- Sickness, Medical Welfare and the English Poor 1750–1834 by Steven King
Steven King's new book on the medical components of England's poor relief system 1750–1834 represents the most extensively researched analysis of the subject to date. It significantly enhances our understanding of the medical services provided under the Old Poor Law.
King brings together three major datasets. He explores the administrative records of 117 English parishes blessed with lengthy, surviving uninterrupted runs of data that allow for computation. These are augmented by the records of 146 communities where the operational data are rich but somewhat more fractured. Third, King compiled nearly 13,000 narratives by or about the poor primarily from letters, whether by the poor requesting relief, advocates writing on their behalf, or poor law officials. The locales studied represent a broad cross-section of regions and community types, from small rural parishes to towns and early industrial communities. It is worth noting that England's very largest cities are underrepresented. In a period that saw London reach a million souls and when [End Page 616] another fifteen cities had between 20,000 and 100,000, the largest community in King's core dataset had 16,000. Nevertheless, King can deservedly crow that the research base assembled here "represent[s] the most extensive and intensive corpus ever brought to bear on the Old Poor Law."
King wisely applied a wide definition of medical to these records. Thus, he counts not only doctor visits, medicines, or hospital stays, but also cash payments to families of the sick or injured, in-kind relief like clothing or food, costs associated with medical travel or accommodation, sick wards within workhouses, and even funeral payments. King usefully argues for seeing parochial medicine as a multistaged process rather than an event, one that involved considerable negotiation. He thus often speaks of relief "packages" for the sick poor that bundled numerous forms of assistance.
Perhaps the biggest claim arises from his finding that health care became a more pronounced component of overall welfare starting about the 1790s. King speculates that demographic changes related to falling mortality but rising morbidity may have contributed, with overseers confronting more long-term chronic illness, especially among the aged. Whereas medical spending (adjusted for inflation) hovered just above 10 percent of total welfare spending in the 1770s and 1780s, by the 1810s it was regularly around 30 percent, in parishes big and small, urban and rural. This basic fact enables several historiographic interventions. One concerns the so-called crisis of the Old Poor Law. If rising costs drove much of the criticism of the Old Poor Law, it now appears that medical costs specifically represented a major component of that overall spending. Health care became a primary function of the poor law. However, whereas scholars have—with good reason—described the increasingly harsh attitudes toward the poor that would become institutionalized in the New Poor Law (1834), King argues that evidence of increasingly generous relief to the sick poor must complicate that picture.
This point also relates to the important question of whether the poor had a right to medical care. While King maintains that they lacked a legal right in a strictly technical sense, he argues that by the early nineteenth century they had acquired a de facto right to some sort of succor when illness struck. This conclusion arises from King's close readings of the negotiations between paupers and overseers, which provides a nice counterbalance to the computational analysis described above. Following on much recent work about pauper agency, King makes the case that the sick poor used a range of rhetorical strategies when applying for relief. And although such relief was always discretionary, it is clear from their decisions that overseers felt compelled to provide relief to the sick that was "right, proper and fair" (p. 322). Numerous other findings will interest readers of the Bulletin. For example, cash payments to the sick became increasingly common in later decades, as did sojourns to institutions...