The end of the Irish Poor Law? Welfare and healthcare reform in revolutionary and independent Ireland, by Donnacha Seán Lucey, Manchester University Press, £70, ISBN: 978-0719087578
In November 1920, the Sinn Féin-controlled Board of Guardians appointed three vice-guardians to root out wastage, corruption and soaring costs in the Cork City workhouse. The problem had assumed some urgency as the decision by the board and the city council to recognise Dáil Éireann as the legitimate government of Ireland had meant a withdrawal of funds by the British exchequer. The decision was fully in accord with the findings of Dáil Éireann’s own Commission of Inquiry into Local Government, which recommended the abolition of all boards of guardians, the amalgamation of the country’s workhouses and sending the inmates out into the world to live on outdoor relief. The Commission believed that the closure of these “evil institutions” could lead to savings of £50,000 a year to Ireland’s ratepayers.
The senior vice-guardian appointed in Cork was Seamus Lankford, a former officer in the British customs and excise service who returned to Ireland in 1918 after receiving his call-up papers for the front. A longstanding activist in the Gaelic League, he was appointed league organiser for Cork on his return home. He then became registrar of the local Dáil arbitration courts and went to work with a will as vice-guardian of the workhouse. He took up residence with the assistance of the nun in charge, Sister Xavier, who reserved beds for himself and his colleagues as “patients”. She sensibly insisted that they use the institution’s nightwear in case of British raids, which were frequent. Lankford had a particularly narrow escape on the eve of the feast day of Our Lady of Lourdes, which he attributed to her intervention. Like many of his fellow revolutionary apparatchiks his intense religious faith helped sustain him through the grim months ahead, but it also informed his approach to the problems he had to tackle.
The end of the First World War saw a rise in the Irish workhouse population, as the social supports for groups such as dependents of British soldiers were wound down. The workhouse became ever more crowded. One of Lankford’s fellow vice-guardians, Pat Higgins, recalled that “the male lunatic division” in particular “was a place for pandemonium – all kinds of people were put in there – robbers, drunkards, imbeciles and people suffering from DTs. Spies and prisoners were brought in, as they [the IRA] had no other place for them.” On one occasion a suspected British spy was transferred to the workhouse from the North Infirmary hospital and detained until an IRA execution squad arrived and took him out the back gate to be shot, at which point an ambulance was summoned from the South Infirmary hospital to remove the body. It showed a degree of co-operation between the three institutions that the citizens of Cork could only dream about in normal times.
Lankford considered the presence on the workhouse premises of so many people dependent on the British state as a considerable disadvantage. His narrow escape from arrest, with the assistance of Our Lady of Lourdes, was on a night when a British raiding party arrived accompanied by a local prostitute who was a frequent resident at the workhouse and able to identify men on the run. An even greater concern was the moral threat posed to other inmates by groups such as unmarried mothers, some of whom were “repeat offenders”. This threat exercised Lankford so much that when the Truce was declared in July 1921 he travelled to London and visited a number of religious orders working with “fallen women”. As a result of his efforts the Sisters of the Sacred Heart of Jesus and Mary in Chigwell agreed to establish the Bessborough House Mother and Baby Home. Almost a century later the HSE found that babies were considered “little more than a commodity for trade” in the home, that the order had “a preoccupation with materialism, wealth and social status” and that the high infant mortality rates were not only due to poor management and penny-pinching but may have been overstated to conceal the sale of infants for foreign adoption.
Lucey’s book helps redress the enormous imbalance that exists between the attention given to the political and military aspects of the struggle for independence, often examined in excruciating detail, and the comparative neglect of its consequences for Irish society. It concentrates on Cork and Kerry but sets events in a national context.
What was happening in the Cork workhouse was replicated across most of what became the Irish Free State, with the notable exception of Dublin. One very positive consequence in the longer term was the decision to separate the residential and medical functions of the workhouse. This would ultimately help remove much of the stigma attached to our social welfare system and ensure the integration of the old workhouse hospitals into the wider health services. But it would prove a slow process, driven in the “revolutionary” years by the conservative morality of men such as Lankford and by the need to save the ratepayer and, subsequently, the taxpayer money.
The crackdown in Cork yielded enormous savings. Theft of materials by staff and inmates, from enamel mugs to coal, and from bandages to drugs, was stopped. So was illicit shoemaking by the inmates. Able-bodied “loafers” and “casual paupers”, many of them migrant workers, were evicted and stringent new rules of admission were introduced ‑ some of which were illegal ‑ to turn away undesirables. Staffing levels were reduced, cheaper foodstuffs introduced, old age pensions expropriated from elderly inmates and charges imposed on fever hospital patients. As a result, expenditure was reduced by £30,000 in 1921.
The only opposition to these charges came from the Cork Trades Council and Labour TD Pat Day, who topped the poll in the 1922 election. Initially labour supported the anti-corruption drive, but it felt it had gone too far. On the other hand, the Cork Chamber of Commerce congratulated the board on the “great saving effected by the very efficient management of the vice guardians”. The policy was generally welcomed locally as a departure from the “failed, corrupt and costly” British welfare model. Whether consciously or not, Lankford was reasserting the old guiding principle of the workhouse system, now discredited in Britain itself, that inmates “should not be made more comfortable than people outside”. Lankford and his colleague Higgins rejected criticism from “politicians who wish to foist themselves on the public as humanitarian ‘friends of the poor’ or ‘friends of the worker’.” They reminded critics that they had the support of the majority of the board of guardians and the Dáil Éireann Department of Local Government in the battle to end “waste and extravagance”.
When the new Free State’s Department of Local Government and Public Health (DLGPH) set up an inquiry in January 1923 into complaints against the vice-guardians, the inspectors were kidnapped and, when it was reconvened in May, Bishop Daniel Cohalan forbid nuns to give evidence. Lankford, now a full-time civil servant, refused to testify, but was exonerated; although the inquiry did recommend that the conditions of the inmates should not be reduced further.
Moves to replace the old workhouse structures with county council subcommittees for health and public relief began before the First World War in Britain. While public opinion was one factor, the most important solvent was the 1908 Old Age Pensions Act. The large number of “aged and infirm” workhouse inmates began to drop as many pensioners could now manage to live in the community. Acceptance of the need to provide a social welfare and health safety net for the poor rose in Britain after the shared sacrifices of the war and the growing strength of the labour movement. These factors were much weaker in Ireland, where the war was a far less universal experience and the Irish labour movement relatively weak. For many militant nationalists, whether they took the pro- or anti-Treaty side in the Civil War, the people they believed deserved most consideration were veterans of the independence struggle and their dependents. Ireland would become unusual in that everyone who could satisfy the relevant referees that they had given military service in 1916, the War of Independence and, later, the Civil War, was entitled to a pension, whereas British servicemen only received one if they suffered a disability resulting from their military service. The vast majority received nothing beyond a six months’ allowance, or “donation”, while they looked for a job.
While the switch to outdoor relief in Ireland was an improvement, it was restricted initially to the old, sick, disabled and widows with dependent children. Darrell Figgis, who drafted the Free State constitution, argued that it should not be given to anyone who owned or had the use of an acre of land, which he considered quite sufficient to live off. On the other hand, the Minister for Finance, Ernest Blythe, accepted that closing workhouses would increase the demand for outdoor relief, but that this could be less costly than maintaining people inside them. Labour deputy Cathal O’Shannon called for the “right to relief” to be based solely on a person’s need, but this had little resonance outside Labour ranks. By 1924 outdoor relief was costing £372,654, compared with £112,245 in 1913, and the number of people assisted had risen by almost 50 per cent, from 14,663 in 1913 to 21,650 by 1924. Conversely the workhouse population had dropped from 26,791 in 1913 to 18,113 in 1925.
Control of expenditure remained a priority. Home assistance covered food, fuel and “other articles of absolute necessity”. It did not cover medical bills or funeral expenses and relief was limited to one month except in cases of physical or intellectual disability. Even the latter cases were subject to quarterly review. Able-bodied recipients only received half their basic requirements and might have to work on relief schemes, while forbidden the right to pursue a trade. The officials who implemented the system were similar in background to Lankford, such as Padraig O’Mahony, secretary of Kerry county council, who was a former IRB member active in the Easter Rising and a full-time organiser for the republican movement during the War of Independence. While he acknowledged the effects of the postwar depression he shared the fears of his peers that outdoor relief led to welfare dependency and “developed idleness and improvidence”. He advocated public work programmes for all, while the Commissioner appointed to North and West Cork, Sean O’Farrell, said district justices should be empowered to commit men who spent their relief money on drink to “labour camps”, an option the Commission on the Relief of the Sick and Destitute Poor, including the Insane Poor (CRSDPIP), looked at but did not recommend in its 1927 report.
Fortunately, many of the Home Assistance Officers (HAOs) appointed to administer outdoor relief took a less draconian approach than their superiors. Their willingness to turn a blind eye on occasion might also have been encouraged by workloads that made it impossible to monitor recipients closely. The amounts paid out were a pittance. Mrs Maria Lynch, a former Poor Law guardian in Cork and secretary to the city’s Child Welfare Committee said that 4s per head was not enough to keep a man and woman alive, while Joseph Glynn, president of the Society of St Vincent de Paul, said that 80 to 90 per cent of residents at the society’s hostel in Dublin’s Back Lane were not idlers but “decent working class” men. However senior officials such as Lankford and O’Mahony continued to refer to relief applicants as “riff-raff” and “scum”.
As we have seen, the latter group included single mothers. Prior to independence they were often accommodated in workhouses, but the need to protect the “moral” poor assumed a new urgency under men bent on national regeneration. Bessborough House may have been Lankford’s most lethal intervention in the reform of the poor laws, but it was also his most popular. Even in pre-independence days, single mothers entering workhouses were often put under the charge of a nun “to prevent them abandoning hope” or becoming susceptible to “relapses”. By 1924 Bessborough had been inducted as an auxiliary home into the South Cork Board of Public Assistance structures, but retained its independence. The local authority paid the Sacred Heart Order 3s a day for each mother and child in Bessborough, but left overall supervision to the bishop, who, according to Daniel Egan, the secretary of the South Cork Board of Public Assistance “looks after the place very closely and takes a great interest in it”. Egan told his board that “it would have to be borne in mind there are no establishment expenses; no staff maintained by us and that we barely pay the capitation grant”. Furthermore, Bessborough facilitated women returning to the “work-a-day” world and prevented them becoming a “permanent burden” on the ratepayer. He praised the home for training women in domestic duties, cookery, needlework, laundry and dairy work, poultry-keeping and gardening. While the regime in this and other mother and baby homes was acknowledged to be harsh, Dublin workhouse inspector Seamus MacLysaght said the religious orders had a “duty” to ensure these women “mend their ways”. Usually single mothers were divided into first offenders, capable of redemption by discipline “blended with sympathy”, while kept separate from contagion by “repeat offenders”. The secrecy of the regimes was defended on the basis that anonymity allowed women to return to a normal existence, albeit usually without their child. We now know it also allowed for widespread abuse and long incarcerations, with some inmates spending their entire lives in captivity. Nor was it only male administrators who endorsed this approach. Mrs Jane Power, commissioner of the Dublin Poor Law Union in evidence to the CRSDPIP said that detention and segregation were both the most appropriate punishment for single mothers and the best form of protection for society. By the time the Commission made its report in 1927, a “moral panic” had taken hold in the Free State that affected everything from primary legislation on matters such as contraception and divorce, to censorship of books and restrictions on “decadent” music.
Although the Commission made no recommendations on how long women should be incarcerated and the practice was never legally sanctioned, it did suggest first offenders be institutionalised for one year, second-time offenders for two years and others indefinitely, in consultation with the matron or mother superior of the institution concerned. Ideally it recommended separate institutions for different levels of offender but accepted that insufficient funds prevented this. Not surprisingly, the Catholic church welcomed the report, and one of its principal spokesmen, Fr Richard Devane SJ, said the new approach meant that the “poor law is exorcised of the paganism in which it was originally conceived”. The Sacred Heart congregation opened new homes in Castlepollard, Co Westmeath and Roscrea, Co Tipperary so that it was dealing with 375 women by 1937. Other orders soon joined the mother and baby homes industry. In some cases, such as Pelletstown House in Dublin and the former workhouse in Tuam, publicly owned buildings were handed over, to the Sisters of Charity and Bon Secours respectively, to run.
Infant mortality rates in these homes were recognised as notoriously high as early as 1927 by the CRSDPIP, but nothing was done to tackle them. Bessborough had a 47 per cent infant death rate, Pelletstown 23 per cent, Roscrea 18 per cent, Tuam 15 per cent and Castlepollard 7 per cent. In spite of these horrific figures, which were to rise again in the coming years, in 1935 the DLGBPH felt institutions were achieving “satisfactory results2, with “very few girls” being admitted a second time (possibly because so many were never let out). Crucially, religiously run homes remained a cheap alternative to establishing state institutions.
While the religious orders have received deserved obloquy over for their role there has been little attention given to the complicity of the rest of society in this system of incarceration. Individual cases can be illuminating in explaining why, as with a nineteen-year-old girl from a small farming family in Kerry whose mother approached a middle class neighbour for “help and advice”. The neighbour wrote to the Reverend Mother at Bessborough who advised her to get an admission note from the Kerry Board of Health and Public Assistance. The board, in turn, said the pregnant girl would first have to be admitted to the county home. Afterwards her father sought his daughter’s return and Padraig O’Mahony, as secretary of the KBHPA, contacted the middle class woman who had organised the pregnant girl’s admission to Bessborough to ask if this was in accordance with the desires of the people responsible for incurring the expense of sending the girl to the county home in the first place. The woman concerned, who presumably bore whatever cost was involved, made it clear that she was strongly opposed to the girl returning home as the parents lacked the character to control their daughter. She would also be “a bad influence” on her sisters and, if allowed home might create the impression that local girls “may come and go as they pleased” to Bessborough. In another case the father offered to pay maintenance of 7s 6d a week towards the baby’s upkeep and then asked to marry the mother and emigrate with her to London. The Reverend Mother rejected his proposal because she did not believe he could adequately provide for the mother and child. She further decided that the mother was in no fit state of mind to meet the child’s father or make a decision of her own.
Of 961 women discharged from Sacred Heart institutions between 1935 and 1939, 531 returned to their families and relations, 309 were found situations, only twenty-four were married and eighty-five women were designated “others”, suggesting incarceration in Magdalene laundries or other institutions. Women found “situations” were expected to contribute to their children’s upbringing. This usually meant transferring the bulk of their meagre earnings to the sisters. The vast majority of women left the Sacred Heart institutions without their children. Some mothers were also refused admission, or readmission to the Sacred Heart premises because of their “temper” or “low” character. The prospects of a mother leaving the institutions with her child appear to have depended in many cases on her background, and unmarried mothers from poor families could expect little if any consideration or consultation.
Although mother and baby homes were the preferred option of officialdom, it is hardly surprising that 70 per cent of single mothers remained in county homes, which they could leave if they wished, and did not have to give up their basic rights and identity. Often they were given temporary passes to go home if they wished and if inmates sometimes had to work as “ward maids”, discipline and supervision were less strict than in religious institutions. The fate of their children could be problematic.
By the 1930s it was widely accepted that workhouses were unsuitable environments for children and industrial schools or boarding out emerged as the two main alternatives. Boarding out had existed under the Irish Poor Law since 1862, but it was rarely used by the new Free State and local authorities required prior approval by the Department. The number of boarded out children fell from 2,226 in 1913 to 1,907 in 1925, although the number of people on relief rose from 14,663 to 21,650 in 1925. By 1931, 2,826 children were in local authority institutions of whom the Department reported 1,219 were sick and another 26 intellectually disabled. There appears to have been a change in attitudes during the 1930s and boarded out children rose to 2,349 by 1939, but resistance remained to including illegitimate children in the scheme. Many of these children received no education and were kept in confined accommodation with adults. Prevailing opinion ruled that a workhouse or a religiously run institution provided a better atmosphere for inculcating good habits and Christian virtues than the homes of families willing to foster children. Besides, there were only two inspectors initially to oversee the boarding out system of the new Free State. Again, the minister responsible, Ernest Blythe, was an agnostic. But veteran feminist campaigner Senator Jenny Wyse Power believed that few family homes could have as bad an influence on a child as a “big institution”, and Maria Lynch said that her experience as a poor law guardian had convinced her that foster parents were nearly as good as birth mothers in rearing children.
The Department’s own inspectors for boarding out children, and even mother and baby home operators, were united in condemnation of industrial schools. A meeting of the managers of female industrial schools was quick to respond to criticism as “Wild” and “unfounded”. A former school inmate, Bridget Crosbie, wrote a letter to The Irish Times praising her industrial school experience and saying many former residents were doing well. Brother O’Ryan, manager of Artane and secretary of the Industrial Schools Association, said that families taking boarded out children were motivated by “pecuniary profit” and often turned them into “drudges” with “no hope for them … no matter what their antecedents or their talents”. This was particularly so if the child was illegitimate. He believed children needed removal from parental influence when their “salvation” was at stake. He claimed that many widows were unfit to look after children because they became alcoholics and that parents whose children ended up in Artane were generally “unfit” and “fond of drink”. However he never responded to the 1936 Commission of Inquiry into the Reformatory and Industrial School System when it raised concerns over physical and sexual abuse. While industrial schools were closing in Britain they were robustly defended by champions such as O’Ryan in Ireland.
Not only did local authorities show a much greater appetite for consigning children to industrial schools than its board of guardians predecessors but so did other agencies, including the courts and voluntary bodies such as the NCPCC. All were complicit in expanding the sector on an unprecedented scale, a clear indication of the prestige of the religious orders in providing a parallel welfare state. Orders even sought out children in county homes as young as two for transfer to their care. In some local authorities such as Kerry it was policy to separate illegitimate children from their “immoral” mothers as soon as practicable. Even applications for outdoor relief from poor families could trigger such transfers instead.
While religious institutions were rarely monitored, the criteria for foster parents were often set prohibitively high. Candidates were generally required to be in early middle age, live in a healthy rural setting, have good living and moral standards, have children of their own and not be located too far from a school. Despite these rigorous criteria after children were boarded out there was often little subsequent oversight and no supports were available once a child reached fifteen. They then became dependent on the generosity of the foster parents. This meant that further education or even an apprenticeship were not options in most cases. However, many children were adopted and some sympathetic HAOs sanctioned extended payments where a youngster showed exceptional academic talent. On the other hand, there were many cases of children being used as cheap labour, especially in farming families, where they were sometimes retained as labourers or domestic servants. One girl who gave her foster family a bill for unpaid wages ended up in a Magdalene laundry.
Like the treatment of single mothers, child welfare was as much about social control as it was about care in the early decades of the new state. The poor, the widowed, orphaned and illegitimate were seen as problem groups that were a drain on scarce resources, a threat to the social order and a disgrace to the nation, as well as inherently anti-national. They needed policing and, where necessary, confinement. There was a strong correlation between the instability of the revolutionary years and the Free State’s reliance on traditional Catholic values. By contrast, radical republicans who sought to demonstrate their bona fides by adherence to the wording and ideals of the 1916 Proclamation, or the Democratic Programme of the First Dáil, found themselves marginalised, not alone by the pro-Treaty establishment but by its Fianna Fáil successor. This appears to have been particularly so with women, whose continuing dissent put them at odds with the new establishment.
This conservative consensus extended to health. Ireland’s exclusion from the expanded British health insurance scheme before the First World War was one of the most expensive victories that John Redmond and the Irish Party secured for Irish employers, the medical profession and religious orders. After independence it became an obstacle to health reform and aggravated the chronic underfunding of services, while insured workers in Britain were making a major contribution to financing health care and securing much better access to services in return.
Workhouse infirmaries had opened their doors to the general sick poor well before the outbreak of the First World War and a few had even evolved into teaching centres for doctors and nurses. However external patients were still subject to workhouse discipline, sometimes even required to wear workhouse uniforms and so be tainted by pauperism and poverty.
As smaller workhouses were closed by the economy drive that accompanied the War of Independence there was a proliferation of district hospitals. Unfortunately, most were only capable of dealing with simple, non-surgical short-term cases and were almost invariably located inside or beside the old workhouse institutions. In Cork, the District Hospital and County Home (CDHCH) remained the largest hospital in the southwest, with between eight and nine hundred beds, compared with eight hundred in all the voluntary hospitals in the city. But the CDHCH only had facilities for 150 acute patients. The rest were for the long-term and chronically ill. People in rural areas who could afford it went to voluntary hospitals in the nearest major urban centre, be it Cork, Limerick, Galway or Dublin. Within the voluntary sector there were also major disparities in levels of service. For instance, the Bon Secours sisters in Cork and Kerry held higher nursing certificates than the Mercy sisters, many of whom had no qualifications at all. Yet both orders were only answerable to their order and to the local bishops. After the county surgeon in Tralee complained that the Mercy sisters were “not within twenty-five per cent” of his own Bon Secours staff as far as their performance was concerned, the bishop wrote to the Minister, Richard Mulcahy, to complain that such comments were “mischievous and harmful to religion”.
Meanwhile the new state, torn by civil war, was desperately short of financial resources. Expenditure on buildings and infrastructure fell from £28,569 in 1922/3 to £6,009 by 1925/6 and only rose slowly thereafter. While workhouse populations fell drastically medical patient numbers rose, leading to serious overcrowding. Often young and old, medical and psychiatric patients shared the same wards. Many married women refused to deliver their babies in hospital for fear they would be put in the same ward as unmarried mothers. A sample of CDHCH patients in 1926 found that 59 of the 578 patients were “tramps” or homeless. While 202 patients had an occupation, 166 of these were labourers and only 22 were skilled workers.
The Free State government drove amalgamations of workhouse hospitals with county infirmaries, which were acute hospitals without any social stigma. The change also increased opportunities for hospital managements to extract payments from former workhouse patients and advise local authorities on means tests that took account of property valuations, wages, salaries and other sources of income. This scheme to squeeze the sick was relatively successful. In Kerry, for instance, only £508 was received from hospital patients by the local authority in 1922/3 but by 1930/1 the figure had risen to £4,398. Nationally contributions by patients rose from £13,068 in 1922/3 to £48,877 in 1929/30 and £79,909 in 1938/9.
Patients were divided into those who could pay nothing, those who could pay something and those who could pay all the costs. This hybrid model is still with us and was welcomed at the time by the Irish Committee of the British Medical Association. The DLGPH’s chief medical adviser, Dr EF Stephenson, advised that poor patients who were not eligible to be charged should be kept in separate wards, but should receive priority in state-funded institutions. In spite of this injunction, the 1927 Commission was left with the impression from hospitals it visited that paying patients were more welcome.
Dublin had a particularly large number of voluntary hospitals which provided specialist services and the expertise needed to deal with complex cases. Like other voluntary hospitals throughout the state, they took in some “deserving poor” patients, who were expected to subscribe to the religious ethos of the institution. The Free State promoted these hospitals for economic and ideological reasons. The 1927 Commission believed the voluntary sector was vital to the moral wellbeing of society as well as being able to tend the sick more cheaply than the state. In the 1920s and 1930s however, many voluntary hospitals faced a financial crisis as medical technology became more expensive, patient demand grew and private subscriptions fell away. This saw a reduction in “free beds” and an increase in fees. Dublin’s Meath, for example, only drew £100 in fees in 1913 but received almost £4,000 in 1918. While most hospitals would accept all accident and emergency cases, other patients usually needed a letter of introduction from a subscriber or a member of the committee and were expected to contribute according to their means. Efforts in Cork to create a municipal hospital combining the CDHCH with the North and South infirmaries would not succeed, hospital consultants warned, because fee-paying patients would not attend. At the city’s Mercy Hospital only 13 per cent of patients were treated freely and another 0.2 per cent were charged less than 10s. Seventy per cent paid between 10s and £2 2s and 14.5 per cent over £2 2s. By contrast, in the North Infirmary over 55 per cent of patients were treated free and in the South Infirmary 46.5 per cent. The national average for the Free State was 39.4 per cent, which would become the maximum percentage of the population granted access to the medical card scheme when it was introduced in 1970.
Another reminder that few things change was the existence of an earlier version of the National Purchase Treatment Fund under the 1862 Poor Law Act. This allowed local boards of guardians to pay for the specialist treatment of poor patients. In 1910, 3,621 workhouse patients had treatment in non-poor law institutions. This was particularly important in counties with no large voluntary hospitals. By 1923/4 Kerry was paying out £420 for such treatment, rising to £2,975 in 1928/9. In South Cork the figures were £521 in 1924/5 and £1,292 in 1928/9. Nationally, expenditure rose from £13,225 in 1923 to £31,776 by 1929. In 1933, of 10,868 poor patients 6,360 received attention in specialist and 4,505 in general voluntary hospitals paid for by local authorities. Of 26,897 patients treated in Dublin’s voluntary hospitals that year 8,831 were from outside Dublin, the majority of them poor law patients.
Ireland’s exclusion from the health dimensions of the 1911 Insurance Act meant it ended up with the worst of both worlds; more limited access by the working poor to health treatment and higher expenditure by the rate- and taxpayer to provide this inferior cover. By the 1930s ten million British workers were making health contributions that generated up to half of all hospital income. In Ireland very few workers were in such schemes and these were usually run by progressive if paternalistic enterprises such as the Guinness brewery and the railway companies.
Inevitably, the voluntary hospitals came in for severe criticism in the debate on the new Fianna Fáil government’s 1931 Public Charitable Hospitals Bill to administer the Irish Sweepstakes fund. This gave the DLGPH much greater potential influence as hospitals had to provide a quarter of their beds free to qualify for sweepstake funding.
The Sweepstakes money came at just the right time and when the Irish Hospitals Commission was established in 1933 it had high hopes of transforming the state’s competing fiefdoms into a rational system with four main centres of regional excellence in Cork, Dublin, Galway and Limerick to which district hospitals would act as feeders. However, plans already adopted by local authorities and voluntary hospitals to upgrade existing services made any radical reform a political impossibility. Instead of being used to overhaul the system, the Sweepstakes money provided a drip feed that kept existing services on life support. A quarter of sweepstakes money went to local authority and public hospitals, which spent it on new buildings and redevelopment of existing campuses. Money invested in the voluntary sector went largely to meeting current running costs and paying off deficits. The extra money put into bricks, mortar and extra beds certainly helped improve services to patients but the influence of vested interests prevented that investment delivering better long-term outcomes. Fees in Ireland remained high, often higher than in Britain, for private patients and, while there was greater access for poorer patients to some institutions, a queue-jumping two tier system continued to characterise the health services.
Whether the outcome would have been better if the Twenty-six Counties had remained part of the United Kingdom is debatable. The Irish Party would have been at least as cognisant and deferential to the medical profession and Catholic church in a Home Rule Ireland as its Free State successor. It would be 1942 before medical benefits were introduced, but the link between the national insurance scheme and health services was a shadow of that in Britain or Europe. The Northern Ireland regime did not embrace radical change until the creation of the welfare state after the Second World War, but embrace it the Unionists eventually did.
Lucey’s book provides a useful, if expensive, antidote to the narratives that lazily equate militant nationalism with progress. There was nothing particularly progressive about the way architects of the new state such as Lankford and O’Mahony treated single mothers and other “riff raff”. Nor could Unionist or British administrators give them lessons in how to protect the interests of the nation’s elites.
Padraig Yeates is a journalist and author whose books include A City in Wartime: Dublin 1914-1918,A City in Turmoil: Dublin 1919-1921 and A City in Civil War.