An Attempt to Show from what Class the Out-Patients of a Voluntary Hospital are DrawnAuthor(s): Stewart JohnsonSource: Journal of the Royal Statistical Society, Vol. 74, No. 6 (May, 1911), pp. 630-640Published by: Wiley for the Royal Statistical SocietyStable URL: http://www.jstor.org/stable/2340077 .

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630 [May,

MIJISCELLANEA.

An Attempt to Show from what Class the Out-Patients of a Voluntary Hospital are Drawn. By STEWART JOHNSON, Secretary of the Ilospital for Sick Children, Great Ormond Street.

THE fo]lowing statistics have been collected with a view to ascer- taining from how large a section of the population the out-patients of a hospital have been drawn, and whether it is larger or not than that section of the population which competent authorities have declared to be in poverty. Of the two forms of abuse which hospitals are sometimes accused of tolerating-first, negligence in allowing patients to deceive them by making false statements of income; and secondly, ignoranice of what constitutes poverty and the consequent admission of many who are not poor-it is obvious that the latter is by far the most mischievous. The number of impostors which even the laxest and blindest hospital could permit to pass must be small compared to the number which a hospital that has adopted an erroneous standard of poverty might allow to attend. It is important therefore for this reason that an effort should be made to ascertain from what class hospital out-patients are drawn, but it is perhaps of still more importance for economic and social reasons that knowledge should be obtained as to the inter-relationship of poverty and sickness. It is with these objects that this inquiry has been undertaken. The task is not an easy one. It cannot be accomplished by simply giving a list of the incomes of which the families of the various patients are in receipt.

Poverty is so largely individual. Of two families consisting of the same number of persons with the same income one may be poor and the other not. Necessities differ in each case, and one must know what a family's wants are in relation to their income before they can be judged poor or otherwise. In fact the judging of poverty is a matter for an expert.

For this reason few hospitals have a wage limit, since in practice almost as many wage limnits as there are patients are required; and for this reason it is difficult, if not impossible, to show in terms of earnings to what class hospital patients belong. One can give the average wage earned by a large number of families, but it is impos- sible to strike an average between, say a clerk, a bricklayer, a baker's assistant and a railway porter.

Poverty then is relative and individual. There is, however, one point in this connection which can be seized upoIl with advantage. Though it is true down to a certain point that what is poverty to one is riches to another, yet a certain point must be reached at last when poverty must be poverty and nothing else, even to a family of the humblest and most exiguous wants. When the income of a family is so small that it is not sufficient to satisfy its smallest wants then the relativeness of its poverty becomes negligible, and it and others like it can be called absolutely poor. This is precisely

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1911.] Prom whiat Class Oat-Patients of a Hospital are DrawA. 631

in fact what Mr. Rowntree has done in estimating the amount and degree of poverty in York. Having first selected by means of an expert, individual by individual, out of the population of York all those who might be considered poor he next divided them into two classes

1. Families whose total earnings are insufficient to obtain the minimum necessaries for the maintenance of merely physical efficiency.

2. Families whose total earnings would be sufficient for the maintenance of merely physical efficiency, were it not that some portion of it is absorbed by other expenditure either useful or wasteful.

Poverty falling under the first head he described as " primary," under the last as "secondary" poverty. Minimum necessities he determined as follows: For food he allowed the smallest quantity of the cheapest kind that scientific opinion holds is necessary to support human existence in health and vigour; for clothing, the most econiomical adequate to keep the family in health without being so shabby as to injutre the wage-earner's chance of gaining respectable employment; and for other household wants, only such as careful inquiry amongst working people, who had gained their knowledge by hard experience, showed could not be " done without." For rent he allowed the actual suims paid, " since rent is almost the first thing in which a poor family will try to economise." He allowed nothing whatever for travelling, or luxuries of any kind, or for sick and funeral clubs. His estimates suffice only for the bare necessities of merely physical efficiency in times of health.

Having first ascertained that the total of persons in poverty in York amounted to 27 per cent. of the whole population, he next by means of his new standard of measurement, divided this body of persons into the two classes of those in primary and those in secondary poverty, and found that the proportion that the first of these bore to the second was as 35 to 65. These figures were obtained by Mr. Rowntree for York only. Before Mr. Rowntree had begun this work, Mr. Charles Booth had almost finished his survey of life and labour in London. In this inquiry he found that 3o per cent. of the population were living in poverty, a result which agreed very closely with that of Mr. Rowntree in York. In fact Mr. Rowntree writes " From the commencement of my inquiry I have had opportunities of consulting with Mr. Booth and comparing the methods of investigation anid standards of poverty adopted. As a result I feel no hesitation in regarding my estimate of the total poverty in York as comparable with Mr. Booth's estimate of the total poverty in Lonidon, and in this Mr. Booth agrees." Working in so much wider a field it was not possible for Mr. Charles Booth to divide his body of poor into two divisions by any such exact method as that employed by Mr. Rowntree. He did, however, divide it into two classes, the " poor," those "living under a struggle to obtain the necessaries of life," and the "very poor," " who live in a state of chronic want," and agaiin into the " crowded," " those living two or more but less than three to a room," and the " very

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632 Miscellanea. [AMay,

crowded," "those living three or more to a room." The proportion which the "very poor" bore to the "poor " was 27 to 73, and of the " very crowded " to the " crowded " 38 to 62, and the mean of these two processes 32 to 68 as against 35 to 65 at York. This would make the "very poor" of London rather less in proportion than the "primary poor" of York, but it must not be forgotten that the two are arrived at by different methods.

TABLE 1.-Comparisoni of poverty in Lonidon and in lYork.

London York (Ilooth1). (Rowlitree).

Per cent. Per cent. Mean of poor and crowded ........ 58 65 Secondary poverty.

,, rery poor and very7 ) 32 35 Primary poverty. crowded ................................

It seems not unsafe then to infer that the amount of poverty in York is comparable with thatin London, and that in both places it can be divided into two bodies of approximately proportionate dimensions. It would be possible then for a general hospital to divide its patients into two bodies by the method used by Mr. Rowntree, and to show what proportion the one bore to the other. From this an idea could be gained from what class the patients of the hospital are drawn. In the case of a children's hospital, however, one must find the number of children in each class and the proportion between them. As large families are one of the chief causes of primary poverty, it would naturally be expected that there would be a greater proportion of children in primary than in secondary poverty. This is, in fact, the case at York. Out of the 7,230 persons in primary poverty, 4,215 were children, while only a very few more, 4,836, were children out of 13,072 persons in secondary poverty. Thus the proportion which children in primary poverty bear to children in secondary poverty is 47 to 53 instead of 35 to 65 for the whole classes, adults and children together.

TABLE 2.-Comparison of children under 15 and of adults and children together in primary and secondary poverty respectively in lork.

Adults Cilri ny and children. Children only.

Per cent. Per cent. Secondary poverty .65 53 Primary poverty 35 47

If then it was found at Great Ormond Street that of the children treated, those in primary poverty are to those in secondary poverty as 47 is to 53, it might be inferred that the patients are drawn from the 30 per cent. of the population that is in poverty; and that if the proportion is less or more, that more or less than this 3o per cent. are treated.

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1911.] From what Class Out-Patients of a Hospital are Drawn. 633

During a year about 30,000 patients are treated in the out- patient department of Great Ormond Street. These patients are drawn from all parts of greater London and beyond, rather more from the Northern districts than the Southern.

Of these 30,000 patients, about one-half are seen by members of the honorary visiting staff in the general department. The other half are seen by the casualty medical officers or by the honorary visiting staff in the special departments. As the general department is fed by the casualty department and feeds the special departments, the patients seen in the general department are a fair sample of the whole, and it is from their statements that the following tables are prepared.

The figures below give a comparison of the various departments from August 13 to December 31, 1910:

24s. a week Under anid over. 24s. a week.

Per ce,it. Per cent. Patients seeni by the lion. staff in general 1 i 44

department.. Patients seen by castualty medical officers 55 45

anid in special departments .....................

Two sets have been prepared, one for the year 1908, and another for the twelvemonth April 1, 1909, to April 1, 1910. The former is based on the statements of 13,377 patients, the latter on those of 9,85i. The explanation of the numbers being smaller in the second period than in the first is that the year April 1, 1909, to April 1, 1910, contained two Easters, and that in the latter year, in order to obtain more reliable figures, the statements of all patients interviewed by deputies of the inquiry officer when he was absent oni his holiday, or through occasional illness, were omitted. In both periods, to avoid counting the same family twice over, the records of all second or subsequent visits after discharge of the same patient, or of all second or subsequent members of the same family have been eliminated from the tables. Then as the object of the inquiry officer's questions was not to provide material for the compilation of statistics, but to enable him to satisfy himself that the patient was suitable for hospital treatment, a result he could attain without eliciting all the facts necessary to classify a family with any certainty according to Mr. Rowntree's methods, a further deduction has been made. All patients sent with a doctor's letter or card are also omitted. These subtractions have reduced the odd I 5,000 to I3,377 and 9,85I respectively, numbers which may be regarded either as individual children or as. separate families about whom sufficiently full information was recorded to enable them to be classified after the manner of Rowntree. In the rest of the paper the figures for 1908 will be placed in brackets after those for 1909-10 for purposes of comparison and to avoid repetition.

A few words may be inserted here as to the method and scope of the inquiry into the means of these families. About each one the

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634 Miscellanea. [May,

following facts were recorded: name, address, father's occupation, total family income, total number of family dependent, rent, number of rooms, whether the case had been before a private doctor or not.

In the case of irregular earnings, the inquiry officer tries to strike an average for the twelve months immediately preceding the date of questioning. In many cases no douibt the estimate thus formed is erroneous, but taken altogether the results are believed to be correct. For it is to be remembered that the greater the irregularity of the employmenit or the variation of the earnings the greater is the certainty of the family being very poor. The more difficulty there has been to determine the average income of family to a shilling, the more certitude there is that it could not be above primary poverty.

Every effort has been made to ensure accuracy. Indeed, the writer has to acknowledge his indebtedness to the inquiry officer of the hospital, Mr.- W. T. Owen, for his care in taking down the statements of the patients, and to Mr. R. Addingtorn, a life governor of the hospital, for carrying out the laborious work of making the 23,000 calculations necessary to determine the financial position of each of the patient's families. Moreover, the standard of measure- ment adopted, Rowntree's line of primary poverty, is in itself largely a guarantee of this accuracy. The line is drawn so low that there is no temptation to those on or about it to make out their income to be any lower than it really is, while even a large understatement by one far above it going undetected would be as likely to place the family just above as just below the line. There is an additional safety, too, in the slightly complicated nature of the standard. If a simple wage line such as 24S. or 25S. a week is taken, it is difficult for the recorder of the statements, where border line cases are concerned, to remain quite unbiassed. In a case of doubt he is ilclined to give the benefit, according to temperament, for or against the hospital. But in the case of Rowntree's standard he cannot tell, as he takes the statement down, whether the family is going to be over or under the line. It is not until he has the income, rent, and family before him, and has deducted the second from the first, and compared the result with the amount allowed for a family of that particular size, an amount be it remembered which ends with an odd number of pence for each successive child, that the investigator can xy whether a family is above or below the line.

Again, only errors sufficiently large to transfer a family that is above the line to below the line are of consequence. An inaccuracy that brings a family nearer, but not below the line, or which brings a family already below the line still lower, can be disregarded, since the argument rests on the proportion which those above the line bear to those below.

Statements as to income, however, even in returns for income-tax, on which very much more ambitious statistics than these are founded, are notoriously unreliable.

An attempt therefore has been made to detect and gauge any inaccuracy in the statements macie by the parents. For this purpose 93 families, unsuspicious cases (suspicious cases were of course

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1911.] Fron what Class Out-Patients of a Hospital are Drawn. 635

refulsed treatment at the hospital until they could bring a private doctor's card) selected at random, were visited in their homes, and the statements as far as possible verified. This investigation revealed several discrepancies ; sometimes the families were found to be earning more and paying less rent than they had stated at the hospital, sometimes, oddly enough, though the fact is not unfamiliar to the most experienced almoners, the reverse was the case, the family actually earned less, and paid more rent, than they originally stated. The result of the inquiry, however, showed that out of the 93, three who had been placed below the line at the hospital, ought really to have been above it, say 4 per cent. None of these or any of the others, whose earnings were found to be greater than what they had stated at the hospital, were found to be sufficiently well off to be refused treatment at the hospital even had they made a more accurate statement in the first instance. Four could not be found at the addresses they gave, but according to their statements at the hospital they were already above the line. Five of those classed as "regular " ought to have been "irregular," and one "irregular" ought to have been "regular," that is to say, that on a more thorough inquiry one was in a better and five in a worse position thain had at first appeared.

After these somewhat long but indispensable preliminaries the results of the classification of the patients at Great Ormond Street may now be given. Table 3 shows them:

TABLE 3.-Comparison of the children in poverty at JOrk wvith patient.s at Great Ormond Street in the years 1909-10 andl 1908.

Great Ormond Great Ormond Yok 1899 Street, 1909-10. Street, 1908. ;k,

Per ceint. Per cent. Per cenit. Above the line of primary poverty 55 53 53

(secondary poverty) . Below the line of primary poverty 45 47 47

(primary poverty) .............

These figures, however, are subject to correction on account of under-statements of income.

Before this conclusion is formed, however, certain other considera- tions must be reviewed. Two of these relate to differences between London and York. First, travelling expenses. Mr. Rowntree made no allowance for these, since in a moderate sized town like York it is presumably possible for most workmen to go to and from their work on foot, whereas in London many workmen have to pay a daily fare on this account. In fact, travelling expenses in London are a corollary of rent. The lower rents in the outer districts can only be obtained at the cost of a journey every day. A shilling or two shillings a week would have to be deducted, in the same way as rent has been, from many of the family incomes, and would bring below the line many that are now just above.

Secondly, it miust be noted that the cost of living is lower in

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636 Miscellanea. [May,

York than in London. According to the inquiry made by the Board of Trade, retaiJ prices in York are as 96 to IOO to those in London, that is to say it takes 25S. to buiy in London what can be bought for 24S. in York. If the difference in time is taken as well as the difference in place, the cost of living is still greater. Prices in 1899, the year of Mr. Rowntree's inquiry, are as 96 to Io8 to those in 1908, 1909, 1910, the periods during which statistics have been collected at Great Ormond Street. That is to say, it would take 27S. to buy in 1909-10 what could be bought for 24S. inl 1899. Had the minimum cost of living in York in 1899 as ascertained by Mr. Rowntree been corrected to suit conditions prevailing in London during 1908 and 1909-10, the line of primary poverty would have been raised, and there would have been more below it, and fewer above it. Next, it must be remarked that the "very poor," such as those in primary poverty, have an alternative gratuitous medical service in the Poor Law. In York, in the same year that Mr. Rowntree made his inquiry, 889 children received out-relief. About a third of these, 296, or 3 per cent. of the total nunmber in poverty, primary and secondary, would probably receive medical relief. In Holborn Union, in which the hospital is situated, inquiry of Mr. Allan Battersby, the Clerk, who kindly allows the result to be published, shows that I23 orders for medical out-relief were granted to children during the last three months of 1910. Multiplying this number by four we get 492 patients, many of whom, but for the attentions of the parish doctor, would probably have been added to the odd 2,000 who annually come from the Holborn Uniion area. It will readily be seen that, if any children are kept away for these reasons, the numbers of those in primary poverty presenting themselves for treatment will be diminished, and their percentage decreased, while the percentage of those above the line will be increased. If to the numbers of patients in primary poverty were added the numbers kept away by the Poor Law, and the numbers of those wrongly included in secondary poverty, on account of the omission of travelling expenses, and of Rowntree's line not being adjusted to London conditions and the rise of price in recent years, there can be little doubt that the increase of the primary poverty class would be sufficiently great not only to absorb the supposed excess of 6 per cent. (or 4 per cent.) of persons out of poverty, but to compensate for still greater errors in the statements of patients that may not have been detected.

If this explanation is deemed satisfactory, it may neverthe- less be urged that although the 45 per cent. (47 per cent.) below the line are undoubtedly in primary poverty, it does not necessarily follow that the 55 per cent. (53 per cent.) above the line are in secondary poverty. Some may be in secondary poverty, but others may be above, even far above, secondary poverty. In answer to this it must be pointed out, first that all these patients are chosen on the same principles as those in secondary poverty in York, on the same principles though bv opposite methods, since in York they were selected out of the general population, whereas the hospital patients are the residue after those not in poverty have been rejected.

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1911.] From what Class Out-Patients of a Hospital are Drawn. 637

Even if there has been any undue laxity in rejecting, it is manifest that there canlot be room among the 55 per cent. (53 per cent.) who are over the line for any who are above even secondary poverty, unless a corresponding number of those in secondary poverty stay away. If the secondary poverty class send their full quota of patients, and others come as well, then the percentage of those above the line would at once rise, and the percentage of those below would be correspondingly depressed. Likely though it is, as is some- times thought, that those who are not poor should wish to attend the hospital, it is yet more unlikely that others who are unquestionably poorer should refrain from attending. Some intsrchange there un- doubtedly is between those in secondary poverty and those above it, since seventy-seven cases of those over Rowntree's line were rejected on social grounds first, and subsequently passed for treatment on medical grounds, but changes other than these cannot in the nature of things be extensive.

The most reasonable interpretation of the figures that have been tabulated seems to be that the class from which the patients at Great Ormond Street are drawn is that 3o per cent. or 27 per cent. of the population termed by Mr. Booth and Mr. Rowntree the "poor," with two exceptions. At the verv bottom of the scale some of the children in primary poverty who might become patients are kept away by reason of their receiving medical relief from the Poor Law; while at the other end of the scale at the extreme top, some children, whose parents could not be said in normal times to be in secondary poverty, are treated as patients owing to the exceptional nature of their illness, while room is made for them by the abstention of a corresponding number of children of parents in secondary poverty who enjoy better health. More- over, the medical treatment of these classes is undertaken not solely by the hospitals, but is shared to an appreciable extent by private practitioners.' This is the interpretation which the writer, striving to be impartial, places upon the figures which have been collected and tabulated under his direction, but the figures may be capable of other interpretation.

Assuming, however, that the writer's interpretation of the figures is correct-that the out-patients of the hospital are drawn from a class equal to the poorest third of the population, one naturally asks, " Are these more or less than are entitled to such treatment ? " It is probable that this question will be answered differently by different parsons. Yet one would think it cannot be very far wrong for hospitals which are intended for the poor to treat those who have been defined as poor by the foremost authority on the subject. At any rate, it is open to those who disagree to state what propor- tion cases out of primary poverty ought to bear to cases in primary poverty, or what proportion of those in primary and of those in secondary poverty should be allowed to attend. If an agreement on this point could be reached, the controversy as to hospital

X 30 per cent. [31 per cent.] of the patients had prceiously been to private dloctors. I9 per cent. [zo per cent.] of thes,3 were above Uowntree's line and X per cent. [ ii per cent.] were below.

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638 Miscellanea. [May,

abuse, which has lasted more than half a century because no one on either side defines what he means by poor, might be brought to a speedy termination.

The children and families that have been under review have been divided into two classes, for the sake of comparison with the two classes into which Mr. Rowntree has divided the poor of York. But the picture thus obtained, valuable as it is for comparative purposes, suffers from being an instantaneouis picture. The tables merely show one mioment in the lives of the families concerned. The groups into which the population is statistically divided may indeed persist, but the units which compose them are continually changing places.

In fact, it is scarcely necessary to say, except that it is so easy to forget it oneself, that these groups as groups do not really exist, or rather the groups themselves exist, but not the dividing lines between them. That is to say the groups are not divided from one another like regiments of soldiers, but fade insensibly one into the other. Indeed, the aptest illustration that can be made is to compare them with various layers of a liquid each of varying temperature, the particles of which are for ever changing places with one another while simultaneously the layers themselves are perpetually rising and falling.

With this caution in mind, it is possible to analyse the patients' families in such a manner as to obtain a glimpse both into their past and into their future. The families have not simply been divided into two classes, one over, and one under, the line of primary poverty; they have been graded by intervals of is. above and below that line. If, therefore, we take five persons as the average sized family-father, mother and three children, and if we allow 3s. as the cost of a child per week (2S. iod. is the allowance of Rowntree, but the extra 2d. can be taken to represent the increase of rent which cannot be avoided as the family grows larger), we can trace the financial position of the various families in relation to the datum level of Rowntree's line both backwards and forwards in time. The first group in this analysis consists of 3,052 (3,606) families, or 31 per cent. (27 per cent.) of the whole, who from the time they have three children, the average number-the least number to a marriage that can possibly ensuire an increase of the population-are below the line. The next group is comprised of 1,393 (2,715) or r4 per cent. (20 per cent.), who only fell below the line when their children numbered more than three. The poverty of the first of these may be said to be due to smalrness of wages, of the second to the large- ness of their family. Next in order comes a group of 2,302 (2,670) families who are above the line at the mioment, but who will presently be below. To arrive at this figure, all those families with two children who are not more than 38. above, and all those with one child who are not more than 6s. above, have been taken. Of course some of these families will never have more children than the one or two that they have at present, but on the other hand several families with only one or two who are more than 6s. and 3s. respectively above the line at present will have more than three,

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1911.] Fr-o0t whlat Class Out-Patients of a Hospital are Drawn. 639

children, so that the numbers will be equalised. These families are 23 per cent. (20 per cent.) of the whole. Some of them will ultimately be classed with group i as having low wages, and some with group 2 as having large families. The next division is not so easy to make, but since we have been measuring in terms of children it will be convenient to take all those families who by the previous methods of reckoning have remained above the line, but who would be precipitated below it if they had one more child still. That is to say, 3S. a week better off than any of the families already enumerated. This accounts for I,644 (2,446) families or 17 per cent. (i8 per cent.). The remainder are 1,460 (1,940) or 15 per cent. (1I5 per cent.).

TABLE 4.-Analysis of patients' families itto five groups acco-ding to their past or futur e positions as to Rowntree's line of primnary poverty.

Group ILI.op V Groip I. In Grouip 1II. GAroup Group V. Iao primary poverty W nlo will iiot nmore than All

f)roiniy toverty from the psima.y poverty Ss. a week better off timie thiev have tine they had povteirt or x chiild than

3 cildreii. nivmore tihan families increase. better off thian Group IV. 3ideildreicea. Group 111.

Per ceint. Per cent. Per cent. Per cetit. Per cenit. 1909-10 31 14 23 17 15 '08 . 27... 27 20 20 18 15

Surveying these groups we see that for I and II providence is either out of the question or the choice of two evils. Insurance is not one of the expenses allowed for by Mr. Rowntree, and the cost of it can only be met by curtailing the diet. That is to say these people have to choose whether they will provide for future illness at the risk of bringing on illness, or try to keep themselves in health at the cost of making no provision for future illness. Class III could for the moment pay a small sum for insurance, but as they are destined ultimately to fall below the line, they will then be in the same dilemma as the members of Class I and II, and if they happen to have insured before, will run the risk of losing all that they have paid in policies, by lapsing. Class IV is only in a little better position than Class III. If their conventional necessities are greater, if they have appearances to keep up which are essential to their means of livelihood, if the wife is the slightly less skilful as housekeeper, they are no better off. It is only possible to maintain physical efficiency on the sums which Mr. Rowntree allows, if every penny is spent in the most judicious manner possible. When the law does not require a surgeon who has had a long and expensive education to use the highest possible degree of skill, but only a fair, reasonable and competent degree of skill, it is unreasonable to exact a higher standard in the ordering of their lives from a workman and his wife. On the other hand it is true that if these people planned their life some way in advance they might by postponing their marriage and by saving up while their children were few, accumulate a fund on

VOL. LXXIV. PART VI. 3 B

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640 Miscellanea. [ May,

which they could subsist until their children became self-supporting. It is probable, however, that persorns of this degree of foresight and will power would be able to earn sufficient wages to render such a process either not strictly necessary, or of no great difficulty. Of the people who are lacking in these qualities one might say, " If they were not poor, they would not be poor." There remains the 15 per cent. who compose Class V. The members of it belong largely to the body of what is called " the black-coated working man," clerks, minor civil servants. Included amongst it are the seventy-seven cases before mentioned who were rejected on social, but passed on medical grounds. One hundred and sixty-eight had minor operations, ninety-three were prolonged cases. It is possible that, had the hospital possessed a skilled almoner for the whole period instead of for the last month oinly, some of thenm would have been rejected. If on the one hand these I 5 per cent. or some of - them may be regarded as debatable cases, as bordering on abuse, on the other hand they are the only patients who are able to take full advantage of the treatment given by the hospital. All the other 85 per cent. must at some time or other plunge through " primary poverty " or its fringes, an ordeal which may undo past years of care, -or lay seeds of illness for life, against the consequences of which it would be unreasonable to expect even the best medical advice and skill to prevail. It would be difficult perhaps to find more striking evidence of the costliness and wastefulness of poverty.

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