The Development of Medical Services in the Highlands and Islands of Scotland, 1843-1936
This thesis charts the development of medical services in the Highlands and Islands of Scotland from the establishment of the new Poor Law in 1843 to the inception and development of the Highlands and Islands Medical Service from 1913 to 1936. It begins with a brief survey of the topographical, social and economic conditions of the Highlands from 1845. It was within that context that the administrative structures that constituted Highland medical services were situated. They are traced in detail as is the interdependence which developed between local authorities, poor law administrative structures and, later, public health authorities, within the political context of the gradual extension of the authority of the state, enlightened medical thought, land reform and ‘new liberalism’. It is argued that those factors, together with the longer-standing perception of the Highlands as an area requiring special attention, culminated in the establishment of the Highlands and Islands Medical Service enquiry, known as the Dewar enquiry. Established in 1912 it investigated the level and adequacy of medical services in the region. It recommended the establishment of a central body to improve the provision of medical services for the majority of the population and it also highlighted a need for a greater number of fully-trained nurses. The Dewar enquiry’s methodology is documented and its findings assessed and evaluated. The development of district nursing is examined in a separate chapter to avoid duplication and to facilitate its specific features to be highlighted. The recommendations of the Dewar enquiry resulted in the establishment in 1913 of the Highlands and Islands Medical Service, which provided the first State-funded medical care for the Highland non-pauper population and also aimed to improve the conditions of medical practitioners working there. It is widely described, uncritically, as a ‘forerunner of the National Health Service’. Existing secondary literature on it is generally superficial, largely uncritical and relies primarily on published annual reports. One of the aims of this study has been to use new primary sources to investigate in detail its structure, administration and policy development and to provide a more balanced analysis of its development and impact. This study challenges the veracity of the view that it was an unqualified success and demonstrates that while it was unique, innovative and did achieve improvements in many areas of medical and nursing service, by 1936, there were still accepted weaknesses in the provision of medical and nursing services. Furthermore, integral to the Servicewere many of the tenets of self-help and philanthropy; voluntary contributions from all individuals and bodies related to it were embedded into its policies and administration, closely monitored by the Treasury. Following Cameron and Hunter’s work on land reform this thesis makes a contribution to historical understanding of the development of public policy in the Highlands, within a medical context, during the second half of the nineteenth and early decades of the twentieth century. The period of study ends in 1936, the date of the Cathcart Report, which reviewed the state of Scottish health services. The principal achievement of this thesis is to present a fuller and more accurate understanding of the complexity of the nature and development of medical services in the Highlands, with particular emphasis placed on the Highlands and Islands Medical Service. Widely held perceptions of it have been moderated while its importance has been demonstrated, not as a forerunner of the National Health Service, but as a striking example of the modification of the Victorian self-help ethic within the context of a publicly-funded subsidised service for a particularly vulnerable section of society. A major conclusion is that many of the problems inherent in the Highlands and Islands, related to geography, isolation and weather, which were insurmountable in the nineteenth and early twentieth centuries, still exist today and present a greater indomitable force than any level of medical service can mitigate against
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