Social Work History and the Lady Almoner

Tomorrow is World Social Work Day, so it’s a fitting time to think about the history of social work. This is a field I’ve been interested in for a while – and to which I hope to return in the near future. In 2012 Professor John Stewart and I co-organised a workshop at Glasgow Caledonian University on Social Work, Health and the Home: New Directions in Historical Research.

This event brought together academics at all stages of their careers and from across a number of disciplines. Some were scholars of social work or social policy, others historians who had not considered their research part of the wider history of ‘social work’ until invited. In this category we might put two speakers from Oxford Brookes University: Dr Alysa Levene argued the presence of children made a family more worthy of support in the charity work of the late-eighteenth century, while now-Dr Stephen Byrne argued the late-nineteenth century saw the established notion of ‘collective responsibility’ for child protection, on the part of the whole community rather than the family alone.

It is not surprising that a workshop on the history of social work should find a prominent place for discussion of ‘family’, but what was striking was that our focus was not on professional practices designed to support or restructure the family from any institutional perspective. Rather, on the day, our attention was directed to the home itself and placed the activities of social work firmly within the context of the family. This was also notable when John Stewart located psychiatric social work within ‘the family constellation’ by means of home visiting, and when Dr Pamela Dale of the University of Exeter placed social work activities with unmarried mothers within a wider context of health and welfare programmes in the 1940s.

The relationship between social work and the family was one of three core themes that emerged. Another was social work as a profession. Should we think of social work as a profession or a set of activities? Professor Malcolm Payne separated ‘work, profession and discipline’ as distinct aspects of social work to be researched and discussed – something that allows us to write a longer history than encompasses the eighteenth and nineteenth centuries, where we can see recognisable activities taking place before the beginnings of the social work profession in the 1890s. Meanwhile, there was a number of thought-provoking papers given on different aspects of the 120-year history of the more formal profession.

Dr Graham Bowpitt, Reader in Social Policy at Nottingham Trent University, drew attention to the use of rational methods and social science approaches to deliver ‘spiritual regeneration’ and serve as a form of evangelical outreach in the foundations of social work. Dr Georgina Brewis of the University of London’s Institute of Education and now-Dr Lynn Bruce of the University of Glasgow both discussed the place of university settlements and projects in the first decades of the twentieth century. John Stewart considered the place of the psychiatric social worker in the mid-twentieth century, working alongside psychiatrists and psychologists in the ‘classic’ child guidance team. And Mike Burt, former social work lecturer at the University of Chester, examined the move from a focus on ‘ascertainment’ to one on ‘assessment’ as social work struggled to find a secure position within the local authority between the 1950s and 1970s.

The third core theme of the workshop was an introspective one, as the discussion returned repeatedly to the various uses of history. The key question was: Do we intend to use social work as a way of understanding the social world of the past, or to use history to inform our understanding of social work today? Given the presence of researchers from a variety of disciplinary backgrounds, it’s not surprising no definitive answer emerged. Rather, it prompted us to think about how we each conceptualise our own work. It, moreover, allowed us to work through this in the Scottish case.

Emeritus Reader Dr Chris Nottingham addressed the importance of child protection as a central issue in the development of the social work profession then research student Stephen Plunkett spoke on the introduction of community care. In addition to historians, we also heard from two expert commentators: Honorary Professor George Irving, a former Director of Social Work, and Chris Robinson of the Social Work Inspection Agency. This allowed for the idea of Scottish distinctiveness (with the role of Church significant) to questioned and discussed, both from historical and professional viewpoints. This is the sort of interdisciplinary collaboration – both grounding the history of a profession in professional practice and putting that experience in context – that I’m convinced is essential in taking forward the history of social work.

So why am I writing about this now, two years later? Well, this workshop was the major event in my long-running interest in the history of social work – something I’m hoping to come back to in the near future. The uncertainties of being an early career academic mean it’s all too easy to let good ideas fall to the wayside. Writing this blog post is one way for me to keep revisiting these ideas and make sure they don’t die a slow death for lack of attention. A funding bid for a major project I recently put together with Dr Alannah Tomkins and Professor Karen Hunt at Keele University is another. (I’ll be blogging more about that if the bid is successful.)

The paper I gave at the workshop was on a topic that will come up in the book I’m currently writing, but I also hope to make the focus of new research as well – an influential yet often overlooked figure in British social and medical history: the Lady Almoner. Later renamed the medical social worker, she was initially appointed to hospitals as a way of weeding out middle-class ‘abuse’ of the charitable system. This was distinctly the case when Miss Mary Stewart, a Charity Organisation Society case worker, was appointed the first almoner at London’s Royal Free Hospital in 1895. By 1964, however, it was felt so strongly that an almoner was no different from any other social worker (apart from the hospital setting) that the profession’s national association, Institute of Almoners, officially changed its name to the Institute of Medical Social Workers.

Sheffield almoner, c.1922

The almoner was an important figure both for the hospital and for the patient. She (and it was almost never ‘he’) replaced the old infirmary subscriber as the respectable gatekeeper of medical philanthropy. In the past, a potential patient would have needed the approval of a donor to the hospital, pleading cap in hand for a ‘subscriber’s ticket’ as a passport to free medical treatment. By the twentieth century that was seen as outmoded, but the almoner served much the same purpose. Upon arrival at hospital, the patient would be assessed twice. The first time, a medical decision would be made: was admission necessary and clinically appropriate? The second time, the almoner’s assessment: could they afford to pay something to the institution towards their maintenance? Investigating this question also allowed the almoner to weed out those who did not need the medical charity of the infirmary and send them separately to a private ward, where they might pay as much as ten times the rate of those who paid anything in the ordinary wards.

Much of the writing we have from the time emphasises that money wasn’t the only thing the almoner did – but, rather, understanding the home and work life of the patient was an important part of getting a broader view and being able to understand what other support their might need beyond medical treatment. The following was written in the 1935 annual report of Addenbrooke’s Hospital in Cambridge:

Each Department of the Hospital sees the patient from a different angle. In the Almoner’s Office he is no longer the gangrenous appendix, the obstinate arthritis, or the glaucoma that has responded so well to treatment, but an ordinary human being with his background of ordinary human cares and relationships. He is for us the out-of-work trying to balance a budget that can never quite meet the household needs; an Old Age Pensioner without kith or kin; a child whose future still hangs precariously in the balance. Through the Almoner’s Office pass all the types which go to make up the Hospital world, the lonely, the misfits, the discouraged and the difficult–all through sickness or poverty, in need of some help or advice.

So the work of the Lady Almoner was about more than administering payment schemes. But that financial side was important for the patient, for whom the experience could sometimes be an intimidating interrogation, and for shaping the profession itself. When I spoke at the the GCU workshop, Sir George Irving, who was once – in the 1960s, I believe – an almoner’s assistant, recognised my account of the role as more centred on means testing and social enquiry than social work as we know it today.

So it was an important position within the hospital with significant influence over how and where people were treated, what support they might receive after leaving hospital, and how much they would be asked to pay. Yet there is still much we don’t really know in any detail about the almoner. Here are a few of the questions I really want to explore.

Who actually became an almoner? The 1910-1912 Every Woman’s Encyclopaedia drew attention to the opportunities this new profession offered for ‘a woman of culture and education’, as an alternative to ‘teaching or one of the ordinary professions’. But what about the background, training and career trajectories of almoners? What about almoner’s assistants (the equivalents of today’s under-trained, under-paid and over-worked social work assistants)? I’ve found memoirs suggesting the position may have offered a chance for women without previous education or relevant experience to enter the profession. But then I’ve also looked at the central register of almoners, which suggests almoner’s assistants were more often the first position for fully qualified almoners. The membership and structure of the profession is still largely unknown.

What difference did the almoner make to the hospital? The fact it was a female profession is worth thinking about here. After all, it took two years at university to reach this high-status position within the hospital, at the same time as women doctors were still struggling to find a foothold in their profession. Since a new role was carved out for a distinctly female profession, not only in the institution but also within the clinical team, does this mean the professional arrival of women in the hospital was diverted away from medicine and to the social function of the hospital? This matters both for women’s history and for medical history – as it’s a notable caveat to the broader narrative of the hospital becoming entirely ‘medicalised’ over recent centuries.

Was the almoner socially divisive or seen as ensuring fairness? A middle-class woman telling working-class patients they should pay for their time at hospital is how some writings from the time and looking back characterise the almoner. But she was also policing middle-class patients, removing them entirely from what we might think of as affordable healthcare and telling them they were not entitled to medical charity. It was her job to enforce the class divisions of the early twentieth century that were so ingrained at one time. Yet they were also brushed aside in 1948 by the introduction of the NHS with a new universalist approach. So how did a profession so clearly shaped by older principles adapt to this new age?

While occasions such as World Social Work Day might focus attention on the profession’s contribution to society, we should bear in mind that these things are not fixed but must be constantly renegotiated. Asking these questions about its history is key to placing in context and better understanding what it is that is being celebrated and defended today.

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