My research diary – The Citadel by AJ Cronin

20th October 2017

I’ve started reading the eBook I bought earlier. It is cited as being influential in the setting up of the NHS.

Published in 1937, I am hoping it will give me an insight to conditions before the 1940s. AJ Cronin knew what he was talking about:

“Born in Cardross, Scotland, A. J. Cronin studied at the University of Glasgow. In 1916 he served as a surgeon sub-lieutenant in the Royal Navy Volunteers Reserve, and at the war’s end he completed his medical studies and practiced in South Wales. He was later appointed to the Ministry of Mines, studying the medical problems of the mining industry.”

Cronin, A. J.. The Citadel (Bello) (p. 2). Pan Macmillan. Kindle Edition.

I also discovered that there is a 1938 film, so I watched it.

The story begins with a newly qualified doctor (Andrew Manson) arriving for his first assistant post in a mining community in Wales. The doctors’ sister (Blodwen Page) explains that the Mine has 3 doctors on its list, of which her brother is one. The miners have money deducted from their wages to cover medical costs. This money is paid to the doctors according to how many patients they have registered with them. But Andrew discovers that Dr Page is bedridden and he is expected to run the practice alone. The fees from the miners are given to Blodwen Page and Andrew works as a doctor on the salary of an assistant.

Dr Denny, the assistant  of a rival doctor, describes the conditions:

“There’s no hospital, no ambulance, no X-rays, no anything. If you want to operate you use the kitchen table. You wash up afterwards at the scullery bosh. The sanitation won’t bear looking at. In a dry summer the kids die like flies with infantile cholera.”

Cronin, A. J.. The Citadel (Bello) (pp. 13-14). Pan Macmillan. Kindle Edition.

After working for Doctor Page for a month, Andrew discovers the reality of healthcare in Britain:

“Denny at first had aggravated him intensely by his weary contention that all over Britain there were thousands of incompetent doctors distinguished for nothing but their sheer stupidity and an acquired capacity for bluffing their patients. Now he began to question if there were not some truth in what Denny said.”

Cronin, A. J.. The Citadel (Bello) (p. 28). Pan Macmillan. Kindle Edition.

Andrew and Denny discover an outbreak of Typhoid Fever, and they identify the source as being a well. The two of them advise all of their patients to boil the water before drinking it, and with treatment the epidemic comes under control. But their efforts to deal with the source come to nothing:

“It’s the main sewer that’s to blame. It leaks like the devil and seeps into half the low wells at the bottom of the town. I’ve hammered at Griffiths about it till I’m tired. He’s a lazy, evasive, incompetent, pious swine.”

Cronin, A. J.. The Citadel (Bello) (p. 21). Pan Macmillan. Kindle Edition.

There is an interesting section of the book which didn’t make the film. It is about a suspected case of madness. One of the miners had been:

“acting strangely lately, getting into trouble at the mine, losing his memory. He had turned quarrelsome and violent. ‘I don’t like it, Manson.’ Bramwell nodded sagely. ‘I’ve seen mental trouble before. And this looks uncommonly like it.’”

Cronin, A. J.. The Citadel (Bello) (p. 58). Pan Macmillan. Kindle Edition.

The patient had set upon his wife with a bread knife and Andrew receives a note asking him to attend as two signatures were needed to “certify a lunatic”. Andrew attends the patient and examines him:

“He went over to Emlyn and at first he hardly recognised him. The change was not gross, it was Emlyn true enough, but a blurred and altered Emlyn, his features coarsened in some subtle way. His face seemed swollen, the nostrils thickened, the skin waxy, except for a faint reddish patch that spread across the nose. His whole appearance was heavy, apathetic. Andrew spoke to him. He muttered an unintelligible reply. Then, clenching his hands, he came out with a tirade of aggressive nonsense, which, added to Bramwell’s account, made the case for his removal only too conclusive. A silence followed. Andrew felt that he ought to be convinced. Yet inexplicably, he was not satisfied. Why, why, he kept asking himself, why should Hughes talk like this? Supposing the man had gone out of his mind, what was the cause of it all. He had always been a happy contented man – no worries, easy going, amicable. Why, without apparent reason, had he changed to this!”

Cronin, A. J.. The Citadel (Bello) (p. 60). Pan Macmillan. Kindle Edition.

Andrew diagnoses thyroid deficiency and after successful treatment the patient is returned to his former self.

After a while Andrew has an argument with Miss Page over money. His frustrations about his assistant status lead him to give notice and leave the practice. He finds a post as a qualified doctor and applies for it. He is interviewed by a committee which is made up of medical experts and miners:

“About thirty miners filled the room, seated, and all of them smoking, gazing at him, with blunt, but not unfriendly curiosity. At the small side-table was a pale quiet man with a sensitive, intelligent face who looked, from his blue pitted features, as if he had once been a miner. He was Owen, the secretary. Lounging on the edge of the table, smiling good naturedly at Andrew, was Doctor Llewellyn. The interview began. Owen, in a quiet voice, explained the conditions of the post. ‘It’s like this you see, doctor. Under our scheme, the workers in Aberalaw – there are two anthracite mines here, a steel works and one coal mine in the district – pay over a certain amount to the Society out of their wages every week. Out of this the Society administers the necessary medical services, provides a nice little hospital, surgeries, medicines, splints, etcetera. In addition the Society engages doctors, Doctor Llewellyn, the head physician and surgeon, and four assistants, together with a surgeon dentist, and pays them a capitation fee – so much per head according to the number on their list. I believe Doctor Leslie was making something like five hundred pounds a year when he left us.’ He paused. ‘Altogether we find it a good scheme.’ There was a mutter of approval from the thirty committee men.’”

Cronin, A. J.. The Citadel (Bello) (pp. 96-97). Pan Macmillan. Kindle Edition.

Andrew accepts the job offer and the house that goes with it, on the understanding that he is engaged to be married. The miners prefer a married man attending their wives and daughters. Andrew proposes to his girlfriend and is able to take up the position of GP with immediate effect.

To be continued………….


If this is based in truth, it seems that the system is inadequate. The miners, or shall we say the end users, seem to have too much influence in the running of the practice. Andrews employer, Dr Page, is kept on as a GP despite the fact that he is unable to perform his duties. This is the result of his patients loyalty allowing him to stay on the company books. This in turn affects the status and pay of Andrew who is running the practice alone but not receiving the financial reward or professional recognition for doing so. There is also the possibility that Dr Page and his sister rely on the fees from the mining company and would not have the financial means to retire.

There are a lot of examples of incompetence by doctors and Public Health representatives. I have also picked up a sense that most of the GPs either don’t know or don’t care about the symptoms of their patients and are happy to fob them off with ineffectual remedies. There seems to be an attitude of “things have always been done this way, why change now?”. This distrust of new methods becomes more apparent later in the book.

Till next time.

As a footnote, the father in law of my Great Aunt was a doctor and surgeon from the late 1880s. He died in 1938. So I’ll see what I can find out about his career. The information I have at the moment suggests that he had a surgery in Yorkshire and also worked at the hospital. He left £21, 267 12s 11d to his daughter. The equivalent value is about £610,000. They were wealthy enough to have a governess, a cook and a private nurse (I’m not sure if she was just for the family or whether she also worked in the practice) and they could afford to go to Australia for a holiday (I think there were relatives there).





I have a hobby: researching my family tree. It is a very addictive hobby which keeps me busy when I’m not writing about mental health. My two interests came together when I found where a very distant relative by marriage had died. She died in North Spring House in 1953 at the age of 75. She had survived her husband by 32 years and had one son who was a weaver by trade. She left her son £515 15s 4d, which in today’s money is about £8,900. In 1953 that would have been equivalent to nearly a years’ wages for a tradesman. Or two horses!

When I googled the address it came up under a different name – an asylum which later became a mental hospital.

North Spring House appears to have been half a mile from the main hospital building. The area is now partly used as a campus for students at the University of Huddersfield.

“Storthes Hall Mansion, built in about 1788 as a private house for the mill owning Horsefall family and located closer to Kirkburton centre, was converted into an asylum in 1904, renamed The Mansion Hospital and run independently as a hospital for people with learning disabilities. It closed in 1991 and was eventually converted back to a private residence.”

“In the early part of the 20th century, part of the Kirkburton hospital was devoted to treating shell-shocked World War One soldiers, but most of the patients were ‘pauper lunatics’ who were detained under the Lunacy Act 1890.”

“The hall was also home to women who were locked up for having children out of wedlock. Many had to spend the rest of their lives there.”

In 1967 and 1968 a committee appointed by the Leeds Hospital Board deliberated over accusations against staff at Storthes Hall and another hospital.

“The allegations which covered a thirty-two week period, were of serious violent assaults, with fists or weapons, against male patients of all ages, committed by four of the five named Male Nurses; and condonation, indifference and apathy on the part of the fifth Male Nurse; against unnamed Doctors and Charge Nurses, that they colluded and conspired to subject patients to physical violence; and against those responsible for the running of the Hospital—(the Medical Superintendent was specifically excluded on the fourth day of sittings at this Hospital)—that they had a mentality only slightly better than that of those responsible for Belsen Concentration Camp; that the Hospital was like Belsen because it was a “brutal, bestial, beastly place”—it was a “hell-hole”.”

Due to lack of evidence it was found that none of the accusations could be proved. The recommendation of the committee was:

“We recommend a review of the nursing staff establishment; and, in addition, the making of improvements in the methods of selection and early training of those recruited as Nursing Assistant. We further recommend that, wherever possible, bed-complements of wards should be reduced.”

This BBC documentary provides an interesting overview of mental health treatment in the UK:

Continue reading “Asylums”

My research diary

9th October 2017



It’s been a while since I felt able to do research. I have tried to get other people involved in helping by joining Helpfulpeeps, a website that puts people in touch with each other with the aim of helping each other. No cash involved. I have had a little interest and am still hopeful that help will arrive.

I think I have discovered that researching the services on offer in the UK is not my strong point. So I have decided to concentrate on the things I find easier to do, writing blogs and reporting on news items.

I have decided to turn my attention to researching the history of the NHS and how it was before the NHS came into being.

This sounds like a project more suited to my strengths as it involves history. I have already found a useful article in Wikipedia which I will use to guide me through my research, and I have bought 2 books (another love of mine) which I am hoping will provide some information. The first book is The Citadel by AJ Cronin, which I have downloaded as an eBook. Apparently, this novel published in 1937 instigated criticism about health care in England and it is cited as being  important in laying the foundation for the NHS.

The other book I have ordered is The Dawn of the Health Age by Dr Benjamin Moore. It was published in 1910. This synopsis is a quote from Amazon:

“written by an Englishman, it applies to conditions in the United States as well as in Great Britain. The author endeavors to demonstrate the necessity for an entire remodeling of the present system of medical service in the interest of the whole community, by showing that thousands of lives and millions of money can be saved every year if disease is attacked on scientific principles “instead of being dallied with as at present.” Dr. Moore advocates a system of state medicine by which competent physicians are made officers of the state for the suppression of disease…”

This sounds quite interesting and useful as a reference point. I just hope that it is easy to read as I often find my attention wandering.

That’s where I’m up to at the moment. I shall try to keep you posted as to my progress.



My research diary

22nd September 2017

I have decided to start using dates instead of a day count. My research is sporadic, some days I’m just not up for it. And anyway, I keep losing count!

Yesterday I was quite excited. I watched a video about the German Healthcare system. I have not corroborated the facts yet, but I found some similarities and a few differences. The point that intrigued me most was that the German General Practice system has a maximum patient limit. It also scored very highly on patients getting appointments either the same day or the next day.

I hate making appointments to see my GP.

The phone lines open at 8.30 am.  Everybody tries to phone as soon as the practice is open for business because everyone knows that everybody else is doing the same thing and they need to be quick to get an appointment. Then the line is constantly engaged because everyone is phoning……

When you get a ringtone (oh joy) it doesn’t necessarily mean you will get to speak to someone. Sometimes you just have to wait for the phone to be answered (the poor receptionist is trying to answer the phone and help patients who are in the surgery and get medical notes for the doctor….etc), or you might get put through to another receptionist who tells you that your call is on hold, please wait.

Eventually, you speak to someone. They offer available times, take your details and you’re in. Or not. “Sorry, there are no appointments for today, phone again at 8.30 tomorrow”. WHAT??!!

I can’t decide which is worse. Going through this when you are also trying to get ready for work or maybe are on speakerphone and automatic redial because you’re driving to work, or you’re at home with small children who are refusing to eat breakfast; or going through this when you are crippled with anxiety, not sleeping properly and have hauled yourself out of bed because you need to phone at a specific time. In all cases anxiety levels are bound to be high. Tempers will flare. You may start shouting at the receptionist because you are so frustrated and have lots of more important things to do and don’t have time for this but need to see a doctor. Today. You wouldn’t be phoning otherwise.

How do receptionists stay sane in this environment?

Writing this has given me an idea. (And I’ve noticed that I have deviated from my main point a little.) In my surgery, if you get told to phone again the next day, there is no guarantee that after going through the same process the next day you will be given an appointment. My idea is that a system be created to give priority to people who have phoned previously. This might get complicated and involve urgency ratings (because there have to be appointments available each day). I haven’t thought it through yet.

This is why I either don’t make the appointment at all (I’m fine, really, I don’t need to go) or if I’m desperate I use the electronic appointment system. (I have been using the electronic repeat prescription services for a few years now because getting an appointment to see a doctor to say I need more tablets was way too stressful – I suffer from anxiety). Electronic appointments are much easier, but there are only advance bookings, and sometimes advance means a few weeks away.

I think you can safely say that I don’t like the system as it is.

So in Germany a practice has a maximum number of patients. This initially excited me because the easy access to appointments appeared to be a direct consequence.

Looking in to how it would work over here, I’m not so sure now. We have a GP system where we are free to register with whichever practice we think suits us best. The practice is legally bound to accept your registration unless there are reasonable grounds not to, which must be explained. I like this, freedom of choice. This is to help people who want a GP nearer to the place they work, someone who has moved but wants to keep their family GP, or someone who feels they are not getting their needs met at their current practice.

But this freedom of choice means that practices can get oversubscribed. Which is why I can never get an appointment and when I do I have to regularly wait half an hour after the appointment time to actually get seen. And this must also have a huge impact on doctors and nurses and receptionists……..

Do we need more doctors for the growing population? Where will they come from? How long will it take to get them trained? Who is going to pay for them?

The Royal College of General Practitioners (the body which regulates family doctors in the UK) produced a report on patient access in 2015. It has some interesting arguments and can be downloaded here.

Lots of questions, not many answers. Yet.





My research diary

Days 5 to 9

My last blog ended by saying I was feeling anxious.

It got worse.

I had been being strong and supportive for my family. I don’t know how many other people experience this, but I have the ability to be strong and in control when other people are in trouble. So it could be being a passenger in a car and the driver taking a wrong turn and getting lost. I am mostly able to be calm and supportive and encouraging while everyone else is flapping. In my work life I was able to work for a deadline and get everything done properly and on time. In personal dramas I am able to take control of the situation, whatever it may be. It’s like I thrive on danger and adrenaline and I do things I never knew I could do.

The down side to this is after the “danger” is over. I can go from being strong and decisive one minute to being weak and vulnerable and scared the next.

I think this is what happened a few days ago. I was being strong and capable for my family, then as soon as they were feeling less vulnerable, my vulnerability soared. I know this happens, I have experienced it many times. The result is complete helplessness and fear. For a few days I try to maintain semi normal life, but I struggle. Then I give up and just zone out. My feelings are numb, I feel vacant, I experience heightened sensitivity to sound. I want to hide away and sleep forever. I want everyone to leave me alone but secretly crave help. I isolate.

And then I start coming back to life. In this instance it was a phone call from the health centre telling me I needed to book a routine appointment. The following day I went to see my GP and told her my fears and concerns. She listened, she made a suggestion about the possibility of staying with family until I felt better. I cried.

The next day I was me again. I was (and am) still tired, the experience always takes a lot out of me, but I was functioning and had emotions and wasn’t scared of people any more. My head was full of ideas, I was back in doing mode.

Which brings us to…… Continue reading “My research diary”

My research diary

Days 3 & 4

Day 3 of my research didn’t really happen. I did a couple of hours then found myself struggling.

So Day 4. There is a Foundation Meeting on the 13th September for the Tees, Esk and Wear Foundation Trust. The public are invited to participate. I have decided to find out everything I can about this trust. They produced a Quality report, which is attached below.


“The Trust provides a range of mental health, learning disability and autism services for around two million people across a wide geographical area. Within this area our main towns and cities are: Bishop Auckland, Darlington, Durham, Hartlepool, Harrogate, Malton, Middlesbrough, Northallerton, Redcar, Ripon, Scarborough, Selby, Stockton, Whitby and York and there are numerous smaller seaside and market towns scattered throughout the Trust’s geography.”



“Tees, Esk and Wear Valleys NHS Trust was created in April 2006, following the merger of County Durham and Darlington Priority Services NHS Trust and Tees and North East Yorkshire NHS Trust.

In July 2008 we achieved foundation trust status under the NHS Act 2006. As a foundation trust we are accountable to local people through our Council of Governors and are regulated by Monitor, the health sector regulator.

In June 2011 we took over the contract to provide mental health and learning disability services to the people of Harrogate, Hambleton and Richmondshire. On 1 October 2015 we took over the contract to provide mental health and learning disability services in the Vale of York.

In December 2014 we were awarded the ‘Gold Standard’ by Investors in People (the highest level of accreditation). This is a nationally recognised people management standard which assesses how well organisations manage and develop their staff.

In May 2015 our services were rated as ‘GOOD’ by the Care Quality Commission (CQC) following the Trust-wide inspection of our services in January 2015.

We provide a range of mental health, learning disability and eating disorder services for the people living in County Durham and Darlington, the Tees Valley and most of North Yorkshire.

With over 6,500 staff and an annual operating income of over £300 million we deliver our services by working in partnership with local authorities and clinical commissioning groups, a wide range of other providers including voluntary organisations and the private sector, as well as service users, their carers and the public.

TEWV serves patients across a large geographical area. Our main towns and cities are Durham, Darlington, Middlesbrough, Scarborough, Whitby, Harrogate,  Ripon, Vale of York and there are numerous smaller seaside and market towns scattered throughout our patch. We are also in the catchment area for the largest concentration of armed forces personnel in the UK (Catterick Garrison).

Read more about the Trust’s achievements over the past decade in our special commemorative brochure “TEWV – the first ten years”.

We have five operational directorates, one for each of our localities (County Durham and Darlington, Teesside, North Yorkshire, Vale of York) and a separate forensic directorate.

Within each of the three local areas we have four clinical directorates:

  • adult mental health and substance misuse services
  • mental health services for older people
  • children and young people’s services
  • learning disability services

Adult mental health services

We provide mental health services to adults of working age in partnership with social care and a wide range of voluntary and independent services providers for the people of County Durham, Darlington, Teesside and North Yorkshire and the Vale of York, including:

  • A wide range of community based assessment and treatment services including primary care, liaison, crisis intervention, assertive outreach, community affective disorders and psychosis teams and eating disorders. The Trust also provides community mental health and deafness services and adult attention deficit hyperactivity disorder (ADHD) across Teesside, County Durham and Darlington.
  • Inpatient assessment and treatment services, including acute, intensive care, challenging behaviour, 24 hour nursed care and rehabilitation services
  • Improving access to psychological therapy (IAPT) services (working with partners) in Durham, Darlington and Teesside
  • The region’s specialist eating disorder service (for the North East and North Cumbria)

Older people’s services

We provide mental health services for older people working in partnership with social care and a wide range of voluntary and independent service providers. The services we provide include:

  • Inpatient assessment and treatment services, including acute and challenging behaviour services
  • A wide range of community based services including; mental health teams, acute liaison, care home liaison, day services and memory clinics

Children and young people’s services

This service includes all child and adolescent mental health services and early intervention in psychosis services for the people of County Durham, Darlington, Teesside and North Yorkshire.

Services for children with learning disabilities are also provided in County Durham, Darlington and Teesside.

Our hospital at West Lane is also the base for our specialist regional North East and North Cumbria eating disorder inpatient service for children and young people.

Adult learning disabilities

We provide community and inpatient specialist assessment and treatment services to people with learning disabilities and mental health problems, autism, epilepsy and challenging behavior.

Forensic mental health and learning disabilities forensic services

Forensic services are specialist services which treat patients referred to us by the criminal justice system because of mental health or learning disabilities conditions, which have been a factor behind their offending. We provide community, inpatient and rehabilitation forensic services for people with mental health problems and learning disabilities.

We also provide community forensic services including criminal justice liaison services that work across the whole offending behavior pathway, for example street triage and the mental health services within all seven North East prisons.”

Here is a link to the Trust’s services:

Trust Services


This is not a good day today. I am easily overwhelmed by the amount of information available and my anxiety is rearing its ugly head. So today I will just have to accept that it’s one of those days.

My research diary

Day 2

Unable to focus

This is what I wrote yesterday:


 My plan for tomorrow is to start analysing the data I have. I can ask questions later.

Yesterday my brain was overfull with ideas. Today I am feeling tired and stressed.

But I made a promise, to myself, to my co pilot in this venture, and to the public. So I’m going to write this diary entry and get on with the rest of my day.

I went back to the My NHS site and have downloaded some data so that I can study it and present it in a more exciting way.

Then I found that you can sign up for data feeds, which I have done:


There are 3 other options but I’m just concentrating on the feeds for now.

My next idea was to revisit what I had started yesterday. I decided to start with

Leeds and York Partnership NHS Foundation Trust

Leeds and York Partnership overview

(This link will take you to the page shown on the image below)

Please don’t try to click on this, it is a screen shot!

I had a quick read of the information in each tab. The Reviews and Ratings page brought back memories of when I was under the care of my local mental health trust. Specifically the feelings of not being listened to or understood, the constant change of staff leading to repeated explanations of your story, and the criticism of crisis team.

But this is something I can work with. I can create a National list of services.

But then I started to get a bit lost and overwhelmed. There were links to the Trust Homepage, and to MindWell, which is “Mental health information for everyone in Leeds”.

I have a tendency to overstretch myself. I was like this when I was working. At work at least I had a structure and deadlines. But I would still work my socks off then wonder why I didn’t want to go to work the following Monday. I’ve lost count of the number of “breakdowns” I had at work over the years. I’m an extreme person, everything or nothing, it’s hard for me to find the middle ground.

For now I’m going to concentrate on one site, the NHS site. But it can wait until tomorrow.

My research diary

Day 1


I have decided to find out what NHS services are currently available. My plan is to go round the country (via the internet) comparing what treatments are available and maybe produce some sort of graph to illustrate my findings.  I’ve chosen Surrey and Yorkshire as my starting points, as that is where the 2 of us behind the project live. I will start with all the County towns, so Guildford and York will be first. This seems to be a good starting point. 

I’ve only just started and already it seems like a mammoth task.

I have found a reporting tool on the NHS Choices site:

Within 25 miles of York
Within 25 miles of Guildford

The first thing that is apparent is that there are only 2 Trusts within 25 miles of York, whereas the Guildford area has 4 (the image shows 2 entries, but there are 4 of 4, they just didn’t all fit on the page).  So what does this mean from a population point of view? Something else to think about…..

This report refers to crisis care in Mental Health Trusts. The columns are:

  1. Bed Occupancy Rate – the proportion of adult acute beds that were occupied by patients. The recommended average occupancy rate is 85%
  2. Proportion of admissions gate-kept by CRHT teams – percentage of inpatient admissions where alternatives to inpatient admission were properly considered beforehand
  3. Help out of hours – whether people in secondary mental health services have access to crisis care outside of office hours and whether this was helpful
  4. Proportion of people on CPA with a crisis plan in place – CPA is Care Plan Approach
  5. Delayed Transfers of care – proportion of bed days occupied by patients whose discharge has been delayed. A delayed discharge is defined in cases where someone is fit to leave hospital but remains for non clinical reasons

There are other subsections in this category, then another category called Psychological Therapies (IAPT)

Ok, so this looks like something I can do. I’m starting to feel as if I have a plan that is achievable. The no data available entries pose a problem, but I’ll work something out.

Population of York (copied from Wikipedia):

From 1996, the term ‘City of York’ describes a unitary authority area which includes rural areas beyond the old city boundaries. In 2011 the urban area had a population of 153,717,[3] while in 2010 the entire unitary authority had an estimated population of 202,400.[1]

Population of Guildford (Wikipedia):

The town has a population of just over 137,000 and is the seat of the wider Borough of Guildford which had an estimated 146,100 inhabitants in 2015.

As I thought, York is larger/more populous than Guildford. If 1 in 4 people in the UK suffer from depression at some time in their lives, shouldn’t each area have equal opportunities to get basic, free NHS support? 

Ok, enough for today. My plan for tomorrow is to start analysing the data I have. I can ask questions later.

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