The concept of the care homes stemmed from workhouses under the 1834 English Poor Laws in the UK, imposing legal responsibility for care of the aged on society. Those lacking in employment, money, shelter, and health (and without family support) were obliged to seek indoor relief, which many found through workhouses (1). One of the most widely known depictions of workhouses was through literature in Dickens' Oliver Twist (1838), and their design was paralleled to prisons. As only those with the financial capability could be cared for in voluntary hospitals set up by charities, the workhouse became an advantageous option for the vulnerable as they would be given food and medical care. Over the 19th century, workhouses inevitably began filling with more sick people in their infirmaries than the developing hospitals which primarily focused on acute illnesses than chronic, and older people would continue to reside in workhouses until they passed away (1). The workhouses also had cemeteries built within proximity to bury their dead without charge, whereas outside the workhouse system many had to pay for burials.
Under the development of liberal and socialist philosophy did a reform in workhouse systems generate acknowledgement for the need of public health and social welfare. Construction of public hospitals and the breakout of small pox epidemics led to a wider variety of people seeking hospital care. From this, care accommodation divided into nursing homes, pay hospitals, and pay beds from the 1880s (1). There was also a growing realisation that workhouses were no longer used for its intended purpose, but rather as a hospital, orphanage and elderly home (2). The responsibility of these institutions were transferred from the Poor Law Board of Governors to local authorities, reclassifying them as Public Assistance Institutions (PAIs) in the late 1920s.
As the Second World War brought air raids and casualties, some elderly found themselves discharged from hospitals or homeless and sought refuge in PAIs, leading to overcrowding. Smaller private accommodations began to be encouraged, moving away from mass institutionalisation. Postwar, the National Assistance Act 1948 abolished the last traces of the Poor Law and placed further responsibility in local authorities to provide residential accommodation to those in need of care (3). Workhouses were taken over and converted to public sector residential care homes. This allowed residential care homes and nursing homes to be differentiated as homes providing personal care or on-site nursing care, and provision guidance policies issued in the 1960s and 70s for homes to distinguish levels of frailty further cemented the division. This was also the time where the first care homes began to be established in Hong Kong, but not through the government.
Penistone Workhouse, West Yorkshire, is one of the last surviving workhouses that was converted into Netherfield Aged Persons Home as a PAI. It is now used as the sixth form college of Penistone Grammar School.
Prior to this, the Western healthcare and medical services were first introduced to Hong Kong when the British Armed Forces took possession of the then-fishing village in 1841. The Naval and Military Hospital was constructed solely for the British but was destroyed by seasonal typhoons (4). The HMS Minden was the first colonial hospital ship to be stationed fitted for its purpose and stayed in commission from 1842 to 1846, paving the way for future hospital ships and eventually land based hospitals. On the other hand, public health and social services for the Chinese population was not a priority to the government who only provided emergency relief, creating racial and class segregation.
The first Chinese hospital was established by the Tung Wah Group of Hospitals, a charity organisation set up by local Chinese magnates. The group found roots at the small Kwong Fook I Tsz Temple at Tai Ping Shan Street, taking in the sick and destitute as a refuge alongside ancestral spirit-tablets already housed inside (5). Tung Wah Hospital was eventually constructed in 1872 (for which community leaders raised funds), providing free Chinese medicine, funeral services, and more. Other sources of social support included clan associations, missionaries, and churches. Churches in particular built "hospitals, clinics orphanages and homes for the elderly" - one of the first instances of elderly accommodation in Hong Kong (6). It is interesting to note that Christianity (both Protestant and Catholic) was introduced to Hong Kong in 1841 alongside the colonial occupation (7).
Kwong Fook I Tsz Temple The Rise of Western Medicine in Hong Kong
Western medicine prevailed over Chinese medicine with the advancement of medical knowledge, invention of technology such as the microscope (allowing bacteria observation and understanding of disease, and subsequently viruses and developing antibiotics), institutionalisation through founding medical schools, and the 1861-1895 Self-Strengthening Movement (4). The government did still not see social welfare as their responsibility but rather directed effort into disease prevention through infrastructure and public health education, especially after the 1894 plague (8). Tung Wah Hospital too had to begin offering western medicine to tackle disease. Following this, political events such as the Chinese Civil War and World War 2 caused population expansion in Hong Kong from a massive influx of immigrants from the Mainland, of which were primarily young to middle-aged, contributing to the overflowing demand for residential care services today (9). Industrialisation just beginning and many lived in hardship. Provision of social welfare could not rely solely on voluntary agencies and emergency relief.
It was not until 1971 that legislation under public assistance was introduced, the first public assistance scheme modelled off the British National Assistance Act (10). Up to this point, the government stressed that senior citizens and welfare were the filial responsibility of families, and retirement homes were established by religious organisations in the early 1960s (11). The government began to take responsibility for social welfare and services - although the Social Welfare Department had existed since the 50s, they began studying long-term elderly care strategies and the first programme plan on elderly care was prepared in 1976 (12). Small private residential care homes finally began to emerge in the mid 1980s, filling the service gaps (9).
The Hong Kong Family Welfare Society, a non-government organisation, piloted the "Home Help Service" in 1972
Residential care accommodation in the UK can be seen to have developed from public assistance through the government: poverty relief - which despite being arguably a means to hide the poor away was in itself was a form of social care - and public health provision. Responsibility begun from the state and was transferred to smaller scale local authorities. Later under the Thatcher Conservative government did residential care homes become market commodities, shifting the scales to favour development of private provisions. In contrast, social care provision in Hong Kong developed from the Chinese population themselves through charitable voluntary groups and religious groups. The government allowed public health and social welfare to develop its their own, encouraging self-reliance until public assistance was required to support the massive growth and industrialisation. Today, care homes in the UK are scaling down with various options in the large private sector, whereas those in Hong Kong are scaling up as there is need for government subsidised care, with new build institutions looking to accommodate as many as possible - in this sense, the two are going in opposite trajectories regarding elderly accommodation.