Essays

Between 1877 and 1903 something extraordinary in the history of health services happened in a small north Kent town.

The number of hospital beds in Dartford increased a staggering 60-fold to reach almost 10,000, this in a local population of just over 20,000. The earlier history of the town offers no clues as to why this happened.

How did a small town, 15 miles from central London on the south side of the River Thames, acquire 11 hospitals and so many beds? And why did such a concentration of hospitals occur here rather than elsewhere?

To begin addressing these questions, clues may be found in the origins and history of Dartford.

History of Dartford

Dartford was established in Roman times, around the ford which carried Watling Street over the River Darent. (1) This was a key strategic route carrying troops and produce between London and Dover. With the fertile Darent valley to the south and river access to the Thames, Dartford was ideally placed to develop as a market town. (2)

In medieval times, Watling Street took on additional significance as the route for pilgrims visiting the shrine of Becket in Canterbury (from 1170) and William of Perth in Rochester (from 1201). While this stimulated religious orders to establish hospitals to care for sick and infirm pilgrims along the route, there was no particular concentration of such facilities in Dartford. The financial benefits that accrued from such religious tourism largely ended with the Reformation in the 1530s.

With the start of industrialisation in the 17th century, Dartford was well placed to benefit given its copious supply of fresh water from the River Darent, the potential to harness the power of the river with water-mills, and ready access to the Thames to import coal and timber and export manufactured goods. (3) This made it an ideal location for brewing (benefiting from nearby hop fields) and paper-making, both established by 1600. (4) Later, in the 18th century, came gunpowder manufacture and engineering. By then transport links with London had improved, with almost 100 stage-coaches a day, and this was further enhanced in 1849 with the first railway line, followed by two additional routes in 1866 and 1895. (5)

Until 1866 the only hospital beds in Dartford were those provided for local paupers in the Dartford Union Workhouse. In response to the requirements of the 1834 Poor Law Reform Act, a new workhouse had been built in 1836 to meet the needs of the recently established union of 21 parishes. Health care provision was limited to a paltry 20 beds in the ‘accident’ and lying-in wards.

So by 1866, Dartford was a thriving market town with good transport connections to London and diverse industries. In these and other regards Dartford did not differ significantly from other small towns around London and there were no indications as to what was to happen over the coming years.

City of London’s need for an ‘airy and healthy situation’ (1866)

Before 1800 there was little or no care provided for paupers deemed to be ‘lunatics’. Although the 1808 County Asylums Act encouraged local government to provide asylums to house the insane poor, who were otherwise incarcerated in prisons or workhouses, by 1845 only about 20 had been established throughout England & Wales. The 1853 Lunatic Asylum Act put further pressure on local government to review their provision. The concept of an asylum as place of refuge meant a large amount of land and a calm environment was needed, ideally in ‘an airy and healthy situation’. (6). Like other urban areas, the City of London Corporation sought a site some distance from the hurly burly of the city.

An initial estimate of £50 000 (equivalent to £5m in 2007, using GDP deflator) met with strong opposition from those who would have to pay. Meetings and petitions led to demands for the cheaper option of continuing to rely on the charity of the Royal Bethlehem Hospital (‘Bedlam’) and purchasing accommodation for the insane from neighbouring workhouses. The latter view was supported by Poor Law Unions who claimed that the transfer of patients would be clinically inappropriate, though their real concern was the prospect of losing income from the City of London. Despite such opposition, legal advice led the Corporation to start a search for affordable land which took only three months to identify Stone House, a 33 acre hilltop site one mile from the centre of Dartford. It was purchased for £3550 and construction cost about £40 000. Before building commenced, a well had to be sunk to confirm an adequate supply would be available, a task successfully carried out for £247.

The City of London Lunatic Asylum opened in 1866. (7) In addition to wards, it included administration offices, staff accommodation, workshops, a bake-house, a coach-house and steam engines to generate electricity. Over the following three decades it expanded so that by 1903 it accommodated 540 patients, had its own isolation ward, an impressive chapel with separate entrances for men and women, and a neighbouring 200 acre farm. (8) Responding to the decline in the population of the City of London, the asylum had successfully marketed its services to private patients who, by 1900, made up half the inmates.

Progressive home for London’s ‘imbecile’ children (1878-81)

Twelve years were to pass before another hospital was established in Dartford. And again, it was to meet the needs of London. Recognition of the inadequacies of locally provided workhouses and the need for better health care for inmates had led in 1867 to the creation of the Metropolitan Asylums Board (MAB). For the first time, London-wide planning and management of hospitals was possible, albeit limited to patients with fevers, smallpox and ‘imbeciles’. (9) This was to have a significant impact on Dartford.

In 1870 the Board created two large asylums for ‘imbeciles’, one in Hertfordshire and one in Surrey. However, there was increasing concern that accommodating children with adults missed the opportunity to educate rather than just contain them. A facility exclusively for children was established in 1873 in London. Meanwhile the search for a site to build both a home for children and an third adult asylum got underway which resulted in the purchase of 109 acres of land at Darenth owned by the Bishop of Rochester. (10) When it opened in 1878,  the Darenth School & Asylum for Imbeciles accommodated 580 children and included schoolrooms, workshops for industrial training, kitchens, laundries, a chapel and a cemetery. (11) Alongside it, the adult asylum accommodated 1000 patients. However, just before the asylum was scheduled to open, the Metropolitan Asylums Board faced a more pressing need which would result in yet more bed provision in Dartford.

Desperate measures to cope with London smallpox epidemics (1881-90)

Despite the introduction of smallpox vaccination in London in the early 19th century, epidemics still occurred and when they did the London Smallpox Hospital, a 100 bedded voluntary hospital located in Highgate, was unable to cope. On assuming statutory responsibility for managing services for smallpox in 1867, the Metropolitan Asylums Board decided to construct new fever and smallpox hospitals at  geographically dispersed locations across London. All proposed sites met with local opposition and, together with concerns about cost, this meant that by the time of the 1871 epidemic only two facilities had been established (Homerton and Stockwell). This meant that only a third of cases could be admitted. The Board’s plans continued to be frustrated with only two additional hospitals being constructed (Deptford, Fulham) over the following decade. Not surprisingly, the next epidemic in 1880-1 overwhelmed the MAB’s resources again.

In desperation, the Board decided on two radical solutions that would circumvent political obstacles. First they acquired two old wooden ships, converted them to accommodate acute smallpox cases and moored them at Greenwich, and second they  established a temporary tented camp on land they already owned in the grounds of Darenth Asylum. In May 1881 London’s first systematic transport service for hospital patients started ferrying convalescent smallpox victims from London, in hired four-in-hand horsed vehicles. However, during the winter of 1881-2 the tents proved inadequate against the cold so the recently completed adult asylum for imbeciles was temporarily requisitioned.

With the passing of the epidemic, the Board returned to considering its long term arrangements. The relative ease in establishing facilities on the hospital ships and at Darenth, compared with the opposition and intransigence experienced across London, offered a new option. In 1884, the ships, together with a third one, were moved and moored at Long Reach, the stretch of the Thames nearest to Dartford. There were few local residents to complain. And with the need to vacate the Darenth Asylum site, the adjacent Gore Farm was purchased and 300 beds were set up in tents to relieve pressure on the hospital ships. During the 1884-5 epidemic, 10 000 patients made the four mile journey across Dartford to Gore Farm Convalescent Hospital. These arrangements were consolidated when the tents were replaced in 1857 with huts accommodating 850 patients (the Lower Hospital) and in 1890 with brick buildings housing an additional 964 patients (the Upper Hospital).

Starting to meet local needs (1887-94)

By 1887 the establishment of hospitals to meet the needs of Londoners had not been matched by any improvement in provision for local people. Despite the population having more than doubled (from under 5000 to about 11 000) since the opening of the Dartford Union Workhouse fifty years earlier, the only inpatient care available remained the handful of beds for workhouse inmates plus the occasional referral to St Thomas’s or Guy’s Hospital. While funds had been found to build a new chapel in 1878, it wasn’t until 1887 that  an infirmary block was constructed. The addition of a second block in 1897 increased the number of beds to 140. But these were only for those who were so poor they had no other option than to enter the workhouse.

However, the Dartford Poor Law Union, together with the local Rural Sanitary Authority, one of 572 established in England & Wales in 1875, was responsible for the public health not only of paupers but of the whole population. At the time the sanitarians’ view of miasma as the cause of infectious diseases was giving way to acceptance of the germ theory. Together the two authorities established a hospital just to the north-west of the City of London Asylum. Bow Arrow Hospital, with 88 beds, opened in 1893 to isolate those believed to be suffering from an infectious disease.

As regards other diseases, although the size and wealth of the local population was insufficient to establish a voluntary general hospital, it was sufficient to support a cottage hospital. Despite this, Dartford lagged behind other towns in east Kent which had already established such institutions: Deal 1863; Betteshanger 1873; Margate 1876; Faversham 1887; Herne Bay 1892. The principal instigator of the cottage hospital in Dartford was Silas Burroughs who, with Henry Wellcome, had taken over the former Phoenix Paper Mills in 1889 as their factory to produce medicinal ‘tabloids’. Burroughs provided a third of the £3100 cost of the hospital, the rest coming from a myriad of local subscribers. At his suggestion, it was named Livingstone Cottage Hospital after the Christian explorer, David Livingstone, who had died in 1873. Appropriately it was opened by Henry Stanley.

Like all voluntary hospitals, its services were principally for the ‘deserving’ working class, with admission to the 18 beds requiring a subscriber’s letter of recommendation. More affluent people would either travel to London to seek care from private physicians and surgeons or make use of the one physician and four surgeons resident in Dartford. (12)

London‘s need for a refuge…again (1898)

With the passing of another Lunacy Act in 1890, responsibility for mental health care passed to the recently created county councils. Although the preceding 40 years had seen a trebling in the number of asylums in England & Wales to 66 (including the City of London Asylum) (6), the newly formed London County Council decided they required more than the four (plus one being planned) they had inherited. That all five were located to the north and west of London must have influenced the search for two more sites.

Advertisements in 1891 for a site led to numerous offers but the only one considered suitable was Baldwyn’s, an estate on the edge of Dartford Heath. (13) It was purchased in 1894 for £24 500 was purchased and, four years later, the Heath Asylum opened. (14) By then the earlier belief in the prospect of curing patients had given way to containment and custodial care, and the creation of small communities had been replaced by the construction of large institutions. The Heath Asylum was not unusual in having accommodation for over 2000. Although no physical restraints were used, the airing courts had six foot high railings, the wards were locked and the huge chapel held separate services for men and women.

 

Finally, a permanent solution for smallpox epidemics (1901-3)

While the hospital ships moored at Long Reach since 1884 had coped reasonably with minor epidemics, by the 1890s the MAB recognised the potential inadequacy of only 350 beds. While they coped with the 4500 cases in the 1893-5 epidemic, there were concerns about the ability to handle a major epidemic.

In anticipation of moving on shore, in 1894 the Board sought to buy 340 acres adjacent to the landing pier. Faced with Dartford residents’ concern about the increased risk of infection that might result, the local council only agreed to the purchase on the understanding that any local smallpox victims could share the benefits of the facilities being provided for Londoners. However, this did little to reduce the increasing tension between the hospital and the town.

By 1900 the concern of the MAB as to the adequacy of the hospital ships included not only their capacity but also the cost of maintenance, risk of fire and collisions with other shipping, and the safety of patients given that delirious patients sometimes jumped overboard. However, plans to build a permanent new hospital had to be deferred as the MAB was faced with the threat of a new smallpox epidemic. Instead, two temporary hospitals were constructed in 1901-2 consisting of single-storey wooden buildings: Long Reach Hospital which housed 324 patients and Orchard Hospital which accommodated 800. In the event the scale of the epidemic did not require the use of the latter. (14)

Concerns among the citizens of Dartford inevitably increased during the epidemic when convalescent patients were regularly transferred through the town from the river hospitals to Gore Farm Hospital. In practice the greater danger was posed by local tradesmen ignoring the requirement to have been successfully vaccinated before making deliveries to the hospitals. This did not diminish local opponents of the hospitals from voicing their concerns.

With the demise of the 1901-2 epidemic, the MAB resurrected their plans to build a permanent new smallpox hospital. (14) The state-of-the-art Joyce Green Hospital, with 986 beds, opened in 1903 replacing the ships (which were sold) as the centre-piece of the Board’s complex of smallpox hospitals in Dartford. Patients arriving at the landing pier by river ambulance from London would be transferred to the river hospitals by unique horse-drawn ambulances on tramways. Those who had campaigned long and hard for adequate hospital services to cope with smallpox epidemics could take satisfaction from their achievements. Ironically the services were never put to the test as no further major epidemics were to occur. But the opening of Joyce Green Hospital had brought the number of hospital beds in Dartford to almost 10 000.

Hospitals’ fortunes and fates (1904-2009)

The vast number of beds in Dartford at the start of the 20th century was maintained until the 1960s. Along the way, all eleven hospitals were incorporated in the NHS in 1948, some having served key roles as part of the Emergency Medical Service during the Second World War. Today only one, Livingstone Cottage Hospital, birth place of Mick Jagger and Keith Richard, is still in use with most of the others having been demolished.

The demise of smallpox led to the redesignation of the three river hospitals and Gore Farm Convalescent Hospital (renamed the Southern Hospital in 1908) for fever patients. Despite their supposed temporary status, Orchard Hospital survived until 1940 when it was destroyed by fire bombs and Long Reach Hospital was rebuilt in 1929, survived the bombs and the 1953 inundation before being abandoned and demolished in 1975. Joyce Green Hospital fared better, being reinvented as one of three sites providing  general hospital services for the area in 1948, a role it fulfilled until 2000 when services transferred to the new Darent Valley Hospital. One of the other two sites was the Southern Hospital (Upper) which contributed until 1959 when its services had to be transferred to Joyce Green Hospital as it lay in the path of the new A2 road. Part of the Southern Hospital (Lower) also had to be demolished, though the rest survived until 1985 as a mental hospital.

The third component of general hospital provision in the NHS was West Hill Hospital, formerly the Dartford Union Workhouse. Although the original 1836 building was converted for commercial uses in 1986, the rest of the site continued to provide hospital services until 2000, since when it has been demolished.

The stories of the three asylums is typical of all such institutions. Having been incorporated in the NHS in 1948, a gradual closure programme was initiated in 1960s as hospital care gave way to community care. Darenth Park Hospital (its fifth and final name) closed in 1988 and was demolished in 1995; Bexley Hospital (as Heath Asylum had become) closed in the 1990s and was almost entirely demolished; and Stone House Hospital (formerly, City of London Asylum) closed in 2005 but survives and awaits conversion.

 

Discussion

In 1866 there was nothing in the history of Dartford to suggest it would become a ‘hospital town’. So why, by 1903, were there 11 hospitals with almost 10 000 beds? Meeting the needs of local people contributed little, with only 2.6% of the beds for their use. Two factors probably contributed: local geography favoured the location of the asylums while the absence of effective opposition facilitated the development of the isolation hospitals.

First, geography. Asylums, by their very nature as havens of refuge, were located outside cities in rural hinterlands. London was typical in being ringed by large, self-sufficient institutions. While Dartford was not unique in hosting an asylum, the presence of three made it unusual. The attraction of the area may have been the availability of elevated sites above the flood plains of the Thames (City of London Asylum at 35 metres; Darenth Asylum at 70 metres; Heath Asylum at 40 metres). Other favourable features were plentiful water supplies (via wells), good drainage and the absence of public rights of way. Unfortunately the way the sites were identified by London bodies remains a mystery. The City of London’s Lunatic Asylum Committee decided on Stone House in a matter of weeks, apparently without recourse to advertising or considering any other sites. In contrast, while the MAB visited and inspected several sites that were offered in response to advertisements before selecting Darenth and London County Council inspected numerous sites over two years before announcing that Baldwyn’s on Dartford Heath was the only suitable site, the basis of their decisions was not made public.

Second, the lack of effective opposition. The establishment of what was to become London’s principal isolation facilities owes much to the MAB’s pursuit of policies that sought to avoid opposition. This was combined with an unplanned, incremental approach. The initial opportunism of the temporary use of land at the Darenth Asylum (already owned by the MAB) to house convalescent smallpox cases in 1881 led to the purchase of the adjacent Gore Farm to provide a permanent site for a tented hospital for convalescent smallpox patients. It then made sense for the hospital ships (for acute cases) to be moved from Greenwich to Dartford in 1884, so as to minimise the distance for transferring convalescent patients. Initially avoiding the construction of a smallpox hospital cleverly minimised the fears and hence the opposition of local residents. But by then the die was cast and permanent buildings followed, first at Gore Farm in 1887 and 1890, and then in 1901 acute cases started to come ashore with the building of the three river hospitals. This was policy development by incrementalism rather than the realisation of any grand plan.

While there was no effective opposition, the establishment both of asylums and smallpox hospitals was challenged at times. The first opposition to the smallpox hospitals was in 1883 when a local landowner, Mr Fleet, unsuccessfully tried to prevent the MAB purchasing Gore Farm. Later there were concerns about convalescent patients being transported across Dartford from the hospital ships to Gore Farm Hospital. Predictably, any case of smallpox contracted in Dartford was ascribed to the presence of the hospitals and, regardless of strict control over contacts (all suppliers and workers had to be vaccinated), some people would not be reassured. Such fears were fuelled when local people became infected, such as in 1901 when workmen building Joyce Green Hospital spread smallpox to Dartford residents. Attitudes to ‘lunacy’ also gave rise to opposition to asylums. For example, when London County Council wanted to rename Heath Asylum after the nearby village of Bexley, the local council felt it was ” a grave injustice to the district and if persistent, will cause serious loss to all property owners”. (13)

While it is difficult to explain why Dartford became a ‘hospital town’, there is no doubting the economic benefits it enjoyed. There may not have been much local benefit from land sales (given the owners were often not local) but the construction of the hospitals provided plenty of local employment. These were large building contracts: Heath Asylum cost £400k (£34m in 2008 using the RPI); Joyce Green Hospital cost £319k (£26m). And once built, there were even greater employment opportunities, though not through clinical posts. There were few doctors (for example the City of London Asylum employed 3, Heath Asylum 7) and although there were large numbers of nurses or attendants needed (City of London Asylum employed 67; Heath Asylum 283; Gore Farm Hospital 158), these were mostly filled by trained staff from London. In addition, the smallpox hospitals employed mainly temporary staff during epidemics, achieved by importing staff from other MAB institutions and hiring private nurses from London.

Where local people gained most was in non-clinical roles. Some of these were to meet patients’ needs: food (cooks, kitchen maids, bakers), clothing (seamstresses, tailors, shoemakers, laundresses), heating (stokers), porters and cleaners. But asylums also needed staff to provide training or occupational therapy such as mattress makers, basket makers, bookbinders. And given their size, these large institutions employed their own maintenance staff: bricklayers, masons, plumbers, painters, glazers, carpenters. And to achieve self-sufficiency, hospital farms (at all three asylums, Gore Farm Hospital and the river hospitals) required farmers, carters and cowmen, and those with their own gas-works and bore-holes needed yet additional specialised staff. There were also economic benefits for local tradesmen and suppliers. While some hospitals achieved self-sufficiency in food supplies, others remained major customers for local suppliers. Overall, the eight Dartford hospitals serving London provided hundreds of jobs for local people.

 Conclusion

As so often with health services, developments reflect ad hoc, chance events rather than carefully formulated strategies. The staggering increase in hospital beds in Dartford in the late 19th century is just an exceptional example of the way health services develop. Although politicians and planners devise visions and comprehensive plans to meet the health care needs of populations, these are rarely enacted. Instead, services develop in a more piecemeal way reflecting the many forces and interests at work in any complex industrial or post-industrial society. The events in Dartford serve to illustrate this. No one set out in 1866 to increase the bed provision 60-fold in this small, unassuming town. Yet that it was happened. And as such, it offers a graphic illustration of the vagaries of health care planning and a caution to those who would try and impose order on such a complex system as health care, however well-intentioned and justified their aims may be.

References

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5. Jessup F. Kent history illustrated (2nd ed). Maidstone: Kent County Council, 1973
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9. Ayers GM. England’s first state hospitals 1867-1930. London: Wellcome Institute of the History of Medicine, 1971
10. Metropolitan Asylum District. Report of Committee for Hampstead Asylum. 6 February 1875. Managers of MAD Minutes.
11. Payne F. The history of the Darenth Hospitals. Dartford: DWS Print Services, 2000
12. Workers Educational Association. Victorian Dartford 1837-1901. Dartford: WEA, 1998
13. van Zweigbergk B, Armstrong M. The village on the heath. A history of Bexley Hospital. Brentwood: Doppler Press, 2003
14. London County Council. Minutes of Proceedings of the Council. 24 November 1893. London: JAS Truscott & Son
15. Payne F. Joyce Green and the River Hospitals. Dartford: DWS Print Services, 2001
16. Metropolitan Asylums Board. Annual Report 1910. London: Ben Johnson & Co Ltd, 1911

 

This first appeared in the Journal of the Royal Society of Medicine 2009: 102: 521–529. DOI 10.1258/jrsm.2009.090349

https://doi.org/10.1258/jrsm.2009.090349