“Old Problems, New Solutions” to admitting patients out of area

By Dr Claire Hilton, Historian in Residence at the RCPsych.

Today, the term “Inappropriate out of area placement” refers to the situation when a patient is admitted to an inpatient unit over 50 km away from their home “because no appropriate bed is available locally.” The Crisp Commission was set up to address this and other issues, to ensure that patients in England have swift access to intensive high quality care when it is needed, whether in hospital or under a Crisis Resolution Home Treatment Team (CRHT). The Commission’s report (2016) emphasised that long distance admissions are mainly due to difficulties in finding acute inpatient beds or a suitable CRHT in their home area, “a symptom of far more widespread problems in the functioning of the whole mental health system.”  The report was called Old Problems, New Solutions. Old problems they are indeed: but so far, judging by the RCPsych policy briefing (2022) regarding out of area placements, it is hard to see any new solutions coming into play.

The old problems: pounds (shillings) and pence

Moving patients to an inpatient unit far from their home, family and friends, has long been practiced and the emotional harm recognised. The Lunacy Act 1890 permitted an overcrowded public asylum to establish contracts to transfer patients elsewhere. The receiving asylum often charged a higher fee for these “out-county” contract patients compared to patients from their local population. For example, in 1925, the Three Counties Mental Hospital at Stotfold, Bedfordshire, estimated that it cost 20s 6½d (103p) a week to treat a patient in their institution, but it charged 23s 11d (120p) for “home-county” patients, and 29s 2d (146p) for those on contract. Around the same time, the local authorities also used private sector mental hospitals for publicly funded patients.  We know of patients from north London transferred to the Old Manor Hospital (Fisherton House) in Salisbury, around 150 km away.  

Alongside under-provision of beds being associated with moving patients out of area, there were also rules regarding which locality was obliged to pay for a patient’s treatment. Until 1930, in-patient admission was funded through the Boards of Guardians and means tested under the Poor Law. The Poor Law designated responsibility for funding to the patient’s official parish of “settlement”, rather than where they lived when they became ill.  Generally, parish of settlement was the parish of birth, or for a married woman, the parish of her husband’s birth, although it could change over the lifetime, such as through apprenticeship or living elsewhere for a set period of time. Under the scheme, if someone required mental hospital admission, they could be moved hundreds of miles from family and friends to the mental hospital serving their official parish of settlement.

The Royal Commission on Lunacy and Mental Disorder, 1924-6, received evidence on this.  Drs Helen Boyle and Henry Devine both advocated for care close to home, preferably in the towns where their friends and family lived, so that patients could interact with them and their community. As Dr Devine put it: “The more social contact of the ordinary kind that a mental case can have, so much the better for him.” Dr Boyle was also clear: “We should not be so hidebound about settlement. Sometimes their settlement is miles from their friends, and they do not want to go such a long way away.”

Distress caused

We hear of patients’ distress at being moved between institutions early in the First World War, when civilian patients were transferred from asylums requisitioned as military hospitals. One medical superintendent described the patients when they left his asylum in 1915:

“the whole gamut of emotion was exhibited by the patients on leaving, ranging from acute distress and misery, through gay indifference, to maniacal fury and indignation….I did not realise the strong mutual attachment till it was severed.”

The asylums were by no means ideal, and the dependence which they created for their patients probably contributed to their sense of loss. Nevertheless, meaningful human relationships still existed within them.

Letters from Colney Hatch Mental Hospital files (now at London Metropolitan Archives ref: H12/CH/B/47/037) add to the picture. Unfortunately, the hospital’s method of filing papers by gluing them together at their corners has obscured details in the letter below: the gaps are indicated by […]. Note also that the writer’s shillings and pence notation is a forward slash /.

1.5.1928

Dear Mother

How are you?  Isn’t this weather changeable?  Mid-summer one day, freezing the next. Enclosed please find 1/6 not much but all I can afford at present.  Have you received your goods from Highgate because I went up after them.  Then they sent me a written notice to attend a committee meeting. I replied that I could not attend as they arranged it for 2.30 on a Tuesday afternoon […]

I shall not come out to Southgate this weekend as I really can’t afford it.  Have you heard from Lily yet?  If you haven’t its because she hasn’t been very well. I think I am going away with her to Ramsgate for the holidays. The air is quite decent there.  So it will do her good.  I sold three hats today 39/11, 12/11 and 10/11.  Good, eh?  I feel quite pleased […]

Well Goodbye Mama

Lots of […]

PS Excuse the awful scribble but I am very tired. Goodnight now. 

The letter did not reach the mother. She was transferred 200 miles away to the Yorkshire mental hospital which served her parish of settlement. In the days of few cars and many financial pressures, her husband and daughters living and working in London would have had little opportunity of visiting her.  

New solutions?

Unlike beds in hospital corridors or dilapidated buildings which are highly visible to the public and attract attention, moving patients far from home is an invisible cruelty perpetuated over generations. Placing patients out of area makes me wonder whether the attitudes and priorities of the authorities who design the mental health services and allocate funding today have, in essence, changed from those of their predecessors.  A century or more of old problems and plenty of evidence and ideas, but we have still not implemented adequate new solutions, to mend a broken system.