Anne Borsay. Disability and Social Policy in Britain since 1750: A History of Exclusion. New York: Palgrave Macmillan, 2005. 288 pp. $31.95 (paper), ISBN 978-0-333-91255-3.

Reviewed by Iain C. Hutchison (University of Stirling)
Published on H-Disability (March, 2010)
Commissioned by Iain C. Hutchison (University of Glasgow)

Confinement and Community Living: The Contest for Disabled People's Lives from the Industrial Revolution to the Postindustrial Era

Editor's Note: This review was commissioned by Robyn Fishman for H-Disability.

Anne Borsay's Disability and Social Policy in Britain since 1750 undertakes an ambitious, but sorely needed task in addressing disability from the onset of "industrial revolution" in Britain to the 1970s. Historians have, of course, been writing about disability, and the policies considered necessary for its relief and control, throughout the period addressed in this work, but, as Borsay says, this has often been portrayed as "a journey of improvement," which modern historians now challenge in their realization that "in the history of disability, therapeutic intentions have not always been good," and even when those intentions were honorable, they "created passive recipients who bowed to professional advice" (pp. 3, 7). This work therefore sets out not only to survey the administrative changes that have taken place during more than two centuries of public intervention in the lives of people with disabilities, but also to undertake presentation of a balanced assessment that considers the "providers" as well as the "recipients" of this intervention.

The book is divided into two parts, which are then subdivided into specific themes that enable easy reference when pursuing research into specific facets of peoples' lives impinged on because of the experience of disablement. The book therefore looks at both "incarceration" and community. The section on "institutional living" is subdivided into workhouses, hospitals, asylums, and schools, terms that have certain interchangeability over time. Schools for people with disabilities were often residential institutions although their educational roles were frequently blurred, their roles encompassing removal from society and medical intervention before leading to eventual release, the conversion from "disabled" to "able-bodied," from "abnormal" to "normal" achieved. The second part of Borsay's work addresses community living. Many people with disabilities never entered institutions, and this is therefore an important part of this volume, which she addresses through the themes of work, financial relief, and community care.

The evolving definitions of "disability" are considered, an essential component in a work that addresses a period of such cataclysmic economic change. Disability is seen to "fan out" from the "cripple," "halt," and "lame" to progressively encompass sensory, intellectual, and psychological impairment. The individual nature of impairment highlights that there is greater diversity of experience than there is common experience of impairment. Disability is often defined and identified by able-bodied society, and the boundaries and criteria are constantly shifting, the one exception perhaps being the elderly, disablement, and old age being given a compatibility and acceptability that are not acknowledged during childhood, youth, and "productive" adulthood.

Workhouses, the subject of the first institutional living chapter, did not take on in Scotland so this chapter focuses primarily on England, and occasionally Wales. Borsay argues that Michel Foucault's "great confinement" came late to Britain, but when institutions did become widespread, they represented the ultimate form of exclusion for people with disabilities. In England and Wales, there were 600 workhouses by 1750, but this had increased to 4,800 by 1834 when the New Poor Law was inaugurated. Under the Old Poor Law, workhouses were for the "undeserving" poor, while the "deserving" poor retained their "freedom" through being supported by outdoor relief. Initially intended to provide work for able-bodied paupers, Gilbert's Act of 1782 changed their focus to the "impotent" or disabled poor. However, the function of workhouses was never constant, and, ultimately, they were often catch-all repositories that endeavored to sift and sort inmates into different categories, a process aided by walls and partitions, gates, and grilles. The regime was prison-like, and the work provided was relentlessly soul destroying. People with disabilities were a minority among the many categories of inmates that included "harmless" mental cases because workhouses were cheaper than mental asylums.

Borsay compares the conditions in early nineteenth-century workhouses, contrasting the "ameliorat[ing] and enhance[ing]" environment at Bradfield with the "sordid" conditions at Bolton (p. 29). By the 1860s, the need for separate accommodation for different categories of inmates was increasingly catered for by the erection of segregated blocks at workhouses and by the expansion of specialist institutions. This should have eased pressure on workhouses, but the workhouse population was driven upward by moves to reduce outdoor relief through application of the "workhouse test" on poor relief applicants. Joyce Brayne provides bottom-up experience from the 1920s when, as a six-year-old in the workhouse, her days were filled with child-minding, work, and no education. Borsay uses Brayne's testimony to justify the use of oral evidence to the body of historians who remain skeptical of the validity of such material. However, although the term "workhouse," perceived in the public eye as representing squalor and lack of dignity, was dropped in 1913, and the next five decades saw a growing role for state welfare, the value of oral testimony is perhaps reinforced by Borsay's revelation that, by 1960, thirty-five thousand elderly people were still housed in former workhouse buildings.

Economic rationality is evaluated as driving policy for the poor and disabled, and Borsay sees this as a major motivation in hospital policy. While hospitals evolved in many ways, over the period there was a recurring theme of them putting more effort and resource in the direction of patients who could be cured or repaired, than of caring for those who were incurable or in decline. This philosophy can be found in the late eighteenth century, and Borsay argues that little had changed by the late twentieth century when geriatric care remained under-resourced and understaffed. The early voluntary hospitals were useful laboratories for doctors who gave their services free because their livelihoods came from private patients. Some workhouses had their own wards or hospitals, but expanding focus on people with disabilities came with hospital specialization in orthopedics and eye surgery early in the nineteenth century. In 1817, the first orthopedic hospital opened in Birmingham, treating bodily deformity, spinal diseases, and club foot, the latter being "popular" because it could be "cured"--the Birmingham Royal Cripples Hospital was later to claim to perform "miracles," transforming crippled children into happy, useful, working citizens. Borsay argues that orthopedics created a medical career structure for specialists that continuously reinvented itself to adjust to the economic demands of society--maimed and wounded soldiers from World War One, children caught in a dragnet under a national scheme of "surveillance medicine," and industrially injured men and women whose neglected rehabilitation was later given urgency by World War Two labor shortages.[1] Borsay exposes "the uniformly benign image of medical intervention"; for example, she looks at children who had been struck by polio, in comparison to the elderly disabled who constantly received a raw deal, because they were deemed to no longer have economic value (p. 56).

If hospitals were not always benign in the consideration of patients' wishes and aspirations, asylums had an even less attractive image in the public perception. By the late eighteenth century, London's Bethlem (Bedlam) Hospital already had a long pedigree of housing mentally troubled people, but by our period networks of asylums were spreading at least throughout England. Regulation of asylums often struggled to keep up with events and trends in, firstly, confinement, and later, therapeutic exploration and intervention. Control of patients, especially as asylums grew in size to accommodate hundreds, and then thousands, is a contentious issue. Enlightened thinking saw the abandonment of physical restraint with chains and irons, in favor of moral therapy, but Borsay finds that by the 1870s, there was a rise in repressive treatment of patients as the asylum population mushroomed, resulting in a recurrence of physical restraint, and followed later by "chemical restraint," increased use of drugs to sedate and control patients. Legislation often struggled to contain the running of asylums where patients had little redress. In England, commercially run madhouses thwarted adequate regulation until the 1845 Lunacy Acts (although private madhouses in Scotland were not adequately regulated until the Lunacy Commission made extensive investigations in 1855). A century later, the 1959 Mental Health Act marked the move from reliance on the institutional regime for mentally troubled people to consideration of options within the community, but abuse remained a hazard for patients, and it was not until the 1983 Mental Health Act that professional discretion in the treatment of patients received some challenge by the assertion of patient civil rights. Loss of agency by asylum patients was, arguably, a greater issue than mental wellbeing.

Education for disabled children, Borsay argues, was often a competition between economic rationality, religious interests, and professional interests. Focusing initially on sensory impairment, children became a contested group between educators and the medical profession. There was conflict over methodology, such as oralism and signing for deaf children, and differing raised-type systems for blind children. For example, the "British" statistics suggested  success for oralism, but they hide the predominance that the combined method held in Scotland until the early twentieth century. School experience for disabled children was mixed, and this includes the rise of special schools that grew as an alternative to the traditional residential institutions. Mainstreaming of children with impairments provided opportunity for greater social inclusion, but they were open to misunderstanding and outright hostility by fellow pupils and teachers, so that "special schools" remained more attractive to many children and their parents because of their sometimes greater empathy and the specialist skills of their teachers. But it was a mixed experience because the special schools also highlighted "abnormality" and masked the occurrence of cruel treatment. Education for disabled children aimed to give children skills, but these were restricted by their conformity to class and gender stereotypes and by depression of pupils' expectations and aspirations. In 1909, manual training was emphasized instead of "the pointless aim of teaching pupils to read and write" (p. 109). The "need" for special schools was reduced by the 1981 Educational Act.

There is inevitably an overlap between the experience of "Institutional Living," the focus of the first four chapters of this work, and "Community Living," the concluding three chapters. Institutions had some degree of commitment to return their inmates to their communities and people with disabilities did not spend their lives exclusively in one realm or the other. A goal of workhouses, hospitals, asylums, and schools was to endow, wherever possible, their subjects with skills to enable them to embrace economic rationality--to integrate them into the world of work. While charities and missions in the nineteenth century endeavored to provide employment for disabled people, even if it were subsidized and intended more to promote the principal of work than to create economic independence, this chapter concentrates on the period following the Boer War. War is shown to have a particular impact on employment for disabled people (although with diverse gender experiences). The Boer War and World War One increased the number of disabled people seeking employment and created competition between civilian and military interests and affiliations, while World War Two created a demand for disabled workers, one newspaper urging a response with the headline "Cripples Can Do Vital War Work" (p. 134). This scheme attracted three hundred thousand applications. However, well-intentioned 1944 legislation reinforced the division between "normal" and "abnormal," and disabled people again experienced employment marginalization, especially in the economic environment of labor surpluses in the 1970s. Testimonies suggest that the worst discrimination was not difficult access to employment, deskilling, and low wages, but the personal invectiveness experienced from employers and able-bodied fellow employees.

Exclusion and marginalization from the workplace lead directly to the struggle for financial relief. The inadequacies of the Poor Law meant that poor relief often had to be supplemented by appeals for alms, yet begging was subject to suppression and punished by withdrawal of certain forms of charitable aid. Reform of the Poor Law in England in 1834 marked a change from the vagaries of altruistic paternal relief to a reluctant relief of "moral failure." While, from the 1890s, state intervention came in the form of workers' compensation schemes and old age pensions (1908), economic and moral tests retained the stigmatization associated with the Poor Law. Benefits were distributed unevenly and people with disabilities often fared worst in the wider sharing of state largesse. Even with the reforms that resulted from the Beveridge Plan after World War Two, Borsay notes that "the range of benefits available to disabled people was paid at rates that varied according to the cause and not the effects of impairment" (p. 161). In the 1970s, she notes that schemes continued to have biases, based on, for example, gender and age, and that administrative bureaucracy and confusing application forms resulted in unclaimed benefits, notably among the poorest members of society, while accessing benefits retained the aura of stigma for many people who had entitlement.

Borsay notes that the term "community care" was introduced as suggestive of a new concept in 1957, but that has long-standing antecedents in the almshouses provided by charities, paternal benefactors, and religious orders. The modern model has developed through sheltered housing and group homes on the one hand, and family care on the other. As witnessed with "special" schools, the likes of "special" housing, argues the author, in providing "community living did not necessarily bring community inclusion" (p. 172). Home support of an impaired relative has often made great demands on families, yet rather than credit being given for responsibilities willingly shouldered, changing circumstances that led to the need for outside intervention were generally portrayed as "family deficiency." Gradually, state support following World War One, and the introduction of a National Health Service after World War Two, should have changed things, but Borsay points out that central government has tended to delegate responsibility to local government, which in turn has relied heavily on voluntary organizations for delivery. Home support has been patchy, thinking has continued to follow a medical model to the detriment of social needs, people with disabilities have continued to lack agency, and "community care" tended to be a slogan rather than a coherent policy.

In concluding, Borsay highlights some of the deficiencies of historical enquiry in the field of disability history. She argues that it has been skewed toward mental impairment with much work remaining to be undertaken on physical, sensory, and age-related impairment. She also highlights how service providers dominate historical sources available to historians, and counters some of this bias by use of twentieth-century oral testimony. Disabled experience from the earlier period covered by this work presents a greater challenge for the historian, but can occasionally be found, for example, in patient letters, diaries, poor relief applications case notes, and legal depositions. What emerges from Borsay's investigation is that the culture of work and economic rationality have dominated the administration of people with disabilities in both institutional settings and within the community throughout the period, while access to civil liberties, for example, through personal agency and through access to the franchise, required people to be "rational" and self-sufficient. Borsay argues persuasively that there is a need to "cultivate a model of citizenship for which paid employment is not a qualifying condition" (p. 206).

A study of "Britain" often falters through confusion of what defines "Britain," both politically and geographically, and across different eras. Borsay identifies these problems from the outset, not only through recognition of the different structures that have been maintained since Scotland's political union with England in 1707, but also from the presence of different Welsh institutions since its "absorption" by England in 1536. With the exception of the likes of the Welsh and Scottish use of "boarding-out" for mentally impaired people, the book is nonetheless light on identifying distinctive Scottish and Welsh provisions and responses in their juxtaposition with England. It is not until the conclusion that Borsay touches on post-1979 developments under Margaret Thatcher, which she cites as a return to a mid-nineteenth-century laissez-faire ethos of citizenship obligations taking precedence over citizenship rights, a stance that she notes has been endorsed by New Labour since 1997 despite major reforms to voting enfranchisement in 2000. Perhaps this period is too recent to be adequately subjected to historical analysis. The creation of Scottish and Welsh legislative bodies in 1999 with the scope to diverge in responses to social policy perhaps emphasizes this. For example, the UK government rejected proposals for free nursing and personal care for the elderly as proposed by the Sutherland Report of 1999, but the Scottish Parliament adopted these measures for Scotland in its Community Care and Health (Scotland) Act of 2002, a measure of significant importance to older people experiencing disabling conditions. Ireland falls beyond the scope of this study, but remains another area to be investigated, particularly in the realms of its economic relationships with Britain; patterns of migration; and, for example, the implications that these had on different Poor Law arrangements for Ireland, England and Wales, and Scotland.

In endeavoring to cover two and a half centuries of policy intrusion into the lives of people with disabilities into this compact and very readable volume, Disability and Social Policy in Britain since 1750 fulfills a very ambitious task. There will always be areas and themes for further historical research and analysis. Borsay's volume provides a launching platform for students of the history of disability that will surely become a standard text to launch and inspire them on their own personal journeys of enquiry.

Note

[1]. On World War One, see, for example, see Joanna Bourke, Dismembering the Male: Men's Bodies, Britain and the Great War (London: Reaktion Books, 1996).

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Citation: Iain C. Hutchison. Review of Borsay, Anne, Disability and Social Policy in Britain since 1750: A History of Exclusion. H-Disability, H-Net Reviews. March, 2010.
URL: http://www.h-net.org/reviews/showrev.php?id=29620

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