### Mental Health in Historical Perspective

Series Editors Catharine Coleborne School of Humanities and Social Science University of Newcastle Callaghan, Australia

> Matthew Smith History of Psychiatry University of Strathclyde Glasgow, United Kingdom

Covering all historical periods and geographical contexts, the series explores how mental illness has been understood, experienced, diagnosed, treated and contested. It will publish works that engage actively with contemporary debates related to mental health and, as such, will be of interest not only to historians, but also mental health professionals, patients and policy makers. With its focus on mental health, rather than just psychiatry, the series will endeavour to provide more patient-centred histories. Although this has long been an aim of health historians, it has not been realised, and this series aims to change that.

The scope of the series is kept as broad as possible to attract good quality proposals about all aspects of the history of mental health from all periods. The series emphasises interdisciplinary approaches to the field of study, and encourages short titles, longer works, collections, and titles which stretch the boundaries of academic publishing in new ways.

More information about this series at http://www.springer.com/series/14806 Claire Hilton

# Improving Psychiatric Care for Older People

Barbara Robb's Campaign 1965–1975

Claire Hilton Institute of Contemporary British History and Institute of Psychiatry, Psychology and Neuroscience King's College London London, United Kingdom

Mental Health in Historical Perspective ISBN 978-3-319-54812-8 ISBN 978-3-319-54813-5 (eBook) DOI 10.1007/978-3-319-54813-5

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This Palgrave Macmillan imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland To Samuel, Jacob and Benjamin and their friends who are trying to make the world a better place.

### FOREWORD

My beloved grandmother died frail and confused in an overcrowded longstay ward in a decrepit Victorian National Health Service hospital. There were so many beds in the ward there was barely room to stand between them. Nurses were seemingly indifferent towards their impossible task. In 1968 I was a bewildered and angry medical student with no idea how to voice my concerns at her evident distress and the lack of personal care. My parents too were troubled by the poor conditions, my grandmother's unkempt appearance, the meals left untouched and out of her reach, the terrible ward stench. They never made a formal complaint, hardly knew where to begin, and in any case my grandmother died soon after admission. I have no doubt that this experience was one of the triggers for my choice of career in the psychiatry of old age. I did not know then that there was a battle in progress in the late 1960s and early 1970s between those who grasped how widespread was the poor care of older people in the National Health Service and were determined to improve it and those lined up against them, the forces of denial inside the service, who really believed there was not much wrong and in any case thought there was nothing to be done about any shortcomings given the resourcing and public ignorance. At the vanguard of the battlefront was one remarkable woman, Barbara Robb, who published Sans Everything: A Case to Answer in 1967, a searing indictment of the conditions for older people in longstay hospital wards, initiated by her own observations of the care of one of her psychotherapy patients.

In this book, Claire Hilton has set out the campaign waged by this one inimitable woman, her organisation Aid for the Elderly in Government Institutions (AEGIS) and the long struggles to convince the Ministry and its constituent Regional Hospital Boards that the truth was as she described it and to get them to accept that change was necessary. There could be no better qualified person to document this enlightening story than Claire Hilton. Claire is a dedicated, talented clinician, a psychiatrist working with older people, who has for some years immersed herself in the history of the development of the specialty of old age psychiatry in the twentieth century. She has illuminated the period by bringing together the characters and politics of the influential clinical professionals, policy makers, public health observers, press and government funders. In this new work, Claire has drawn on her profound understanding of the period and, through further scrupulously detailed research, has exposed a story that has wider implications, showing how policy makers can be easily misled by misinformation when the truth is unpalatable. But what she has also given us here is a cracking good read, a compelling story of one woman's battle tragically cut short by Robb's too early death in 1976.

The fact is that the scandals have continued in National Health Service hospitals, but more often today in the myriad of independent-sector nursing and care homes that now provide the majority of long-term care for those institutionalised at the end of their lives. Scandals are no longer swept under the carpet, rather under many small rugs, as psychiatrist Klaus Bergmann so memorably put it and quoted by Claire in her disturbing final analysis of what has changed for the better and how much still needs to be done. In spite of the cautionary finale, this is an uplifting story, and anyone who is interested in how to campaign on a social issue will learn some invaluable lessons from this splendid book.

> Elaine Murphy, Baroness Murphy of Aldgate

### PREFACE

In 1967, Sans Everything: A Case to Answer, was a best seller, a remarkable achievement for a nonfiction book about the unappealing subject of the poor care of older people in English psychiatric hospitals. The title and scandalous content remained familiar over the years, particularly to old age psychiatrists and others who aimed to provide high-quality mental health services for older people. None of them, however, could tell me anything about its author, Barbara Robb, although at the time she wrote, she was quite a celebrity, achieving both fame and notoriety. Cabinet Minister Richard Crossman wrote in his diary that she was a 'terrible danger' to the government, and a 'bomb' who had to be defused.

I first read Sans Everything in about 2006 after my husband bought it for me as a birthday present. The contents were gruesome, and like other readers, I focused on them, paying little attention to the chapters providing direction about how to improve care. Breathing a sigh of relief, I reassured myself that things aren't nearly so bad today.

While undertaking related historical research, the names of several Sans Everything contributors came to light. Who were they? How did Barbara get them to write for her? Who were the people and places behind the pseudonyms? Who was 'Miss Wills' who Barbara rescued from 'Cossett Hospital'? Who was Barbara? How did she get involved with the psychiatric hospitals, and what else did she do? These and other questions aroused my curiosity.

There are many reasons Barbara Robb was forgotten. She fought to improve provision for institutionalised older people and not for personal acclaim. She was a thorn in the side of the National Health Service leadership who did not want to remember her, and both she and her husband, Brian, died prematurely. Half a century since publication of Sans Everything, it is time to reconsider the story behind it and its messages, much of which remains relevant to the care of unwell and frail older people today. Perhaps my sigh of relief was only partly justified.

### ACKNOWLEDGEMENTS

Investigating Barbara Robb and Sans Everything was exhilarating, delving into archives and meeting many people who helped and offered much encouragement. Barbara's family were enthusiastic. Her cousin William Charlton and his wife, Anne, welcomed me to their home in Northumberland, and her great-niece Anna Charlton showed me round Hesleyside Hall. Barbara's niece Elizabeth Ellison-Anne lent me Barbara's photograph album depicting the years 1937–1941, and she, with friends Cynthia Bressani, John Gilliver and Colin Bowes, showed me round the family home, Burghwallis Hall, and the adjoining church. Sister Deirdre McCormack showed me round St Peter's Residence, and Constanza Isaza Martínez and Andrés Pantoja allowed me to wander round their home, the cottage where Barbara and Brian lived for many years. Charles and Robin Daniel, whose mother, Joyce, spoke out for more humane hospital provision in Cornwall, told me about her in the cottage where she lived. David Cochrane gave valuable advice at the beginning of the project, and Margaret Shepherd NDS, explained aspects of Roman Catholic practice. Other people told me about Barbara's life and times and provided archives and photographs: they are acknowledged in the endnotes. Anna Towlson, archivist at London School of Economics, was always helpful with my visits to, and queries about, Barbara's extensive archive. Many other archivists and librarians answered questions, retrieved documents and assisted with the project. Numerous historians offered constructive advice, including Tim Hurley, Michael Kandiah, Chris Knowles, Michael Passmore, Mary Salinsky, Sally Sheard, Kathleen Sherit, Mari Takayanagi and Pat Thane.

Tom Arie and David Jolley, my esteemed colleagues in old age psychiatry, read and commented on every chapter with great tact and patience. My husband, Michael, and sons, Samuel, Jacob and Benjamin, all guided me through computer hitches and accompanied me on visits to former psychiatric hospitals. Benjamin also gave advice on logical fallacies in the Sans Everything inquiries. Michael has been endlessly patient with the time spent on this project and has enjoyed our visits to people, places and archives from Cornwall to Northumberland.

I am indebted to the Wellcome Trust for funding this study during an eight-month sabbatical from clinical work as an old age psychiatrist. I am also grateful to Central and North West London NHS Foundation Trust for allowing me to take time off and to Lynis Lewis and North Central London Research Network for help with administrative matters.

My link to Palgrave Macmillan began with a chance meeting with historian John Stewart at a conference at the Wellcome Trust. He introduced me to Matthew Smith and Catharine Coleborne, academic editors of the series Mental Health in Historical Perspective. They were endlessly enthusiastic and guided me through many stages towards publication. I'm also grateful to Vicky Long who reviewed the manuscript and whose comments helped shape the book, and to Palgrave's editors, Molly Beck, Oliver Dyer and Sundar Ananthapadmanabhan, who were a pleasure to work with.

This list of helpers, encouragers and friends is not exhaustive, and I apologise to anyone missed out who thinks they should have been included. To them too I am most grateful.

### CONTENTS

### ABBREVIATIONS

### LIST OF FIGURES

### LIST OF TABLES

Table 4.1 The Sans Everything witnesses 116

### DRAMATIS PERSONAE

People most closely concerned with the narrative of Barbara Robb and the AEGIS campaign and those who played a part at several stages in the story:

Academics and government advisors Brian Abel-Smith Peter Townsend Barbara Robb's family Ernest Charlton Anne, grandfather Ernestine 'Missie' Anne, aunt William Charlton, cousin Brian Robb, husband; an artist Campaigners and supporters Mary Applebey, general secretary of NAMH Mabel Franks, an admirer from Leeds Audrey Harvey, Barbara's neighbour and social rights campaigner Helen Hodgson, founder of the Patients Association Lord Strabolgi Chairmen of committees of inquiry First Friern Inquiry 1965 Ann Blofeld Sans Everything inquiries Douglas Lowe, Friern George Polson, St Lawrence's Ely Inquiry Geoffrey Howe

Doctors Psychiatrists and psychogeriatricians Tom Arie Alex Baker, director of the Hospital Advisory Service, 1969–1974 Russell Barton Klaus Bergmann Garry Blessed M David Enoch Bertram Mandelbrote Brice Pitt Ronald 'Sam' Robinson J Anthony 'Tony' Whitehead Other doctors Malcolm Campbell, Friern Hospital, 1964–1965 Lionel Cosin, geriatrician Geoffrey Tooth, Principal Medical Officer, Ministry of Health Friern 'Cossett' Hospital staff, pseudonyms Dr Aix, consultant psychiatrist Miss Cloake, social worker Dr Giddie, ward doctor Journalists and editors Anne Allen, Sunday Mirror Yvonne Cross, Nursing Mirror Anne Robinson, Sunday Times CH Rolph (Bill Hewitt), New Statesman David Roxan, News of the World Ann Shearer, Guardian Hugo Young, Sunday Times RHB chairman Maurice Hackett, North West Metropolitan Isabel Graham Bryce, Oxford Nurses in senior roles who supported AEGIS Keith Newstead WJA 'Bill' Kirkpatrick Doreen Norton Phyllis Rowe, deputy president of the RCN

Psychotherapists Carl Jung Victor White Politicians and civil servants Minister of Health Kenneth Robinson, 1964–1968 Secretaries of State for Social Services Richard Crossman, 1968–1970 Keith Joseph, 1970–1974 Barbara Castle, 1974–1976 Others Beatrice Serota, Minister of State for Health, 1968–1970 Arnold France, Permanent Secretary, Ministry of Health, 1964–1968 Patients, their relatives and friends Eric Buss, friend of Amy Gibbs Mrs Dickens, sister of Bob, a patient at Friern Hospital Amy Gibbs, 'Miss Wills', a patient at Friern Hospital Whistle-blowers Sans Everything author-witnesses and their pseudonyms Jean Biss, Laura Heneage Dorothy Crofts, Elizabeth Tasburg Joyce Daniel, Adeline Craythorne James Davie, Frederick Isham Dennis Moodie, Michael Osbaldeston Roger Moody Eileen Porter, Emily Swinburne Susan Skrine, Louisa Fenton Ely Hospital Michael Pantelides

### Introduction: A Strange Eventful History

Last scene of all, That ends this strange eventful history Is second childishness and mere oblivion; Sans teeth, sans eyes, sans taste, sans everything.

William Shakespeare, As You Like It (Act II, scene vii)

On 21 January 1965 Barbara Robb visited an elderly acquaintance, Amy Gibbs, an in-patient on a long-stay back ward at Friern psychiatric hospital, North London. There, she stepped into the murky, longstanding and hardly shifting territory of older people's institutional care. Shocked by what she saw, such as harshness from nurses and the patients' uniform haircuts, institutional clothing and lack of personal possessions and occupation, Barbara began a diary of her visits because 'I felt that I would never have another really easy moment unless I did everything I could to try to right this situation' (Allen 1967). Within months she established AEGIS, Aid for the Elderly in Government Institutions, which became one of the country's most determined pressure groups (Robinson 1970). Barbara Robb resembled earlier well-known women campaigners, such as Elizabeth Fry (1780–1845) the prison reformer, and Florence Nightingale (1820–1910) who professionalised nursing. All three women were appalled by the inhumanity they witnessed in institutions and set their minds to eliminating it. They were upper-class women of independent means with strong religious inspiration for their work. They all dedicated years to achieving improvements.

This study primarily concerns the back wards of National Health Service (NHS) psychiatric hospitals in England.  Psychiatric hospitals were only one part of the health and welfare services used by older people, but care provided in them was particularly problematic. Patients, their families and hospital staff, all had low expectations of improvement or discharge. Staff showed little interest in older people who often received no clear psychiatric diagnosis, treatment or rehabilitation, unlike younger people in the same hospital (Martin 1962). Many staff could not 'formulate a "psychogeriatric" problem in any other terms but as the need to get it instantly off their hands' (Arie 1973, p. 541). The patients did not benefit from the expertise of geriatricians, the doctors who specialised in older people's physical healthcare. Geriatricians aimed to diagnose illness accurately and provide treatment to improve health, well-being and function, but they worked mainly in general hospitals and hardly entered psychiatric hospitals (Denham 2004, p. 357). In hospitals without geriatricians, older people were particularly at risk of poor-quality care associated with negative, ageist stereotypes, which assumed they were all afflicted with irreversible chronic illness that would result in inevitable and hopeless decline.

AEGIS's book, Sans Everything: A Case to Answer (Robb 1967), described scandalous inhumane and inadequate care in long-stay wards. The wards were overcrowded and understaffed. Undignified and unkind practices included teasing, hitting and swearing at patients. In many hospitals, there was no privacy for personal care, and bedtime could be as early as 5 P.M. Sans Everything revealed deficits and proposed remedies, including specialist psychiatric services to treat and rehabilitate mentally unwell older people to prevent admission and enable discharge, and housing schemes on surplus land around psychiatric hospitals to generate income to help pay for the services. It also recommended a hospital ombudsman, an inspectorate to monitor and ensure high standards, and better NHS complaints procedures.

Throughout AEGIS's campaign, NHS staff, patients and their relatives, the media and the wider public responded in a diversity of ways. These ranged from acknowledgement of the allegations of bad practice, such as by the press, to rejection, particularly in higher tiers of NHS administration. AEGIS struggled to convince the Ministry of Health and the Regional Hospital Boards (RHBs) about the happenings in the hospitals that they oversaw.

This study argues that Barbara Robb, AEGIS and Sans Everything had a far greater role than previously recognised in influencing improvements in services. Sans Everything was controversial, and the Ministry of Health discredited it, which obscured its centrality. However, Richard Crossman, Secretary of State for Social Services (1968–1970), and Brian Abel-Smith, Professor of Social Administration at the London School of Economics (LSE) who had a long-term interest in the NHS, regarded AEGIS as a powerful influence on NHS policy and development (Crossman 1977, p. 727; Abel-Smith 1990, p. 259). Alternative views include those in Robin Means and Randall Smith's (1985) study about welfare services for older people, which emphasised the government's role in making improvements, rather than pressure from AEGIS to ensure that it acted. Charles Webster (1998, p. 119), official historian of the NHS, regarded the Ely Hospital Inquiry as pivotal for stimulating change, rather than the events that preceded and followed it, which Barbara steered, often behind the scenes.

The primary aim of this book is to tell the story of AEGIS, Sans Everything and the campaign to improve older people's care. Barbara intended to do this herself, but time did not permit it.1 Little is known of the people and events behind the allegations described in Sans Everything, who made them and what inspired them to do so. Published sources reveal merely summaries of the official inquiries into the allegations, the shortest being one and a half pages (Ministry of Health (MoH) 1968, pp. 82–83). These reports only glimpse at the inquiry processes, their findings and recommendations stemming from them. Barbara's tenacity to the cause was remarkable: every defeat or success increased her resolve to achieve her aims, yet little is known of her background and personality, and the support mechanisms that enabled her to do so. She organised AEGIS from her cottage home and was constantly at the helm. AEGIS's story is thus inextricably interwoven with her life. When Barbara died in 1976 at age sixty-four, AEGIS died with her. However, by then the government had initiated many of the Sans Everything proposals, and other campaigners, such as the Group for the Psychiatry of Old Age at the Royal College of Psychiatrists, adopted some of AEGIS's longer-term objectives (Hilton 2016b).

This book also has a secondary aim: to explore whether issues raised by AEGIS have lessons for today, because many of its themes ring true fifty years on. It aims to give insights into the reasons for repeated deficits in provision and inform current debate concerning older people's health and social care. Recent scandals have included Care and Compassion? (Health Service Ombudsman 2011), the Mid Staffordshire Inquiry (2013), Orchid View Serious Case Review (West Sussex 2014), and the BBC Panorama documentary Behind Closed Doors (2014). Analysis of: how, why and by whom abuse and neglect took place in the 1960s; the recommendations made to remedy the situations; and what was (and was not) achieved, may contribute to understanding the mechanisms behind abuse in institutions and hence the steps that can be taken to prevent recurrences. Historical studies of the care of older people are particularly important as inhumanities towards them escape from public memory more rapidly than cruelties towards children. Margaret Panting, a seventy-eight-year-old woman who suffered repeated physical injury and died at the hands of relatives in 2001 is virtually unknown (Ash 2011, p. 100). In contrast, children, such as Victoria Climbié, killed by her guardians in 2000, and 'Baby Peter' who died at the hands of relatives in 2007, are embedded in public consciousness.

 It reveals much about the workings of higher levels of NHS administration, such as how it managed complaints and deficits in services and its relationship with the public. It fills a gap in twentieth-century women's history, including from the slant of their position as older patients. Adequate health and welfare support in old age is particularly relevant to women because on average they live longer than men. They often live alone while suffering from frailty and age-related chronic degenerative illnesses. They may struggle to cope and require institutional care towards the end of their lives. In the 1960s, older working-class women often had particularly meagre financial resources so depended on state welfare provision and occupied a disproportionate number of psychiatric hospital beds. Other women discussed in the study besides Barbara include her supporters and author-witnesses; journalists who publicised her concerns; hospital staff; and middle-class women undertaking voluntary roles on RHBs, on Hospital Management Committees (HMCs) and with charities.

To understand the context and background of AEGIS's campaign, and to highlight this study's contemporary relevance, several further issues are discussed in this introduction: early- and mid-twentieth-century psychiatric hospital scandals; the handful of studies concerned directly with AEGIS; pressure groups; and ageism. The larger background subject of how psychiatric hospital provision developed for older people until the mid-1960s is explained in the next chapter.

#### SCANDALS OF PSYCHIATRIC HOSPITAL CARE

Sans Everything was not the first or the last time poor care in psychiatric hospitals was reported and investigated. A review of existing historical studies about these episodes gives some indication of the hurdles which AEGIS might face in its endeavours. Montagu Lomax, a doctor who worked at Prestwich Asylum for a short time, wrote The Experiences of an Asylum Doctor (1921) about inadequate clinical practice there. It became a cause célèbre. Colleagues were hostile and accused him of sensationalism and exaggeration. The asylum regulatory authority, the Board of Control, criticised 'the methods which Dr Lomax has seen fit to adopt in preparation and publishing his book ...the charges made were sheer nonsense and a gross calumny' (Harding 1990, p. 180). A committee of inquiry was unreceptive, and an anonymous contributor to an academic psychiatric journal (Anon. 1923, p. 91) praised it for a 'masterly and logical' rejection of Lomax's complaints. Despite the rejection, the committee made recommendations for improvements based on Lomax's report, as did the Royal Commission on Lunacy (1924–1926), whose conclusions underpinned the Mental Treatment Act 1930 (Harding 1990, p. 181). Harding provided insights into the way a whistle-blower can be victimised and officialdom can viciously reject constructive criticism but then use it as a basis for proposing improvements.

Relatively little historiography is available about AEGIS. Four researchers from the academic discipline of social administration and policy explored its work. Kathleen Jones and AJ Fowles (1984) included AEGIS as part of their study on the literature of long-term care and custody in the 1960s. John Martin (1984) analysed hospital inquiries from 1968 until 1984, and David Cochrane (1990) based his doctoral thesis on a case study of AEGIS and the process of health policy change in England. Some other writers have touched on Sans Everything but have tended to follow the Ministry of Health's interpretation, that Sans Everything was irresponsible scare mongering and an inappropriate smear on all psychiatric hospital nurses.<sup>2</sup> Although even a cursory glance at Sans Everything (p. xiv) shows this is incorrect, the perception has crept into secondary sources. Michael Arton (1998, p. 288), for example, stated that AEGIS gave 'the impression to the general public that mental nurses were a group of uncaring sadists', but he did not cite confirmatory evidence for his statement.

Jones and Fowles' analysis was based on a handful of published works, leading them to place little credibility on the accounts of neglect and abuse in Sans Everything. They accepted the official inquiry reports that most of the allegations were false. They concluded, in an uncomplimentary way, that: 'The whole affair was a very skilful exercise in public relations; and despite the flamboyance, the distortions and the inaccuracies, it worked' (p. 108). Archival sources used in the present study challenge their criticisms; the 'affair' label would be more apt for the Ministry's handling of the situation than for AEGIS's allegations.

Martin (1984) analysed the first cluster of inquiries into psychiatric hospitals, including Sans Everything (MoH 1968), Ely (Department of Health and Social Security (DHSS) 1969), Farleigh (DHSS 1971), Whittingham (DHSS 1972), and South Ockendon (DHSS 1974). He described them as being of the 'old order', because 'their circumstances derived from past inadequacies of provision, and from lack of new thinking'. <sup>3</sup> Martin concurred with the published inquiry reports into Sans Everything and with the Ministry's view, that almost all allegations were disproved, thus discrediting AEGIS. However, he did not discuss the incongruity of that in the context of the rapid succession of investigations into similar allegations in other hospitals that were shown to be justified.

Martin discussed patterns of malpractice. Usually there was a chain of events and a broad context of failures of care rather than a single 'bad apple'. Staff often knew what was going on but did nothing about it, partly because of the power of the work group and of staff loyalty to it (Martin 1984, p. 243). Good clinical practice was undermined when secondary aims (making things easier for the staff) were substituted for primary ones of person-centred care. This resulted in gradual deterioration of standards, and 'the ultimate exposure made by a newcomer who is not conditioned to standards which have become familiar to the long-term staff' (p. 244). Martin also noted that hospital hierarchies, especially in the nursing profession, did not encourage questioning by the all-important ward staff undertaking face-to-face work with patients, and that creativity, individuality and clinical responsibility produced better care. Failure of staff to take on as much personal responsibility as possible was 'likely to result in the quality of care sinking to that level which is most convenient for the staff to provide and which satisfies minimum standards' (p. 243). This conclusion was unnervingly close to a comment made by Andy Burnham, Secretary of State for Health, 2009–2010, to the Mid Staffordshire Inquiry (2013, p. 1378): 'the NHS is not good at giving its front-line staff a sense of empowerment. People with good ideas do not feel that they can easily put them into action.' Martin's comment about the importance of the newcomer in detecting poor standards was apparent in the role of Julie Bailey, who visited her mother in hospital and whose concerns culminated in the Mid Staffordshire Inquiry (Cure the NHS 2016).

Martin also argued that professionally isolated staff, such as in the rural psychiatric hospitals, could perceive outside influences as threatening and likely to show up their deficiencies, rather than being revitalising. On wards with inadequate staff levels and resources, complaints could be resented strongly. In such circumstances, staff stuck together, showing up 'the darker side of group loyalty', suppressing criticism and victimising the critic. Martin also noted that 'To say one is doing one's best under the circumstances is to recognise that one is not doing the best work. It is a defence with built-in vulnerability. It almost invites attack and it generates a guilty sensitivity to criticism' (p. 245). 'Doing one's best under the circumstances' is also heard in the NHS today, to justify inadequate clinical services associated with underresourcing.4

Cochrane's (1990) analysis of the important role of AEGIS in NHS policy development challenged the earlier interpretations, which were largely based on published texts. He demonstrated how it initiated the succession of scandals in psychiatric hospitals (c.1968–1974) and contributed to health service policy, including raising the priority of mental illness and mental handicap services and influencing the establishment of a hospitals' inspectorate, ombudsman and NHS complaints procedures. Cochrane documented Barbara's political career as a social reformer, but some of his conclusions, such as extrapolating her influence into the late 1980s, are hard to justify historically in view of the complex processes of social and health policy change.

Cochrane was fortunate to have Abel-Smith to supervise his thesis. He also had the advantage of being able to undertake oral history interviews with people who knew Barbara, collaborated with her or opposed her. They included Geoffrey Howe, WJA 'Bill' Kirkpatrick, Kenneth Robinson, CH Rolph (Bill Hewitt), David Roxan and Lord Strabolgi, all of whom have since died. Cochrane did not give reasons why Sir Arnold France, Permanent Secretary and Robinson's 'right hand man' at the Ministry of Health (1964–1968) (Green 2004) declined to be interviewed, and other DHSS officials and 'senior health authority officers' asked not to be named (Cochrane 1990, p. 389).

The present study differs from Cochrane's in several ways. First, it is outside the constraints of a social science discipline and aims to explore what happened historically rather than relate events to a theoretical model. Second, it is more people focussed. Who was Amy Gibbs, 'Miss Wills' in Sans Everything? Who were the pseudonymous contributors to the book? How did Barbara cope with the hostility and discrediting of her work? Third, now that the closure period for official archives has expired, more sources are available so it is possible to explore the Sans Everything allegations and inquiries in greater depth. This supports the timeliness of a further study of AEGIS's work.

#### SOCIAL JUSTICE, PRESSURE GROUPS AND THE EMERGENCE OF AEGIS

Societal changes in the 1960s included a focus on personal autonomy and individuality with less submissiveness to authority. This affected lifestyles, expectations about standards of living and demands for humane and safe public services and environments. Despite greater affluence for many people, disturbing large-scale poverty, especially affecting children, large families and older people, was 'rediscovered' by researchers at LSE (Thane 2011). LSE academics particularly conspicuous in this work included Abel-Smith and Peter Townsend. Abel-Smith supported and gave credence to several campaigns, such as the Child Poverty Action Group (CPAG) (Townsend 2004; Sheard 2014, pp. 224, 256). Townsend (1962, 1963) published in-depth sociological studies, including about the needs of older people. He wrote about their poverty and the disadvantageous health inequalities that accompanied it. He cited a 1950s estimate that up to 75 percent of retired people had incomes low enough to qualify for meanstested National Assistance (Townsend 1963, p. 186). Poverty became an important social justice issue and a matter for 'pressure groups'.

Pressure groups, and lobbying and petitioning governments and leaders, were well-established mechanisms for conveying public unease and encouraging social change. For example, 150 years before Barbara formed AEGIS, Elizabeth Fry established a small campaign organisation, Association for the Improvement of the Females at Newgate, after her first visit to the London prison (Howard League 2016). In the 1960s many new organisations emerged, expressing concerns and aiming to generate action. They campaigned on issues such as the environment, nuclear disarmament, abortion, homosexual and women's rights and other 'conscience' issues. The broadly focussed Consumers' Association, founded in 1957, became a powerful representative of this general trend (O'Hara 2013). Crossman was wary of well-run pressure groups, like AEGIS and CPAG: 'these small splinter groups, can be extremely powerful if they provide the press with hot poisonous news. They can really damage our image.' 5

Investigative journalism and a less deferential media emerged in the 1960s, with some newspapers 'geared to shaking and rattling', seeking justice and making 'people sit up straight'. <sup>6</sup> One journalist, Andrew Roth, contrasted the changes in his profession from the 1950s to the 1960s:

Pressmen, political correspondents like myself, for example, would know a great deal more than they would report because they didn't think it was 'nice' to report about certain things. ... Now that's changed very considerably, thanks to a number of institutions like Private Eye and the breakout of the BBC in That was the week that was (Davies 1985, pp. 17–18).

This gave opportunities for professionalised, media-aware campaigning organisations to publicise their concerns to help achieve solutions. The BBC, for example, showed Cathy Come Home, Ken Loach's film that told the bleak tale of Cathy, who lost her home, husband and eventually her child through the inflexibility of the British welfare system. The film was central to founding the housing charity Shelter (Shelter 2016).

Before the creation of the NHS in 1948, financing of hospitals and long-stay care was largely addressed through philanthropic and Poor Law mechanisms. The donor–beneficiary relationship inhibited protest about substandard practice or facilities, a deeply engrained pattern that, to some extent, recurs or has continued. In the 1960s, patients generally expressed their appreciation and uncritical acceptance of the care they received (Cartwright 1964, pp. 8, 203). Older people rarely complained then or now (Parliamentary and Health Service Ombudsman (PHSO) 2015). The authorities interpreted lack of complaints to mean that provision was satisfactory.7 They did not take into account that many patients and their relatives feared the consequences of complaining or did not know how to complain (also PHSO 2015), and there were no guidelines informing them how to do so.

Although patients had individual contact with doctors, the paternalistic doctor–patient relationship in the 1960s discouraged patients from asking questions about their own health or commenting on aspects of the service they received. Societal changes away from conformity towards greater personal autonomy were associated with less acceptance of medical paternalism and a shift away from the assumption that the doctor and the NHS always knew best. Disquiet about experiences of NHS patients received public airing, such as in Gerda Cohen's What's Wrong with Hospitals? (1964), based on her own frustrating and depersonalising experience of hospital care. She wrote that patients of all ages had 'no rights, no dignity, no status', were treated 'like chipped flower-pots in for repair' and were kept in ignorance 'merely because it's no one's job in a hospital to tell the patient what is happening' (pp. 7, 9).

In contrast to pre-NHS days, after 1948, general taxation funded the NHS. Public funding meant public ownership. In the early 1960s this linked to the idea of patients as 'consumers' of health services with some control of the 'product' they used (Anon. 1961). This connected to the creation of NHS-focussed pressure groups, which concentrated on efficacy of official policy, or post-policy failure, rather than on individual needs (O'Hara 2013). Helen Hodgson, a teacher, set up the Patients Association (PA) in 1963 following reports about the drug thalidomide that caused severe physical deformities in children born to mothers who took it during pregnancy, and Maurice Pappworth's (1962) revelations in 'Human guinea pigs: a warning', about doctors' experiments on unknowing patients (Mold 2012, p. 2032). The PA aimed to be a nationwide patient-participatory organisation, focussing on a growing tide of discontent with NHS services, particularly hospitals, doctors and bureaucracy, including the paucity of information on how to make a complaint. It aimed to educate the public on their rights and responsibilities as patients and to improve care across the NHS (Macfarlane 2009). Pressure groups developed various styles, ranging from the antagonistic (such as the PA) to the National Association for the Welfare of Children in Hospital (founded 1961) (Action for Sick Children 2016), whose members were afraid of being seen as difficult, partly out of a fear that hospital staff would exact reprisals on their children (Mold 2013, p. 238).

Alex Mold's study (2013, p. 240) of the changing role of the patient and NHS consumer groups concentrated on acute hospitals, only once mentioning long-stay patients. The care of older, mentally ill and mentally handicapped people on long-stay wards was peripheral to health service pressure groups such as the PA. Concerning older people, the National Old Peoples' Welfare Committee (founded 1944; later Age Concern) mainly provided practical philanthropic support and lobbied the government about community provision for older people, and Help the Aged (founded 1961) emphasised social support and relief of poverty (Age UK 2016).<sup>8</sup> Neither had specific expertise or interest in mental health. The National Association for Mental Health (NAMH; founded 1946; later MIND) focussed mainly on younger people. Nevertheless, in 1963, NAMH devoted one issue of its journal to older people. An editorial, 'The elderly: "Living and partly living"' (Anon. 1963) referred to many older people 'with little sense of usefulness, little interest in anything, and little affection from anyone'. It was hardly optimistic, but did suggest that interested psychiatrists could work together with 'the many other workers in this field—within the health service and outside'.

AEGIS emerged into this climate of more pressure groups eager to make improvements in NHS and social care. AEGIS was the only one doing that specifically for around 60,000 older people in NHS long-stay psychiatric wards (Townsend 1962, p. 282).

#### AGEISM

New social constructs in the 1960s included ageism, a term coined by Robert Butler (1969) in the United States, and gerontophobia, which was coined by Alex Comfort (1967) in England. These terms reflected excessively negative attitudes and practices, or age discrimination, that could affect provision of services for older people. Ageism is unlike many other sorts of discrimination, such as gender, sexual orientation, race and religion because most of us will live into old age. Ageism means that paradoxically we treat ourselves as 'other'. It is self-perpetuating: ageist stereotypes may be internalised in childhood and reinforced across the life span, often unconsciously, so that when someone becomes old they may adopt the stereotypes themselves (Levy 2009, p. 333).

Pat Thane (1993, 2000) took up some of the issues around ageism and stereotypes in her historical studies of old age. She noted that the 'cultural conservatism' of the 'continuing belief that it is "common sense" to expect inequality past a certain age' was used to justify ageist attitudes (Thane 2010, p. 22). She also explored the complex issue of mass retirement in the mid-twentieth century, which had an impact on ageist ideas. In her view, it was one of several changes that 'increasingly defined old people as a distinct social group defined by marginalisation and dependency' (Thane 2000, p. 406). Socially accepted marginalisation can affect expectations of people providing services and older people receiving them. It can legitimise governments overlooking older people's needs, thus affecting the resources allocated to them. Paul Bridgen (2001, pp. 507–508), in his analysis of geriatric medicine and long-term care, concluded that the early NHS was disappointing from the old age perspective: despite relative improvements in provision in acute hospitals, ideas about rehabilitating older people were slow to be integrated, and no firm strategy for longterm care provision was established, either by the NHS or by local authorities. Marginalisation of older people could also affect historians' interest in them, as Webster commented (1991, p. 165): 'Considering the importance of the elderly as users of the NHS, remarkably little retrospective analysis has been written about the health services from their perspective.' Since 1991, more historical research has been undertaken, including about psychiatric services for older people (Hilton 2015, 2016a, 2016b), considered in the next chapter.

#### METHODOLOGY

If Barbara had persisted with her initial idea to destroy her archive, far fewer sources about the AEGIS campaign would be available today. In a letter in 1970 to her executor, her brother 'Darling FJ', Frederick John Charlton, she said she had changed her mind because someone at the DHSS 'surprisingly enough' suggested that many files 'had a certain sociological interest'. She bequeathed her files to Abel-Smith.<sup>9</sup> He arranged for them to be deposited at LSE. The AEGIS archive, as far as we know, is as Barbara left it. It did not encounter pruning after retirement or weeding, common to organisational archives when a new leader takes over or the organisation changes its archives policy. It takes up eight metres of shelf space and includes thousands of letters and hundreds of cuttings from newspapers, magazines, medical journals and nursing journals about positive and negative aspects of the NHS and related subjects. It records Barbara's campaign in minute detail but contains little autobiographical material. A separate personal archive appears not to have survived. Most biographical information was drawn from private archives, The Jung-White Letters(Lammers and Cunningham 2007), and other people's memories and memoirs. Much was recorded by the author in semistructured oral history interviews (2015– 2016). Interviews quoted in Cochrane's thesis provided valuable insights where other sources were unavailable. Unfortunately, Cochrane's original interview transcripts have not survived.10

Other public and private archive collections were used, to ensure inclusion of different perspectives. The National Archives (TNA) and county record offices hold extensive relevant official documentation. The London Metropolitan Archives (LMA) holds records of Friern Hospital, central to the AEGIS story. The Royal College of Nursing (RCN) unfortunately lacks archives relating to nurses' roles in, or perspectives on, Sans Everything and AEGIS.<sup>11</sup> The University of Warwick Modern Records Centre holds the unedited typescripts of Richard Crossman's diaries, which provide his personal perspectives on Barbara and her campaign.

Some terms used in this book require clarification. A challenge of writing about stigmatised people and places is that terminology changes frequently in the hope that new language will be associated with less stigma and kinder attitudes and practices. The Mental Treatment Act (1930), for example, replaced asylum with mental hospital, which became psychiatric hospital after the Mental Health Act (MHA) 1959. Uptake of new terms was inconsistent, and, for example, well after the MHA 1959, the terms mental hospital and psychiatric hospital were used interchangeably in official sources for no apparent reason.  Colloquially, out-dated language risks being used pejoratively, but I have used terms when they convey meanings, attitudes and expectations in the historical context better than modern alternatives.

The term the elderly is avoided. Geriatrician Bernard Isaacs (1982) and Pat Thane (2010, p. 19) criticised its use because it reinforces a stereotype of older people, conveying an unhelpful and inaccurate impression that they are a homogeneous group, rather than being as diverse as the rest of the population. Psychogeriatric is used only to refer to modern proactive psychiatric services for older people, which began in a few hospitals by the end of the 1960s (Hilton 2016b). It is not used to refer to the earlier passive custodial system of care for older people in the psychiatric hospitals. Another inconsistency in official documents was the spelling of inquiry and enquiry. I have used the former throughout except where enquiry appears in quotations.

Writing about Barbara Robb, I have referred to her as 'Barbara' throughout. Letters in Barbara's archives reveal her often informal approach, and Ann Lammers (2007, p. 258) noted her ability to 'melt' formality; she would have been comfortable with a respectful but casual approach. More difficult to deal with historically is the blurring of identities between Barbara and AEGIS. Taking into account that AEGIS would not have existed or functioned without Barbara, it is sometimes unclear whether to refer to 'AEGIS' or 'Barbara'. The Ministry, for example, was uncertain whether to blame her or AEGIS for fanning criticism<sup>12</sup> and accused her of 'making as damaging a case as she can'. <sup>13</sup> Crossman and Rolph, in diaries and memoirs, tended to refer to her by name rather than the organisation she represented, both because of her influence and because she was unforgettable as a person (Rolph 1987, p. 183). This account uses both 'AEGIS' and 'Barbara', whichever seems most appropriate and accurate in each context.

Barbara was conscious of the huge trust people put in her by revealing sensitive information. She did not want a witch-hunt or for individual staff who revealed their concerns to be scapegoated by the authorities. Nor did she want a backlash of reprisals by angry staff against their colleagues, patients or their visitors who made criticisms, a fear that prevented many from doing so.14 Similarly, it is not my intention to embarrass the descendants of the staff discussed whose behaviours were allegedly unsatisfactory. Most were not deliberately cruel but thought they were practising according to professional standards (Whitehead 1970, p. 13). I have therefore identified them by their pseudonym, if Barbara allocated one, or by a single initial. In contrast, for the author-witnesses in Sans Everything, except in quotations, I have used their real names. Fifty years on, the pseudonyms are no longer required: the course of events showed the legitimacy of the allegations, and the witnesses' courage and humanity in revealing them.

#### NOTES

#### BIBLIOGRAPHY

Anon. 1923. 'The administration of public mental hospitals in England and Wales'. British Journal of Psychiatry, 69, 90–98.

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### Psychiatric Hospitals and Older People: Status Quo or Making Changes?

Huge and forbidding, Friern Hospital, where the AEGIS (Aid for the Elderly in Government Institutions) campaign began in 1965, had 2,250 beds and an unwelcoming, dimly lit corridor more than one third of a mile long, which connected most of the wards. The corridor lights could go off unexpectedly as Friern's electricity supply needed upgrading:1 'it would not do to ask a nervous person to visit' said Barbara Robb (1967, p. 78). A male junior doctor recollected:

You were a bit fearful walking down the corridor. It was the most peculiar experience ... you would see a furtive head looking quietly out of a little nook or cranny, which was actually an entrance to a ward ...so you would wonder what was going to happen to you. You had to be rather bold.

While working at Friern in 1964–1965, that doctor hardly mentioned to his colleagues in other hospitals that he was employed there: 'I think it was regarded as being rather a tainted claim to fame. ... I don't think my peers were aware of it, to be honest. ... It wasn't something you wanted to crow about or boast about amongst other trainees or amongst your seniors.' 2

Friern Hospital was originally named Colney Hatch Asylum. It opened in 1851, the largest and most modern institution of its kind in Europe (Hunter and Macalpine 1974, p. 11). It was one of a network of county asylums built in the mid-nineteenth century, based on humanitarian principles and optimism by the 'mad doctors' that they would find treatments

<sup>©</sup> The Author(s) 2017

C. Hilton, Improving Psychiatric Care for Older People, Mental Health in Historical Perspective, DOI 10.1007/978-3-319-54813-5\_2

for insanity. Alongside demographic changes of an increasing population, tolerance of bizarre behaviour lessened, particularly in more urbanised and regulated environments, and demands for beds rose. Hopes of effective treatment diminished and a custodial approach became common (Rogers and Pilgrim 1996, pp. 46–50). In 1884 the Lunacy Commission (renamed Board of Control in 1913), the public authority overseeing the asylums, commented that older people at Colney Hatch occupied disproportionately more beds than would be expected from their number in the population, and that 'special provision for the aged' was essential to reverse the trend (Hunter and Macalpine 1974, p. 62). The Commissioners observed the pattern elsewhere and in 1897 reported their concern to the responsible authorities (Lewis 1946, p. 151). The government ignored the worsening situation, fearing the economic costs of providing for more older people. The medical profession lacked interest, and there was no public pressure to make changes (Hilton 2016, p. 20). By 1963, people over age sixty-five made up 12 percent of the population but occupied 39 percent of psychiatric hospital beds (47,782 of 123,744), and startlingly, women over age seventy-five (making up 5 percent of the female population) occupied 25 percent of all female beds in those hospitals (Brooke 1967, p. 4).<sup>3</sup>

The most progressive psychiatric hospitals functioned therapeutically despite antiquated buildings. During the 1950s and early 1960s, they were led by dynamic psychiatrist 'medical superintendents', such as Bertram Mandelbrote at Littlemore (Oxford), Denis Martin at Claybury (Essex) (Martin 1962), and Russell Barton at Severalls (Colchester) (Jolley 2003).<sup>4</sup> Other hospitals, such as Friern, lacked a forceful leadership. <sup>5</sup> The medical superintendent, together with the senior nurses and administrative staff of the hospitals—usually a matron, chief male nurse and hospital secretary—were expected to liaise with their voluntary Hospital Management Committee (HMC). The Minister of Health, through the Regional Hospital Boards (RHBs), appointed HMC members, based on their 'knowledge and experience', without defining what that meant (Ministry of Health (MoH) 1966, p. 6). HMC members were usually highly committed and well intentioned,<sup>6</sup> and the Ministry delegated a high level of financial and organisational responsibility to them (MoH 1966, p. iii). The National Association for Mental Health (NAMH), however, regarded HMCs as 'too often ill-qualified—by reason of their age, their backgrounds, the rigidity of their outlook, or their sheer ignorance and inexperience of the matters with which they must deal'. <sup>7</sup> The Patients Association (PA) had other concerns about the effects of delegation to RHBs and HMCs because it resulted in lack of ministerial control over the hospitals, to the extent that 'guidance' or 'advice' that the Ministry sent to RHBs was usually ignored.8

HMCs faced numerous challenges in their hospitals, including ensuring adequate staffing and standards of care, managing overcrowding, and maintaining and modernising buildings. When the Mental Health Act (MHA) 1959 abolished the Board of Control, responsibility for inspections and maintaining standards passed to HMCs who would 'visit' their own hospitals. HMCs received little guidance about how to determine quality. A senior member of the hospital staff usually accompanied them during their visits, which discouraged patients and most staff from voicing concerns. HMC visitors focussed on the physical environment rather than what went on in it. Good interior decor led to glowing reports when psychological and social care was atrocious (Barton 1959, p. 48).

To contextualise the situation that so disturbed Barbara Robb when she visited Amy Gibbs in 1965, it is necessary to understand the interactions between older people and the hospital wards and community services, research and innovation about their needs and the government's standpoint on service provision. During the period from the early 1940s until the mid-1960s, these strands had no clear single chronology and only limited overlap, so in this chapter they are explored thematically. Research on diagnosis and treatment of mental illnesses in older people, for example, had little effect on clinical practice, and government initiatives for older people did little to implement the research findings or remedy overcrowding in back wards. The relevant developments during the same period at Friern are described at the end of the chapter.

#### THE PSYCHIATRIC HOSPITAL WARDS

In the mid-twentieth century, some patients with mental illnesses were discharged from hospital in an improved state, but there were, and are, always some who require on-going care. Proportions of short- and longstay patients varied, depending on a combination of factors, which Kathleen Jones (1993, pp. 150–158) optimistically alluded to, in the 1950s and 1960s, as the social, pharmacological and legislative 'revolutions' of psychiatric care. Social developments included day hospitals, therapeutic communities and the 'open door movement' (p. 151). Pharmacological treatments, research and greater understanding about mental illness helped shape medical practice and enabled more people to be discharged. New legislation—the MHA 1959—facilitated and encouraged, but did not mandate, more liberal and community approaches. Another factor noted around the same time was the psychological damage resulting from long-stay custodial care. In 1959, Barton coined the term institutional neurosis to describe this. Hallmarks of institutional neurosis comprised apathy, loss of interest, submissiveness and social withdrawal. Barton identified seven causes: ward atmosphere; bossiness of staff; medication; enforced idleness; loss of personal friends, possessions and life events; loss of contact with the outside world; and loss of prospects outside the institution (Barton 1959, p. 17). He did not claim to have introduced a new neurotic illness, despite the name he gave it, but aimed to use his observations as a means to improving care (Jones and Fowles 1984, pp. 71–78).

In 1961, Erving Goffman, a sociologist in the United States, wrote about 'total institutions', including 'stripping', a dehumanising removal of all personal belongings as part of the process of complying with group living on admission to an institution. Uniform haircuts, enforced bathing or showering on entry and other demeaning practices, accompanied stripping. Officials could rationalise the practices, such as being for safety or hygiene, but they cumulatively destroyed individuality and ensured compliance in an institution segregated from the outside world. Compliance, by staff and 'inmates', was key to managing large numbers in a limited space with inadequate resources, as in prisons, concentration camps and custodial back wards (Goffman 1961, pp. 8, 119–220).

Psychiatrists and nurses in the hospitals often held unhelpful attitudes about their older patients, with low expectations about improving their health. In 1952, three well-regarded and experienced psychiatrists suggested:

we must be practical and temper our remedies to the gravity of the situation. It is more economical ...to treat—say—60 patients in two wards, than the same number in three wards. We are forced ...to overcrowd in the mental hospitals, and senile patients have proved to be the patients least affected by this (Cook et al. 1952, p. 382).

These psychiatrists did not explain how they assessed older people to be the 'least affected', but older people characteristically stoically accepted the care they received and the restrictions placed on them in an institution. The psychiatrists also did not mention how they ascertained that their patients were 'senile', raising the possibility that some were apathetic associated with undiagnosed depressive illness that could have been actively treated leading to discharge. They stated that they did not advocate a lower standard of care for older people, although it is impossible to see how their proposal to overcrowd wards could be interpreted otherwise.

Nurses on psychiatric wards mainly dealt with physical aspects of care, with a focus on neatness rather than therapy. For older patients they typically provided passive physical care and, fearful of reprimand, would overprotect their patients, such as wheeling them in a chair rather than allowing them to walk unsteadily, and other restrictions that undermined their independence (Whitehead 1970, pp. 26–29). They also removed patients' belongings, such as spectacles, to avoid them being lost or broken (Townsend 1973, pp. 132–135), concerning themselves with the loss of the objects for which they might be reprimanded, rather than on the benefits to the patient. In 1957, an enlightened textbook by Annie Altschul (a psychiatric and general trained nurse, later professor of nursing in Edinburgh) taught about encouraging older patients to lead fulfilling lives either within the hospital or aiming for discharge. Altschul's chapter on 'habit training' optimistically tackled rehabilitating demented patients who had lost skills due to being nursed in bed. She warned that nurses must 'never... allow patients to deteriorate to the degree to which they did in the past' (Altschul 1957, pp. 131–150, 145). Her teaching was radical in the 1950s: modern geriatric nursing became a compulsory component of training only in 1979 to comply with European Union requirements (Norton 1956, 1988, p. 34).

In understaffed wards, nurses often worked under pressure to complete the practical tasks delegated to them, and time-saving regimes could result in undignified care. Nurses interviewed in Jane Brooks' oral history study recollected lack of privacy, 'open bed-panning' (without screens between beds, visible to all on the ward), and the feeling of nursing a 'body' without being aware of the 'person' (Brooks 2009). Tommy Dickinson (2015, p. 114), in his study of 'mental nurses' in mid-twentieth-century psychiatric hospitals, commented on other harmful practices, including physical force and 'production line' bathing, where several people were bathed speedily at one time in a communal bathroom. One nurse he interviewed told him that 'because it was the norm you didn't question it' (Dickinson 2015, p. 110). The issue of communal bathing is worthy of discussion because it highlights grey areas encountered when deciding whether practices were acceptable or degrading.<sup>9</sup> For standards of institutional care to be humane, they should be appropriate to the age, gender, physical, psychological and cultural needs of the individual. This necessitates modelling them on accepted practices outside the institution at the same time. In their own homes, older people usually bathed in private. Based on their practices before admission, older frail people, some of whom might be embarrassingly soiled due to incontinence, would have likely found the rushed process of communal production line bathing degrading. However, in some other contexts shared bathing was socially acceptable, such as for sports teams, creating a degree of subjectivity. Although some practices were categorically unjust, when techniques acceptable to staff but not to patients passed unchallenged, and were condoned by seniors, they became established as standard care.

Changing practice away from custodial methods towards rehabilitation was difficult to achieve. A cultural conservatism existed in many isolated, inward-looking psychiatric hospitals, which made introducing new practices difficult (Carse et al. 1958). A charge nurse who was previously a miner demonstrated this when he likened his hospital to 'a close knit mining community where relationships are very strong'. <sup>10</sup> In such communities, established traditions and practices may be resistant to criticism and slow to change.  Thus in some hospitals, almost military hierarchies, consisting of the incontestable and fear-provoking senior nurses plus many inadequately trained staff, reinforced regimented obeying of instructions, inflexibility and task-driven rather than individually focused nursing practices. Patients who conformed to rules were easier to manage and less labour intensive than individuals with personalised programmes of treatment or rehabilitation, thus the rigid system helped maintain a custodial approach. This corroborates the views of one psychiatrist in the 1960s, who recollected some ward-level obstacles to change, when interviewed in 2016:

So far as the charge nurses were concerned, ... [wards] were run by the nurses, they belonged to the nurses, the patients belonged to the nurses, and they felt they were their property, and they wanted people who were reasonably easy to look after, because that made life a lot easier.<sup>11</sup>

Dickinson's analysis revealed punitive aspects of the rigid staff hierarchy: staff disobedience, complaints or questioning of practices, even if trying to introduce more therapeutic regimes, could be, and was, punished by instant dismissal (DHSS 1971, p. 21; Dickinson 2015, pp. 112, 179–199). Other penalties included banishing a nurse to a less prestigious or 'punishment' ward, often one caring for the most impaired older patients (Dickinson 2015, p. 114; Norton 1988, pp. 25–27). Former staff recalled seniors using underhand bullying tactics to 'get rid of oppositional people' or 'make the complainant see the error of his ways' (Dickinson 2015, pp. 183, 185). Most nurses accepted their role, to carry out, uncritically, whatever medical staff or their nursing superiors prescribed. A few took subversive action and maintained their careers, but the overall pattern was of passive obedience (Dickinson 2015, pp. 179– 199; Brooks 2009, p. 2768). According to Barton, a regimented approach could not fully succeed as 'kindness, pleasantness, sympathy and forbearance cannot be commanded by giving orders or passing resolutions' (Barton 1967, p. x). Nurse Bill Kirkpatrick (1967, pp. 52, 55) noted that the problem was compounded when the hospital leadership did not fully understand the challenges of nursing older people and showed lack of interest towards patients and staff on the back wards, which contributed to nurses feeling unwanted. He wrote, 'anyone who feels unwanted becomes apathetic towards all those in his care, to say the least'(p. 52).

Social factors also influenced nurses' approach to criticising. They often had a long-term relationship with their hospital. Their relatives worked there and they lived, with their families, in tied accommodation. Antagonising the hospital authorities could risk losing job, home and family life, and according to Abel-Smith, some feared that their children would be beaten up by members of staff against whom they lodged complaints.<sup>12</sup> Junior doctors, as the nurses, had cultural norms concerning challenging their superiors. They could also be victimised if they criticised.13 However, junior doctors often had short-term contracts, lived outside the hospital and, although they feared a detrimental reference for their next post, were in less personal jeopardy if they spoke up.

Comments made to external independent researchers were likely to have been more honest. In a study by social scientists Kathleen Jones and Roy Sidebotham (1958–1959), student nurses described their experiences in three mental hospitals. On one ward in a large hospital the nurses' role was 'chiefly that of custodian and domestic help' (Jones and Sidebotham 1962, p. 204). Nurses were 'full of genuine care and interest' for their patients but did not seem to understand the important part they could play in helping them with social activities. Patients who exhibited difficult behaviours were treated like naughty children and the ward lacked a 'fundamental attitude of respect towards patients, that they were adult human beings' (p. 204). Nurses feared the sister's wrath if they sat and talked to a patient, or attempted psychological and social therapeutic interventions, because it was considered 'slacking' (p. 203). By contrast, in another hospital in the study, the ward doors were unlocked, and nurses 'acted as friend and companion rather than as warder' and helped the patients to preserve their independence and autonomy (p. 198).

By the early 1950s, many mental hospitals implemented successful open-door policies. Jones referred to this as part of the 'social revolution' of psychiatric treatment, alongside industrial therapy, therapeutic communities, social clubs for patients and other 'normal' activities (Jones 1993, pp. 150–154). Mandelbrote (1964, pp. 268–270) evaluated an open-door policy in his hospital. He found that a therapeutic ward environment that gave patients greater autonomy meant that 'locked doors and physical barriers against escape were no longer necessary.' Incontinence, incidents requiring seclusion, and destructive and impulsive behaviours also declined, to about one fifth, one year after introducing the policy, with minimal increase in absconding, no increase in serious injuries, and reduced use of night sedation (pp. 272–273). By contrast, Friern maintained a policy of locked wards into the 1960s (MoH 1968a, p. 22).

Hospitals usually began to implement liberal policies on wards with patients perceived as most likely to benefit. This strategy was logical because success would build staff confidence and therefore help alter a large institution that was resistant to change. Thus wards for younger patients became hotbeds of innovation, with active treatment and rehabilitation (Martin 1962). Patients perceived as difficult or less likely to benefit, such as older people, were left until last for experimental approaches (Barham 1997, p. 22). This created a two-tier system within the institution. Psychiatrist Brice Pitt (1968, p. 29) wrote:

Claybury's present reputation rests largely on these units. There are, however, snags, and instead of the whole hospital going on to develop similarly, a sizable split has appeared between these wards where the action is, which get lots of visitors and publicity, and the 'Chronic Hospital' which feels more out of things than in the bad old days when there was little treatment. Whether the Ministry understood the pitfalls of two-tiers is unclear (Jones and Sidebotham 1962, p. 62) but it added to staff tensions in many hospitals, including Friern.14 In 1958, Friern opened Halliwick, a separate treatment and rehabilitation hospital in the grounds. It was better staffed than the main hospital and there were no long-stay patients. Only 5 percent of admissions were older than sixty-five years of age, compared to 23 percent in the main hospital.15 Staff in the main hospital perceived Halliwick as attracting the 'cream' of the staff, the most 'rewarding' patients and better resources.<sup>16</sup> Few staff crossed the metaphorical fence between them.<sup>17</sup> When Barbara discussed the two-tier system with Richard Crossman in 1969, she told him that she declined Friern's suggestion that she should visit Halliwick because she had received reports about it from the family of a peer's wife. Crossman responded that 'it would probably be impossible to get into Halliwick unless you are at least a peer's wife' and it staggered him 'that this could be allowed under socialism'. 18

Secondary historical sources rarely mention complications associated with the two-tiers. Progress towards community care is celebrated, while those patients who were most disabled and mainly older remained in the hospitals as late as the 1990s and are hardly mentioned. Peter Barham wrote about the resettlement of long-stay patients to the community, mentioning one study about the most mentally disabled and hardest to discharge long-stay patients, which, curiously, excluded people with dementia (Barham 1997, p. 22). This hardly clarified the issues as they related to older people. Antipsychiatry, which emphasised personal autonomy and criticised the way society defined mental illness through social, political and legal means, also affected hospital practice in the 1960s. It particularly encouraged rehabilitation programmes and more liberal care regimes, but it too overlooked older people. A handful of antipsychiatry writers, psychiatrists among them, advocated primarily for younger mentally ill people. For example, RD Laing and Aaron Esterson (1964, pp. 31–264) described patients under forty years of age, mainly with schizophrenia, and Goffman (1961, 1963) hardly mentioned older people in his monographs on discrimination and institutionalisation despite their increasing presence in psychiatric hospitals. Any influence of antipsychiatry on services for older people was incidental to its main objectives.

Social scientists documented, and attempted to improve, care for older people. In Townsend's (1965) chapter 'Prisoners of neglect', he noted that levels of function of many older people on back wards were similar to those in local authority care homes, suggesting that they did not need specific psychiatric hospital placement. Townsend also reported boredom, uniform haircuts and disrespect for personal identity on the back wards. Some older people on these wards were very lucid, but had hearing, visual or speech impediments, and staff labelled them as mentally impaired. Many lacked aids that could enable communication and improve function. Deplorably,

A considerable number possess capacities and skills which are held in check or even stultified. Staff sometimes do not recognise their patients' abilities, though more commonly they do not have time to cater for them (Townsend 1965, p. 229).

Many older people were trapped in psychiatric hospitals because of lack of more appropriate alternatives, including geriatric medical wards, domiciliary support and residential care homes. With older people's needs straddling health and social care, the authorities argued about which of them should take financial responsibility for providing support, rather than ensure the most appropriate use of resources (Means and Smith 1985, p. 173).

Townsend criticised the authorities for hiding the worst aspects of the psychiatric hospitals when, in his view, the defects were remediable. Although hospital conditions for older people were by no means uniform, his negative experiences lingered:

It is not just the appearance, the coarseness to the touch, the noise or the impenetrable silence but the smell of neglect that remains imprinted on the mind: the sweet but slightly rotting smell of an assortment of bewildered human beings who exist in claustrophobic proximity like wrinkling apples spaced fractionally apart in a dark cupboard (Townsend 1965, p. 135).

#### WARDS AND COMMUNITY: GETTING THE BALANCE RIGHT

Ward environments were often inadequate, but many domestic dwellings were also impoverished, especially in urban areas. Doctors visiting patients in Birmingham in 1949 described some homes as 'dark, infested slums' (Thomson 1950, pp. 930–931). A survey in Glasgow in the late 1950s, where housing was particularly bad, indicated that 'in spite of housing difficulties, almost all the old people we met had no desire to make a change and any suggestions to this end were usually met with hostility' (Thomson 1959, p. 447). Older people perceived the hospitals as institutions with the stigma of workhouses and asylums. Their own homes, though poor and lacking in facilities, were more than buildings. They contained personal possessions and memories that contributed to the occupier's sense of identity, security, self-esteem and perceived roles in their family and community (Macmillan 1960). Long-term hospital admission deprived older people of these assets, but their wishes were often not acknowledged. Wealthier older people could choose to stay in their own homes, but poorer people usually had no choice and little was done, such as through welfare schemes, to enable them to do so (Harvey 1965). Community welfare provision was insufficient in many places. John Welshman (1996 p. 89), in his study of public health and older people, concluded that stagnation, patchiness and haphazard local authority social care was common, associated with financial constraints, and that central government encouraged, rather than insisted, that services were provided.

According to psychiatrist Cecil Kidd (1962a, p. 457) younger people were admitted to hospital because they needed treatment for their illness, whereas older people were admitted because 'either they cannot be treated or cannot be tolerated at home' (italics in original). Thus for some older people assumed to have no hope of recovery, who could not be supported at home by their families and for whom no alternatives existed, psychiatric hospitals were 'dumping grounds' (Strabolgi 1965; DHSS 1972, pp. 20– 21). Assumptions about irreversible decline were associated with older people bypassing the hospital assessment wards and being admitted directly to long-stay psychiatric wards (Robinson 2009, pp. 9–10). This precluded thorough medical assessment, so remediable physical illness, which in older people could be masked by mental disturbance ('acute confusion' or 'delirium'), would remain undiagnosed and untreated. This relationship was known to general practitioners (GPs) in the 1950s: 'The noisy, restless, agitated old person will often die if moved to a mental hospital' (Batt 1949; Taylor 1954, p. 414).

Evidence accumulated from the 1940s about the need to support families caring for an older person to prevent them despairing and giving up, but little was done to remedy the situation (Rowntree 1947; Sheldon 1948). Families were often 'unreasonably willing' to provide care at home (Lowther and Williamson 1966, p. 1460) but a sudden deterioration in an older person's level of confusion 'nearly always precipitates a crisis in the patient's family' (Anderson 1956, p. 343), the final straw for a family lacking practical support and without emotional reserve to cope with additional stress. Townsend reiterated the need for more support for older people living alone, and for families caring for them, to prevent 'dumping' (Townsend 1962, pp. 106–108, 1965, p. 233).

GPs held the key to community medical and nursing resources and to hospital services. Stephen Taylor (later, Lord Taylor of Harlow), a physician, investigated thirty outstanding general practices, aiming to depict practice worthy of adoption elsewhere. Taylor noted diverse views about older people. Some GPs thought that, with time and patience, working with them could be rewarding. Others viewed them as 'difficult, and even unpleasant ... often inarticulate, hard to get to know, and slow to respond' (Taylor 1954, p. 413). One husband and wife GP team, Cuthbert and Beatrice Watts, wrote gloomily that 'senile demensia' (sic) is common in the 'last decade of life', 'Nothing can be done for these unfortunate people' and older people 'can be most difficult and trying' (Watts and Watts 1952, pp. 140,145). Some GPs were aware of the need to support families, but others thought it best to advise them that providing care 'can only have an adverse effect on their own lives, without benefiting the patient's in the slightest', and because 'no additional help can be sufficient to make it bearable', admission to long-stay care was preferable (Gibson 1957, p. 111). Conveniently for GPs, this fitted with psychiatrists' views that their hospitals had an obligation to fulfil GPs' requests 'to admit the elderly dementing type of patients from the catchment area'. <sup>19</sup> Psychiatrists genuinely tried to help older people by admitting them when they had nowhere else to go and no one to help them with the essentials of daily life,<sup>20</sup> but neither GPs nor psychiatrists were keen to actively work with them (Watts and Watts 1952, p. 140). Tensions existed between GPs and the psychiatric hospitals, as David Enoch, a consultant psychiatrist at Shelton Hospital, Shrewsbury, described in the early 1960s:

GPs used to ring us up and say: 'An old bird is on the way to you.' Sometimes we were lucky if we even had a message at all! When we went round in the week we were told that there were three people over 80 that had been 'pushed in.' The matron and the chief male nurse just had to find a bed. These patients merely appeared. I have great respect for the local authority and those trying to deal with the chronic sick – but Shelton was the 'dumping ground' for this county. I think the hospital deserves a medal.21

Webster noted that GPs perpetuated adverse assumptions of the irreversibility of the problems of old age (Webster 1991a, p. 181). GPs' comments suggested lack of motivation to attempt to improve community psychiatric care for older people, or lack of understanding that it might be possible. How widespread those attitudes were is unclear, but they indicate the depth of pessimism that needed to be overcome to provide psychiatric care in the community.

#### RESEARCH AND INNOVATION: CHALLENGING MEDICAL DOCTRINE ABOUT OLDER PEOPLE

In the 1940s, some psychiatrists in Britain began to challenge the medical profession's clinical negativity towards mentally unwell older people. One surveyed his older patients, concluding that their mental illnesses were not inevitable, that depressive illness could be distinguished from dementia and that interventions could help (Post 1944). Successful treatment of depressed older people using the new electroconvulsive therapy (ECT) (Mayer-Gross 1945, p. 101) and evidence that social interventions could prevent admission and enable discharge of confused older people (Lewis and Goldschmidt 1943) surprised the clinicians.

In 1950, the Bethlem and Maudsley Hospital in South London was the only mental hospital in the country to have a psychiatrist working specifically with older people—Felix Post. He aimed to diagnose their illnesses accurately and actively to treat depression, schizophrenia and other disorders. He achieved good results (Hilton 2007). Post's work was reinforced by Martin Roth's meticulous study (1955), which demonstrated conclusively that the practice of labelling all 'confused' older people as having irreversible 'senile dementia' was obsolete. He identified five psychiatric disorders in its place, of which delirium, depressive illness and 'late paraphrenia' <sup>22</sup> were particularly important because they were often reversible. The medical profession paid little attention to Post's and Roth's findings, which challenged time-honoured teaching and the common stereotypes of old age (Robinson 2009, p. 8; World Health Organisation 1959, p. 10). Failing to take heed of their discoveries prolonged unnecessary suffering. Psychiatrist Anthony 'Tony' Whitehead (1974), commented:

Old people may spend their last years in dreadful misery because severe depression has been wrongly diagnosed as senile decay. ... If you are anxious and depressed, and more and more people start treating you as if you were a difficult child, and you are finally incarcerated in a ward full of other elderly people who are being treated in the same way, it is likely that in time you will give up and take on the role of not just a child, but a baby.

The new ideas about older people's mental illness emerged in tandem with geriatric medicine (Warren 1943). Geriatric medicine had a slow start, and in the 1950s, geriatricians were few and far between. In general hospitals without them, consultant physicians often resisted admitting older people because they feared that these patients' illnesses were chronic, and that they would remain in hospital and 'block beds' (Howell 1951, p. 505). Brice Pitt recollected in an oral history interview about his experience as a junior doctor in the 1950s:

Even my very good mentor had the attitude that a good registrar did not admit an old person. A bad registrar did ...

The hospital ... was like a castle, a good registrar would fend off the elderly, as those who got in were bound to stay, bound to be dumped by their family.<sup>23</sup>

The general hospital consultants held disproportionate power in local hospital hierarchies, so a GP's request for admission to their hospital could be rejected on the basis of the patient's age, before the hospital made a clinical assessment. Admission to a psychiatric hospital was often the only alternative.

Sometimes geriatricians, notably, Lionel Cosin in Oxford, attempted to treat and support older people suffering from mental illness (Anon. 1954). Cosin's innovations included a day hospital plus respite beds to help families undertaking long-term care. However, the local psychiatrists' priorities mainly concerned younger patients, and they were often unsupportive of him.<sup>24</sup> In Cosin's view, and that of other eminent geriatricians,<sup>25</sup> psychiatrists were clinically inept with older people, an attitude unlikely to promote collaboration.

Geriatricians had plenty to do in general hospitals and rarely worked in mental hospitals, and most psychiatrists had little enthusiasm to implement the principles of geriatric medicine (Denham 2004, p. 357). One nurse in 1967 gave her view of the attitude of many psychiatrists towards older people: 'Oh! They're just Anno Domini, any old thing will do.' 26 This might have allowed interested psychiatrists carte blanche to work with older people. However, such freedom was moderated by complex interactions in the psychiatric hospitals, such as weighting the salaries of some senior hospital staff by the number of beds standing,<sup>27</sup> which would not incentivise rehabilitation and discharge. Nevertheless, in 1958, psychiatrist Ronald 'Sam' Robinson established a proactive, assessment and rehabilitation-based psychiatric service specifically for older people, at Crichton Royal Hospital, Scotland, which gradually inspired practice south of the border (Bergmann 2009; Gulland 2014). It comprised outpatient, domiciliary, in-patient (including respite) and community services. Sam Robinson incorporated principles of geriatric medicine into his psychiatric wards, which contrasted with practices observed in the 1960s at Friern and in other hospitals. He took into account, for example, that incontinence was unintentional and was associated with toilet facilities at a distance and poor mobility and that regular toileting minimised daytime incontinence, even for people with dementia. At Crichton Royal, good-quality flooring and shoes encouraged mobility and minimised falls, occupational therapy reduced agitation and 'wandering', men and women shared the same wards and wore their own clothes, and staff found that respecting the patients' dignity and wishes gained their cooperation. Sam Robinson achieved high discharge rates compared to other hospitals (Robinson 1965), demonstrating what could be achieved, even for incurable disorders such as dementia. Unfortunately, the Ministry of Health oversaw the NHS only in England and Wales, so Sam Robinson's scheme was outside their watch. Evidence is lacking that they sought to find out more about it when results were published.

In 1961, inspired by the scheme at Crichton Royal, Barton and Whitehead, introduced similar plans at Severalls Hospital.28 Severalls' service operated on the principle that older people should remain in their own homes as long as possible and that admission was primarily short-term for active treatment. The total number of beds used by older in-patients fell by a quarter (374 to 296) over sixteen months, despite more brief admissions for assessment and treatment (Whitehead 1965). Barton and Whitehead helped staff overcome deeply embedded unhelpful attitudes towards older people, including lack of interest, infantilising approaches to dependency (such as referring to patients in cot beds as 'babies') and harsh undignified criticism ('You filthy old thing. I shall smack you if you do that again') (Whitehead 1970, p. 28). The Ministry attributed the scheme's success to local circumstances rather than envisioning wider application and encouraging its adoption elsewhere (Brothwood 1971, p. 110). Barton and Whitehead also encouraged older people to have a say in their care, acknowledging that 'doctors and nurses do not necessarily know best' (Whitehead 1970, p. 35). This concurred with Cohen's (1964) observations, that the paternalistic style of the NHS had not yet adopted values centred on patient autonomy and individuality.

Several well-constructed epidemiological studies in the early 1960s indicated scope to improve the mental health of older people, avoid admission to hospital and alleviate the stresses on families caring for them (Kay et al. 1957, 1964a, 1964b). Recommendations included health and welfare services complementing the work of GPs, housing schemes for older people and appropriate social and recreational facilities. Registers of vulnerable older people could facilitate assessments to help detect mental and physical disorders at an early stage and provide treatment and support (Kay et al. 1964b, p. 681). This was important because GPs were often unaware of disabilities, depression and dementia. Although GPs' expectations and knowledge were crucial to awareness, other contributory factors included older people and their families not reporting ailments to their GPs, and, linked to age stereotypes, attributing symptoms to age rather than treatable illness and assuming that nothing could be done to help. Thus underdiagnosis and treatment was associated with avoidable and neglected illness that contributed to crises and emergency hospital admissions (Williamson et al. 1964). Post, Roth, Cosin, Sam Robinson, Whitehead and Barton demonstrated what could be achieved, but they were a minority. More common was the fear of the 'looming geriatric impasse' (Kingston 1963) and the assumption, based on demographic change and increasing demand, that it would be impossible to prevent overcrowding the hospitals. To achieve widespread active treatment and rehabilitation for older people required: a culture shift among GPs, doctors and other staff in psychiatric and general hospitals; higher expectations by the public of what could be achieved; and support from central government.

#### THE GOVERNMENT'<sup>S</sup> STANDPOINT

William Beveridge's (1942, p. 92) proposals for the welfare state included older people, but lacked enthusiasm, precision or a sense of priority about them. Nevertheless, Minister of Health Aneurin Bevan stated optimistically in the House of Commons in 1947: 'The workhouse is to go.' In their place, a five-year goal was set to achieve better domiciliary support to enable older people to remain longer in their own homes, and to provide small attractive community residential units each accommodating twenty to thirty people.29 The leadership did not enforce provision, a pattern of failed implementation for older people's services recognised before the NHS (Webster 1991a, p. 166). Webster (p. 188) noted that 'the elderly bore their disappointment with dignity, and general public indignation was slow to materialise.' Some doctors and administrative authorities blamed older people for the inadequacy of hospital and community services: beds were 'blocked by cured cases' (MoH 1957, p. 27), reflecting the 'burden of those old people' (Bickford 1955). Postwar austerity complicated planning, and demographic predictions created unease about the effect of older people on the economy and how the country would provide for them (Political and Economic Planning 1948). Ominous speculations surpassed the optimistic (Thane 1990, p. 292). The Royal Commission on Population (1949, p. 113) commented: 'It is the fact that (with some exceptions) the old consume without producing which differentiates them from the active population and makes of them a factor reducing the average standard of living of the community.' Little account was taken of many retired people who continued to contribute to society, by doing voluntary work and supporting their families, friends and neighbours, rather than requiring care.

The complex needs of unwell older people and the families who supported them, required planning and coordination across several professions and at all levels of health and social services administration. This received much discussion during the 1940s, such as by the British Medical Association (BMA) and the NHS mental health specialist advisory committee (Webster 1991b, p. 103). They helped shape two government circulars, Care of the Aged Suffering from Mental Infirmity and Treatment of the Elderly Chronic Sick (MoH 1950a, 1950b). The circulars recommended joint psychiatric–geriatric assessment schemes, but were noncommittal about funding and did not inspire or entice clinicians into the field. Joint schemes hardly materialised (Hilton 2014; Webster 1991a, p. 178). The titles of the circulars also revealed prevailing attitudes and expectations: passive 'care' for mental disorders compared to active 'treatment' for physical conditions. Assumptions about the need for passive care underpinned other proposals, such as by Donald Johnson, a medically qualified Conservative MP, who described day-care facilities, in a caring and thoughtful manner, as places where older people 'can be parked for two or three days a week'. 30

The Board of Control expressed ambivalence about modernising mental health services to coincide with proposals for the NHS. Mental health legislation, it said, would need to change first, but that would require a review on the scale of a Royal Commission (Rogers and Pilgrim 1996, p. 65). A Cabinet memorandum in 1950 indicated that Bevan was uneasy about the mental hospitals: some 'are very near to a public scandal and we are lucky that they have not so far attracted more limelight and publicity'. <sup>31</sup> Merrick Winn (1955) wrote in the Daily Express that most mental hospitals are 'a disgrace to a nation that calls itself civilised. They [nurses] are doing a magnificent job. But they often do it in conditions in which, had I not seen them, I would not have believed could exist in Britain.' With little public pressure or motivation by the Ministry to back improvements, poor standards persisted.

Postwar, health and social care provision for mental illness and for older people lagged behind other clinical services. Widespread excessively negative beliefs about chronicity, mental illness and old age and increasing demands on the NHS to provide highly technical investigations and treatment for acute physical illnesses, influenced government priorities. 'Cinderella' services became casualties of unremitting retrenchment in the 1950s and victims of broken promises, such as those made in election manifestos (Webster 1991a, p. 188). The UK was not alone in its deliberations, and the World Health Organisation (WHO 1959) issued pragmatic and far-sighted recommendations, influenced by Roth and Post, about mental health and older people. WHO's report, like others from reputable bodies (e.g., National Old People's Welfare Council 1958) created little professional, public or government interest or activity.

Speculative estimates of NHS costs dominated the government's and society's perceptions and discouraged spending (Rowntree 1947, p. 2; Mass Observation 1948). A Commons debate in 1954 estimated that it cost £20 a week to keep a patient in a teaching hospital and £5 a week in a mental hospital. Precise comparisons are difficult because of technological input and higher rates of acute physical illness in the former, but MPs did not raise the possibility that underspending in the mental hospitals might be detrimental.<sup>32</sup> From the government's perspective, fitting more people into mental hospitals was economical. The same year, the title of another government report, The Economic and Financial Problems of the Provision for Old Age, hardly indicated impartiality (Phillips 1954). It focussed mainly on social needs but acknowledged that there were more admissions of older people to mental hospitals, often for social rather than health reasons (p. 74). It commented wishfully that 'their discharge rate will also increase in the near future' (p. 9), an assertion attributed to a recent report by the Board of Control. Evidence of that trend beginning was lacking, but citing it unquestioningly supported the committee's objective of minimising expenditure (Webster 1998, pp. 32–33). By contrast, the Guillebaud Report (MoH 1956) on the cost of the NHS indicated that, in the context of relatively stable NHS costs during the previous five years, additional funding for the needs of older people was affordable. It concluded with a much needed but unheeded message, to give older people 'their due priority in the allocation of additional resources' so that they are 'not overlooked amid the pressure of other competing needs' (p. 219). Guillebaud's report was unpalatable to the Conservative government, which expected it to provide evidence of excessive expenditure to enable tighter retrenchment of the NHS (Webster 1998, pp. 32–33).

The attitude that old age was a burden (rather than an achievement to be celebrated) reduced in the late 1950s (Thane 2000, pp. 475, 479). That linked to a persistently higher birth rate, the baby-boomers, some of whom were coming close to school-leaving age and could supplement the workforce to care for older people. This helped diminish the panic of the 'menace' of an ageing population (Thane 1990), but more younger people to care for them also lifted pressure from the government to improve services. With greater prosperity towards the late 1950s, provision for older people changed little: in austerity everyone waited, and when the economy improved, older people waited until last.

At the end of the 1950s in England and Wales, about 300,000 people out of a population of 6.7 million of pensionable age (4.5 percent) lived in institutions of some sort. Approximately 60,000 lived in mental hospital back wards compared to 6,000 in modern purpose-built care homes. Former workhouses housed 30,000; 85,000 lived in geriatric wards of non–mental hospitals; and 120,000 lived in private, charitable and other communal establishments (Townsend 1962, pp. 44, 282). Unwell, frail older people were generally hidden in their homes or in institutions. They were invisible to most people and politically could be ignored. In 1961, the Ministry commented: 'One of the most urgent and complex problems is the care of mentally enfeebled old people.' It 'hoped' that more geriatric–psychiatric links would be forged (MoH 1961, p. 98). That a problem could be described as 'urgent' and the response as 'hope' suggested lack of commitment to resolve it.

Broad plans for the NHS had potential to improve older people's provision. The MHA 1959 permitted modernisation of mental health services, such as relocating them from the psychiatric hospitals into the community and to district general hospitals (DGHs). In 1961, Minister of Health Enoch Powell optimistically addressed a NAMH conference (Powell 1961). He included the well-being of older people, the need to close the psychiatric hospitals and provide more community services and referred to the Hospital Plan (MoH 1962), a five-year national scheme for which fresh capital sums were allocated to build DGHs. Powell's Health and Welfare, a ten-year plan for community care, lacked dedicated resources or leadership (MoH 1963). Government proposals failed to delineate lines of responsibility for funding, organising and integrating services within the NHS and between the NHS and social welfare authorities, as needed to provide for the most vulnerable older people (Means and Smith 1985, p. 167). Implementation was predictably slow, with lack of direction, and perhaps will, to fulfil commitments to enable older people to remain in their own homes as long as possible.

In 1963, a flurry of activity resulted from an alarming study that found that older people admitted to the wrong sort of hospital—to a psychiatric hospital when they needed physical healthcare and vice versa—had worse prognosis (Kidd 1962b). This rekindled the idea of joint psychiatric– geriatric assessment units. The Ministry drew on its broadly unimplemented guidance issued in 1950,<sup>33</sup> but evidence is lacking that it explored reasons for the failure of the earlier proposals. Dr Geoffrey Tooth, head of mental health at the Ministry was involved in planning for older people. Although he was not always effective (some psychiatrists nicknamed him 'the carious Tooth' 34) his report in 1964 mentioned the need to prevent older people becoming mentally ill, such as with depression. For admission to psychiatric hospitals, he was aware of the clinical and social dangers:

a combination of superficial assessment and expediency leads to the filling of mental hospitals with old people whose physical needs are unrecognised and many of whom do not require in-patient treatment. The uprooting of such old people usually exacerbates their mental condition and, once in a mental hospital, it is exceedingly difficult to get them out. Added to which most mental hospitals lack the facilities for the assessment and treatment of the organic conditions that so often complicate or cause mental disorder.<sup>35</sup>

By 1964, every RHB in England except Oxford had some wards of over seventy people (MoH 1968b, p. 11). A Ministry of Health report admitted that 'their sheer size makes it virtually impossible to provide a satisfactory standard of nursing care' (MoH 1968c, p. 52). A memorandum on older people in 1965 reiterated earlier recommendations, such as better collaboration for planning services and joint domiciliary assessment of patients by health and welfare staff to decide the most appropriate place for admission (MoH 1965, p. 4). It did not mention the specific problems in psychiatric hospitals.

Townsend (1962, p. 7) regarded information about the care of older people in official reports as 'extraordinarily scanty and inept' and it 'did not speak much for the importance attached to these services by the central government.' He asked: 'Why, after 12 or 13 years' experience of post-war legislation, are the problems of the aged so insistent and disturbing and so far from amelioration, still less solution?' (Townsend 1961). No answer was forthcoming, but Webster (1991a, p. 166) offered the explanation that, alongside 'the mentally handicapped', as more people survived into old age, they were regarded negatively as part of the dependent 'growing tide of the unfit' about which little could be done.

By the mid-1960s, particularly for older people, underresourcing, understaffing, dilapidated buildings, and stagnation or good intentions hampered by professional and political paralysis, characterised the psychiatric hospitals. Despite evidence from a few places that improvements were possible, negativity towards unwell older people, and expectations that their demand on NHS resources would increase overwhelmingly, compounded the difficulties. In the competition for NHS resources, mentally unwell older people never reached top priority.

#### INTRODUCING FRIERN HOSPITAL

Many of the broader concerns described earlier set the backdrop for the circumstances that shocked Barbara Robb in 1965 when she first visited Friern (Fig. 2.1). The rest of this chapter explores some of the issues at Friern directly pertinent to the AEGIS campaign and Sans Everything. It focusses on older people on the back wards, especially facilities, personal possessions, activities and staffing, but it draws on evidence about younger people or the entire hospital when necessary. Most information about Friern was obtained from HMC and RHB archives, but General Nursing Council (GNC) inspections, to licence the nurse-training school, provide an independent source.<sup>36</sup> Another valuable autonomous perspective was given by Malcolm Campbell in an oral history interview in 2015. He worked as a locum junior doctor at Friern from November 1964 until

Fig 2.1 Friern Hospital, 1957. Photograph by Karl Ruge, reproduced courtesy of Friern Barnet and District Local History Society.

March 1965, between training posts in neurology, his chosen career. He worked in no other psychiatric hospitals so his recollections relate solely to Friern. His first impressions, vivid fifty years later, were of horror, 'Bedlam', or 'a dumping ground', which provided custodial care and where little medicine was practiced.<sup>37</sup>

The HMC faced numerous challenges. Second World War bombing destroyed five of the six villas in the grounds and damaged the main building, contributing significantly to overcrowding of patients and to Friern's dilapidated state. Friern was not alone in suffering in this way, but other hospitals affected, such as Claybury and the Bethlem, modernised their clinical work significantly more than Friern, despite structural limitations.<sup>38</sup> In 1959, the GNC compared its findings to those in 1951, noting some environmental improvements, such as 1,500 new beds and 'plastic curtains giving a degree of privacy in bathrooms'. It also reported difficulties, including severe overcrowding and lack of storage space for patients' belongings so that 'day clothes are made into bundles at night' rather than being stored in bedside lockers.<sup>39</sup> Lack of storage space meant lack of personal possessions, which could affect self-esteem, behaviour and rehabilitation (Barton 1959, p. 41). In 1963, the GNC made some positive comments, noting more lockers, pictures and plants, to make wards more home like. Many male patients had their own clothes,<sup>40</sup> although female patients still wore hospital clothes, which Campbell described as 'very much a pre-war poor-house style.' Another positive factor was the opening of new facilities in the grounds the same year, for social activities and for patients to have refreshments with their visitors at visiting time.<sup>41</sup>

In 1964–1965 the HMC acknowledged overcrowding and lack of personal possessions. Some wards had up to 90 beds. On some wards, all patients had lockers, on others, none.<sup>42</sup> To provide space for every patient to have a locker, 195 more beds would have to close.<sup>43</sup> The HMC also recorded that about eight older people sustained fractures each month, mainly due to falls, more than in comparable psychiatric hospitals. Adequate nursing supervision and good-quality flooring and footwear could have prevented falls,<sup>44</sup> as Sam Robinson (1965, pp. 188–190) found at Crichton Royal. Inspections revealed inadequate facilities for personal care and privacy, such as patients' toilet doors without locks.<sup>45</sup> Ward E3, where Amy Gibbs spent a year, had no heating in the large, communal bathroom, hardly ideal for bathing dependent older, frail people, although the ward sister 'in charge of the ward for some years ... had no complaint about lack of warmth.' 46 This was alarming, considering that the HMC noted punishingly low ward temperatures at night,<sup>47</sup> and Campbell remembered seeing urine frozen in a bed pan. Hospital hygiene was also poor. In 1965 the hospital suffered a typhoid outbreak (Anon. 1965). Typhoid spreads only in environments where human faeces or urine come into contact with food or drinking water. Campbell recalled 'a fairly strong smell, urine, faeces, or perhaps of disinfectant [and] when I went home at night I would feel the need to have a wash and totally change my clothes because it was all pervading'. 48

Student nurse recruitment was difficult. Much nurse training comprised direct patient care on the wards, so nursing school underrecruitment meant understaffed wards, resulting in excessively busy trained staff and lack of teaching and supervision for students. Promising students were disenchanted by the training received at Friern, some preferring to become bus conductors.49 In 1951 the GNC noted a 'great wastage amongst female students': fifty of the sixty-eight who entered training in 1950 left within a year,<sup>50</sup> significantly worse than the usual one third dropping out of training in general hospitals (Lyth 1988, p. 45). In 1963, the GNC inspected one geriatric ward with forty-five patients, average age eightyfour years, staffed during the day by one qualified nursing sister, three unqualified nursing assistants and one ward orderly. Nursing tasks included personal care, serving meals, washing up, cleaning and administration, so there was little time available to interact meaningfully with patients. Some practices were unsafe, such as dispensing medication from memory without referring to written prescription cards.51

In 1965, the HMC commissioned expert help to ascertain reasons for nursing shortages. Two surveys were undertaken, one on the 'female side' and another on the 'male side'. Miss Craig, a researcher from the King Edward's Hospital Fund (later, King's Fund, an independent charity working to improve health and care in England) asked nurses and doctors on twenty-three female wards why they thought the hospital was short of nursing staff. She was unaccompanied by senior staff, in whose presence juniors might have been unwilling to criticise, but it is unclear whether she spoke to nurses in groups or individually, which could also have affected their answers. Overall, discontent was common and mutual. Doctors criticised nurses for low standards, and nurses complained about lack of medical attention for patients on the back wards. Nurses disliked working on understaffed wards and those with poor facilities. Understaffing meant less attention for patients, who consequently stayed longer and increased the overcrowding, which made the hospital a less desirable place to work and undermined recruitment. Senior staff criticised 'The calibre of student nurses in mental hospitals to-day' who had no sense of ambition or vocation and who 'only come into hospital to have a roof over their heads and some money in their pockets', <sup>52</sup> a hostile attitude that would hardly entice them in.

The HMC feared that Craig's report, and a similar one on the male side, would generate unfavourable publicity, damage their reputation and further discourage recruitment. They therefore concealed the full reports, alleging that some conclusions were based on 'misapprehension or lack of knowledge of the situation' <sup>53</sup> or 'false information'. <sup>54</sup> Deliberate distortion by independent researchers was unlikely, and the HMC did not reveal how they reached their conclusions. Condemning parts of the reports was easy compared to dealing with the problems. There is no evidence that the HMC used the reports constructively to exert pressure on the RHB to allocate more money or as tools to stimulate thought about how to reverse the trends.

A memorandum from the Ministry (MoH 1964, pp. 1–4) on improving psychiatric services recommended more outpatient clinics, day services and community resources and emphasised rehabilitation, with patients having suitable occupation, their own clothes and greater privacy and autonomy, such as deciding when to go to bed. It placed little emphasis on hospital buildings, in accordance with plans for closing them and moving services to DGHs and into the community. It also noted the gradually widening chasm between standards in the best and the worst psychiatric hospitals. It required HMCs to inform their RHBs about recent and proposed improvements. Most psychiatric hospitals within the North West Metropolitan region responded with patient-focused plans for therapy and rehabilitation. Friern HMC, however, outlined rudimentary needs:

Upgrading of existing lavatory and sanitary accommodation has been dealt with over the years, but new standards are constantly being set. In the 50 wards of this hospital there are no low level suites and the old fashioned type of chain-pull cistern continues to exist. ... not in the bulk of the ward lavatories is there a washhand basin. ... Half-doors to the lavatories have been replaced in many wards with a modern door.<sup>55</sup>

The HMC's grumble that 'new standards are constantly being set' gave the impression that it considered that making basic improvements was burdensome. The medical superintendent, Isaac Sutton, appeared indifferent to the inadequacies. Campbell contrasted him with Barton: 'Sutton was the absolute opposite, [wanted] the quiet life and didn't want to make any disruption or say boo to a goose really, and that was one of the big problems with Friern, why it lagged behind and didn't change.' <sup>56</sup> Apathy and resignation from Sutton and the HMC, and the 'vicious cycle where apathy hinders staff recruitment' were consistent with the hurdles to improvement that the memorandum envisaged in some hospitals (MoH 1964, p. 6). Barbara also detected Friern's fatalistic attitudes, when, early in her campaign, she spoke with HMC member Rose Hacker. Hacker doubted whether the recruitment cycle could be broken so Barbara informed her about hospitals where it had been. Hacker replied: 'It's all very well for them. They've all got really good senior medical staff.' 57

#### PATIENTS AND COMPLAINTS AT FRIERN

Generally, patients in the 1960s accepted NHS care uncritically (Cartwright 1964, pp. 8, 203) but occasionally complaints reached the RHB and the Ministry. Examining complaints can shed light on standards of clinical practice and administrative procedures, such as how the authorities responded to the complainant and proposed to remedy the situation to avoid similar incidents in the future. At Friern, reports of good practice to balance against the complaints were not identified in archives or oral sources, although amid her criticisms, Barbara praised two helpful and empathetic ward sisters (Robb 1967, pp. 91, 102–103).

In April 1964, one complaint concerned an older man who sustained rib fractures while being looked after by nurses. His son, a senior academic at the University of London, wrote that the ward had a 'para-military atmosphere', that wearing clothes from a pool was depersonalising and that it was 'increasingly difficult [for staff] to treat people as individual human beings'. The staff were humane but the work atmosphere and environment were unacceptable. The complainant offered to talk to the HMC about his concerns rather 'than weigh in on an undiscriminating public campaign'. <sup>58</sup> The HMC minutes contain the written complaint but lack evidence of action to improve the situation. Perhaps pressure from a 'public campaign' might have achieved more.

Another complaint in 1964 related to alleged violence towards a patient named Bob. Staff told the family that he had fallen out of bed, but Bob's brother Fred noted that 'Bob would not tell me anything no matter how I tried to get it out of him but it looked to me that he had a wallop from somebody.' The family also complained about his belongings going missing, for which the staff blamed Bob: he was absentminded, left his belongings lying about or gave them away.59 The family was distraught about his ongoing care: 'no social life, no change of scene, just an overcrowded ward, unsuitable company, drugged and in bed by 7.30 to 8 o'clock every night, sometimes earlier.' <sup>60</sup> Bob's sister, Mrs Dickens, described him as 'a frightened crushed man due to the treatment he has received in this hospital'. She also described one occasion after she took him out and returned with him to the ward, that just after she left 'I heard my brother cry out "Leave go of my arm!" and then I looked through a slit in the side of a curtain on the ward door, and my brother was then pushed and was staggering along the corridor trying to keep his balance.' She reported this but received no adequate explanation.<sup>61</sup>

Mrs Dickens contacted the RHB. The Board replied that Bob's illness, rather than his care, was the cause of her unhappiness, that he experienced 'delusions and is apt to make up stories about imaginary happenings', and that the consultant thought his mental illness explained his allegations about being attacked by another patient.62 No change in his care took place in response to her letters.<sup>63</sup> Negative responses stopped Mrs Dickens complaining: 'I dare not complain any more about anything as I have already been called a "Paranoid case"'. After Mrs Dickens involved her MP, the hospital offered to transfer Bob to Hill End Hospital, St Albans, within the same region, but inaccessible by public transport from where she lived in Muswell Hill.<sup>64</sup> As Bob's only regular visitor, she refused the offer: she could not manage the thrity-mile round trip for each visit instead of the two-mile local bus ride.

Campbell recollected another complaint about a married middle-aged woman with multiple sclerosis who developed disturbed behaviour. She was put into a seclusion room that had a mattress on the floor and no heating. The family

kicked up a tremendous stink, which, I might say was reinforced by us as doctors. We were keen for them to kick up a stink with the superintendent at the time, MPs and everyone else, about these terrible conditions. ... We saw it as a wedge in the door for getting things changed.<sup>65</sup>

The hospital authorities removed the patient to another institution. In Campbell's view, the hospital responded by: 'Sweeping it under the carpet...shift the problem onto somebody else. Back to the quiet life.'

In this small sample, the hospital authorities were evasive, blamed the complainant and the patient, and provided no convincing evidence that the criticisms were investigated or attempts made to remedy deficits. In two cases, the authorities aimed to appease the family by offering to move the patient to another hospital, with the effect of removing the complainant without dealing with the underlying causes that initiated their grievances.

#### COMMENT

A handful of psychiatrists, geriatricians and social scientists, beginning in the 1940s, demonstrated that older people's mental health and well-being could improve with better diagnosis, treatment, rehabilitation and social support. Many doctors overlooked this evidence, which contradicted established teaching and confounded stereotypical low expectations of well-being in old age. Compounding this, rigid hierarchical management in many psychiatric hospitals resisted change and punished staff who criticised disrespectful treatment and care regimes. In a few hospitals with dynamic and supportive leadership, therapeutic environments for older people began to emerge, but these innovative and effective models of psychiatric treatment and care were hardly replicated. Pressure for change in psychiatric hospitals from the antipsychiatry movement hardly touched older people, for whom, in the 1960s, lobbying was largely concerned with poverty, pensions, social welfare and employment rights, rather than with health (Thane 2010, pp. 13–14, 22).

Government plans and recommendations had the potential to improve services for older people, including Bevan's five-year plan to close the workhouses and improve community support, Guillebaud's proposal to spend more on services for older people, and Powell's long-term, timebound plans. However, recommendations for older people were permissive, lacked dedicated funding, clear lines of responsibility and sense of direction; and implementation was negligible in the broader context of competition for resources and NHS and welfare priorities. Older people and their families were frequently resigned to chronic impairment and decline with increasing age and rarely complained if services were inadequate. The Ministry used a simple economic plan of presumed cheapest provision for older people's custodial care, rather than genuinely exploring alternatives, in particular, that improving their health, preventing admission and enabling discharge might prove clinically possible, cheaper and more humane. In the twenty-first century, as in the 1960s, compared to services for younger people, older people's psychiatric provision lags behind, with inequitable allocation of revenue, despite evidence of benefit from interventions (Faculty 2011).

Friern's HMC swept complaints under the carpet and removed the need for the RHB or the Ministry to ask searching questions about the quality of services provided. An 'undiscriminating public campaign', which one complainant mentioned but did not undertake, might have had more impact than his private letter to the HMC, given the HMC's fear of negative publicity about their hospital and the broader lack of public, political and professional understanding of the psychiatric hospitals and what could be done to improve them. At Friern, little changed, but in November 1965, at the start of Barbara's campaign, the RHB informed the HMC that standards were inadequate and the hospital was under greater scrutiny than most.66

#### NOTES

#### 48 2 PSYCHIATRIC HOSPITALS AND OLDER PEOPLE: STATUS QUO ...

#### BIBLIOGRAPHY

Years of British Psychiatry 1841–1991, ed. German Berrios and Hugh Freeman. London: Gaskell.

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### Barbara Robb, Amy Gibbs and the 'Diary of a Nobody'

'Mrs Robb has always been a terrible danger to [the government]. ... I knew we had to defuse this bomb', wrote Richard Crossman in November 1969 (1977, p. 727), a fine compliment from a Cabinet Minister to a woman who emerged from the shadows to fight for improvements in the care of older people. How did she build such a fearsome reputation? What was her background? How did she acquire her skills? What made her take on the cause? What gave her the 'uncrushable belief in the need to expose what was going on'? <sup>1</sup> How did she cope with Hospital Management Committees (HMCs), Regional Hospital Boards (RHBs) and officialdom's tendency to reject critics and criticism and to maintain the status quo? The biographical element of this book seeks to illuminate the aspects of Barbara's background and personality that motivated her and sustained her in her campaign, and to introduce Amy Gibbs. Their life stories lead into the 'Diary of a Nobody', the visit-by-visit record that Barbara felt compelled to start writing on the first day she visited Amy in Friern Hospital, the events of which inspired the founding of AEGIS (Aid for the Elderly in Government Institutions). The Diary ensured that Barbara had an accurate description of happenings that she observed directly or was told about by patients and visitors on the ward in order to achieve her objective of making improvements.<sup>2</sup> It was not written for publication. She used Amy's real name, only later giving her the pseudonym 'Miss Wills'. Barbara did not explain the title.3 Amy, an ordinary patient, could have been the Nobody, or Barbara, accorded the low status of a visitor or non-NHS professional in the hospital hierarchy, especially when criticising it. Both interpretations fit with Cohen's analysis (1964, p. 7), which she italicised for emphasis, that even where treatment of the illness was good, 'patients do not count'.

Building on Amy's story, and linking to Townsend's (1965, p. 229) observation that many older people in psychiatric hospitals did not need long-term admission, we explore evidence about Amy's mental health and consider whether a twenty-month admission was in accordance with recognised good practice at the time. This chapter also covers the events of Barbara's campaign, based on the Diary, until November 1965 when she 'went public'. It includes the outcome of Lord Strabolgi sending a copy of the Diary to Kenneth Robinson (Member of Parliament for St Pancras North, where Amy lived; Minister of Health 1964–1968), Barbara's meeting with Dr Tooth at the Ministry, and Strabolgi's speech in the House of Lords, prompted by lack of constructive response from the Ministry.

#### BARBARA: AN ANNE OF BURGHWALLIS

In the absence of a personal archive, clues to researching Barbara's background initially came from the dust jacket of Sans Everything. It states that she was convent-educated, trained as a psychotherapist during the Second World War and was married to artist Brian Robb, although scanty biographical material about him fails to mention Barbara. Three other clues in the AEGIS archive were the lynchpins to uncovering her life story: a police statement on which she was obliged to give her maiden name, Anne4 ; a biographical note for a conference programme that stated her place of birth as Thorner, Yorkshire5 ; and a cutting from the Sunday Times in 1972 which stated that she had been married for thirty-five years.6

Barbara Robb (née Anne) was born on 15 April 1912,<sup>7</sup> the second child of Major George Charlton Anne (1886–1960) and Amy Violet Anne (née Montagu 1885–1935). The Annes were an affluent Yorkshire recusant Roman Catholic family. They intermarried with other Catholic families, fairly openly adhered to the Catholic faith and harboured Catholic priests (Kingsley 2016). A plaque at the entrance of St Helen's chapel in the family home, Burghwallis Hall (Fig. 3.1), near Doncaster, records the ancestral martyrs who died 'for the faith': George Anne, Elizabeth Anne, Richard Fenton, and John Anne who was hanged, drawn and quartered at York, about 1588. Barbara was very proud of

Fig. 3.1 Burghwallis Hall, c.1941. Photograph by George Anne, reproduced courtesy of Elizabeth Ellison-Anne.