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As we once were - Prof. Peter Townsend (1928-2009): The Last Refuge 1962

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Michael Denham
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History of Geriatric medicine

Professor Peter Townsend, sociologist, social policy analyst and campaigner: was born in Middlesbrough.  His academic career spanned six decades during which he studied poverty, ageing. disability and health inequalities.  In 1979 he published his magnum opus Poverty in the United Kingdom.  

The Last Refuge

Townsend began his seminal study of old people in institutions in 1959.  The four main objectives were: to describe residential accommodation for the aged in England and Wales; to describe the life of those living in these institutions; to discover why residents entered the homes and to assess the adequacy of the services provided.  He notified the 146 local authorities in England and Wales of the purpose of the study.  All responded and listed nearly 3,000 institutions.  Following a lengthy pilot investigation, a random sample of 180 institutions and homes were selected for further investigation.  Seven were not visited because they were closed, had no residents of pensionable age or had been incorrectly registered as homes.  Of the 173 remaining homes: 39 were former Public Assistance Institutions (PAIs), 53 other homes were managed by the local authority, 39 were voluntary homes and 42 were private homes.  Voluntary and private homes tended to be concentrated in south and south-east of the country.  The number of residents of pensionable age in all these institutions ranged from those with fewer than 100 residents to those with 250 or more.  Photographs and field notes about the condition of the buildings and the facilities were made.  Diaries were also kept by a number of residents and staff.

The visits began in October 1959 and lasted a year.  The survey questionnaire, which took 35 minutes to complete, assessed the physical amenities of the accommodation, the staffing levels, occupational activities, freedom in daily life and social provisions available to residents.  Where handicapped residents were unable to complete the questionnaire, information was obtained elsewhere.  Cooperation with the survey was good and only occasionally was information refused.  Although 666 people were entered for the study, only 489 were actually interviewed.  The remaining people had died, returned home or had been transferred elsewhere.  The survey team also interviewed 65 local authority chief welfare officers or their deputies.  

In 1960 there were 95,500 pensioners in former PAIs and local authority premises in England and Wales.  Fewer than half of the 3,600 residential institutions in Great Britain were owned and managed by local authorities although they contained over two thirds of the available beds.  About half the residents in voluntary homes were maintained by the local authorities.  

Public Assistance Institutions (PAIs)

The survey revealed that three quarters of former workhouses, now known as PAIs and currently used as residential homes, were over 100 years old and the rest were over 50 years old.  A small percentage had undergone minor or major improvements but many buildings remained deficient in toilet facilities and single room accommodation. Townsend remembered that Beatrice Webb had once said few objects attracted such universal hatred and hostility as the old workhouse.  

Four fifths of the residents were pensioners and were an eclectic mix of active, bedfast, blind, deaf, dumb, epileptics and mentally subnormal.  Residents were largely from the poorest social class and lacked relatives.  Nearly two thirds of elderly men and women were unmarried or divorced.  Perhaps as many as half were capable of carrying out all or most of the activities of daily living but one third were extremely infirm or bedfast.  The low wages paid to the staff probably accounted for the overall shortage of nursing and attendant staffs.  Few had been given any formal training in the care of elderly and handicapped people and some appeared totally unfit for purpose.  The matrons and wardens welded considerable power and some seemed too authoritarian and insufficiently aware of the latest advances in the care of older people.  Specialist staffs were scarce, GPs made relatively few visits and arrangements for chiropody, dental and optical attention were deficient.  Few residents had their own clothing or belongings.  Institutional clothing was of poor quality and quantity.  The diet was plain and choice limited.  Religious and social activities were arranged but few residents attended.  Segregation of the sexes was widely practised and husbands and wives usually slept and lived apart. Most residents led a self-contained existence, rarely conversing or taking part in activities.

The post war local authority homes

Since 1945 local authorities had built about 1,100 new residential homes in England and Wales but their design still left room for improvement.  Many were not close to the urban centre, some retained long corridors, had excessive uniformity of furnishing, toilet facilities were deficient, lifts were few in number and in many homes residents slept in three-bedded rooms.  The majority of residents were women, were unmarried and/or had no surviving children.  More residents were middle class compared with those in the former PAIs.  The majority could carry out the activities of daily living given modern amenities.  Staff shortages, especially trained nurses, were quite widespread and once again there was insufficient medical care, chiropody and physiotherapy.  Attitudes of matrons were similar to those in PAIs.  Social life, diet, personal belongings were limited, segregation of sexes persisted in some homes and residents were not encouraged to help one another.  These post war homes revealed two conflicting ideologies: the larger new homes perpetuated former institutional practices, while the smaller homes introduced individuality, freedom and self-determination.  

The voluntary homes

Townsend identified four types:

  1. Large religious homes with a substantial mixed population of working class persons of both sexes with varying degrees of infirmity,
  2. Smaller religious homes with a larger proportion of infirm residents and fewer middle class women,
  3. Specialised small homes for residents with specific disabilities such  as blindness or deafness,
  4. Secular homes where most of the residents were middle class and active. 

At the time of the report these 815 voluntary homes had 24,000 residents.  About half the surveyed homes were remote from local facilities but many provided a large measure of comfort, privacy and single or double rooms.  However some lacked lifts, central heating, adequate toilet facilities and sitting areas.  Many of the residents were unmarried or were childless women but were more active compared to counterparts in local authority homes.  

The larger homes tended to have worse staffing than the PAIs or other local authority premises.  Rates of pay tended to be low.  Visits from doctors and specialist services were limited.  The lives of residents in some homes were restricted by formal or informal regulations, social life was meagre and restricted.  

Private homes

Two fifths were remote from local centres but had more single or double rooms, better furniture and facilities than local authority homes.  Most residents were pensioners, married or widowed women, were of great age, middle class and very frail.  

Staffing ratios tended to be better than in other homes.  Residents’ fees varied and sometimes additional charges were added for heating, laundry and nursing.  The daily routine was more flexible with greater privacy than in local authority homes but recreation and entertainment remained restricted.

Good and bad institutions

The report tentatively defined ‘quality' to include physical facilities, staffing, services, means of occupation, freedom in daily life, and social provision.  It concluded that the general level of attainment was low.  ‘Quality’ provided by all the old workhouses, nearly three fifths of the post war local authority buildings, over a fifth of voluntary and two fifths of the private homes were rated as ‘poor’, ‘very poor’ or ‘bad’.  Voluntary homes had better results because they had enhanced physical facilities, more freedom for the residents and better staffing ratios than local authority homes.  On the whole, smaller homes provided higher ‘quality’ than the larger ones because they had better staffing, more toilet facilities, more single or double rooms and more freedom of choice to the residents. 

Aspects of institutional care

Entering a home.  Local authority welfare officers generally had insufficient time to give adequate advice to elderly people about the options available to them or to supply details of the actual homes.  Little assistance was given to potential residents to enable them to retain their current accommodation and choice of homes might be limited.  

Capacity for self-care.  The survey showed that over one half of those newly admitted residents were physically and mentally capable of leading an independent life, although some required minimal help.  Many more bedfast or house bound elderly persons lived in the community as compared with residential homes.  

Reasons for admission.  Reasons given for requesting admission included social isolation, lack of help at home, homelessness, friction with relatives, sleeping rough and financial insecurity.  The proportion of unmarried persons was greater than of widowed and divorced people, and the number of childless persons in the homes was greater than in the population as whole.  Three fifths of residents came directly from private households; the remainder came from hospitals and other facilities.  

Drawbacks of admission.  Many residents found they had no occupation to interest themselves, contact with relatives decreased, were lonely and few made new friendships.  The majority considered they lost privacy and maintained a strong preference for single bedrooms.  Many regretted they no longer had their own clothing, furniture and other possessions.  Overall residents considered they had lost self-determination. 

Townsend concluded that current approaches to providing care were not satisfactory.  The solution could be to abandon institutions as an instrument of social policy, reduce progressively the number of communal homes (especially all former workhouses), extend the responsibility of hospital management committees to the management and supervision of all institutions and communal homes, create a comprehensive local family help service, increase the amount of ‘sheltered’ housing and encourage the development of general practitioner services.

Forty years on

Between May 2005 and April 2007 Townsend's original data from The Last Refuge (1962) was used to assess changes in residential care for older people.  Of the original 173 homes, 25 were still registered as care homes.  Information from 20 showed they were now caring for older and more infirm residents, although some were still relatively independent.  The proportions of women were greater than men and segregation by gender has been replaced by segregation according to functional ability.  Regimes in the homes were less harsh and the punitive attitudes had disappeared, but had been replaced by oppressive risk management.  Attempts to overcome residents’ apathy had largely failed even when activity organisers were employed.  Several homes now had discrete nursing and/or dementia care units and had taken on functions previously fulfilled by the NHS.  

Sources: 

1. The last refuge: a survey of residential institutions and homes for the aged in England and Wales, Townsend P; London: Routledge and K. Paul, 1962

2. Residential Care Transformed: Revisiting the Last Refuge, Julia Johnson, Sheena Rolph and Randall R. Smith; Basingstoke, Palgrave Macmillan, 2010