Hospitals, Almshouses and Colleges
In the beginning there were hospitals, early examples being very widely spread in Alexandria, Baghdad, Paris and elsewhere, and these were primarily, as you might expect, places of care for the sick and wounded but in northern Europe during the early middle ages a new and different kind of hospital, a charitable residence for old men, begins to appear. The first known example is St Peter’s hospital in York, founded by King Aethelstan in 936 and the earliest remaining is the St Cross Hospital in Winchester dating from 1133. Later examples of ‘hospitals’ which are in fact homes for the elderly include the beautiful Lord Leicester’s Hospital in Warwick, the famous Royal Hospitals at Chelsea and Greenwich and,well known but fictional, Hiram’s Hospital in Trollope’s Barchester. Beyond these shores there are records of such an institution in Stavanger founded in 1270.
The major expansion in the charitable provision of housing for the elderly began in northern Europe in the mid fourteenth century and even at that early date has no real parallel further south. There are examples in Italy and Spain where powerful individuals used their money to found or enhance monasteries - , Lodovico Sforza’s Certosa at Pavia, Cosimo de Medici’s work on San Marco in Florence and Philip II’s foundation of the Escorial are all examples - but, with one solitary exception in Pienza, the founding of lay institutions seems to be confined to England, Germany and the Low Countries. This divergence between north and south continues to this day; the recent HAPPI report extols the virtues of retirement housing, co-housing, extra care schemes and care homes in Switzerland, Scandinavia, the Netherlands and the UK, but in southern Europe such things are virtually unknown and care for the elderly is almost entirely within extended family groups.
In particular it was the appalling disaster of the Black Death which triggered the expansion of these foundations; the belief that acts of charity were essential to ward off divine anger and that masses said for the souls of the departed would save them from the torments of Purgatory. The institutions set up as a result of this growth in charitable piety vary in their nature. Some were specifically academic such as Corpus Christi College in Cambridge set up by the town’s guilds immediately after the black death, some, also known as colleges but with no academic basis were set up to ensure that regular prayers were said for the souls of individuals – good examples can be seen in Cobham, Kent and Tattershall in Lincolnshire – and many sets of almshouses were set up as acts of pure charity to provide for those who could no longer look after themselves. In the Netherlands there were no less than 55 sets of almshouses in Haarlem alone and in Augsburg, Jakob Fugger, ‘the Rich’, set up the Fuggerei, often credited as the first social housing scheme.
There is a distinctive character to many of these institutions; two storey houses linked to form terraces or courtyards but with arched front doors and tall chimneys announcing each individual property, they tend to create a sense of place and a certain grandeur that completely belies their essential modesty of scale. The old court at Corpus Christi, Cambridge, already mentioned, though not in fact an almshouse, provides an early and perfect example of the type and there are so many others: the Duchess of Somerset’s almshouses in Froxfield, Wiltshire and Wren’s Lucas almshouses in Wokingham among them.
Workhouses and Asylums
It was not until Tudor times that parliament under the slightly unlikely guidance of Thomas Cromwell, a man not renowned for his warmheartedness, passed the first of the poor laws which paved the way for the first public poor houses or, as they later became known, workhouses. These institutions, making provision for the poor and elderly from the public purse, remained however relatively few in number for another two hundred years during which time the almshouses continued to flourish. It was only as the industrial revolution hastened migration into the towns and urban poverty became a major problem that the Poor Law Amendment Act of 1834 initiated the massive programme of workhouse building and the horrors familiar from the pages of ‘Oliver Twist’. Although the primary intention of the workhouses was to provide a harsh regime for the ‘undeserving poor’, these grim institutions often provided the only available housing for the elderly and this continued to be the case until their final closure in the late 1940s.
Just as each parish was obliged from 1834 onwards to build its own workhouse, each county, from 1845 was required to have an asylum and it is estimated that the numbers of institutionalised mental patients in the UK grew in the nineteenth century from 1000 to 100,000. There has to be a strong probability that this huge growth was strongly linked to major increases in life expectancy and, consequently, in the incidence of dementia. In effect these institutions, including the ring of huge asylums around London, provided a further form of housing for older people; one perhaps even more grim than the workhouses.
The tendency to provide for the elderly within large institutions was also seen in Europe and in Austria the Geriatric Centre in the Vienna Woods provided no fewer than 5000 beds. It is only in the last ten years that this has been replaced by a series of state of the art new homes around Vienna.
Nursing Homes and Care Homes
At the start of the twentieth century then the choice for older people who could not live with their families was between almshouses (if they were lucky and not in need of care) the workhouse, a hospital or and asylum and it was against this unpromising background that private nursing homes began to appear. These were usually smallish institutions with perhaps ten beds in large houses converted and extended for the purpose. It was a useful co-incidence that as the demand for nursing home beds grew, the increase in cost of keeping domestic staff meant that many owners of large houses could no longer afford to run them and had to sell up.
The essentials of the nursing and care homes set up at this period are still very familiar: residents rent a room or a bed space within a shared room with all meals, care and support provided communally. The nursing home is also the only form of elderly accommodation which is widespread internationally, even in southern Europe.
Nowadays UK homes tend to be larger and better regulated than they once were, 60 beds being the norm for new homes with very few shared rooms and en-suite showers as standard, but the principles under which they operate and the very high charges for such accommodation remain much as they were.
Sheltered Housing and Retirement Housing
Towards the end of the nineteenth century the provision of large scale social housing by local authorities and philanthropists such as George Peabody had contributed to a big improvement in general housing standards for the working classes but not until the mid- twentieth century does it seem to have been realised that many tenants whose children had left home were continuing to occupy family houses and flats. It is surprisingly difficult to trace which authority first thought of providing smaller flats and bungalows for their older tenants (usually defined as 55 and over) to alleviate this problem, and difficult too to trace the exact origins of the now well known term ‘sheltered housing’, but this type of scheme is widespread in the UK, albeit that much of the stock is now rather outdated and difficult to upgrade to the extent that ‘sheltered housing’ sometimes tends to be used as a pejorative term for sub- standard accommodation.
Surprisingly it was not until the mid- 1970s that a demand was identified for a private sector equivalent to the well-established local authority sheltered housing schemes - purpose built houses and flats for older owner-occupiers – and in the UK two firms grew up to provide what is known as retirement housing, providing for two different income and age profiles. McCarthy and Stone, always the biggest player in this market, build blocks of flats in prominent town centre locations selling primarily to middle income couples in their early eighties, while English Courtyard, building village schemes based explicitly on medieval almshouse precedents provided for higher income purchasers usually in their early to mid seventies. In both versions of the type however the aim is to provide for the independent elderly; there may be a warden on site but there is no communal catering and, while maintenance of the building and grounds are centrally dealt with, there is little provided by way of personal support. Schemes can for these reasons be quite small in scale, sometimes just 5 or 6 units together.
Retirement and sheltered housing schemes on this relatively small scale and with relatively low emphasis on management, community and support, while common in the UK are rarely found elsewhere.
Extra Care Housing
Going under a number of different names including assisted living and very sheltered housing, extra care housing is a hybrid form and, in the UK at least, of fairly recent origin. Characteristically residents have self-contained apartments, each with its own kitchen, and can if they wish live very independently. In private schemes these apartments will be owned on long leases. Residents will nevertheless pay service charges to cover significant levels of management and will usually be able to have at least one meal a day provided for them.
Larger age restricted settlements have been established as an important form of housing provision for older people in the USA, Australia, New Zealand and South Africa for the last forty years or more and in some cases, particularly in Florida and Arizona these settlements can be very large indeed with up to 5000 dwellings. This scale of settlement , a possibility in areas where land is relatively cheap and where planning laws are relatively unrestrictive, means that lavish communal facilities - golf courses, pools, tennis courts, fitness centres and much else – can be economically provided and it is these facilities which generate demand for such housing, particularly among the younger retired. Downsizing for those in their late 50s is very much more common in the USA than it is for instance in the UK and this trend is reinforced both by the fact that US local taxes are very much lower out of town and by the huge climatic advantages that Arizona and Florida can offer.
Another huge advantage of larger retirement settlements is that care can be provided very flexibly as residents get older and frailer either within individual homes by careworkers operating from a central hub or in care home and supported housing provided within the overall retirement complex.
Until relatively recently nothing of this sort was available in the UK; not only did land values and planning laws work against it but a huge variety of factors meant that early downsizing was an unattractive option. Over the last ten years or so though Continuing Care Retirement Villages have begun to appear in the UK albeit that the largest of them is still under 400 dwellings.