Abstract
In England in the early twentieth century, mental observation wards in workhouses developed as a parallel service to the asylums for emergency mental health admissions under the 1890 Lunacy Act, particularly in urban areas and especially London on account of local policy. The purpose of the wards was initial patient assessment and early discharge or certification, and there was controversy between their medical supporters and the Board of Control about any extension of their remit which might usurp the role of the mental hospitals. Their significance declined with changing policy in the NHS era, as more emergency admissions went to mental hospitals, and local treatment units emerged. This article explores the history of these services in the context of the changing legal and policy frameworks.
Introduction
Throughout the Victorian period and most of the twentieth century in the United Kingdom, the lunatic asylums were the principal provision of formal care for people with mental disorders. Their function included the admission of acute cases, as well as maintaining ever-increasing numbers for long-term care. However, their role in dealing with admission and assessment had a lesser-known parallel to be found in the workhouses and their infirmaries.
These institutions for paupers, i.e. those too poor to survive or obtain care without public funds, had become the principal institutional location for managing pauper lunatics in the early part of the nineteenth century (Bartlett, 1993: 47–8). Around the beginning of the twentieth century, specific locations appeared in workhouses or their infirmaries for dealing with urgent admissions. These were the mental observation wards, which were focused solely on assessment and short-term care.
The story of the mentally ill within the workhouse is compressed into its institutional history as only one of several kinds of destitution, whereas it was the sole focus of the asylums which, with greater prestige and better funding, attracted more attention. Nevertheless, the workhouses and their infirmaries played a significant part in the mental health system of the period, with their average annual admissions for mental illness in the 1930s similar to those of the smaller asylums (National Archives, 1937) and in London they were the initial point of admission for over 6,000 people annually (Fairfield, 1937). Given this important contribution, it is surprising that there is no substantial analysis of their role in this period of dramatic change in social attitudes leading to the welfare state and community-based provision outside the mental hospitals.
This article explores the history of the observation wards and their relationship to the legal framework in which they operated and the changes taking place in wider psychiatric service development. Their documentation is primarily in the medical literature, written by those who worked in the setting, complemented by reports from regulatory authorities in the 1930s. Administrative records of the workhouses rarely refer to observation wards, but an exception to this is London, where the administrative records do contain some more specific material. Of particular interest is the observation ward at St Francis Hospital in London (also known as East Dulwich or Constance Road Institution), the subject of the bulk of the medical studies covering a 30-year period, as well as two doctoral theses from non-medical sources.
These medical sources usually take the observation wards as a well-understood entity requiring no further explanation, so there is only one brief attempt to place them in a historical context (Eilenberg, Pritchard and Whatmore, 1962). The present article aims to make use of this medical literature and widen the context of the analysis through use of other available sources, namely: newspaper reports; Hansard records; contemporary fiction; the administrative records from Bristol and Somerset records offices in the South West of England, the London Metropolitan archives, and the National Archives; literature held by the British Library, the Wellcome Library and Bristol University library; also medical literature between 1885 and 1970 in the online databases EBSCO, PubMed, Access to Research and Science Direct. The term ‘observation ward’ was used for all these searches.
The terminology used in the period of the source documents has been retained, rather than attempting to cast it in contemporary language. This will reflect changes such as asylums becoming designated as ‘mental hospitals’, and lunatic becoming ‘person of unsound mind’ after 1930, and relieving officer becoming ‘duly authorised officer’ after 1948. When referring to the residents of the observation wards, the term ‘patient’ has generally been used, consistent with the practice of most of the medical writers.
Origins
The legal framework
Between 1890 and 1960, the route to compulsory admission was through the 1890 Lunacy Act, until it was replaced by the 1959 Mental Health Act. In most cases, this was through a summary reception order involving a medical certificate of lunacy and an order from a specially appointed justice of the peace or a court, which lasted for a year in the first instance. It was not possible to be in any asylum without being certified in this way. However, there was another provision in the Act, Section 20, which was intended to deal with urgent cases by sending them to a workhouse, or an infirmary associated with the workhouse. The wording defining its operation was: ‘necessary for the public safety or the welfare of the alleged lunatic’; the Poor Law relieving officer (a public official employed by the Board of Guardians for unions of parishes) or a police constable could remove an alleged lunatic without medical involvement to a workhouse for up to three days, pending review for a summary reception order. This non-judicial compulsory procedure may have been common practice for over 40 years (Bartlett, 1993: 197).
There were other short-term provisions in the Lunacy Act relating to workhouses, which could extend the three-day order by a further 14 days. A justice making a summary reception order, often following a Section 20 admission, could suspend removal to the asylum for 14 days to allow detention in the workhouse under Section 19. Justices could also detain people in the workhouse under Section 21 for up to 14 days, where the case for certification was not certain but it was unsafe to let them go. F.S. Toogood (1906), medical superintendent of Lewisham Infirmary, described the procedures in detail and found Section 19 the commonest means of prolonging detentions. However, Nathan Raw (1902), physician at Mill Road Infirmary in Liverpool, described nearly all admissions as being initially under Section 20; the patients could then be detained for up to 14 days by the workhouse medical officer under Section 24. The latter became the principal procedure, as described in a British Medical Journal editorial (Anon., 1919).
Lunacy in the workhouses
From the 1840s onwards, the workhouses catered less for destitute, able-bodied men and their families and increasingly for the elderly, incapable or sick (Fowler, 2007: 92). The Poor Law Guardians were expected to provide infirmaries which were separate from the workhouse, and this led to more new buildings on workhouse premises in the later nineteenth century, with 155 infirmaries built between 1867 and 1883, as well as 14 lunatic wards (Brundage, 2002: 121). Nevertheless, this was a slow process, as 36,500 out of 60,000 sick paupers were still in mixed wards instead of infirmaries in 1896 (Fowler, 2007: 155). By the end of the nineteenth century these infirmaries were often used for poor but not destitute citizens, rather than solely for the workhouse inmates (Webb and Webb, 1910: 149).
Mentally ill paupers had always been found in the mixed general wards of the workhouses, alongside those with other types of chronic sickness (Fowler, 2007: 152). Concerns about their treatment had provided some of the impetus towards establishing the pauper lunatic asylums in the nineteenth century (Select Committee, 1815: 54–7). Nevertheless, throughout that century around a quarter of the insane poor were located in workhouses rather than the county asylum (Bartlett, 1998). Some workhouses established separate mental wards, mainly to house patients who had no prospect of being cured and who did not warrant treatment in an asylum. However, when the mental wards at workhouses in Birmingham, Manchester, Sheffield, Bath, Leicester, Redruth and Norwich were visited by the Lunacy Commissioners in 1842, many patients were considered in fact to be dangerous (Jones, 1972: 39); these wards were often used as a means to avoid transfer of patients to asylums, where the cost to ratepayers was higher (Hodgkinson, 1967: 583). Furthermore, the admission process was considerably less bureaucratic than for the county asylums (Bartlett, 1998).
The workhouse was also a setting for emergency mental health provision. Raw (1902) found that, over five years, he was able to discharge as recovered 32 per cent of his infirmary’s intake of 3,129 patients under Section 20. Many of those admissions were due to ‘toxic poisoning such as alcohol or arsenic or by the toxins produced in the course of any of the infective fevers’. The workhouse was the only place to which those with delirium tremens could be compelled to go if they were not certified under the Lunacy Act to be admitted to an asylum. In Raw’s view, the remedy for unnecessary certifications to the overcrowded asylums was a ‘reception hospital’ in every town, so that all acute cases could be admitted and detained for up to six weeks to allow the best chance of recovery. Toogood (1906) described the provision at Lewisham workhouse for these emergency admissions, before a separate infirmary was built in 1894. There was a room for two female lunatics in a cottage, a dark shed with four beds for the males and a padded room for restraint. This accommodation was for people who were too disturbed to be left even temporarily at home before certification, and for wandering lunatics brought by the police. After the infirmary was built, the situation improved; it had two mental wards, eventually accommodating 11 men and 11 women. A patient could be kept there for up to 17 days, the maximum possible detention period in a workhouse under the Lunacy Act. Half of the admissions recovered sufficiently over that period to be discharged without going to the asylum.
Mental observation wards
It was in this context of emergency mental health provision in the workhouses that a new institutional response to urgent cases of mental disorder appeared from the 1880s onwards: the observation ward. At the end of the nineteenth century, newspaper reports mention observation wards found in many institutions, prisons, military hospitals, children’s hospitals, schools and fever hospitals. Here they were for the purpose of closer observation of unclear cases of illness that might become more serious, or for quarantine, or, in the case of fever hospitals, to avoid putting in the smallpox ward patients who actually had a less serious condition (Anon., 1895). In the workhouses, the purpose was more explicitly for the reception of the mentally ill arrivals, focusing on more urgent and disturbed arrivals without a long-established mental disorder or, for initial assessment, less clear-cut cases who might not need to be certified to an asylum. As early as 1885, a visiting commissioner in lunacy recommended that Fusehill Street workhouse in Carlisle should provide an observation ward in the infirmary block (with a padded cell and an attendant for violent cases) to cater for ‘irresponsible persons’ and to prevent patients escaping by jumping out of windows (Anon., 1885). An inquiry into a death at Holborn Union workhouse in London heard that ‘there were eight in the insane or observation ward’ (Anon., 1892).
Something similar was happening in Scotland, where Poor Law observation wards were developing systematically. Although the legal framework was different, with voluntary admission a (rare) possibility, the emphasis on treating early cases and avoiding certification if possible was similar. An early experimental ward with 12 beds in Barnhill Poorhouse, Glasgow, opened in 1890 for cases of ‘incipient insanity’. This had developed into a 50-bedded provision in Eastern District Hospital by 1904. The Scottish Local Government Board set conditions for these observation wards: they must resemble hospital wards, be separate from the other poor-house wards, have at least 1,000 cubic feet of airspace per bed, and have some single rooms. Their patients needed to be medically certified as suitable for treatment and could not remain longer than 6 weeks; there had to be a resident doctor if there were more than 16 beds, and at least one nurse per 8 patients. The intention was to provide a treatment space for those who were expected to improve quickly but who were not dangerously violent, suicidal or had a long-established mental illness (Anon., 1914). An editorial response to a letter in the Aberdeen Weekly Journal (Duffus, 1898) stated: Where there is the least suspicion of the insanity of the patients they are sent to the observation ward where under the eye of competent medical officers . . . it is decided whether the patients have to go to the asylum, the fatuous wards of the poorhouse or back to their own home.
One English medical deputation was inspired by these developments to lobby for fully informal admission to all observation wards and general hospitals (Anon., 1914).
These early reports all relate to large towns and cities, and specific observation wards probably did not develop in more rural county workhouses. Many, if not most, workhouses would not have had special observation wards for the mentally ill, and any emergency admissions went into the general wards. Where observation wards did exist, they appear to have been part of the main workhouse building and were often fairly small rooms with 2–12 beds. They would have accommodated those brought in under Section 20, and the medical officer would have decided whether the patients were to be detained there for three days before certification to a mental hospital or kept for the maximum of 17 days. Some others were admitted under the Mental Deficiency Act. Early twentieth-century newspaper reports refer to individuals suspected of lunacy and detained in the workhouse observation ward, at least in London (Anon., 1906, 1907); a new workhouse was built in Hammersmith in 1905 with observation wards as part of the reception block (Higginbotham, 2019). Observation wards also found their way into contemporary fiction, one being described in grim detail in Christina Alberta’s Father by novelist H.G. Wells (1925: 221–46), set in London around 1920.
Edward Mapother, consultant psychiatrist at the progressive and influential Maudsley Hospital, and for a period the consultant attending St Francis observation ward which was linked to the Maudsley, was an early enthusiast. In 1929 he was recommending observation centres for the ‘objecting and objectionable’ patients who needed early treatment for curable conditions. His view was that since only 50 per cent of observation ward admissions went on to mental hospitals, these wards were beneficial in avoiding admissions to the latter. He wanted them to be an established part of the mental health system and located on a general hospital site, so that they could easily obtain medical investigations and specialists (Mapother, 1929).
1929–48: the effect of the 1929 Local Government Act
The 1929 Local Government Act substantially altered responsibility for the workhouses by abolishing the Board of Guardians and transferring managerial responsibility to the county council. In particular, it empowered the county council to take over any workhouses used for hospital purposes. The county councils reviewed the existing workhouse provision and divided it into hospitals for the chronic sick, supervised by the Public Health Committee, and public assistance institutions under the Public Assistance Committee. This division was an arbitrary one and, by the end of World War II, there was little improvement in the fabric of the buildings or the minimal facilities and dismal quality of life for the residents (Townsend, 1964: 18). The Lunacy Act had to be amended to allow emergency admissions to go to these renamed facilities, as the workhouses of the previous legislation no longer officially existed (Lawson, 1966: 39).
In London, this change in management meant that the county council found itself responsible for many unsuitable settings for emergency psychiatric admissions. The Mental Hospital Committee noted that there were difficulties in admitting new cases, which were in both general hospital and public assistance institution settings, for various reasons: some beds were occupied by patients who could instead have gone directly to the mental hospital; delays in certification; non-certifiable patients staying on in the ward; and waiting lists for Tooting Bec Hospital for senile dementia (London Metropolitan Archive, 1931a).
Letitia Fairfield, a Senior Medical Officer in Public Health for London, commented that 12 observation wards had no day room and 9 were only single wards for all types of admissions. Some of these were very small, with only six or seven beds, meaning that there would only be one attendant on duty who might have to rely on the porter for help with restraining a patient (Fairfield, 1937). These were all locked facilities. An agreement in 1935 recommending that patients should wear their own clothes as an aid to recovery (London Metropolitan Archive, 1935) suggests some regime liberalization took place.
It was planned to reorganize these wards into specialist observation wards, attached to existing hospitals, for receiving emergency admissions under Section 20. Six units were planned with male and female sections, each comprising 12 beds for acute admissions, 12 for less acute, 12 for convalescents and 2 padded rooms. This planned reorganization did not take place until after World War II, but by 1959 there were four units associated with general hospitals, one with a mental hospital and one with a teaching hospital. They had 224 beds in total; the largest was at St Francis hospital in East Dulwich, with 82 beds (Eilenberg et al., 1962).
Fairfield’s report on Mental Health Services in London (London Metropolitan Archive, 1936) enumerated the advantages of a high-quality observation ward: skilled medical and nursing observation; safe custody if no vacancy in the mental hospital; voluntary admission to the mental hospitals possible as an alternative to certification; some acute cases such as puerperal psychosis and delirium tremens completing treatment there and avoiding any admission to the mental hospital; and doctors and justices could see several cases at once and not need to visit individually at home. However, in the original observation wards, practice was often not satisfactory: no skilled staff; reviews for certification by doctors who had not read the case notes; inadequate treatment while awaiting transfer to a mental hospital; and immediate discharge back home regardless of condition if not certified in the first three days. In her view, the larger consolidated wards would reduce these drawbacks and facilitate the advantages. The ideal model proposed was of at least 35 beds for each sex, divided into two acute wards, a convalescent ward for non-acute patients and those whose detention period had expired and were now voluntary by default, four single rooms, a day room, two padded rooms, a hydrotherapy bath, a waiting room for visitors, a small garden, a duty room for nurses, and rooms for magistrate, relieving officer, medical officer and psychiatric social worker.
Fairfield’s 1936 report documents nine cases where transfer to mental hospital of very disturbed patients was delayed for over a week after certification. This reduced the availability of observation ward beds, as did the regulation that all voluntary patients had first to be seen by a consultant psychiatrist in an outpatient clinic or in the observation ward; this resulted in a typical wait in the observation ward of up to three weeks for a mental hospital and four weeks for the Maudsley Hospital, while being detained under dubious legal provision. The situation was to be improved by consultants from the mental hospitals visiting a specific observation ward weekly. By 1937 Fairfield noted improvements in the skills of the nursing staff and the domesticity of the environment, as well as the arrival of postgraduate psychiatric trainees (Fairfield, 1937).
Controversy between the Board of Control and the enthusiasts: the 1935 report
Observation wards were not universally acclaimed. The Board of Control, the regulatory authority for lunacy and mental deficiency, was in favour of all cases going straight to mental hospitals. In 1935 the Ministry of Health in conjunction with the Board of Control commissioned a report into institutions receiving patients for observation of mental symptoms (National Archives, 1937). This received information from 60 institutions or hospitals, exempting those admitting fewer than 30 patients annually. In 1934 they admitted 15,078 patients, sent 6,350 to mental hospitals, and discharged 4,331; 1,384 patients died and 578 were readmitted within the year. The average of 250 admissions annually was similar to that of smaller mental hospitals at the time, and it was estimated that around 20 per cent were retained in the institution. In London institutions, there was disparity in the proportion sent to mental hospital, ranging from 27 to 72 per cent, and in discharge rates which ranged from 12 to 52 per cent. Even greater differences were seen in provincial institutions where between 15 per cent (Birmingham) and 70 per cent (Sheffield) went on the mental hospitals.
Further differences between London and provincial institutions were apparent. While all of those in London had separate observation wards, only 20 of the 47 provincial institutions did. In the others, admission was to the mental ward for chronic patients or to the ordinary sick wards. Overcrowding was a problem, with the provincial wards generally worse than the London ones; several of the former had no daytime space, and many had inadequate padded rooms and no facilities to separate ‘noisy’ from ‘quiet’ patients. Gardens were rare and airing courts were shared with chronic patients. Half had no trained mental nurses.
In 1935 the Board commented unfavourably about standards in observation wards, particularly those where newly admitted patients were in the same ward as those with chronic illness and intellectual impairment. While accepting that some observation wards in large cities were well-equipped with experienced staff and could be useful, the Board’s conclusion was that this was ‘far from the case generally’. Small observation wards were inevitably poor and inefficient, and should not be functioning at all without a trained nurse for both male and female sides. Their view was that observation wards were only for the diagnosis and quick disposal of doubtful cases; anything more prolonged diverted funds that should have gone to asylums which provided the specialized experience and treatment. Their preference was for admission units in mental hospitals under the Lunacy and Mental Treatment Acts; they believed that this was the way to reduce the stigma of the mental hospital by virtue of having acute cases which could be discharged quickly as well as the chronic ones (Board of Control, 1935: 8).
Nevertheless, in the same year the Board gave answers to questions raised by its Commissioners (who did the visiting of hospitals) and responded to their statement that a considerable number of patients in observation wards were, in practice, detained for long periods (National Archives, 1935). In this answer, the Board noted that admission to observation wards did avoid admission to mental hospitals ‘in a considerable number of cases’, that the public were still fearful of mental hospitals, and that they were ‘some distance from the ideal’ of every observation or treatment case being dealt with by the mental hospital. They were particularly exercised by a proposal for building an observation and treatment centre at Erdington Institution by Birmingham County Council.
The Commissioners later submitted a memorandum urging that observation wards ‘should take no effective part in a proper health service’ and noted that, in many rural areas and some urban ones, admissions for observation went to the mental hospital or to a general hospital where provision was made. Pending this, they proposed a minimum acceptable number of beds, nursing staff and psychiatric visits. Recognizing the overcrowding of mental hospitals, the Board was reluctant to go so far in its response, particularly about the elimination of observation wards as ‘it scarcely does justice to the standard reached by the observation wards of certain Local Authorities’ (National Archives, 1935).
This negative view of observation wards was disputed, especially in London where large well-organized wards were an important part of mental health provision. The medical view expressed in The Lancet (Anon., 1936a) was that while the observation ward was primarily a clearing house for psychiatric emergencies’ it was also valuable for those cases who could be treated in three or four weeks in the confines of a general hospital without the stigma of mental hospital admission, if it was adequately staffed and supported by sufficiently trained nurses, doctors and social workers with a visiting consultant psychiatrist. This would be particularly valid for treating acute or dangerous mental illness, short-lived confusional states or suicidal attempts. However, the mental hospital would be preferable to an observation ward where the staff had no psychiatric experience and functioned as a ‘common dumping-ground’.
Vera Norris, who studied London observation wards in the 1940s, describes ‘heated controversy’ between the Board of Control view and that of the observation ward enthusiasts. She believed that the Board held its view because much of observation unit accommodation was in hospitals unsuitable for the purpose. However, in London the observation wards saved the equivalent of 35 bed years in mental hospitals, minimizing the admission of seriously physically ill patients there, avoiding long journeys for relatives and helping to limit overcrowding in mental hospitals. She concluded they were useful for large cities but, in less populated areas, a mental hospital unit might be better (Norris, 1959: 92–4).
The Board of Control had expressed approval of the development of separate admission units in the mental hospitals as its preferred route for emergency admissions (London Metropolitan Archive, 1931b). These units would be for recent cases and would be separate from the main building, making them similar in function to the observation wards. The Board reaffirmed in 1935 that no mental hospital without a detached admission unit and treatment centre could be regarded as complete (Anon., 1936b). Mental hospitals in Derby, Hampshire and the Isle of Wight had developed these in the 1930s (Asylums Index, 2001) and they became fairly widespread, with 60 per cent of mental hospitals having an admission unit by 1945 (Hansard, 1945).
Clinical accounts
A comprehensive description of the work of one London mental observation ward in the mid-1930s was published by Pentreath and Cunningham Dax (1937), who were the successive medical officers in charge there. Their account gives details about the unit (which is not named, but is recognizable from the description as the St Francis unit) and warrants recounting in more detail as it gives a unique insight into observation units of this period. Located on the site of a large general hospital and chronic sick unit, the unit had 82 beds distributed across two male and two female blocks, and it admitted approximately 1,000 patients per year. There was a self-contained 10-bedded ward in each block for preliminary observation, with two side rooms and two padded rooms for violent patients. (Other observation units used padded high-sided beds enclosed with netting instead of padded rooms.) Also on the ground floor was a larger ward for ‘quieter bed cases’, and above these was a further ward for less disturbed patients with a recreation room and garden for exercise.
A medical officer was in charge, and there was also another medical officer and a psychiatric social worker. Most of the nurses had experience in mental hospitals or a certificate in mental work. Many patients arrived in a state of severe self-neglect, especially senile patients who had been living alone in degraded circumstances: ‘their clothes have not been taken off for months, they are alive with vermin and filthy with excretions. Their mouths are dirty, they are half-starved, constipated, bronchitic, anaemic and toxic’. Consequently, a significant part of the work was in giving physical nursing care. Most were detained under Section 20 by the relieving officer or the police (those detained by the latter more likely to be violent or suicidal), others through the medical officer’s 14-day order under the Section 24 from the general hospital. Surprisingly, a few patients entered entirely of their own accord, free to leave without notice, unlike voluntary patients under the Mental Treatment Act.
A magistrate visited three times a week to make summary reception orders on patients who were to be certified. Usually at the first meeting the magistrate made no order, and the medical officer extended the 3-day order by a further 14 days. About a quarter were discharged in that period. There must have been differences of opinion between the doctors and the magistrates, as some patients were allowed to be voluntary patients who the doctors thought would not stay in the mental hospital long enough for effective treatment. Indiscriminate use of sedatives was discouraged as it obscured the assessment of any underlying condition. A consultant psychiatrist from the nearby Maudsley Hospital came twice weekly to review the admissions, give a prognosis and recommend further investigations. The social worker for the unit wrote up the family, social and financial account of the patient, made arrangements for care homes, hostels or voluntary admission to mental hospitals and liaised with social workers in general hospitals. She also kept in touch with patients who relapsed after discharge, which suggests that there was a continuing relationship between observation unit and the patient.
The principal goal of Pentreath and Cunningham Dax was to counter the Board of Control’s view by providing evidence for the value of their unit. They pointed to the proportion of patients who were discharged home or were improved enough to be admitted voluntarily after successful treatment and who would otherwise have been sent to a mental hospital under the Lunacy Act; this indicated that if observation units kept patients longer for treatment, even fewer would need to go to occupy the oversubscribed mental hospital beds. Further justification for the observation units lay in their location as a safe place within the central area, given the distance of the London mental hospitals out of town and the shortage of beds there. Pentreath and Cunningham Dax thought that the role of the observation ward should be extended to allow longer and more complete treatment, thus avoiding the likelihood of superficial agreement to voluntary admission in order to avoid certification leading to premature discharge.
It must be said that St Francis was an exemplary unit which would have been far removed from the everyday experience across the country. The authors admitted that few other observation wards had consultant psychiatrists, medical and nursing staff with experience in mental disorders and input from a social worker. The unit was well connected to the Maudsley Hospital, adequately staffed and engaged in research, with pioneering enthusiasm that would not be easily replicated elsewhere.
A decade later, there was a study by Vera Norris, Lecturer in Medical Statistics at the Institute of Psychiatry (Norris, 1959). She conducted a survey of admissions to two observation units and three mental hospitals in London in 1947–9; she followed them up until the end of 1951 looking at their patients’ destinations (or death) after leaving the mental hospital or observation ward. The observation wards had 158 beds between them, located at St Francis and St Pancras hospitals, according to a later researcher at St Francis (Lawson, 1966: 14). Over this period, approximately 5,000 patients were admitted to observation units in London annually. Norris found that just under half went home after their stay on the observation ward and a few more went to hostels. Of those who went to the mental hospitals, most were certified, women more commonly than men. Admission via the observation wards was the usual route to the mental hospitals, with two-thirds of their admissions arriving in that way. Some were admitted with delirium because they could not be contained at home or in a general hospital, and over a third of these died in the observation unit, mostly in the over 65 age group. The commonest diagnosis was affective disorder, with schizophrenia and dementia occupying the second and third positions and delirium fourth. The most noticeable change from the situation reported by Pentreath and Cunningham Dax (1937) was the increased proportion of patients who went home.
Outside London
The 1935 report (National Archives, 1937) had revealed poorer provision of observation wards for emergency admissions outside the capital. There were also differences in practice. Fairfield commented that in Birmingham a certifying medical officer saw all the cases for certification at home, with only ‘doubtful cases’ sent to the observation wards and consequently only a small proportion of asylum admissions coming from observation wards (London Metropolitan Archives, 1931c). Furthermore, London was different from many other areas in its policy, established before the 1930s, of admitting patients to the observation wards first and consequently almost never arranging for direct admission to a mental hospital (Fairfield, 1937; Norris, 1959: 58). Another difference was that in London voluntary admissions had to be approved by a psychiatrist in the observation ward or outpatient clinic (Fairfield, 1937). The Board of Control (1935: 7) noted that in some areas of England, almost all cases were admitted directly to a mental hospital.
Accounts of provincial observation wards are limited. Liverpool, at least up to 1942, had an observation ward situated in a separate section of a large municipal general hospital at Smithdown Road; all urgent admissions were taken here first, although voluntary patients were admitted directly to mental hospital and a few went into private care (Hopkins, 1943). In Bristol, observation wards were in operation, although not exclusively for Section 20 admissions, at Stapleton Public Assistance Institution (Early, 1962). In 1934–5 there were 149 Section 20 admissions (Bristol Archives, 1935), later rising from 158 in 1941 to 212 in 1945 (Bristol Archives, 1938–48).
1948–59: the National Health Service era
The welfare state and National Health Service established in 1948 brought about the final abolition of the Poor Law, including its network of former workhouses and infirmaries. There were around 400 of these former workhouses, of which just under 100 became general hospitals, around 200 became joint use between the NHS and local authorities, and just over 100 remained with local authorities for residential accommodation (Townsend, 1964: 20). A list was created of designated hospitals for the purpose of Section 20 and 21 admissions, and this now included some mental hospitals. By 1954 there were only 140 designated for this purpose, of which one-fifth were in general hospitals, one-third in mixed general and mental hospitals, and the rest in mental hospitals (Norris, 1959: 93). Those in mental hospitals started handling more certifications than in general hospitals (Hansard, 1956).
Responsibility for providing mental health services under the Lunacy Act passed to the local NHS health authority, and the successor to the Poor Law relieving officer became the Duly Authorised Officer (DAO) and later the Mental Welfare Officer. In practice, the same person moved into the new role and continued to operate the Lunacy and Mental Treatment Acts. Domiciliary and outpatient psychiatric consultation were becoming more available to GPs, leading to more direct admissions to mental hospital and fewer coming to the DAO (Early, 1962).
One unintended consequence of the NHS era was that prior to 1948 the DAO could have dealt with the majority of elderly cases, including senile dementia, by admission to the workhouse or public service institution using the 1913 Poor Law Institution Order rather than Section 20. Under this Order, the institution managers had to admit anyone sent by the relieving officer, usually acting on the advice of the District Medical Officer. In Bristol it had been the commonest way of dealing with elderly referrals, but there was a significant change after 1948 when the range of institutions available to the DAO reduced from the hostels, hospitals and institutions managed by the local authority to only those beds in hospitals designated for Section 20 admissions to observation wards (Early, 1962).
Clinical accounts
St Pancras Hospital
Psychiatric social worker Margaret Eden described work on a central London observation ward in 1955, almost certainly St Pancras hospital, as it is described as attached to a large teaching hospital and a similar size to other descriptions (Eden, 1955). In her view, the value of the observation unit lay in the closeness to the patient’s home, ease of family visiting, and a general hospital being less stigmatizing than a mental hospital. It also allowed the patient’s relatives, who had the power to discharge the patient from any summary reception order, to see for themselves the nature of the problem and consent to certification by the visiting magistrate. The doors of the ward were locked, and the majority of patients were detained under Section 20, although most did not resist coming in. There were typically over 30 admissions weekly and around a third went home before the maximum detention period of 17 days had expired.
The St Pancras observation ward generated general medical interest from University College Hospital, the teaching hospital associated with it (Steel, 1960; Stokes et al., 1954). A neurological article, principally about 500 referrals for the weekly visit by a consultant neurologist between 1953 and 1958, shows there were occasional non-compulsory admissions and that many patients stayed beyond the original detention period instead of being transferred to a mental hospital. Consequently, bed availability was reduced and admissions had dropped from 1,700 in 1952 to 700 in 1958 (Gooddy, Gautier-Smith and Dunkley, 1960). So at this point, just prior to the 1959 Mental Health Act, the unit was providing short-term psychiatric treatment with some patients staying for up to three months, typical of most of the London observation wards apart from St Francis (Lawson, 1966: 11).
Nationally, there was a move towards local psychiatric treatment units, and observation wards were being absorbed into this. By 1963 the St Pancras observation unit had become North Wing, an acute psychiatric unit within the general hospital in which therapeutic community principles were operating (Dunkley and Lewis, 1963). It had a local catchment area, and there were fewer disturbed patients admitted than 20 years earlier. These authors were critical of the observation ward system that had gone before, seeing it as an unnecessary imposition between a family doctor and the psychiatrist with final responsibility; they also criticized their location in long-stay general hospitals rather than in acute ones.
St Francis Hospital
Ten years after the study by Norris, there were two reports specifically on the St Francis observation ward. Annette Lawson was a social scientist with the Institute of Psychiatry who studied the decision-making in the process of admission (Lawson, 1966). Less than 20 per cent of patients were admitted directly by the police, who could only deal with those found ‘wandering at large’ and not in private houses. The ward doors were still locked, not out of staff preference but because the patients were compulsorily admitted, and male and female units remained separate. The official policy of London County Council was that observation wards should be shortterm: receiving patients temporarily to diagnose, then discharge or transfer them. Nearly half of all referrals came from a general practitioner, although families were often involved in bringing the crisis to their attention, and a quarter from hospital doctors. Admissions of patients aged over 65 had dropped markedly compared with the figures in earlier surveys, as the local authority had changed its policy about admitting this age group to observation wards.
Around the same time, psychiatrists working at the Maudsley Hospital in London conducted a survey at St Francis over 12 months in 1959–60 (Eilenberg et al., 1962). They were interested in what the effect of informal admission might be on the observation ward in the new era of the 1959 Act, and the St Francis unit had started taking informal patients after November 1959 in anticipation of this. By then, it was staffed by a senior registrar and three registrars from the Maudsley, with a weekly visit from a consultant psychiatrist. There was out-of-hours support from the on-call registrar, and the team was complemented by two psychiatric social workers – a considerable improvement on 1937. The unit had still not introduced extended treatment, as other observation units had, and it admitted 1,239 patients during the year. These admissions included over half of all police detentions in London, and the unit continued to deal with a high proportion of patients with psychoses.
Outside London
Most of the published evaluation and clinical description of observation wards is focused on London. The only available example from outside London in this period was by Bristol consultant psychiatrist Donal Early, who conducted annual surveys of psychiatric patients at Stapleton Hospital (a public service institution before 1948) between 1946 and 1956 (Early, 1962). The observation wards initially consisted of two wards for 8 males and 12 females ‘in the most gloomy surroundings imaginable’. In 1947 there were 358 observation ward admissions, and the numbers of admissions increased until 1956; this was partly attributable to an increase in elderly patients after 1948, when the DAO could only admit them to beds designated under Section 20. There was a reduction in use of the observation wards after 1956, with a corresponding increase in mental hospital admission rates. Early thought this was because GPs had more access to outpatient clinics and also psychiatrists were making domiciliary visits, and therefore the need to involve the DAO and to use Section 20 decreased. Conditions in the observation unit improved with time. In an oral history interview, Early (1999) enthusiastically described a 20-bedded separate unit built at Stapleton in the mid-1950s, which took in the behaviourally disturbed patients; this worked because the visiting magistrate came three times per week to maximize voluntary admissions and to avoid certification where possible.
David Clark, who was appointed in 1953 as Medical Superintendent of Fulbourn Hospital, near Cambridge, commented that many provincial mental hospitals had no observation wards to act as a filter and consequently needed to maintain at least one locked ward to deal with disturbed patients brought in as emergencies (Clark, 1956). This indicates the degree of behavioural disturbance dealt with in the observation wards.
Section 20 was the principal reason for the existence of the observation units, but there were substantial variations in its use between the local authorities (Miles, Loudon and Rawnsley, 1961). In Somerset, Section 20 detentions took place but numbers were much lower than in London. In 1958 the Somerset County Medical Officer reported 70 Section 20 cases out of a total of 947 people dealt with by the Mental Welfare Officers. Of the rest, 40 were certified, 382 became voluntary patients, 5 became temporary patients and 450 had other actions taken (Somerset Archives, 1958). At this time the population of Somerset was approximately one-tenth that of the London County Council area, so the total of 70 cases was small compared with around 5,000 admitted to observation units annually in the LCC area. These findings of very low use of Section 20 in Somerset are roughly similar to the situation in Bedfordshire, which did not have a policy of admitting patients to observation wards first (Miles et al., 1961).
After the Mental Health Act
Ushering out the era of the Lunacy Act and Section 20 admissions, the 1959 Mental Health Act altered the legal situation again and became the new basis for emergency admissions to the observation units. Patients could now be admitted informally, in a further liberalization from the 1930 Mental Treatment Act conditions for voluntary admissions which required 72 hours’ notice to be given for self-discharge. Compulsory admissions no longer needed the involvement of a magistrate. Authorization of emergency admission could not come from the DAO acting alone, but only from medical recommendations with an application by the Mental Welfare Officer who coordinated the joint assessments. The police retained their power to independently remove an individual to a place of safety for three days under Section 136. This had never been a common route into the observation wards: none of the accounts which looked at police admissions under Section 20 found more than 21 per cent of admissions by that route (Copeland and Kelleher, 1972; Eilenberg et al., 1962; Pentreath and Cunningham Dax, 1937). Detention could now be either in a mental hospital or a general hospital (mainly to the remaining observation wards). Another effect of the new Act was that the potential period of detention in observation wards suddenly increased. Now detention could be authorized for a further 28 days after the patient had been brought to the observation ward under Section 25 of the Mental Health Act, instead of the 14-day detention period under the Lunacy Act.
Nationally, observation wards were on the wane with more patients coming directly to the mental hospitals. A House of Lords debate described how the proportion admitted without compulsion reduced after the 1959 Act (admittedly only from 95 to 91.7 per cent); previously there had been admissions from observation wards where patients were detained initially but then came voluntarily to a mental hospital, but now detained patients were coming straight to these hospitals (Hansard, 1962).
Within a few years of the 1959 Act, medical commentators were expecting reorganization with new psychiatric units (Eilenberg and Whatmore, 1962). These came soon afterwards in the 1962 Hospital Plan (House of Commons, 1962) for developing district general hospitals with psychiatric units and phasing out the mental hospitals. In some parts of the country, notably Greater Manchester, observation units in general hospitals were transformed into treatment units rather than new mental hospitals being built. By 1960 there were 82 new general hospital units, most of which had formerly been observation ward buildings (Mayou, 1989).
Clinical accounts
St Clement’s was a public service institution in East London, which had acquired 24 beds in 1933 as part of the consolidation of London observation wards. By 1959, the observation ward was an Emergency Unit, and St Clement’s had become a specialist psychiatric hospital with a neurosis unit (Lost Hospitals of London, 2019). The experience of the unit changed over the five years from 1955/6 to 1960/1 (Benady and Denham, 1963). Overall admissions to the Emergency Unit reduced by a quarter because of patients staying longer than before. These authors saw this as the effect of a change in emphasis for the unit from observation to early treatment, with a consequent improvement in the proportion of patients discharged back home.
After the 1959 Act, St Francis observation ward continued to be a place of safety used by the police under Section 136 and also for three-day orders under Section 29 which only required one medical certificate and could be for either an observation unit or a mental hospital. (Lawson, 1966: 106). In 1967 the St Francis unit formally changed from observation ward to a treatment unit for a defined catchment area. The final clinical report on the observation ward (Copeland and Kelleher, 1972) covered the unit in 1966 and 1970, before and after the change from observation ward to treatment unit, and reported a dramatic reduction of admissions (339 annually in 1969/70 compared with 705 in 1966 and an earlier peak of 1572 in 1957).
In 1961, the Bristol observation wards at Stapleton were still functioning, although now the admissions there were half informal and half detained under the 1959 Mental Health Act. By this time, the observation wards had more beds and the majority of admissions simply remained in the unit after any formal detention period, with 31 per cent of occupants being over 70 years. Early (1962) thought that the majority of admissions did not need mental hospital treatment and that the unit should become either a general hospital treatment unit or a specialized mental health unit, but the trend of managing ever more patients with senile dementia could not be sustained. By 1962 the regional hospital board was planning to close the observation wards.
In 1963, an observation ward at Brighton General Hospital had 25 beds and 2 padded rooms, and it was clearly a ‘diagnose and dispose’ unit as the average stay was 5 days (Snaith and Jacobson, 1965). These authors thought that evolution into a short-term treatment unit for stays of up to three months would reduce the need to transfer to the mental hospital for further treatment, while still dealing effectively with the emergencies.
These developments marked the replacement of the observation ward by the general hospital treatment unit focused on shorter-term treatment and recovery where treatment would be completed. Common to both models was their location, often in the same building, in a general hospital setting, close to the centres of population and separate from the mental hospitals.
Conclusions
The only attempt at a national survey of observation wards, by the Ministry of Health and Board of Control in 1935, was limited to 60 institutions, and generalization from this is difficult. The closest to a systematic description and evaluation is from the London public health department of the 1930s (Fairfield, 1937; London Metropolitan Archives, 1936). Information about other places and other times is limited to accounts that appear in the documentary record through archival material, newspaper reports, parliamentary debate and medical literature. Conditions for patients in the poorly resourced observation wards were undoubtedly miserable and the environment punitive. The environment must have also been challenging for the poorly trained staff, with a vast range of conditions, high levels of serious physical illness, frequent deaths and acutely disturbed and aggressive behaviour to be managed in an isolated service.
However, it is possible to use the London observation wards (and St Francis Hospital in particular) as a better documented example bearing closer analysis. Here the trajectory of their appearance and disappearance can be seen as a tension between roles. At one extreme was the originally conceived three-day holding function, a staging post to the asylum, as in the view of the Board of Control; at the other extreme was the short-term treatment facility, as promoted by its medical enthusiasts. In between, there was the ‘diagnose and dispose’ approach, staying strictly within the maximum 17 days allowed by the Lunacy Act. With the passage of time, attitudes shifted decisively towards the short-term treatment role. This can be linked to wider policy changes under the NHS towards psychiatric admission units having a place in general hospitals (Mayou, 1989), and the observation wards may have been seen as an obvious service on which to base this.
Local policy played a significant part. In London, the deeply embedded policy of all emergency admissions going first to the observation ward was based on pragmatic considerations of the need to filter access to the distant and overcrowded mental hospitals; this continued into the 1950s and may have been responsible for the prominence of observation wards in its mental health system. It resulted in numerous observation wards and large numbers of patients, which in turn attracted the attention of public health officials, more so than anywhere else outside Scotland. A later policy decision to avoid admissions of older patients allowed observation wards to continue dealing effectively with acute admissions because it reduced the problems in finding social care that were experienced in other parts of the country. Finally, the requirement, at least in the 1930s, that even voluntary admissions must be seen by a consultant psychiatrist in the observation ward or outpatient clinic was probably unique to London. This would have enhanced the role of the observation ward by limiting direct voluntary admission to mental hospital. Also significant in London was the involvement, from the early 1930s, of consultant psychiatrists associated with the mental hospitals, including the Maudsley, and the focused attention of the Public Health Department.
The legislative framework shaped the position of observation wards within the mental health system. With the arrival of local psychiatric units and a Mental Health Act with no place for an independent DAO, their role became redundant. Some of the buildings might have been the same, but they were now psychiatric treatment units with doctors taking the decisions.
Summary
The observation wards were a response to the legal framework of the Lunacy Act, which authorized the use of workhouses and later public health hospitals and public service institutions in compulsory emergency removal of patients into institutional provision. This specific role in the operation of Section 20 made these wards an important part of the mental health system, particularly in larger cities, and an alternative emergency service to the mental hospitals. The demise of the observation wards took effect through a redesignation of Section 20 admission locations, which shifted the balance away from the former Poor Law institutions and local authorities towards the NHS mental hospitals – much as the Board of Control would have wanted in 1935. This was hastened by the 1959 Mental Health Act, which made emergency admissions a more streamlined and medicalized process and finally ended the link with the independent decision-making of the Duly Authorised Officer. The emergency admission function of observation wards was taken over by mental hospital admission units, and their buildings redeployed, sometimes as district treatment units fulfilling the vision of the early observation ward advocates for less stigmatized short-term treatment facilities close to home.
Footnotes
Acknowledgements
I would like to thank Claire Hilton, Historian in Residence at the Royal College of Psychiatrists, for her valuable comments on an earlier draft of this article.
Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.