A brief history of healthcare provision in London



For centuries mental illness was regarded as a spiritual affliction rather than a pathological one.  Mentally ill patients were removed from society and 'contained' in workhouses or asylums.


Pauper farms - private workhouses - were established in the early 18th century and were contracted by the Poor Law Guardians of those parishes either lacking a workhouse, or with insufficient room, to provide indoor relief for mentally ill paupers incapable of work - the 'harmless' idiots, the feckless and the chronically mad.  The fee for board and lodging was negotiated between the Guardians and the receiving farm (boarding out for a fixed fee was known as 'farming out').

By the beginning of the 19th century pauper farms had grown into quite large concerns, housing several hundred paupers at a weekly rate of 4 to 6 shillings (20 to 30p) each, and were an important part of public welfare provision.  However, following the Poor Law Amendment Act, 1834, which obliged parishes to provide workhouses, the role of the pauper farms began to diminish.

The Lunacy Act, 1845, compelling the Counties to build lunatic asylums for their mentally ill paupers, further reduced the need for pauper farms.  They became economically unviable as the number of county asylums increased during the mid 19th century.  It became cheaper for parishes to send their patients to county or private lunatic asylums (Licensed Houses).  Some pauper farms, like Grove Hall, became Licensed Houses.


Most 18th century asylums resembled country houses and were privately run.  The earliest was Bethlem, a grand building which opened in 1678 (now demolished).

The Madhouses Act, 1774, laid down that private asylums that were to receive the insane must be licensed by law, and that patients could not be admitted except under medical certificate (hence the term 'certified patient').

Prior to the Act, insane people had been cared for by the local civil authorities.  Pauper lunatics were dealt with under the Poor Law, Vagrancy Law or criminal law and tended to end up in workhouses, Houses of Correction or prisons.  The Act passed responsibility for the care of the insane to the Royal College of Physicians, who visited the private asylums and issued the licenses.

However, until 1811, no certificates were required for pauper patients, who were admitted and detained in licensed houses without formality.  Their only protection was the fear on the part of those detaining them of being accused of illegal detention.

Licensed houses fell into two categories:  Metropolitan Licensed Houses (privately owned asylyms or madhouses in a city), which were licensed by the Commissioners of the Board of Control (who also inspected them several times a year), and Provincial Licensed Houses (those outside a city), which were licensed by the local judges.  They varied greatly in size.  The largest in the United Kingdom housed 672 patients, and the smallest one 4 patients.

During the 19th century, many large Metropolitan Licensed Houses were established.  There were three types - those that took private patients only, those that took paupers only, and those that took both private patients and paupers.   In 1847 there were 141 licensed houses in the United Kingdom housing 6,629 inmates, of whom 3,996 were paupers.


ASYLUM Type of patient
Bethnal House Private and pauper of both sexes
Brooke House Private only, both sexes
Camberwell House Private and pauper of both sexes
Chiswick House Private only, both sexes
Clarence Lodge Private only (female)
Featherstone Hall Private only (female)
Fenstanton Private only (female)
Flower House Private only (male)
(The) Grange Private only (female)
Grove Hall Private and pauper of both sexes
Halliford House Private only, both sexes
Hayes Park Private only (female)
Hendon Grove Private only (female)
Hoxton House Private and pauper of both sexes
(The) Huguenots Private only (female)
Moorcroft House Private only (male)
Newlands House Private only (male)
Northumberland House Private only, both sexes
Otto House Private only (female)
Peckham House Private and pauper of both sexes
Peterborough House Private only (female)
(The) Priory Private only, both sexes
Vine Cottage Private only (female)
Wood End House Private only (female)
Wyke House Private only, both sexes

By 1914 only 69 licensed houses existed, with 3,493 inmates, of whom 638 were paupers.  In 1923 there were 56 licensed houses with 2,686 inmates, none of them paupers.  The decline is explained partly by the establishment by the County Councils of their own public mental institutions (especially when this became compulsory in 1845) and partly by the fact that many licensed houses had been started by medical men particularly interested in the care and treatment of the insane.  On their death the licensed house, which was their private property, passed to their heirs, who were not interested in continuing to run it.

Licensed houses continued to exist, however, not for charity but as private mental hospitals, as they satisfied a demand from relatives for mentally ill patients to be treated in other than a public institution.


The County Asylums Act, 1808, led to marginally more humane treatment of the inmates.  It also provided for the funding of county asylums, but not many were built (by 1827 only nine had opened).  Many paupers with mental illness and the criminally insane therefore remained in workhouses, pauper farms or in prisons, but those with the means could arrange for their mentally ill relatives to be admitted to private asylums.

In 1845, both the Lunacy Act and County Asylums Act legally compelled counties to build asylums for their lunatic poor and criminally insane inhabitants.  All asylums were required to have a chapel.  Most asylums were built on a 'corridor plan', with small secure rooms on either side of a corridor.  Some were set out in a radial pattern (panopticon) or as a double-cross.  The later asylums were built on an echelon plan - pavilions laid out in a V- or arrowhead shape - with different categories of patients occupying each pavilion.  The Claybury Asylum became the standard model.  Most were self-sufficient with farms and workshops, the patients providing the manual labour.


The Lunacy Act, 1845, also established the Lunacy Commission, a permanent central regulatory body which had national authority over all asylums.  It consisted of eleven Metropolitan Commissioners of Lunacy - three lawyers, three medical doctors and five laymen.

Their main function was to oversee the building of publicly owned county asylums (required under the County Asylums Act, 1845).  All asylums, apart from Bethlem Hospital, were required to be registered with the Commission, to have written regulations and to employ a resident physician.

The Commission was also responsible for removing mentally ill paupers from workhouses and prisons and placing them in private or county asylums, where they could receive treatment.  Together with the Poor Law Commission, it monitored the treatment of any remaining in workhouses or on outdoor relief.  The Commissioners in Lunacy also visited and inspected all types of asylums and hospitals for the insane.


There was little provision for incurable mental conditions in the Lunacy Act of 1845 and therefore hospitals for the mentally handicapped were privately funded.  Modelled on private houses, they were equipped with workshops and a recreation hall, emphasizing training and entertainment.

In 1867 the newly established Metropolitan Asylums Board was tasked with providing care for children and adults with mental deficiency who, until then, lived in workhouses.  The first asylums for these patients opened in 1870.


Colonies for epileptics were first established in the late 19th century, that at Chalfont St Peter being the earliest, funded by the philanthropist John Passmore Edwards (1823-1911).  The Mental Deficiency Act, 1913, required local authorities to make provision for these patients.

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References (Accessed 19th June 2016)

(Author unstated) 1925 Royal Commission on lunacy and mental disorder.  British Medical Journal 2 (3339), 1211.

Barry G, Carruthers LA 2005  A History of Britain's Hospitals. Sussex, Book Guild Publishing.

Bartlett P 1999 The Poor Law of Lunacy.  The Administration of Pauper Lunatics in Mid-ninetheenth Century England. Leicester University Press.

Busfield J 2015 Managing Madness (Psychology Revivals):  Changing Ideas and Practice.  Hove, Routledge.

Jones K 1993  Asylums and After: A Revised History of the Mental Health Services: From the Early 19th Century to the 1990s.  London, Athlone Press.

Parry-Jones WL 1972 The Trade in Lunacy: A Study of Private Madhouses in England in the Eighteenth and Nineteenth Centuries.  London, Routledge.

Scull A 2005 The Most Solitary of Afflictions: Madness and Society in Britain 1700-1900.  London, Yale University Press.

Winslow LS 1874 Manual of Lunacy:  A Handbook Relating to the Legal Care and Treatment of the Insane.  London, Smith, Elder & Co.


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