The emergence of both primary health care and coordinated approaches to public health in the UK is generally traced to the 19th century, that is, to the second half of the Industrial Revolution. In 1800, around 80% of the British population lived in rural communities, in villages, hamlets and the countryside; within 100 years, almost three-quarters of the population lived in towns and cities (Gregg, 1976 and Briggs, 1983). This had major implications for family life, including significant changes to the care and welfare of children as the nature of rural/village/community existence was transformed. Blair et al (2003) graphically illustrates the consequences of this for the children of the working classes:

This ‘someone’ was often a young aunt or even an older sibling and, as Lomax (1996 p 2) acknowledges, at that time ‘…the concept of state or even charitable intervention in family to enhance the welfare of children was frowned upon’. It might be argued that such a view prevails even to the present day! However, Blair and colleagues (2003) suggest that as the 19th century progressed a number of factors came together to enable a more coordinated public health response. These included:

• The emergence of philanthropic approaches towards the poor and needy.

• The need for ‘self-preservation’ for the middle/upper classes as it became widely recognised that diseases such as cholera and smallpox, often endemic in the growing cities, were no respecter of social class.

• Utilitarian approaches to social policy/welfare reform.

• The need for a healthy, well-fed productive workforce.

The mass migration of the population from the countryside into the larger towns and cities led to major problems of overcrowding, and in particular to problems of waste disposal and sanitation. Overcrowded and poor conditions provided the ideal environment for the spread of infectious disease and, during the early part of the 19th century, in response to concerns about potential or actual epidemics, a number of local Boards of Health were established by the Privy Council. Fears of a cholera epidemic lead to the creation of a consultative Board of Health in June 1831 and, later that year, to the establishment of the Central Board of Health under the aegis of the Privy Council. Within the year, nearly 1200 local Boards of Health were established by order of the Council but, just as quickly, as the threat of the cholera epidemic receded, the central and local Boards were dissolved in 1832. However, conditions of public health and, in particular, sanitation remained a concern of the Poor Law Commissioners. Their work, and perhaps most significantly, Edwin Chadwick’s 1842 report ‘A survey into the sanitary condition of the labouring classes in Great Britain’ (with its detailed and graphic accounts of how the insanitary conditions in which the poor were forced to live was a major factor in the spread of disease) led directly to the establishment of The Royal Commission on the Health of Towns.

The Royal Commission set to work immediately, following-up Chadwick’s report and undertaking an investigation of sanitary conditions in 50 English towns. The findings of the Royal Commission investigation directly led to the publication of the first Public Health Act in 1848.

Perhaps the most widely recognised event from this period of public health history relates to Dr John Snow who, in 1854, plotted the pattern of occurrence of deaths from cholera in the Golden Square area of Soho, London. As a direct result of Snow’s work, the spread of disease was linked directly to water supplied from the water pump in Broad Street. Snow himself removed this pump and, within 7 days, the cholera outbreak was officially declared as over. Snow’s action demonstrated that the spread of this particular disease could be prevented by replacing a contaminated water supply with an alternative source of clean water.

Thus the public health movement of the 19th century involved a combination of health services provision (at both local and governmental levels), social reform (at both local and governmental levels) and investigation into the causes, effects and distribution of disease (epidemiology).

In 1739, over 100 years before the Public Health Act of 1848, Thomas Coram had established the Foundling Hospital in an attempt to provide care for the growing number of babies (often illegitimate children of the poor/working classes) abandoned on London’s streets. Coram’s initial attempts to secure funding from the government and the Anglican Church were rejected, but with perseverance and the help of charitable funding, he established a hospital that rapidly became overwhelmed with admissions (Franklin, 1964, Kosky and Lunnon, 1991 and Lomax, 1996). Government financial support was eventually forthcoming, although Lomax (1996 p 4) suggests that State intervention was, in part, responsible for the discrediting of the hospital, leading to accusations that by agreeing to accept all children arriving at its doors, it encouraged ‘irresponsibility and immorality’.

The Foundling Hospital was primarily concerned with providing protection and education for children. Its support of the medical or healthcare needs of children was somewhat of a secondary consideration. By contrast, the work of Dr John Bunnell Davis, who established a children’s dispensary in London in 1816, set out to both treat children (on what would now be described as an outpatient basis) and also ‘serve to train parents in the better care of their offspring’ (Lomax 1996 p 5). When Davis died in 1824, the work of the dispensary went through a period of decline until the arrival, in 1839, of Dr Charles West, who worked at what was now referred to as the Royal Universal Dispensary for 10 years while simultaneously striving to convert the dispensary into an inpatient hospital. Although this particular aspiration floundered, Charles West is often credited with being almost single-handedly responsible for the establishment of the first Hospital for Sick Children in Great Ormond Street, London, in 1852. West’s pioneering endeavour was then followed by a period of 50 years of intense activity in building and establishing children’s hospitals throughout the UK. By 1900, there were over 30 children’s hospitals and upwards of 50 children’s convalescent homes. In addition, many general hospitals had formally dedicated one or more wards exclusively for the care of children (Lomax 1996).

This dramatic growth in the provision of hospital care for children occurred largely as a result of charitable intervention and voluntary funding. Many of the hospitals or wards therein bore the names of the benefactors whose contributions had made the building and staffing of the institutions possible. In addition, ‘private’ payments for care afforded to children within the hospitals contributed significantly to the hospitals’ income and thus to the provision of care to those who could not afford to pay, but who might be considered as ‘interesting cases’.

Lomax (1996) suggests that, in addition to providing inpatient and outpatient services, many of the children’s hospitals also established private home-nursing services, particularly when they first opened. However, such initiatives were often short-lived, partly because of the expense but also because of resistance from the hospital medical staff and hospital administrators. Charles West, however, considered this to be an essential element of the service provided by Great Ormond Street and, in the mid-1870s, made formal proposals to develop a private domiciliary nursing service to the hospital’s management committee:

It was another 14 years before the persistence and persuasion of Dr West and Dame Catherine Wood, the Lady Superintendent of the hospital, led to the establishment of the Great Ormond Street private domiciliary nursing service in 1888 (Whiting 2000). Elsewhere in the country, those children’s hospitals that continued to provide a domiciliary outreach service did so on a private, fee-paying basis only.

The provision of non-fee-paying nursing support of children in the community did, however, begin to develop towards the end of the 19th century from two distinct sources: district nursing and in the forerunner of current health visiting service, the Sanitary Reform Associations. In addition, school-nursing services for children began to emerge in the final decade of the century.