Inequality in nineteenth-century welfare provision : a study of access to and quality of institutional medical care for the elderly in England
My thesis question whether access to and quality of medical care for the elderly deteriorated over
the nineteenth century and thereby contributed negatively to welfare inequality. This hypothesis
is based on a reading of the historiography of old age, in which historians and gerontologists
develop a picture of declining socio-economic status of the elderly, an erosion of cultural
meanings of ageing, and a scientific emphasis on the pathology and negative physiology of old
age. It is also based on the assumption that Victorian providers were willing and able to allocate
resources according to patient characteristics other than medical need. Informed by current health
policies in the British National Health Service, I develop a rationing approach to examine the
strategies employed to control supply and demand for scarce resources by the Bristol Royal
Infirmary and Shoreditch Workhouse and Infirmary in London.
Case study evidence on care inputs, admissions length of stay and treatment outcomes from both
infirmaries is analysed for the period 1820-90. The data are correlated with trends in local
demographic profiles and my own estimate of age-based medical need. I show that neither the
Bristol Royal nor Shoreditch Infirmary allocated resources according to the relative medical need
of their local population age groups. Instead, the young and middle-aged were prioritised at the
expense of children and the elderly, most notably at the voluntary hospital. Access for the elderly
did, however, improve at both institutions over time. As regards the quality of medical care,
various outcome measures suggest that any differences n treatment content did not translate into
worse survival chances for poor law patients.
I conclude that, unlike societal status, medical care provision for the elderly did not deteriorate
during my period, and that further research is needed to explain why they were underrepresented
in the public as well as the private sector.