In the early 1980s I was a student psychiatric nurse at St Bernard’s Hospital, in Southall, West London. St Bernard’s had dominated the area since it opened in 1831. It was originally known as Hanwell Asylum, and was one of the many huge state-run institutions for mentally ill people that were constructed in the first half of the 19th century. These asylums formed the basis of mental health services for 150 years, but by the time I worked at St Bernard’s, the winds of change were starting to blow through their echoing corridors. By the end of the decade, many former asylums had closed down, and St Bernard’s, though still standing, was radically changed as ‘Community Care’ became the dominant philosophy for the mentally ill.
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| Hanwell Asylum as originally built in 1831 |
I was an indifferent student nurse, although I did manage to gain my Registered Mental Nurse (RMN) qualification. Soon after, however, I left St Bernard’s (and left London) and never again worked in a psychiatric hospital. But I was a witness to the last days of the asylums and the early days of care in the community. In this article, I will consider the 150-year history of St Bernard’s up to my time there between 1981-1985, to commemorate a mode of health care – and a way of life – that has now disappeared.
Names change as times change. St Bernard’s started out in 1831 as the Middlesex County Pauper Lunatic Asylum, or Hanwell Asylum, after the then small rural village that stood nearby. In 1929 it became Hanwell Mental Hospital, and then St Bernard’s Hospital in 1938. By the time I worked there it was awkwardly named the St Bernard’s Wing of Ealing Hospital, having been swallowed up, following some NHS reorganisation or other, by the brutalist, multi-storey District General Hospital (DGH) that was built next to it in the 1970s. Today it is the St Bernard’s Hospital site of West London NHS Trust, a large mental health and community services organisation. The original asylum buildings, extended in the 1850s, all still stand and are grade 2 listed, but few now echo with the voices of patients or staff, the rattle of keys or the crash of trolleys. Indeed, most are converted into that ubiquitous city feature, the luxury apartment block, and are hidden among the housing estates and office blocks that have been built on the former hospital grounds.
The Rise of the Asylums
Prior to the 19th century, very few mentally ill people were cared for in asylums. Most with long-term difficulties received a primitive form of community care, by families or the parish, under Poor Law arrangements. A few lunatic asylums (or ‘mad houses’) existed, funded privately and catering for the well-off, or run by religious charities. They had a poor reputation, typified by a famous 1735 image by William Hogarth of the Bethlem hospital in London (Bedlam), showing inmates in degrading poses, sometimes restrained by chains and gawped at by society ladies on an afternoon out.
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| Hogarth's 1735 depiction of 'Bedlam' |
By the late 18th century, however, some attempted a more humane version of the lunatic asylum. In the 1790s, Phillipe Pinel introduced ‘moral treatment’ (moral meaning emotional) to the Bicetre and Salpetriere asylums in Paris. Basing his approach on the insight that much of the violent or difficult behaviour that asylum inmates demonstrated was caused by the fact that they were being treated in a coercive and degraded way, Pinel and his Head Attendant removed physical restraints and introduced a regime of respect and meaningful activity. Violence, distress and difficult behaviour were all reduced. At the same time, William Tuke founded an asylum in York, England (the York Retreat), which also followed ‘moral therapy’ principles, combining a peaceful, semi-rural environment with a humane, respectful regime and the provision of work and leisure activities. Such initiatives reflected the original meaning of ‘asylum’ as ‘a place of safety’ – a calm and positive environment where mentally ill people could achieve relief from distress and hopefully, improvement in their condition.
This upbeat perspective caught the imagination of 19th century governments, and across Europe asylum care became the norm for the mentally ill. In Britain, an 1808 Act of Parliament allowed local authorities to fund asylums from the rates, and a further Act of 1845 required counties that had not already done so to establish a ‘county pauper lunatic asylum’ (‘pauper’ in this context meaning paid for by the state under Poor Law provisions). In 1850 there were 24 publically funded asylums in England and Wales, with an average population of 297 inmates. By 1900, there were 77 asylums, and their average population had grown to 961.
Hanwell Asylum in the 19th Century
The Middlesex County Pauper Lunatic Asylum at Hanwell opened in 1831. Its design reflected best practice in asylum architecture at the time. At its centre was a chapel, offices and accommodation for the asylum’s medical superintendent and other senior staff. Wards stretched out along either side (male to the east and female to the west) in long, continuous corridors, with right-angled bends to reduce walking distances. Around the wards were ‘airing courts’ and in front of the site were pleasure grounds (male and female). Towards the rear of the site were washhouses, workshops, a gas works and a farm and market garden – 19th century asylums were to a large extent self-contained and self-sufficient communities, with more able inmates (from the lower classes) put to work. The Grand Junction canal ran along the back of the site, and the asylum had its own dock for bringing in coal and supplies. Finally, there was a burial ground for deceased inmates.
The first Medical Superintendent was William Ellis; later Sir William, the first person to be knighted for services to psychiatry. He was succeeded in 1839 by Dr John Connolly. Connolly was a firm advocate of the principles of moral therapy and abolished all physical restraints, in the face of opposition from both within and outside the asylum. Connolly’s association with Hanwell asylum lasted until 1852, after 1844 as visiting physician, and he was succeeded by Dr William Begley, who was medical superintendent for over twenty years.
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| A Plan of Hanwell Asylum in 1843, when Dr John Connolly was Medical Superintendent. Note the extensive farm buildings and fields |
A constraint on moral therapy in asylums such as Hanwell was that demand for admissions quickly outgrew supply. From the outset, some queried whether the size of Hanwell asylum was compatible with moral therapy principles, and by the 1850s it had grown still larger, with an extra storey being added to the male and female wings. Recruiting sufficient nurses and attendants was a challenge, and the attitudes of staff often leant more towards ‘control’ of inmates rather than ‘care’ (a tension that still exists today). A further issue was that moral therapy rarely led to a cure for madness, and inmates frequently spent the rest of their lives in the asylum. By the end of the 19th century, physical restraints had found their way back into Hanwell asylum, and most others.
The standard mechanism by which a person was admitted to an asylum was through the issuing of a ‘Certificate of Insanity’, applied by a magistrate on medical recommendations. Prior to 1930, asylums only took certified patients; after the Mental Treatment Act of that year, patients could enter a ‘mental hospital’ (as the asylums were by then called) on a voluntary basis. The legal mechanism of Certification of Insanity lasted until the 1959 Mental Health Act, and in the 1980s, long-stay patients’ case notes still contained light-blue cardboard Certificates of Insanity that had in some cases been issued fifty or sixty years previously.
Today’s classifications of mental disorders did not emerge until the early twentieth century, and it would be invidious to apply modern labels to those deemed to be insane in the 19th century. However, it seems safe to assume that most inmates of Hanwell asylum would today be diagnosed as having schizophrenia, major depression or bipolar disorder. There were, however, other conditions common in the 19th century that are rare today, in particular General Paresis (or General Paralysis of the Insane), a degenerative neurological condition that was at the time both mysterious and incurable, but which was subsequently discovered to be an outcome of tertiary syphilis. Other conditions that lead to dementia, such as Alzheimer’s disease, were rare in the 19th century, as relatively few people lived long enough to contract them, but as life expectancy increased in the 20th century, dementia became more common, and people with dementia often ended their days as long-stay patients on the growing number of ‘psychogeriatric’ wards.
There were no effective medical treatments for mental illness until after the Second World War, but a variety of more-or-less drastic therapies were tried. In the 19th century, cold water baths, centrifuges and sensory deprivation devices were used in attempts to quieten the agitated, or rouse the apathetic. In the 20th century, convulsive therapy and psycho-surgery were introduced, along with tranquilising drugs such as paraldehyde and chloral hydrate. In the 1980s I nursed patients who had had lobotomies many years before – didn’t work, then.
The 1871 census return for Hanwell asylum provides a snapshot of those who lived and worked within asylums at that time. 984 inmates were listed, 312 male and 672 female. They were identified by their initials and ages, with their previous occupations if they had had one. These reflected the times, with male inmates having mostly been tradesmen or labourers and females having been domestic servants. There were sixteen resident ‘officers’, with their families and servants, including the Medical Superintendents, William Begley and James Lindsey, three Assistant Medical Officers, the Apothecary, the Storekeeper and his clerk and the chief Civil Engineer. Female officers included the Matron, Isabella Hicks and her deputy, Mary Pace; an Assistant Matron, a Housekeeper and Superintendents of the Workroom, the ‘Bazaar’ and the Laundry. There were 136 resident unmarried attendants, 46 male and 90 female, and a Gate Porter and his wife. Other members of staff lived in Hanwell village. The tradition of staff living on site in Nurses’ Homes or rented houses lasted long in the asylums. When I lived in the Nurses’ Home at St Bernard’s in the 1980s, most residents were young student or staff nurses, but some unmarried nurses had lived there for many years, almost as institutionalised as their patients.
Ordnance Survey maps show the growth of Hanwell asylum/St Bernard’s hospital. The original 1831 buildings were soon added to. As mentioned above, a third floor was added to each wing in the 1850s, and by the turn of the century, additional buildings had grown out of the wings and a new, larger chapel had been constructed. Early in the 20th century, new ‘villa-style’ wards were built in the grounds to the west of the main buildings, and these were added to by the 1930s. The Nurse’s Home, which seemed to me to be timeless, was actually not built until after the Second World War. By the 1960s, St Bernard’s had reached its peak size, and then the new Ealing District General Hospital was built on part of its grounds to the east of the main buildings.
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| St Bernard's hospital circa 1960. NB: this map is the other way up to the previous 1843 plan. The original buildings still stand, with extenions built into them. To the left of the picture are 'villa' wards that housed acute patients. The empty areas at the top of the site were playing fields. The bow-shaped building in the top left-hand corner of the site was the nurses' home. |
Post-war Challenges to the Asylums
By the 1930s the terms ‘lunacy’ and ‘asylum’ had disappeared from official usage (though as stated above, the concept of ‘Certification of Insanity’ lasted until 1959). The 1930 Mental Treatment Act replaced the 1890 Lunacy Act, and among other things, decreed that Lunatic Asylums should be renamed Mental Hospitals. Patient numbers continued to increase until the early 1950s. Then a series of factors slowly came into play that were to lead, some forty years later, to the demise of the old asylums. First was a change of attitude that led to greater acceptance of the mentally ill as part of the broader community. This led to increased integration of mental hospitals with their neighbourhoods. Some that had been surrounded by high walls demolished those walls and allowed patients more access to their local communities. Then drug treatments began to be developed that for the first time offered relief of the symptoms of severe mental disorders such as schizophrenia, depression and bipolar disorder, at least while the person continued to take the medication. This meant that many newly diagnosed individuals who would have previously been ‘certified as insane’ for life could now receive hospital treatment for acute distress but then return to the community with long-term medication, reducing drastically the need for long-stay mental hospital beds. This led to the beginnings of community care, with community mental health nurses visiting people in their own homes to give long-lasting injections of anti-psychotic medication, and some acute mental health words being sited within district general hospitals. The 1959 Mental Health Act finally did away with certificates of insanity, replacing them with a system of time-limited compulsory detention for those who were a danger to themselves or to others.
In 1961 the Health Secretary, Enoch Powell delivered a famous speech to the National Association for Mental Health that became known as the ‘Water towers speech’, from this extract:
“There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day”.
The significance of the speech was that for the first time a UK government aspired to close down the Victorian asylums and replace them with a comprehensive system of community care – though it would take another twenty-five years for it to begin to happen.
During the 1960s and 70s, the old mental hospitals came under increasing fire. Some of the criticisms were intellectual, from what became known as the ‘Antipsychiatry’ movement. In 1961, the American sociologist Erving Goffman published Asylums, in which he wrote of ‘institutionalisation’, the process by which living in an institution such as a mental hospital, with its impersonal size and authoritarian regime led to the loss of initiative, individuality and independence on the part of inmates. It was closely followed in 1962 by Ken Kesey’s novel One Flew over the Cuckoo’s Nest, set in an American psychiatric hospital, which made an anti-hero of the domineering and unfeeling Nurse Ratched. The implication of both books was that asylums, far from being benign and therapeutic places, of themselves led to worse outcomes for patients. Later in the 1960s, anti-psychiatry writers such as Thomas Szasz and R D Laing criticised the nature of medical psychiatry itself.
Further blows to the reputations of mental hospitals in the UK came in the form of a series of official inquiries into abuse of patients by staff within psychiatric hospitals, beginning with Ely hospital in Cardiff in 1969, and continuing throughout the 1970s. It was pointed out that the closed nature of the large hospitals, often still self-contained and on out-of-town sites, could lead to a culture in which nursing and other staff felt invulnerable to scrutiny or criticism. Many instances of physical, sexual and financial abuse of patients were reported in many different hospitals. St Bernard’s was however spared from being the subject of an inquiry. By 1980, the feeling that large psychiatric hospitals were at best anachronistic and at worst abusive had become dominant in the UK and elsewhere in the western world.
St Bernard’s Hospital in the 1980s
This was the environment that I entered when I began my RMN training at St Bernard’s in 1981. I had previously worked in a couple of other psychiatric hospitals, so I knew in principle what to expect. Today, student nurses are educated to degree level in universities and are supernumerary when on clinical placements, but my training was under the former ‘apprenticeship’ model, in which we were salaried employees of St Bernard’s and contributed to the ward’s staffing numbers while on placement.
Despite the growing feeling that community care was the future, my training course was almost exclusively hospital based. I spent a total of two weeks in the community, including a few days with an inarticulate Community Psychiatric Nurse who did nothing but give former patients injections of antipsychotic drugs. For the rest of the three years, I went from ward to ward in eight week spells, with weeks in the training school in between and two unseen examinations at the end of the course.
When Hanwell asylum opened in 1831, it was situated, as were most public asylums, in countryside. 150 years later, London had swallowed it up, and it sat between the dense suburbs of Ealing and Southall. It still had its grounds, however, which were peaceful and well-kept, and there were extensive sports fields where there had once been farmland. Previously, these might have been enjoyed by patients, for leisure activities were a constituent part of moral therapy. By my time, however, they were used exclusively by staff. St Bernard’s had a cricket team, a football team, a tennis team, a hockey team and a bowls team, and there were also squash courts in the staff social club. What the patients made of all this sporting activity, from which they were excluded, is a matter for conjecture.
Although it was officially a ‘wing’ of Ealing DGH, St Bernard’s was a world apart from its supposed partner. It had its own management structure, culture and mores and the RMN nurse training school was separate to the Registered General Nurse (RGN) School. Nurses rarely wore uniforms - though I still possess a St Bernard’s issue male nurse’s white coat. Student nurses, RMN and RGN, did a placement in the ‘other’ hospital (and there was a fair amount of nocturnal exchange between the two nurses’ homes) and the main route to career development was to become ‘dual trained’ (RMN and RGN), something I never achieved. However, St Bernard’s had a laid back, informal feel that the DGH never had. It was also determinedly anti-intellectual. On more than one occasion, old ward sisters complained to me about student nurses who were graduates – “full of theory but can’t actually do the job”. I took it as an indirect compliment that they were saying this to me, as I was a graduate myself, but had learned to keep that fact quiet while on placements. However, the ’job’ often seemed to consist of little more than giving out medication, supervising meals, and stamping down on trouble.
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| My surviving St Bernard's issue white coat, now rather paint-stained |
There were four broad types of ward at St Bernard’s. There were ‘acute’ wards, for those living in the community who had had an onset, or relapse of mental illness. There were ‘long stay’ wards, for those who had been in the hospital for many years, some still with their certificates of insanity in their case notes. There were ‘psychogeriatric’ wards for older people with dementia, and a range of more specialised wards, including a locked ‘psychiatric intensive care unit’ for the most disturbed acute patients, a treatment unit for those dependent on alcohol, and a ‘therapeutic community’ (named Connolly ward, after St Bernard’s most famous medical superintendent) for those with personality disorders. The acute wards were situated in the ‘villas’ away from the main building, while the long stay and psychogeriatric wards were in the depths of the Victorian asylum. The original system of wards joining onto each other in continuous corridors still prevailed, meaning that to get to one ward you often had to walk through another, and porters with trolleys crashed through at all times of the day – hardly a homely environment for patients, and unsafe for those with dementia, who often followed passers-through out of their ward and had to be retrieved.
Psychiatric hospitals have long had multi-ethnic staff complements, and St Bernard’s, being close to London, was perhaps more diverse than many. The intake of student nurses of which I was a member came from Ireland, Malaysia, India, Zimbabwe, Tanzania and Sri Lanka, as well as a handful from the UK. A few years before, there had been a mass input of people from the island of Mauritius into mental health nursing in the UK, and some of these were now in senior positions in psychiatric hospitals across the country; the majority of our tutors were Mauritian. There was diversity among the patients too, especially on the acute wards, whose catchment areas included Shepherds Bush and Notting Hill, with large West Indian populations, and Southall, with an extensive Indian community (and some excellent curry houses).
St Bernard’s had an extensive management structure, but one rarely saw nurse managers on the wards. The culture among ward staff was largely to ‘get on with it’. Even when a patient absconded from a ward I was placed on and committed suicide, the Nursing Officer responsible for the ward only felt the need to give the nurse in charge a brief phone call rather than come to the ward to offer support. We had to ‘get on with it’ when it came to ward supplies as well. There was often a shortage of bed linen, and on psychogeriatric wards, with patients who were sometimes incontinent, beds had to be made up with counterpanes, due to a shortage of sheets.
The hospital's senior manager was the Principal Nursing Officer (PNO), who later, following yet another NHS reorganisation, became General Manager. One odd decision that he made during my time was to close the hospital’s psychiatric intensive care unit, on cost grounds, meaning that disturbed patients had to be nursed on open acute wards, with no extra staff support. The result was increased stress all round, with some acutely ill and vulnerable patients spending long periods alone in ‘seclusion rooms’. I only met the PNO once. This was when community care was starting to get underway and rumours were starting to spread that St Bernard’s was earmarked for closure. The PNO decided to hold meetings on each ward to try to reassure the staff about the future of the hospital and I attended a meeting on the ward on which I was doing my placement. After haranguing us for fifteen minutes or so the PNO left, with none of us much wiser, or reassured.
So this was my experience of St Bernard’s. By mid-1985 I had left, and so I missed the upheaval that ensued in the late 1980s, when the Thatcher government finally began to close the asylums and ‘community care’, after a fashion, became the norm.
The End of the Asylums
‘Community care’ began in Italy in the early 1980s and was adopted by other western countries as the decade progressed. In the UK, it was driven by an unholy alliance between professionals, who were either idealistic or opportunistic, and the Conservative government of Margaret Thatcher, who saw an opportunity to save public money, while pursuing its agenda to increase the role of the private sector in health care. The first Victorian asylum to close, Banstead hospital in Surrey, did so in 1986, and by the turn of the last century all had either closed or been drastically reduced in scale.
Closure meant relocating acute and specialised mental health services and resettling long-stay and psychogeriatric patients. Acute in-patient wards moved to specialised units, often attached to district general hospitals, while specialised services were often re-established on a community care basis – rightly or wrongly. The residential alcohol treatment and personality disorder wards at St Bernard’s were phased out. As time went on, Community Mental Health teams were established, to support people with mental health difficulties in the community and – in theory – reduce the need for in-patient beds.
The closure of the Victorian asylums meant that the long-stay and psychogeriatric patients living within them had to be ‘decanted’ to other settings. It was with these groups that the community care changes became most controversial. Those with dementia were of course vulnerable and lacked the capacity to make choices or to agree to being moved. Many long-stay patients were in a similar position. Where they ended up became a matter of controversy, as did the fate of those newly diagnosed with severe mental illness and for whom living in the community was difficult.
As stated above, mental health professionals tacitly colluded with the Thatcher government to promote community care. While it was difficult to argue that the Victorian asylums were the best settings for people to live, or provided a first-class standard of care, it was unclear that community care was better for the most disabled former patients. The prime motivation for the government was to save money – the asylums were very expensive to run – and it largely failed to fund comprehensive community alternatives. Some professionals were motivated by idealism, believing that community care would provide freedom and dignity and a better quality of life for individuals. Others saw opportunities to improve their work situations, by ‘moving on’ tiresome, old and smelly long-term patients and concentrating on more interesting area such as counselling and psychotherapy. Still others recognised the opportunities that community care gave them to make money. The government’s main alternative for long-stay and psychogeriatric patients was to encourage the establishment of private sector care homes, and many psychiatric nurses and doctors became care home proprietors, taking in older people with dementia or elderly long-stay patients. In the late 1980s, the General Manager of St Bernard’s (who as PNO had controversially closed the hospital’s psychiatric intensive care unit) was suspended and subsequently resigned when it emerged that a group of 20 former long stay patients had been removed 200 miles away to Lytham St Annes, to a care home set up as a business venture by former St Bernard’s nurses.
There were undoubtedly other casualties of the move to community care, among both patients and staff. Some former asylum staff lost their jobs, or lacked the skills to adapt to working in the community. Some who had lived in hospital accommodation for many years lost their homes. And while some former patients were successfully resettled, others fell between the cracks of community care and ended up on the streets, in prison or dead.
Mental Health Care – and St Bernard’s Hospital – Today
By the turn of the century, the Victorian asylums were gone and today there is a more diverse structure of services for people with mental health needs. St Bernard’s, or what remains of it, is now the St Bernard’s site of West London NHS Trust, which provides mental health services (and some other community services) to the London boroughs of Ealing, Hammersmith and Fulham and Hounslow, along with some regional and national specialisms. There have been few medical advances in the treatment of mental illness since the 1950s. Medical treatments for schizophrenia, severe depression and bipolar disorder still provide symptom relief only, and the person must take the drugs (and cope with their side effects) long term, or risk relapse. The life expectancy of people with schizophrenia today is around 15 years less than that of the population as a whole. There are no effective drugs for Alzheimer’s disease or other forms of dementia, and numbers of people with dementia are growing with an ageing population. There is a vast and growing need for treatment for so-called ‘common mental health problems’ – depression and anxiety – but no breakthroughs in psychotherapy. Drug and alcohol dependency, eating disorders and personality disorders are still treated in the same ways as they were when St Bernard’s had specialised wards for such issues, and with similarly indifferent success rates. Finally, many expect major consequences for mental health of the current coronavirus pandemic, with children and adolescents particularly vulnerable.
To respond to these challenges, West London NHS Trust’s web site lists a range of services that reflect current best practice in mental health care. There are acute inpatient wards – and psychiatric intensive care units. There are a number of different community mental health teams, which together are supposed to provide a comprehensive service for those with severe mental health problems who are not actually in hospital. One can get counselling on the NHS through the Trust’s ‘Improving Access to Psychological Therapy’ service and specialisms include an eating disorder and a child and adolescent psychiatry service.
There are other mental health services that the Trust does not provide. There are no alcohol or drug services, as these have been privatised. And sometime during the 1990s, dementia was quietly reframed by the government from being a health issue, with long-term care provided for free by the NHS, to a social care issue, provided for by private care homes and means tested, with many having to sell their homes to pay for residential care.
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| The entrance arch and the chapel are among the listed buildings still standing at the St Bernard's site |
What role does St Bernard’s play in West London’s mental health services today? Well, the Trust’s website lists a variety of mainly community-based services that have their bases at the St Bernard’s site. But its main role is to provide secure in-patient wards, for people with mental health problems who have committed offences. There has been an explosion of secure provision since the closure of the large psychiatric hospitals, and around 20% of the NHS’s mental health budget goes on providing high-medium- and low-secure units. The original idealistic philosophy of community care was to give people with severe mental health needs greater freedom and a better quality of life. As time has gone on, concern has shifted to reducing the risk, perceived and actual, that severely mentally ill people might cause harm to others. Some people with severe mental illness commit offences, and end up in prison. Others are diverted from prison by the courts to secure mental health facilities, such as those at St Bernard’s.
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| Images of St Bernard's today. Top left: some of the original ward buildings. Top right: the site is now hemmed in by modern office and housing blocks built on the former grounds. Bottom left: Three Bridges Medium Secure Unit was built in the late 1980s on the former asylum inmates' burial ground. Bottom right: The Orchard is one of the secure mental health units that take up the bulk of the remaining site |
So in a way, St Bernard’s has come full circle. When it opened as Hanwell Asylum in 1831, its doors were locked and its inmates were legally obliged to live within it due to having been certified as insane. Today, those patients who occupy the locked secure units that have been formed from some of the original buildings are similarly obliged by the Mental Health Act to remain there. They are also legally required to take anti-psychotic medicine and some have become ‘new long stay’ patients, incarcerated for many years. What would Dr John Connolly make of it all? He would at least have the satisfaction of knowing that his regime of moral therapy was as humane as, or possibly more so than that faced by the inmates of St Bernard’s today.
Additional Sources Used
Andrews J (2004) The rise of the asylum in Britain. In: Brunton D (ed) Medicine Transformed: Health, disease and society in Europe, 1800 - 1930. Manchester: Open University Press
The King's Fund (2014) Service Transformation: Lessons from Mental Health.
Turner J et al (2015) The history of mental health services in modern England: Practitioner memories and the direction of future research.
