Patient Pathways: Solving the Problem of Institutional Mortality in London during the later Nineteenth Century

Abstract

This paper confronts a major problem in relation to the metropolitan and urban mortality declines in Britain during the later nineteenth century: the extent to which cause-specific death rates at district level were distorted by an official failure to redistribute deaths occurring in institutions back to "normal" place of residence. Describing and analysing the manner in which hospital and infirmary provision in the capital during this period determined the geographical incidence of mortality, the article develops methodologies that bring the researcher progressively closer to more accurate spatial facts of demographic and epidemiological experience. Devoting separate sections to general voluntary and fever hospitals as well as to institutions administered by the Metropolitan Asylums Board, the paper also engages with similar problems in relation to workhouses and Poor Law infirmaries. By way of conclusion, it shows that, far from generating demographically trivial results, the process of redistribution radically revises the epidemiological history of London in the crucial years between the 1860s and the mid-1880s and provides a dataset that will allow controlled interrogation of the metropolitan mortality decline during this period.

The geography of early childhood mortality in England and Wales, 1881–1911

“…Therefore those dying in a hospital may not have lived in the same area, and hospitals are likely to have 'imported' deaths from other areas. It is thus possible that this variable may act as a proxy for mortality inflated by nonresidents (Mooney, Luckin, and Tanner 1999).…”

“…However, by 1911 the share of health employees in the spatial error model was associated with higher mortality although not statistically significant. The change in the sign may stem from the fact that by the early 20th century, deaths occurring in institutions (including hospitals) had increased considerably, but the Registrar General's Reports failed to redistribute these deaths back to the place of residence (Mooney, Luckin, and Tanner 1999). Therefore, it was more likely that high mortality areas coincided with large numbers of employees in hospitals.…”

Diagnostic Spaces

“…That 21 percent of respiratory tuberculosis deaths occurred in institutions can be explained by the fact that so many-more than half-were workhouse deaths. As for the rest, we already know that general voluntary hospitals habitually ignored their own rules on the exclusion of chronically ill tuberculous patients (Mooney et al 1999). The relatively high percentage of institutional cholera deaths was skewed by the increased availability of hospital accommodation during the epidemic.…”

“…The institutionalization of sickness was mirrored by the institutionalization of mortality. In 1900 about one-third of all metropolitan deaths occurred in an institution, a proportion divided fairly evenly between hospitals and workhouses (Mooney et al 1999). Despite this shift toward institutionalization, the vast majority of medical diagnoses were made in homes, and that is where most patients lived with their illnesses, even if they did enter an institution at some point ( Jalland 1996;Lewis 2007).1 Guenter B.…”

Shifting sex differentials in mortality during urban epidemiological transition: the case of Victorian London

“…As the spatial polarisation of social classes within the metropolis intensi®ed, so too did experiences of ill-health and death, re¯ecting nutritional levels, working conditions, and access to affordable, good-quality housing and health care. However, problems of even greater magnitude occur because the mortality rate of many individual districts in the capital was distorted by deaths occurring to patients in hospitals and other institutions such as workhouse in®rmaries (Mooney et al, 1999;Mooney, 2000). Districts containing such institutions had overstated mortality rates, and not until 1911 were such deaths`returned' to the mortality schedules of the district in which the patient last resided.…”