In 1929, the Local Government Act broke up the apparatus of the Poor Law Guardians and Unions, and transferred responsibility for the care of the poor to local councils. In theory, the period between the passing of the Act and the formation of the National Health Service witnessed a large-scale reclassification of the sick poor as patients rather than paupers. In reality, as this investigation of contemporary judgements of hospital quality and bed and staff numbers in English and Welsh county boroughs shows, the national picture was very varied at the local level. Local and sometimes regional traditions of care, finance and council priorities had a large influence on the ongoing development of a unified medical service which included the poor. In the best case scenario, hospitals were classified by patient type, and the principle of ‘less eligibility’ was discarded. Elsewhere, economic status continued to direct medical treatment, but in almost all cases, the chronic and elderly poor were more likely to remain in low-quality and unmodernized buildings than the acutely sick. The investigation highlights the disjuncture between the changed vision for the sick poor and its patchy enforcement on the ground.