Florence Nightingale as a Social Reformer
Lynn McDonald describes the lasting impact of Florence Nightingale on improving public health for the poor.
Had Miss Nightingale’s advice on the Poor Law been taken and her plans accepted there might have been a universal health service before 1948.
Nightingale’s achievement in introducing professional nursing into the dreaded workhouse infirmaries was one of the greatest contributions of her long life, and it is not possible to imagine a National Health Service without it. Prior to her reforms there were no trained nurses for workhouse patients only ‘pauper nurses’, or women inmates who were not themselves sick, notorious for stealing their patients’ food and gin, no permanent medical staff, only visiting doctors, while shared beds were but one of the santitary defects. Nursing itself, and hospitals as institutions, would have improved without Nightingale, for many people were working on them. But no one else was bold enough to take on the workhouse infirmaries, the ‘real hospitals of the sick poor’, as they have been called, for they held five people for every one in an ordinary hospital.
Visitors such as Louisa Twining (1820-1912) sought to eliminate abuses in the workhouses and doctors formed an Association for the Improvement of the London Workhouse Infirmaries, which sought various improvements. But Nightingale’s vision (shared with her colleague Dr John Sutherland) was much bolder: that the care given in the workhouse infirmaries should be just as good as that in the best nursed civil hospitals in the suburbs. The realization of that vision began in 1865, in the Liverpool Workhouse Infirmary, with nurses and a superintendent, Agnes Jones, who had trained at the Nightingale School at St Thomas’ Hospital. It was funded by Christian philanthropist William Rathbone.
Nightingale’s strong faith and the ‘call to service’ she experienced in 1837, at the age of sixteen, is critical to understanding her motivation and the methodology she evolved, which shaped her work. Initially she interpreted her ‘call to service’ to mean nursing, then not a profession at all but a lower-class and ill-paid occupation. Her family would not permit her to nurse, a source of great frustration, as she tried to act on this call. However, she was allowed to visit hospitals and workhouses, and this she did in her early twenties. A little later she came to understand the call to mean to save lives, for which nursing was but one possibility. Indeed, when she discovered that administrative blunders and bad hospital siting and construction cost so many lives she increasingly directed her attention to these issues.
Nightingale’s workhouse visits were to have a great impact. In particular, her tour of the great Marylebone Workhouse in the early 1840s ‘broke her heart’, as she later wrote. She realized she could do nothing to change the wretched conditions she saw but resolved to do something when she could. The opportunity did not arise until well after her return in 1856 from the Crimean War. She was now feted as a heroine, a status she abhorred, but found useful for getting people’s attention and assistance. In January 1864 the Liverpool philanthropist William Rathbone offered to fund a ‘lady visitor’ at the Liverpool Workhouse Infirmary. Nightingale persuaded Rathbone that skilled nursing was needed, not merely a lady visitor, and nominated Agnes Jones (1832–1868) who had trained at Kaiserwerth and St Thomas’ Hospital. Jones became lady superindendent, assisted by a number of Nightingale nurses in April 1865, the first trained nurses in a poor-law institution.
The death of a workhouse inmate from lack of nursing, in November 1864 in the Holborn Union Workhouse, London, prompted an inquiry and press attention. Nightingale seized upon the misfortune to press for reforms in London, telling C.P. Villiers, the President of the Poor Law Board (a Cabinet position), that there was no nursing to speak of in any of the workhouse infirmaries. He responded promptly, visited her and considered fundamental reform, even promising a new bill.
The Liberal government fell in 1866 before Villiers could introduce his reform – although in any case he had some doubts about the radical nature of the changes Nightingale proposed. Nevertheless he continued to support her out of office in his capacity as an MP. In one letter referring to her reforms, he thanked her for the ‘peep behind the curtain’, but said no one could guess what the ‘broth’ would be when ready. The fall of the Liberal government also meant the loss in influence of Nightingale’s greatest ally, Lord Palmerston.
The new Conservative President of the Poor Law Board was Gathorne Hardy. Nightingale, who did not know Hardy, set about lobbying him. She sent her first letter on July 25th, 1866, enclosing letters from mutual friends to act as an introduction. Hardy proceeded with a less far-reaching set of reforms than Nightingale wanted, that eventually took shape as the Metropolitan Poor Bill, (passed the following year). Asked by Hardy’s committee to prepare a brief on cubic space in workhouse infirmaries, Nightingale was not deterred by the narrow terms of reference. Instead, she devoted most of her paper, entitled Suggestions on the Subject of Providing Training and Organizing Nurses for the Sick Poor in Workhouse Infirmaries, to what she considered most important.
Nightingale also persuaded key figures such as Edwin Chadwick and J.S. Mill to support the thrust of her reforms. This was some achievement as Chadwick had been a major architect of the punitive amendment to the Poor Law in 1834, and Mill was a newcomer to workhouse reform (and his initial concerns, like Chadwick, were reducing the numbers in workhouses). Both went along with the conventional wisdom, not based on evidence, that the major problem in workhouses was the able-bodied unemployed. Yet a quarter of the workhouse inmates were children, who, Nightingale believed, should not be there at all, while many more were aged and sick.
A. To insist on the great principle of separating the sick, insane, incurable and children from the usual pauper population of the metropolis...
B. To advocate a general metropolitan rate for this purpose and a central administration.
C. To leave the pauper and casual population and the rating for under the boards of guardians, as at present.
Provide a scheme of suburban hospitals and asylums (1) for sick; (2) for infirm, aged and invalids; (3) for insane and imbeciles; (4) industrial schools for children.
Sickness, madness, imbecility and permanent infirmity are general afflictions affecting the entire community and are not (like pauperism) to be kept down by local knowledge or by hard usage. The sick or infirm or mad pauper ceases to be a pauper when so afflicted and should be chargeable to the community at large, as a fellow-creature in suffering.
There should be ‘a general rate for this purpose to be levied over the whole metropolitan area, to be administered by the central authority’. J.S. Mill argued precisely this last point in committee.
... an important step in English social history... the first explicit acknowledgment that it was the duty of the state to provide hospitals for the poor ... an important step towards the National Health Service Act which followed some eighty years later.
The legislation was permissive only, however, so that improvements had to be fought for workhouse by workhouse, which Nightingale, and an increasing number of others did. The broader ‘ABC’ of reform she had envisaged was not implemented as a system, although many specific improvements were made. The recommendations of the Minority Report of the Poor Law Commission in 1909, advocated by Sidney and Beatrice Webb, were similar. Even then many were only partially enacted, to reappear as recommendations in the Beveridge Report at the end of the Second World War.
That Nightingale obtained the support and assistance of so many high-level medical experts, cabinet ministers and senior officials is a tribute to her careful preparation and attention to detail. People knew they could rely on her and that she did her homework. The best Victorian sanitarians, people like John Sutherland (who for years advised Nightingale, and found data and material for her), statistician William Farr at the General Register Office, engineer and water expert Robert Rawlinson, and many others, were willing to work with her because they shared her vision and respected her methods. Throughout her life Nightingale was able to recruit experts she did not know to her causes.
Although she never used the term, a ‘Nightingale methodology’ can be identified: read the best information available in print, especially government reports and statistics; interview experts; if the available information is inadequate send out your own questionnaire; test it first at one institution; consult practitioners who use the material; send out draft reports to experts for vetting before publication.
The emphasis Nightingale placed on statistics was bound up with her faith. Not for nothing was she called the ‘passionate statistician’. She believed it was ‘the plan of God’ to teach us ‘the laws by which our moral progress is to be attained’, or ‘the road we must take if we are to discover the laws of God’s government of His moral world’. Social reform work, carefully grounded on the best (quantitative) data had a divine mission.
It would be exceedingly interesting to find out the relative rates of mortality and duration of sickness in children’s cases, otherwise similar, placed in ‘general’ or children’s wards or hospitals, but unfortunately hospital statistics are not sufficiently well kept to ascertain this.
Keen as she was on scientific method, Nightingale was well aware of the possibility of unintended consequences from the best-intentioned measures, even with the highest religious principles behind them. She urged the monitoring of results from all new programmes. Further, when data showed negative results the intervention should be revised, and the new measures in turn evaluated.
Nightingale’s methodology is perhaps best seen in the data collection for the two royal commissions she got appointed after the Crimean War, the first on that war itself and its unnecessarily high mortality rate, and the second on India. Other attempts to use data to fuel and guide reform failed when governments failed to collect the data. For example, Nightingale succeeded in getting the Colonial Office to send out questionnaires she designed (and checked with experts) to colonies on mortality and sickness in their aboriginal hospitals and schools. The data that came back were poor, but enough to show excessive rates. Nightingale’s recommendations for improved statistical gathering and ongoing monitoring were not heeded. She gave up on the colonies in general, to concentrate instead on India.
Her methodology also failed, unsurprisingly, when the best available information (previous studies and her own) was not up to the problem at hand. This occurred with her midwifery nurse training programme, which started at King’s College Hospital in 1861, but was closed down six years later on account of high maternal mortality from puerperal fever. The cause of this disease was not fully identified until well into the twentieth century, and measures to reduce mortality, beginning with the better use of disinfectants in the 1870s, still left the rates high. It was not until the 1930s, with the introduction of the sulfa drugs, that the rates of maternal mortality were substantially reduced.
Nightingale was well aware that a report was not ‘self-executive’, as she put it, and that recommendations needed a carefully-devised implementation strategy. In the case of the two royal commissions (influencing not only the terms of reference but the appointment of members) the final reports detailed the changes in administrative structure necessary for implementation.
Nightingale understood the political process well. In a democracy there must be political will to achieve change: questions in the House of Commons, media coverage and the good will of the relevant professionals and opinion leaders. She took pains with both of the royal commissions to get the right people reviewing the reports in the right journals. She knew the circulation of the major periodicals. She understood the importance of getting a story or letter-to-the-editor into The Times.
Clearly it was important that able men, committed to the reforms on which Nightingale was working, held key Cabinet posts. On Sidney Herbert’s death in 1861 much was lost by the appointment of Sir George Lewis as the new war minister. When he died in 1863 she lobbied furiously for Lord de Grey to get the appointment, for much had been progress had been lost with the ‘muff’, as she called Lewis, in charge. A telegram to Harriet Martineau famously urged: ‘Agitate, agitate, agitate for Lord de Grey to succeed Sir George Lewis.’ Martineau did, as did others Nightingale asked. She persuaded Lord Palmerston to read a letter of hers favouring Lord de Grey to Queen Victoria. She even prepared a second letter begging the Queen, which she sent to Sir James Clark (the Queen’s physician and a close Nightingale ally) to give her. Clark’s son, John Clark, also an ally, prevailed on Nightingale not to proceed, pointing out that her views were well known both to the Queen and Palmerston. He pointed out that if someone else were to get the appointment, he would undoubtedly resent her opposition. When de Grey won the post John Clark congratulated her. The editor of The Times also credited Nightingale with the appointment.
Nightingale was born, and died, a Liberal. She even joked that God was a Liberal. As a woman she was not a party member, nor even a voter, but she gave money to her party and (occasionally) wrote campaign letters for its candidates. Of course she had to work with Conservatives when they were in office and she was careful not to be overly partisan in public statements. She was also acutely aware that her own party often let her down. In Nightingale’s case the great disappointment was the Liberal failure to take on the cause of India (where, with a population of 150 million in the late 1860s and 1870s, deaths from famine were also counted in the millions). She tried at length to persuade Gladstone to be as liberal on India as he was on Ireland. She failed, or at best got some minor concessions
Nightingale had to protect her time from the many people who wanted it for good reason. She kept her focus on saving lives. When there was an opportunity to intervene she took it. When an influential person might be recruitable to the cause she approached him. In 1880, Indian finance was an urgent issue, when funds for spending on crucial public works (including measures for famine prevention) were cut back for expenditures on war. Henry Fawcett, the ‘MP for India’, received a forty-four-page letter from Nightingale laying out her case in detail. He must have been surprised to get this tirade, but he replied politely. The point is that the influential Fawcett was open to argument, even if he had taken, in Nightingale’s view, the wrong position.
The dominant political theory in Nightingale’s time was laissez-faire liberalism, not the interventionist liberalism that later developed, but the belief that social reforms could not work and should not be attempted. To the extreme left of this position was Karl Marx, who also held that social reform would be futile, but who looked to the overthrow of the capitalist system and its replacement with a more humane one. Nightingale represents the great mainstream, reformist middle. As a major liberal reformer Nightingale was a critic of capitalism, like Marx, but with a thoroughly opposing approach to change. Her vision was of a profoundly reformed system, the private sector largely running the economy, but with measures for income security, savings and pensions, employment stimulation in bad economic times, better housing, provision for the disabled, aged and chronically ill, and a whole system of public health care. This can now be seen as an early conceptualization of the welfare state.
It is high time Nightingale is given due credit as a major social reformer, for her vision of a public health care system within a broader system of social welfare, and for offering a method by which these reforms could be achieved.