Since the early 18th century public healthcare in Ireland had been funded by voluntary donations. The first hospitals in Ireland were founded in the 1720s. The dispensary doctor was formally established by legislation in 1805 under an Act of Parliament. The amount from voluntary donations was matched by county grand juries from local taxation. The Poor Law Act of 1838 improved the distribution of dispensaries and divided Ireland into 130 administrative units known as Poor Law Unions, with their own workhouse, governed by the Poor Law Guardians, who were elected by the local rate payers.
The Poor law unions at the end of the nineteenth century. Courtesy Wiki Commons
The dispensary doctor became the mainstay of healthcare in rural Ireland as many people lived too far from medical help in workhouses. The position of the dispensaries was clarified in the 1851 Medical Charities Act, which introduced a state-funded dispensary system to provide free medical aid to the poor. These were to be funded from local taxation and were subsidised by the Poor Law Commission. To attend the dispensary, a person needed to have a colour-coded ticket, dispensed by the committee. The Poor Law Commission was replaced by the Local Government Board in 1872.
The Irish Poor Law had led to one of the most advanced health services in mid- nineteenth century Europe being a largely a state-supported, centralised system. Free medical care was available to the poor in hospitals, lunatic asylums, dispensaries and in their own homes. By the mid-1830s there were around 500 dispensaries, forty-one county and city infirmaries, and seventy fever hospitals.
The Irish medical profession was well established and quite separate from the rest of Britain. The College of Physicians was chartered in 1667 and the College of Surgeons in 1784. Great advances in medicine came from Ireland such as the work of Robert Graves (1796-1853) who pioneered pulse taking and bedside training for medical students at the Meath and William Stokes (1804-77) who pioneered the use of the stethoscope. However, the medical profession was deeply divided on the grounds of religion unlike the rest of Britain. Medicine was one of the few careers open to Catholics since the eighteenth century but developed separately according to religion . Catholic doctors trained in Catholic institutions and generally worked in positions of lower status. The first voluntary hospitals were established by Protestant patrons and run by Protestant doctors. As appointments of medical officers were made by local boards, usually made up of the local Protestant gentry, there were accusations of favouritism in making such appointments.
Nurse training was similarly divided by religion. Nursing was an integral part of the work of a many Catholic orders of nuns. Various French nursing orders had arrived in Ireland in the mid-nineteenth century such as the Bons Secours in 1861. Nurse training at the time was through apprenticeship with learning taking place on the job as in Catholic hospitals and workhouse hospitals. The Adelaide hospital was established in 1839 to serve the Protestant poor of Dublin. The School of Nursing was founded there in 1859 by Miss Bramwell who served with Florence Nightingale in the Crimea. It provided the first nursing education for lay women in Ireland. Religious control of Irish health professions and service provision lasted for most of the 20th century.
Much of the early healthcare legislation was permissive rather than mandatory which led to variable quality and availability of services. Additionally, by the end of the 19th century medical opinion towards the dispensary system had changed, citing abuse of the ticket system and the hardships suffered by dispensary doctors. The British Medical Journal claimed that the work of Irish dispensary doctors was harder and worse paid than in any other field of medical practice. By the beginning of the 20th century, Protestant doctors found themselves increasingly alienated from the local population by class and religion, and caught between the demands of their patients and their Board of Guardians for economy and efficiency. A form of contributory rather than free relief was beginning to be seen as more appropriate.
When the First Dáil met on 21st January, 1919, one of the elements of its programme related to the Poor Law system. It stated:
‘The Irish Republic fully realises the necessity of abolishing the present odious, degrading and foreign Poor Law System, substituting therefore a sympathetic native scheme for the care of the Nation’s aged and infirm, who shall not be regarded as a burden, but rather entitled to the Nation’s gratitude and consideration. Likewise, it shall be the duty of the Republic to take such measures as will safeguard the health of the people and ensure the physical as well as the moral well-being of the Nation.’
The first meeting of the First Dail, Jan 1919.
Neither W.T. Cosgrave (in jail) nor James O’Mara (absent through illness) were there
Local county councils had given up political control to Republicans in the 1920 local elections. Newly elected councils proceeded to wind down the boards of guardians that oversaw the administration of poor law and attempted to reduce the number of institutions in each county with the aim of making them both more effective and economic to run. Boards of public health and assistance were set up in 1924 under the provisions of the Local Government (Temporary Provisions), Act, 1923.
The County Scheme in Offaly led to the County Infirmary and the workhouses in Tullamore, Edenderry, and Birr being closed in 1921 and the building in Tullamore used as a county home for the elderly, destitute and disabled as well as a home unmarried mothers and their children with provision of maternity services. The old workhouse infirmary became the county hospital for medical and surgical services and there was a separate fever hospital for infectious diseases such tuberculosis on the same site. In Edenderry, a district hospital was established in the old fever hospital attached to the former workhouse. In Birr, the workhouse infirmary was used as a sanatorium for tuberculosis patients, and the district hospital for the Birr area was in the old fever hospital.
Tullamore Workhouse was home for thousands of the poor and destitute from 1842 until its closure in 1921 when it became the County Home. Courtesy of Offaly History
It was not until 1929 that Britain took similar measures to the Free State in replacing the poor law and workhouse system with a new layer of county and district hospitals. However, implementing any changes was difficult for the government of the Free State that started with serious budget deficit. The First World War (1914-18) had already led to a sharp rise in inflation and the disruption of the years 1919–1923 had caused a great deal of economic damage. In terms of voluntary hospitals, there was a decrease in donations. In Britain, many of the large voluntary hospitals were saved through public funding, which led to the development of the National Health Service. In Ireland, the Irish Hospitals’ Sweepstake was established to fund the construction and expansion of County hospitals. However, the funding strengthened voluntary hospitals’ independence from state influence and closely connected them to the medical profession and the religious hierarchy. In Offaly, the sweepstake funded the building of a new county hospital at Tullamore and further improvements to the local hospital network. However, the new Boards of Health were stretched in their capacity, administering direct health services as well wide-ranging responsibilities from poor relief to water supply.
St Vincent’s Hospital, Tullamore, c. 1930
Challenges in accessing healthcare arose not just due the changes being implemented but political turbulence and heavy demand for health services. Tuberculosis was still endemic, fuelled by the overcrowded and inadequately ventilated homes of the poor. An article in The Leinster Reporter of 14th August 1920 concerning the Clara Dispensary identified the high rate of tuberculosis in the town with most patients in domiciliary care. The blame for their condition not improving considered to be the poor housing in which they were living.
Despite the strong words spoken at the First Dail in 1919 , that it ‘ shall be the duty of the Republic to take such measures as will safeguard the health of the people and ensure the physical as well as the moral well-being of the Nation’ , the idea that the State was responsible for health was at odds with the teachings of the Catholic Church. Health was seen as family matter like education and so the responsibility of the Catholic Church. When Ireland became independent, religious beliefs governed most aspects of state policy, including healthcare provision. The Irish mission of ‘nation-building’ emphasised the importance of Catholic Irish-identity as opposed to British customs. Attempts to increase state healthcare led to conflict between the state, Catholic hierarchy and medical profession. The influence of the Catholic Church was felt particularly in maternity and child welfare provision as demonstrated in the Mother and Child Scheme tragedy of the 20th century.
The legacy of healthcare decisions made by successive governments since Partition is still evident in Ireland today. According to the Organisation for Economic Co-operation and Development , the Irish healthcare system is in marked contrast to the rest of Europe as access to universal, equitable healthcare is means tested. Sláintecare, launched in 2018 aims to achieve a universal single-tier health and social care system to provide equitable access to services based on need, and not ability to pay. Despite delay in meeting targets due to constraints caused by the Covid pandemic, the Government’s response to the pandemic of a free vaccination programme and hospital care for serious illness, has given an insight into the reality of universal healthcare.
Government of Ireland Sláintecareavailable @ https://www.gov.ie/en/campaigns/slaintecare-implementation-strategy/ accessed3rd July 2022
OECD, OECD/European Observatory on Health Systems and Policies (2021), Ireland: Country Health Profile 2021, State of Health in the EU, OECD Publishing, Paris available @ https://doi.org/10.1787/4f7fb3b8-en accessed 1st June 2022
Sheelah Connolly & Maev-Ann Wren (2019) Universal Health Care in Ireland—What Are the Prospects for Reform?, Health Systems & Reform, 5:2, 94-99, available @ 10.1080/23288604.2018.1551700 accessed 2nd July 2022
University of London, Institute of Historical Research Healthcare in Ireland and Britain from 1850 Voluntary, regional and comparative perspectives edt Donnacha Seán Lucey and Virginia Crossman available @https://sas-space.sas.ac.uk/6540/1/Lucey.pdf accessed 3rd July 2022
Wellcome Trust (2015) Survey of Hospital Archives in Ireland National Archives available @ https://wellcome.org/grant-funding/people-and-projects/grants-awarded/survey-hospital-archives-ireland accessed 2nd July 2022