Funding an Asylum Patient

In 1808 the County Asylums Act was passed, which enabled counties to use public funds to build institutions for the mentally ill. Whilst the number of counties who took advantage of the system was low, and the majority of counties continued for some time to rely on the workhouse and gaol system to deal with their pauper lunatics, after the 1828 County Asylums (England) Act, the number of new institutions increased. Two doctors were needed to certify a patient after this Act, meaning that more genuine cases and fewer erroneous incarcerations occurred. The Lunacy Commission was also set up, which was a permanent body of inspectors with the power over licenses for madhouses and asylums.

Staffordshire Archive Service

The next step forward was the County Asylums Act of 1845, which established that a patient’s county of origin had to provide for them. The national asylum figures by 1850 were 7,140 patients in 24 County asylums, and by 1860 there were nearly 16,000 patients in 41 public asylums. 1910 saw 100,000 patients in 91 asylums across England and Wales.

This new level of complex bureaucracy and management raises the question – who paid for the patients?

Some were lucky enough to be able to fund their hospitalisation as a private patient. The percentage of private patients in County asylums fell from about 3.6% in 1849, to under 2% in 1855. The numbers stayed at these levels until at least the last decade of the nineteenth century.

The admission of private patients was provided for in 1815, but the clause applied only if the asylum in question had excess capacity. Private patients in the Victorian era could be admitted for the cost of 16 shillings a week, which although out of the reach of most patients’ families, was an affordable alternative to private asylums for middle class and ‘labour aristocrat’ working-class families. The number of private patients which a public asylum could take was always very limited, and often as few as twenty. Their accommodation, in terms of comfort and privacy, was a step up from the other patients, but if money became tight then patients could be transferred to the ‘pauper class’, and changes between classes are not uncommon in Staffordshire’s asylum registers.

Those certified insane by a Doctor and a JP and sent to an asylum as a ‘pauper’ were paid for by their union or parish. The vast majority of the expense of the upkeep of lunatic patients was met by the patient’s own Poor Law union. In the 1870s, around 13 shillings a week was paid for each individual.

Although such patients were ‘paupers’ in the records, because of their funding by a Poor Law union, they were not all destitute, and many had secure incomes before their mental troubles, coming from secure working and middle-class households, and not necessarily in financial dire straits. The term pauper was still in use in documents in the inter-war period, despite the gradual winding down of the Poor Law and the establishment of new bureaucracies before the advent of the NHS. It was only superseded by the term ‘rate-aided’ in the 1930s and early 1940s.

Criminal lunatics were a different case and had a different funding structure again. They were transferred from prisons to asylums on the order of the Home Office, and were funded by the Prison Commissioners, as a stay in an asylum was in lieu of their prison sentence. If a prisoner’s sentence ran out before they were discharged from the asylum, they would be transferred to the pauper class and a Poor Law union would find themselves footing the bill.

Overcrowding in asylums led to some patients in later decades being sent to other institutions. The Lunacy Acts Amendment Act of 1862 allowed Poor Law unions to send what were deemed harmless and incurable cases to workhouse infirmaries, rather than asylums. The building of lunatic wards at workhouses continued right through the later 1800s. It was cheaper to house patients in workhouse wards, but their continuing poor conditions led the asylum to be a preferred alternative in many cases.

Joseph Cotton, male patient at Stafford Asylum (casebook 6756/1 – Male Patients 1894-95)

The Victorian conception of poverty was a major factor behind the better conditions in asylums when compared to workhouses – mentally ill patients were not considered to be to blame for their condition, whilst poverty itself was seen as a moral failing. At various points in the later 1800s, three times the amount spent on the upkeep of a pauper in the workhouse was spent on lunatic patients.

The levels of spending on maintaining asylum patients would never have been considered for other social provision. Poor Law unions were committed to spending over half a million pounds on asylum charges per year by the mid-1860s, during the second great phase of asylum building. By 1890 this had grown to £1.2 million pounds. Peter Bartlett estimates that between 1857 and 1890, the percentage spent on asylum charges grew from 8% to 14% of total poor relief expenditure. He also states that in the 1860s expenditure on pauper lunatics in asylums was more than double the amount spent on all medical relief to the poor, and more than treble by the 1870s – indicating not only the tiny amount spent on public health, but also the commitment to asylums and their ‘deserving’ patients compared to other forms of relief.

All of this spending excludes the cost of building lunatic wards in workhouses and maintaining patients in them, the costs of poor law medical examinations before 1853, and also the cost of transporting patients to the asylum. Peter Bartlett details one parish spending up to £2 10s to transport one patient eleven miles to Leicester Asylum in the 1840s.(Bartlett Thesis, pp.74-75)

Asylum expenses for Poor Law unions increased over time, primarily because demand grew. As the second generation of asylums were built in the 1860s and 70s, so they quickly filled up, and many patients who would have been in workhouses or Poor Law institutions were sent to the new hospitals. In 1844 Lancashire had the largest number of lunatics in workhouses (369) in the country. The county saw large population increases in the following years, partly through Irish migration, and so the pressure of numbers grew. In 1854 a Poor Law Inspector estimated that £174 11s 6d was paid by the Union for patients in Lancaster Asylum, and by 1866 Lancashire County was paying £2,000 a year for the maintenance of asylum patients. As Cox and Marland show, the spirit of reform amongst asylum doctors in the 1850s and 60s meant that their arguments that only they could effectively treat the mentally ill gained ground, and more and more patients were sent to the new asylums rather than workhouse wards.(Cox & Marland)

Aside from the increased pressure of numbers, why was there a willingness to spend on asylums, whilst Poor Law provision in general remained parsimonious? The Victorian idea of poverty and the belief that immorality lay at poverty’s root was the key. Peter Bartlett argues that the asylum was one of the very few institutions of public provision which was kept separate from the New Poor Law in 1834, leading to an ‘arm’s length’ relationship between the two. Asylums had a therapeutic culture, looking after the deserving ill, whilst many others who came into contact with the Poor Law were stigmatised as the ‘undeserving’, whose moral failings had led to their own poverty. Poor Law unions paid for asylum inmates, who in contemporary thought were victims of their illness, but the stigma of the Poor Law did not stick to them. Having said that, Bartlett notes that moral judgements were often made in patients’ case notes by asylum Doctors about the causes of insanity in individuals.(Bartlett Thesis p.22)

The upkeep of nineteenth century mental patients was in some ways more generous than that bestowed on many others, but at the same time the asylum system, funded by the Poor Law unions, could not escape the moral world of Victorian society.

Further Reading:

Peter Bartlett, ‘The Poor Law of Lunacy: The Administration of Pauper Lunatics in Mid-Nineteenth Century England with special Emphasis on Leicestershire and Rutland’, PhD Thesis – Univ. of London (1993)

Peter Bartlett, The Poor Law of Lunacy: the Administration of Pauper Lunatics in Mid-Nineteenth Century England (Continnuum, 1999)

Catherine Cox and Hilary Marland, ‘A Burden on the County’ :Madness, Institutions of Confinement and the Irish Patient in Victorian Lancashire’, Social History of Medicine Vol. 28,No. 2 pp.263–287

Andrew Roberts, Poor Law/Lunacy Commissioners http://www.studymore.org.uk/mott.htm

The Arrival of a Patient

We know a lot about the life in 19^th century lunatic asylums, because of the amount of excellent documentation which has survived from many of the institutions. The first documentation that would be produced in the case of a new admission was before the patient was even admitted.

The decision to admit a relative to an asylum was not an easy one to take. The stigma of seeking help was strong, and many families would try to deal with a mentally ill patient at home, before eventually admitting that they could no longer cope. It is likely that, in many cases, a Poor Law union medical officer would be the first official to get involved. The relieving officer of the union would send the medical officer to examine any potential patient, whether at home or in the workhouse. Questions were also put to relatives, as to mental history, family history, and any underlying illnesses such as epilepsy. Once examined, the doctor would write his report and, if he concluded that symptoms of insanity were present, then another doctor would be called in within a week.  

Another key question which needed to be answered, was which Poor Law union was responsible for the upkeep of the patient. This needed to be clarified early on in the process. If another union was responsible, then efforts were made to move the new patient to the liable union. The relieving officer had only 3 days to complete all of his enquiries.

The next step was to take the case to the magistrates, as they alone had the power to make out the order to admit a patient to a county asylum after the 1845 Lunacy Act. This was a step to ensure that due process was being followed in incarcerating an individual.

The patient would then be admitted, and transport to the asylum (by rail or carriage) would be organised by the Poor Law officer. Hand luggage was allowed for the patient. The asylum, more imposing and elaborate than the workhouse, is perhaps the most impressive building which many of the new arrivals would have seen.

Many of the new arrivals would be confused, but the formal admission process began almost immediately. The admission register would be filled out by the clerk, in consultation with the poor law official who had delivered the patient. The questions followed a set pattern, and by the later 1800s admission registers were of a standardised format, and used throughout the country. Information such as age, marital status, religion, place of abode, and chargeable union were all collected. In some cases, the chargeable union would change upon further investigation, or upon resolution of a dispute between two unions over who should pay.

Burntwood Asylum Admission register from the 1890s.

Medical information was also entered in the admission register, and later a log of health and condition would be kept in the casebook. Admission registers would also record the following: whether this was the first attack, age at first attack, supposed cause, duration of existing attack, bodily condition, whether epileptic or suicidal, and whether dangerous to others. The patient’s date of death or discharge would be entered as and when they occurred.

After this information had been entered, the patient would be formally received into the asylum. A basic medical examination was carried out in a room used for new patients. Height, weight and any evidence of communicable diseases were noted, and anyone found to be a medical risk to others was then placed in the isolation ward in the infirmary. Staffordshire’s asylums took particular note of any patient with a history of phthisis, or pulmonary tuberculosis, which became the scourge of many asylums.

A patients’ belongings would also be taken from them, and they would be made to bathe before progressing further. Any dangers to others such as lice or skin conditions would be treated, even to the extent of shaving the patients’ head.

In later decades, from the 1880s onwards, at some point during the admissions procedure a photograph would often be taken. This might also happen at a later stage, after the patient had settled in to the hospital. For a couple of decades this was common practice, as photographs were considered a potential diagnostic tool.

Patients who were not infested would have their clothes put away for their discharge day, and a set of clothes would be given to them for wear in the asylum. The newly admitted patient would then be taken to the admissions ward – their first typical experience of life in the asylum.