Child: care, heallh and development, 1987, 13, 127-136

The early history of health visiting: a review of the roleof central government (1830-1914)

ALISON E. 'WHILE Leciurer, Department of Nursing Studies, King's College,University of London, 552 King's Road, London SWIOOUA

Accepted for publication 28 November 1986

Summary The emergence of health visiting is traced throughavailable historical material. It is argued that the evidence supports theview that the role of central government was limited and that healthvisiting owes its emergence to the pioneer work of able medicalofficers of health.

The two cholera epidemics in 1831-1832 and 1848 which affected aconsiderable part of the country appeared to act as a catalyst of publicopinion in favour of public health measures (Briggs 1961), althoughBaly (1973) has argued that this interest in sanitary reform subsided asthe epidemics were resolved. However, further public concern wasgenerated by Edwin Chadwick's Sanitary Report (1842) and indeed itcreated sufficient interest to give momentum towards an acceptancethat a control of public health was a legitimate function of government(Frazer 1950).

The Sanitary Report brought together a mass of evidence exposingthe gross inadequacy of urban living conditions.

. . . impurity and its evil consequences are greater or less in different places,according as there is more or less sufficient drainage of houses, streets, roadsand land, combined with more or less sufficient means of cleansing andremoving solid refuse and impurities, by available supplies of water for thepurpose.

(Chadwick t842, page 79 in Flinn edition)

The Report also accumulated evidence of the differing life expectancyof those born to different classes and, in particular, the higher infantmortality rate among the 'labouring population'. This Report wasfollowed by a Royal Commission inquiry which was established on 9May 1843 with the Duke of Buccleuch as its Chairman. The RoyalCommission laid its First Report before Parliament on 27 June 1844

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and a Second Report followed on 3 February 1845. The Reportsrecommended the introduction of legislation to improve the environ-ment but such legislation was delayed by the resignation of the thenPrime Minister over the introduction of the Corn Laws in 1846.

'An Act for Promoting the Public Health' reached the statute bookin 1848 and was the first in a long line of Public Health Acts. Itemerged as an attempt to control various aspects of the environment.

. . . it shall not be lawful newly to erect any House . . ., unless and until acovered Drain or Drains be constructed, . . . sufficient for the proper andeffectual Drainage of the same.

(Clause XLIX)

However, the Bill had been subject to strong parliamentary oppositionwith some Members of Parliament considering the Bill as aninterference with personal liberty while others were anxious to protecttheir pecuniary interests (Frazer 1950). As a result of parliamentarycompromise, the Act was only permissive in its powers, unless adoptedin an area or made enforceable due to the average mortality rate over7 years of age exceeding 23:1000. Together with the adoption ofbuilding regulations, areas were also permitted to appoint medicalofficers of health.

. . . a fit and proper Person, being a legally qualified Medical Practitioner orMember of the Medical Profession, to be and be called the Officer of Health.

(Clause XL)

The 1848 Act did not legislate for improvements in standards ofpersonal health and hygiene but left these improvements for thevoluntary sector. Consequently, the pioneer activities of the newlyappointed medical officers of health were accompanied by develop-ments in the voluntary sector.

THE ROLE OF THE VOLUNTARY SECTOR

Several explanations have been offered to account for the voluntarysector's concern in public health and private hygiene. Firstly, it washeld that there was a relationship between religious belief andpersonal health (Newsholme 1935). Secondly, middle class womenwere becoming an important source of manpower for the voluntarymovement of this period. Indeed, visiting the poor in rural areas wasan established form of charity at this time, although Roof (1957) has

History of health visiting 129

pointed out that extension of such schemes to poor urban areas wasnot without its problems.

It was out of this background that the Ladies Sanitary ReformAssociation was formed in 1862 in Manchester and Salford, 3 yearsafter the foundation of the Manchester and Salford Sanitary Associa-tion whose work was reviewed in the British Medical Journal in 1863.The Ladies Sanitary Reform Association has traditionally beencredited with being the first health visiting practice in the UnitedKingdom and establishing a model of low-cost preventive health carebased upon house to house visiting. Thus, respectable working womenwere appointed by the Association in 1867 to go:

. . . from door to door among the poorer classes of the population, to teach andhelp them as opportunity offered.

(McCleary 1933, page 85)

These visitors have been recognized as the direct antecedents of healthvisitors. Their initial duty to distribute leaflets was extended to includethe teaching of hygiene and child welfare, the provision of socialsupport and the teaching of moral and mental health.

THE INTRODUCTION OF HEALTH VISITING AS AUNIVERSAL SERVICE

Although the voluntary associations of the period were important, theplace of central government involvement was also increasinglyaccepted. Indeed, the state of child health as reflected in mortalitystatistics (Registrar General 1850, 1862, 1872, 1882, 1892, 1902) wascausing increasing concern. The Public Health Act 1872 made theappointment of medical officers of health compulsory.

. . . it shall be the duty of every urban sanitary authority to appoint from time totime a Medical Officer or Officers of Health . . .

(Section 10)

Evidence suggests that such officers were frequently appointed fromthe ranks of poor law medical officers to serve populations of varyingsizes, smaller rural areas frequently sharing one medical officer ofhealth (Frazer 1950).

A patchy development of infant welfare services ensued, while someauthorities benefitted from able medical officers of health, others wereless fortunate. It was among this group of able medical officers that the

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feasibility of individual intervention regarding personal hygiene andhealth through home visiting proved an attraction (Robinson 1982).Thus Buckinghamshire County Council began to employ three healthvisitors in 1892 (Nightingale 1911), and Worcestershire CountyCouncil appointed five iady health missioners' in 1897 (Interdepart-mental Committee on Physical Deterioration 1904a). The Minutes ofthe London Women's Sanitary Inspectors' Association of 4 April 1902note the development of health visitor appointments in London andenvirons, the first appointment being made in the Borough ofKensington. McCleary (1933) has attributed the achievements ofenterprising authorities solely to their greater autonomy since theLocal Government Board failed to take any initiative despite awarning given to Disraeli's Government in 1875 about the inade-quacies of the 1872 Public Health Act {British MedicalJournal 1875).

With no central guidance, the local services varied widely in terms ofthe qualification of the staff and in the ratio of paid to voluntaryhelpers. For example, in 1890 the Manchester Corporation undertookto pay the salaries of six of the 14 agents employed by the SanitaryAssociation (McCleary 1933), by then renamed the Ladies' HealthSociety of Manchester and Salford. (Manchester Corporation werepaying their health visitors 16 shillings per week in 1903 (Interdepart-mental Committee on Physical Deterioration 1904a, para 7265).) Thistook the occupation beyond being a voluntary movement. The work ofthese women was described in verbal evidence to the Interdepartmen-tal Committee on Physical Deterioration (1904a) by Mrs Worthington(paras. 7182-7397) and Mrs Bostock (paras. 7398-7543). Gradually atrend towards a local authority service emerged so that, by 1905, 50towns were employing women in this work (McCleary 1933). Theincreasing appointment of health visitors in the London area can betraced in the Minutes of the London Women's Sanitary Inspectors'Association 1902-1906.

The powerful influence of certain local authorities was demon-strated by the Huddersfield Corporation Act 1906 which introducedstatutory birth notification.

In the case of every child born within the borough . . . it shall be the duty of thefather of the child . . . or in his absence of any person in at tendance upon themother at the time of the birth or within six hours thereafter to send or givenotice of the birth to the Medical Officer within forty eight hours after suchbirth.

(Section 73(i))

History of health visiting 131

A permissive national Act followed this example (Notification ofBirths Act 1907) and national birth notification became mandatory in1915 (Notification of Births Act (Extension) 1915).

THE EARLY HEALTH VISITOR

Mrs Worthington, in verbal evidence to the Interdepartmental Com-mittee (1904a), described health visitor work as follows.

. . . She goes from house to house and does anything she can find to do. She mayfind a house without a mother and put the children into the way of doingsomething. She also reports all sorts of sanitary defects in the house.

(para. 7201)

Further evidence of the work of early health visitors is derived from areport of the Manchester and Salford Ladies' Public Health Society.

In addition to teaching personal and household cleanliness and giving advice andsympathy, much practical help is given in ways such as giving food and clothingto specially needy families, finding work for men and women, gettingrecommendations for different hospitals and institutions, sending children intothe country or to the seaside, making the beds of sick patients and cleaning theirhouses.

However, the report emphasizes that the work was preventive ratherthan curative.

The women in the district are shown the evils of dirt and the dangers of living inunhealthy dwellings; they are taught to prevent the spread of disease, and thelaws which will enable them and their families to lead moral and healthy lives.

(Interdepartmental Committee 1904b, para. 298)

The work of health visitors is also described in the British MedicalJournal (1904).

1 The systematic visitation of babies and the instruction of women in thematter of feeding and care of them.

2 Instruction in cases of infectious diseases . . ., coupled with seeing that thenecessary precautions are taken.

3 The systematic visitation of houses in the district.4 The distribution of leaflets on sanitary and other matters and the supplying

of lime, whitewash brushes, sanitary powder, and also of carbolic soap tothe people of the district.

Unfortunately it has not been possible to trace the original leafletsdistributed by health visitors. However two facsimiles are to be found

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among the Appendices of the Report of the Interdepartmental Com-mittee on Physical Deterioration (1904c). One leaflet which wasissued by the Health Department of Sheffield entitled Advice on theFeeding and Rearing of Infants outlines how infants should be fed andcared for during the first 18 months of life. The second leaflet wasissued by the Wakefield and District Sanitary Aid Society and entitledHow to Rear a Healthy Baby. The leaflet also emphasized that goodinfant feeding practice was of paramount importance.

Evidence brought before the Interdepartmental Committee onPhysical Deterioration (1904a) by Rowntree (para. 5164) and othershas suggested that 'lady' visitors were favoured because the poor tookmore notice of their advice owing to their perceived ability to combineeducation, tact and experience. However, whatever social class theearly health visitors were drawn from, education and training weresoon recognized as important prerequisites for the job. Thus in 1908the Royal Sanitary Institute began to set examinations for healthvisitors, while in 1909 it was noted that authorities were employingvariously trained personnel (doctors, trained nurses, midwives andsanitary inspectors) as health visitors (Dingwall 1977). This reflectedthe belief prevalent at the time of the efficacy of education inovercoming 'maternal ignorance of domestic hygiene'. Thus develop-ments in maternal and infant welfare provision reflected this emphasisupon education despite evidence of the effect of poor socioeconomicconditions on infant mortality (Lewis 1980).

THE PRESSURE TO INVOLVE CENTRALGOVERNMENT

Three factors combined to extend government involvement into thehealth of individuals. Firstly, the 19th century system of health careprovision was managed by two separate authorities, namely theBoards of Guardians and the health authorities, to the detriment ofthe health of mothers and infants. Indeed, by the early 20th centurythe Minority Report of the Poor Law Commission (Webb & Webb1909) drew attention to this shortcoming in the provision of publicwelfare.

. . . the continued existence of two separate rate-supported Medical Services inall parts of the Kingdom, overlapping, uncoordinated with each other andsometimes actually conflicting with each other's work — cannot be justified.

(pages 584-585)

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Secondly, despite public health reform, children's health was stillacknowledged to be poor, as reflected in the high mortality statistics(Registrar General 1882, 1892, 1902) and the evidence from the socialsurveys of Booth (1890) and Rowntree (1901) of the effects of povertyupon child health. Thirdly, the revelation that 40% of the Boer Warrecruits between 1901 and 1902 were unfit for military service onmedical grounds aroused considerable national concern and anInterdepartmental Committee was established to examine theproblem.

The Interdepartmental Committee on Physical Deterioration(1904b) noted that there were considerable differences in the averagedimensions of the different classes of the population (para. 14) andaccumulated much evidence relating to the inadequacy of child healthand welfare provision. By 1905 sufficient interest had been generatedto inspire an organized movement and, as a consequence, the BritishInfant Welfare Movement was registered with the Charity Commis-sion in 1909 (Reg. No. 217740) and in 1928 became part of theNational Council for Maternal and Child Welfare. In summary, it wasfelt that the government should initiate collective action since thehealth of the nation was at stake.

However, despite public pressure, between 1907 and 1914 therewere three sources of preventive health care for families with youngchildren. The Poor Law Administration was the main source of stateaid in health and was centred upon curative provision with theexception of the powers attributed in instances of infectious diseasethrough the Public Health Act of 1875. Some local authoritiesovercame this constraint through a liberal interpretation of infectiousdisease, justifying the employment of health visitors as sanitaryinspectors. However, maternal welfare was less easily accommodatedwith the result that local authorities tended to rely upon voluntarysocieties (Honigsbaum 1970). The publication of the Interdepartmen-tal Committee Report (1904b), however, resulted in an improvementin health care provision in schools. Thus, under the Education(Administrative Provisions) Act of 1907, the Board of Educationintroduced niedical inspection of school children as well as sometreatment for minor ailments. Section 13(i)(b) stated that it was theduty of school boards:

. . . to provide for the medical inspection of children immediately before, or atthe time of, or as soon as possible after, their admission to a public elementaryschool, and on such other occasions as the Board of Education direct.

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and further gave:

the power to make such arrangements as may be sanctioned by the Board ofEducation for attending to the health and physical condition of the childreneducated in public elementary schools.

From 1908 school provision was made for mothers which includedbaby clinics under the Regulations for Technical Schools, Schools ofArt, and other Schools and Classes (Day and Evening) for FurtherEducation. Such a provision was an attempt to fill the gap in theservices between those provided by the health authorities for the firstyear of life and school children at 5 years of age (Honigsbaum 1970).However, according to McCleary (1933), the division betweenpreventive and curative services was such that:

At the outset, the treatment of the sick formed no part of these functions; ifchildren needing treatment came, the mothers were advised to take them to alocal doctor or hospital.

(page 45)

For most families this meant the use of Poor Law medical services.The National Insurance Act 1911 also contributed little to the field ofpublic health in its separation of the preventive services from thecurative services of general practitioners.

CONCLUSION

The available historical evidence would seem to suggest that the roleof central government was limited regarding the establishment of ahealth visiting service. Indeed, during the 80 years covered by thisreview no Act reached the statute book specifically mentioning theprovision of health visiting as either a permissive or statutory serviceand it was not until the Maternity and Child Welfare Act of 1918 thatCounty and County Borough Councils were permitted to providefacilities for the welfare of expectant and nursing mothers and childrenunder 5 years of age under the auspices of the Local GovernmentBoard. This permissive power resulted in a variable development ofservices throughout the country, a situation which was confirmed bythe 1936 Public Health Act which retained this permissive element,although from 1936 Maternity and Child Welfare Committees becamestatutory. Indeed, it was not until the 1946 National Health ServiceAct that the health visiting service became a statutory provision.

History of health visiting 135

The contention that the development of health visiting was one formof public response to the adverse living conditions of the 19th and early20th century would seem to hold. For unlike nurses and midwives,health visitors did not gain the same public recognition and as aconsequence were not the subject of any legislation until the formationof the National Health Service after World War II.

Much can be learnt from thorough historical research and thisreview may in part explain the persistent anxiety of health visitingabout its value in comparison to nursing and midwifery. Except in timeof war, investment in the health of mothers and children has had arelatively low priority. However, health visiting has continued todevelop over time and is now an established statutory provision.

REFERENCES

Copies of the various Acts referred to in this article may be obtained from Her Majesty'sStationery Office, London.

Baly M. (1973) Nursing and Social Change. Heinemann Medical, LondonBoard of Education (1907) Regulations for Technical Schools, Schools of Art, and other Schools

and Classes (Day and Evening) for Further Education (1 August 1907-31 July 1908). Cd3555. HMSO, London

Booth W. (1890) In Darkest England, and the Way Out. LondonBriggs A. (1961) Cholera and society in the nineteenth century. Past and Present 19, 76-96British Medical Journal (1863) The Week. British Medical Journal. 1 Nov., 508British Medical Journal (1875) Editorial. Mr Stansfeld's Sanitary System. British Medical

Journal. 23 Jan.. 112-113British Medical Journal (1904) Special Correspondence. Manchester. British Medical Journal. 30

Jan., 276-277Chadwick E. (1842) Report on the Sanitary Conditions of the Labouring Population of Great

Britain. Reprinted 1965 with introduction by M. W. Flinn, University Press, EdinburghDingwall R.W.J. (1977) Collectivism, regionalism and feminism: health visiting and British social

policy 1850-1975. Journal of Social Policy 6(3), 291-315Frazer W.M. (1950) A History of English Public Health. Balliere, Tindall & Cox, LondonHonigsbaum F. (1970) The Struggle for the Ministry of Health 1914-1919. Occasional Paper on

Social Administration No. 37. Bell, LondonInterdepartmental Committee on Physical Deterioration (1904a) Report of the Interdepartmental

Committee on Physical Deterioration. Cd. 2175. Volume II. HMSO, LondonInterdepartmental Committee on Physical Deterioration (1904b) Report of the Interdepartmental

Committee on Physical Deterioration. Cd. 2175. Volume I. HMSO, LondonInterdepartmental Committee on Physical Deterioration (1904c) Report of the Interdepartmental

Committee on Physical Deterioration. Cd. 2175. Volume III. HMSO, LondonLewis J. (1980) The social history of social policy: infant welfare in Edwardian England. Journal

of Social Policy 9(4), 463-486McCleary G.F. (1933) The Early History of the Infant Welfare Movement. H. K. Lewis, LondonNewsholme A. (1935) Fifty Years in Public Health. George Allen & Unwin, London

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Nightingale F. (1911) Letters of Miss Florence Nightingale on Health Visiting in Rural Districts.P. S. King, London

Registrar General (1850) Weekly Return of Births and Deaths in London. Vol. XI. HMSO,

London

Registrar General (1862) Twenty-Third Annual Report of the Registrar General of Births, Deathsand Marriages 1860. HMSO, London

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Registrar General (1882) Forty-Third Annual Report of the Registrar General of Births, Deathsand Marriages 1880. HMSO, London

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Registrar General (1902) Sixty-Third Annual Report of the Registrar General of Births, Deathsand Marriages 1900. HMSO, London

Robinson J. (1982) An Evaluation of Health Visiting. CETHV, LondonRoof M. (1957) Voluntary Societies and Social Policy. Routledge and Kegan Paul, LondonRowntree B.S. (1901) Poverty — A Study of Town Life. Macmillan, LondonRoyal Commission (1843) Inquiry into the State of Large Towns and Populous Districts. First

Report. Chairman: Duke of Buccleuch. HMSO, LondonRoyal Commission (1844) Inquiry into the State of Large Towns and Populous Districts. Second

Report. Chairman: Duke of Buccleuch. HMSO, LondonWebb S. & Webb B. (1909) The Break-Up of the Poor Law: Being Part 1 of the Minority Report

of the Poor Law Commission. Longmans, Green & Co., London