisms, or requirements, and without their subsequently conferring together as to their reports. Some institutions get pay- ments simultaneously in respect of the same children from different public authorities. With regard to the sick, the 14 local health authorities throughout the kingdom are now maintaining out of the rates more than seven hundred municipal hospitals, originally established for small- pox and fever, but now often taking in patients with other diseases, many sur- gical cases and accidents, and apparently now about to include in their sphere the vast range of tuberculosis. Meanwhile the Poor Law authorities have in every district their own institutions for the sick, frequently only a ward in the general mixed workhouse, but in London and other great towns a highly organised and elaborately equipped infirmary, serving as a public hospi.ol. Competing with both these rate-supported hospitals is the crowd of endowed and voluntary hospitals — existing, however, only in fewer than a hundred towns — which are gratuitously receiving, in many cases, patients of exactly the same class as the rate-sup- ported hospitals of the Poor Law or the public health authorities. It often depends on which doctor gets hold of the case first whether the sick person becomes a pauper, a municipal patient, or the reci- pient of private charity. In many a dis- trict there are now half-a-dozen different doctors receiving money from the Tates and taxes, getting their instructions from half-a-dozen different public offices or departments, often doing exactly the same work, for the same class of persons, and not in the least consulting with each other. Notwithstanding this huge expen- diture, this ignorant multiplication of official inspections, this unintelligent duplication of services, and this wasteful overlapping of work, a large part of the provision now made by the community for the infants, the children, the sick, the mentally defective, the infirm, and the aged — and for these sections undeT any system of society some collective provision has to be made — is scandalously deficient and inhumane. The Minority Report makes the terrible and quite unexpected revelation that there are, at the same time, more than 10,000 healthy, able-bodied men rotting in the general mixed workhouses of London and Liverpool, Dublin and Glasgow, and some other towns ; whilst literally hundreds of thousands more rise up in the morning not know- ing from what work or on what casual jobs they will that day be able to earn their own and their children’s meals. What answer can we make to the criti- cism that such an absurd chaos, a chaos of our own creating, is unworthy of reason- ing beings ? How the Duplication of Services Comes to Exist. We have got into this chaos by three- quarters of a century of drifting in Local Government, no Cabinet since 1834 ever plucking up courage to deal with the ques- tion as a whole. 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 en- trust the administration of the public pro- vision for any of the classes of persons whom they had to deal with. There was in 1834 no sanitary authority in existence charged with the prevention of all disease and with the cure of such diseases as .axe infectious, and having its own hospitals and medical staff. There was no service of sanitary inspectors required to discover every disease that becomes a public nui- sance. There was in 1834 no education authority charged with the schooling of all the children, and having its own elaborate network of schools and staff of teachers. There was no service of school attendance officers, visiting systematically every home to discover whether the children are re- ceiving efficient education. There was in 1834 (outside the metropolis) no force of salaried police, whose duty it was to pre- vent the public nuisance of vagrancy. There was in 1834 even no systematic prison organisation, such gaols as existed being mere dungeons dispersed among en- tirely autonomous lords of manors, close corporations, and county justices. There was, of course, no idea of curative or re- formatory treatment of the persons com- pulsorily detained. There was in 1834 no general public provision for lunatics, out- side 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 district council now assumes to do, with distress from unemployment or with the curative treatment of unemployed workmen. There was in 1834 no idea of a national service of pensions, providing superannuation for all who need it, com- 15 pletely divorced from the Poor Law. The Poor Law Commissioners of 1834 were therefore compelled to recommend that a single local authority should be estab- lished, to deal with all the classes for which public provision had then been made, and this provision, however 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 Upgrowth of New Authorities. The problem before us to-day is 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 need of public aid. Quite apart from the question of relieving destitution, there have grown up in the course of the seventy-five years extensive systems of public provision, out of the rates and taxes, for particular classes of persons, amounting in the aggregate to two or three times the whole Poor Law expendi- ture. 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 ser- vice of education, from the kindergarten to the university college. For various sections of these young people — more ex- tensively than is commonly realised — the State provision of education is accom- panied by partial or complete mainten- ance. This is quite irrespective of the tens of thousands of children in endowed and publicly aided secondary boarding- schools. Leaving these out of account, it is interesting to note that the State pro- vision of maintenance with education now extends to something like a hundred thousand children, some of them because they are the best (scholarships which cover maintenance), some of them be- cause they are the worst (reformatory schools), and some for indiscriminate reasons, including the undesirable charac- ter 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 over fifty cases the local autho- rities actually run their own boarding- schools for particular sections of poor children — at a lower cost per head, be it noted, than the new “cottage homes ” of boards of guardians. All this public aid to the children is without the stigma of pauperism, whether the parents are bad, good, or indifferent. With regard to the sick, theTe haB grown up a public health service, ubiqui- tous in scope and becoming ever larger in volume, for the prevention of all diseases, irrespective of the wealth or conduct of the persons concerned, and for the cure (including maintenance in hospital and domiciliary treatment) of those deemed most injurious to the com- munity. Every year this notion of the protection of the community is advancing on the idea of merely relieving the in- dividual. In 1907 it was made the duty of the education authority to provide re- peated medical examination of all the seven millions of children, with permission actually to supply medical treatment if it chose. All this is without the stigma of pauperism, and the question which of the services should be rendered gratui- tously, and which of them should be made the subject of a nominal and quite inade- quate fee, has ceased to be a matter of principle, and is now one of mere adminis- trative expediency in each case. With regard to the able-bodied in need of assistance, there has grown up the network of Distress Committees under the Unemployed Workmen Act. But this did not begin with M ?. Gerald Balfour’s Act or Mr. Long’s Joint Committees. We see it initiated by the Local Government Board itself in 1886, in the celebrated circular calling on the municipal authori- ties to take the treatment of the unem- ployed out of the Poor Law. Tlhe wihole purpose and intention of this municipal organisation has been to provide some- thing other than the Poor Law for the whole class of workmen unemployed through no fault of their own, irrespective of whether or not they were technically destitute. Ait the other end of the able- bodied class we have the strong recom- mendations that the vagrant should be dealt with, not by the Poor Law Authority but by the police, and the incorrigible wastrel by a Detention Colony — in both cases irrespective of whether or not they apply for relief or are technically desti- tute. Such alternative provision for the able-bodied person homeless through his own fault has been made possible by the growl! of an admirable and complete 16 system of (preventive police, by a national prison organisation, and by the experi- mental development in reformatories of a system of treatment combining compul- sory detention with educational stimulus — all being new since 1834. It is significant that the reformatories, like the prisons, are free from the stigma of pauperism. With regard to the aged, the foundation has been laid by Mr. Asquith’s bold mea- sure of complete national provision free from any stigma of pauperism, and quite unconnected with the Poor Law. Thus it is that the provision made by the Poor Law Authorities for the children, the sick, the able-bodied, and the aged respectively has come to form 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 cannot be marked off from the rest by any significant characteristic — not even by the 18-34 attribute of “ being in a state of destitu tion.” How to Stop the Waste. It is obvious that it is out of the ques- tion to reverse the whole current of legis- lation for the past three-quarters of a century and put all these classes fcaf a memorandum. Contributing members and subscribers are entitled to make full use of this research department. HOW TO GET THE MINORITY REPORT. The Reports of the Poor Law Commis- sion are buried in a gigantic Blue-book weighing, even with thin paper, over 7 lbs. , and extending to over 1,200 folio pages of print. This ponderous tome may be bought of Wyman and Sons for 5s. 6d., which is half the usual charge. A more convenient form of the official edition is that in three volumes octavo, Yols. I. and II. being the Majority Report, price 2s. 3d., and Vol. III. the Minority Re- port, price Is. 9d. The Stationery Office, which does not include it in its lists, ap- parently desires to conceal from the public the fact that it has published this convenient octavo edition, which has, un- fortunately, small type and thin paper. Both these official editions are burdened by innumerable footnotes and references, which are irritating to the reader. There are two handy pocket editions of the Minority Report alone, in large type, without footnotes or references, both pub- lished in two volumes, at Is. each. One of these editions is published by the Fabian Society (3, Clements Inn, Strand, London). The other is published by the National Committee to Promote the Break-up of the Poor Law (5 and 6, Clements Inn, Strand, London). What may be called an edition de luxe, on good paper, two volumes, bound in blue cloth, and furnished with two long intro- ductions by Mr. and Mrs. Sidney Webb, is published by Longmans, Green, and Co. (“ The Break Up of the Poor Law,” price 7s. 6d., and “The Public Organisa- tion of the Labour Market,” price 5s.).. The best propaganda matter is, undoubt- edly, this penny pamphlet, “ The Charter of the Poor,” published by the Christian Commonwealth Co., Ltd., 133, Salisbury Square, E.C. Copies may be had post free at the following rates : — 12 for Is. 2d. ; 50 for 4s. ; 100 for 7s. 6d. The most practical way of getting the Minority Report is to send a subscription to the National Committee to Promote the Break-up of the Poor Law, 5 and 6, Clements Inn, Strand, London. For 5s. you may get not only the Minority Report but also all other literature as issued. Any of the above publications , and other current literature, may be obtained at the vublished price {postage extra) from THE Christian Commonwealth Office , 133. Salisbury Square , London E.C. 24 The Progressive League’s Call to Arms. By Dr. F. W. G. FOAT, M.A. I have been requested to explain in outline the share which the League of Pro- gressive Thought and Social Service is ex- pected to take in the campaign against desti- tution. If tlhe unanimous and urgent recommenda- tions of the Social Inquiry and Service Sub- Committee are approved by the Executive, the League as a whole will give itself for the next few months to the service of the Minority Report, undertaking in the first place to sus- tain in all its circles of influence the public interest already created, and to carry on ac- tive propagandist and educational work among the people. In devoting our energies to this fight we are putting our small army into the field at an early stage of its organisation, but no Leaguer who has caught the spirit of social reform will shrink from active service. I believe there will be a general and eager response to the “ call to arms.” Now what are we to do to equip ourselves at short notice ? Can we put in a sufficient number of “drills” to make ourselves effec- tive instruments of our leaders in the attack ? The Bastille was taken in 1789 by a mob with- out discipline. But in the twentieth century discipline is indispensable. Our Bastille is pauperism, and its guards are ignorance and the new official bumbledom. We have to meet knowledge — of a sort — and must meet it with a larger and better knowledge ; we have to attack an entrenched official position, and nothing less than a “ Territorial ” army well trained to use the latest information will have the least effect. Fortunately we have good leaders of ac- knowledged eminence in the marshalling of indisputable facts, and the League has a staff of general officers who have seen some service. All we need is the training of the rank and file. The one question of the moment in the League is this: Will the branches submit themselves to be well drilled ? If they will, I can show them how to do it. Happily, we have been lately thinking seri- ously of such work as this, and in some memorable gatherings have had encouraging field-dayis. My “Circular” — which I com- mend once more to the attention of the branches — sketches the general outline of our training scheme. It is delightful to be per- mitted so soon to apply it to an issue imme- diately practical. Next, then. Branch secretaries must see that the study circles are fully formed under definite and acknowledged leadership. The leader should be, if available, one of the ac- credited speakers of the League ; in other cases the leader will rank with the speakers. The branches will probably consent to lav aside for the present their general pro- grammes of lectures, and to concentrate their energies on the mastery of the points of the New Charter of the Poor (which is explained on another page of this issue). Thorough facility in the handling of this weapon is absolutely necessary for the rank and file. Deeper study of the whole ques- tion will follow in «vne cases (for which I commend the advice given on page 683 above, “ How to Study the Minority Report ”). But it is hopeless to expect that every Leaguer will manipulate the big guns. First, for each and all, the points of the new Charter. Now, where do the League study circles in particular come in? The general meeting of the branch will do good work only when it contains a number of members who have 'pre- viously prepared for it. The study circles must lead off. Let them meet earlier in the week and do the following things: — (1) Learn by Heart the eight points of the new charter, devoting one week to each ; (2) thoroughly understand what they mean, by the help of the best ex- pert instructors they can obtain, and the pri- vate reading of this week’s symposium (to be reprinted by The Christian Commonwealth, together with the new charter, in pamphlet form). But this is only preparation for the more public meeting of the branch. The people must be taught, in detail, for, as Sir John Gorst says in his article, “ The Need for Pro- paganda ” : “There is little prospect of the recommendations being carried into effect, un- less the people of the country, by some or- ganisation other than the party ones , vigor- ously intervene .” We come, then, to the weekly branch meet- ing. The first “point” of the new charter will be the subject of the first week’s discus- sion ; in the second week, points I. and II. will be taken; in the third, I., II., and III., and so on, by accumulative addition. I par- ticularly commend the following procedure: — The special addition for the week should be recited and expounded for not more than half- an-hour by the best speaker available — the best informed provided he be interesting. At the end of the half-hour the meeting, goes into discussion, arid for that I urge with all my might the use of the social-socrat’c method of question and answer, which I have already demonstrated as a kind of mental cricket at the recent great London “ rally ” at the Hol- born Town Hall. Other forms of discussion are, of course, at the option of the branches, but I would ear- nestly remind leaders and speakers that the “ game” does create and stimulate and main- tain intellectual life. If the branches hope to have full meetings week after week for the study of a dry report they MUST use the “ game.” If they think otherwise let them try, of course, but it will be a pity to waste time. Besides, here is a first test of disci- pline. I am asked to 'take charge of this de- partment for self-education. Well, those are my “orders,” my “ prescription,” advice, or what you will. (The rules of this “ mental cricket” are being printed.) A series of inter- branch competitions or matches as tests of the knowledge so far acquired are being arranged. Now then ! Is it to be drill for active ser- vice or not ? Issues larger than at first appear depend upon the answer. [The Teague of Progressive Thought and Socia l Service, 27, Chancery Lane, E.C. j