Читать книгу Pathy's Principles and Practice of Geriatric Medicine - Группа авторов - Страница 23

Health care in the UK goes back to that provided by the monasteries until they were dissolved in 1536. After the dissolution, many of the aged and infirm, who could not be managed at home with the help of family members, were left uncared for. The Poor Law Relief Act of 1601 attempted to remedy these problems. Parishes levied a rate on all occupiers of property to provide work for the unemployed and accommodation for the lame, old, and blind. Workhouses were built for these purposes but were made as unpleasant as possible to discourage people from entering them. Infirmaries were established to look after sick inmates of the workhouses. Outdoor relief was available for the poor, but this was curtailed in 1832.

Hospitals did not become central to health care until the nineteenth and twentieth centuries, by which time two different types of hospitals were evolving: the voluntary hospitals and the workhouse/municipal infirmaries.¹ Voluntary hospitals, some of which dated back to the tenth century, were financed from endowments, subscriptions, fees, and fundraising. They had a high reputation, with good nursing and medical staff, and acted as a base for clinical teaching of medical students. They were reluctant to admit the chronic sick, fearing that their beds could become blocked because these patients were slower in improving and there could be social problems preventing their discharge. An important consequence was that medical students rarely saw them and, therefore, were not taught about the diseases of old age or how to manage the mixture of medical and social problems they would meet after qualification.

Workhouse infirmaries were funded by local rates. They gradually became long‐stay institutions for the chronic sick. Examples of unsatisfactory conditions and poor care in workhouses and infirmaries surfaced in the 1860s and resulted in visits by the Lancet commissioners and the inspectors of the Poor Law Board. The 1869 report of the Lancet Sanitary Commission was damning, stating, ‘The fate of the “infirm” inmates of crowded workhouses is lamentable in the extreme; they lead a life which would be like that of a vegetable, were it not that it preserves the doubtful privilege of sensibility to pain and mental misery’.²

In 1929, the Local Government Act came into force, which aimed to correct the existing bipartite system of health care of ‘one part for the pauper and the other part for the non‐pauper’. However, Charles Webster concluded that health services between the two world wars were ramshackle and uncoordinated, with hostility between sections of the service, increasingly chaotic funding, and a hospital service that was unevenly distributed and limited in rural areas.³

Further reform came in 1948 with the creation of the National Health Service (NHS), which rearranged British health care into a tripartite system. First, there was the hospital service, which was formed by the nationalization of 1143 voluntary and 1545 municipal hospitals. It became the dominant partner in the Service. Second, there were the general practitioner and the ophthalmic, pharmaceutical, and dental services. The third arm, which was managed by the local authorities, included health centres, health visitors, and ambulance services. Their immensely valuable home help and meals‐on‐wheels services did not really ‘take off’ until some years later. Importantly, health care for all became free of charge.

Voluntary and charitable organizations made important contributions to the care of the older person and research into old age. In 1943, the Nuffield Foundation was created, one of whose objectives was the care of the aged and the poor. This support led to the formation of the National Corporation for the Care of Old People in 1947. The Foundation also stimulated major research into the causes of old age (gerontology). These moves to assist older people became increasingly important as the proportion of older people in the population steadily increased. In 1841, the over‐65‐year‐old people made up 4.5% of the population, which rose to 4.7% by 1901, 7.8% by 1921, 9.6% by 1931, and 10.5% in 1947.