Social Science & Medicine 55 (2002) 2193–2200

From retreat to health centre: legislation, commercialopportunity and the repositioning of a Victorian private

asylum

Alun E. Josepha,*, Graham Moonb

aDepartment of Geography, University of Guelph, Guelph, Ontario, Canada N1G 2W1bSchool of Social and Historical Studies and Institute for the Geography of Health, University of Portsmouth, Portsmouth P01 3AS, UK

Abstract

This paper examines the interplay of commercial imperatives and health care legislation in the survival of a privately

owned psychiatric hospital in Guelph, Ontario, Canada. Using documentary and archival evidence, we show how the

Homewood Retreat (later Sanitarium, and eventually Health Centre) was able to respond to and anticipate legislative

developments through the agency of successive medical superintendents and the structural positioning of the institution

as an inextricably integrated element in local and provincial mental health provision. Our case study is used to draw out

wider lessons concerning agency, legislative context and treatment modality in the determination of organizational

histories. We conclude by noting the important role of the private sector in ensuring the continued provision of an

asylum form of mental health care. r 2002 Elsevier Science Ltd. All rights reserved.

Keywords: Asylum; Private sector; Mental health policy, Canada

Introduction

This Association has been organized under the

Provisions of the ‘‘Act Respecting Private Asylums

for Insane Persons and Inebriates’’ y for the

purpose of founding a Hospital and Retreat for the

care and treatment of the better classes who are

insane, or who, as inebriates require temporary

seclusion and care (Dr. Stephen Lett, Prospectus of1883, quoted in Warsh, 1989, page 177).

The Homewood Retreat, the first private asylum in

Canada for people then known as ‘the insane’, was

founded in the City of Guelph, in the Province of

Ontario, in 1883. It opened for business on January 1,

1884 (Hurd, 1917). Today, its direct descendant, the 312-

bed Homewood Health Centre, is Ontario’s only

comprehensive privately owned psychiatric facility. It

is a ‘psychiatric survivor’ of numerous changes in mental

health legislation and treatment modalities; most ob-

viously, it is a substantial residential in-patient facility in

a system now dominated by community-based ap-

proaches to mental health care.

In this paper, we examine the survival of ‘the

Homewood’ as an exemplar of the historical interplay

of governmental policy and organizational development.

Governmental policy is understood primarily in terms of

health care policy but we also make reference to

legislation concerning the regulation of private enter-

prise; the Homewood has, over time, repeatedly

(re)positioned itself relative to legislation governing

mental health care and to commercial opportunities in

the sector. We are interested in the balance struck

between commercial and medical priorities in these

repositionings, and in the nature of the individual and

corporate agency deployed in ensuring political survival

and commercial viability. To this end we have a central

concern with the changing balance of proactivity and

responsiveness.

Methodologically, we place our discussion of the

Homewood amongst a growing number of n ¼ 1 case*Corresponding author.

E-mail address: ajoseph@uoguelph.ca (A.E. Joseph).

0277-9536/02/$ - see front matter r 2002 Elsevier Science Ltd. All rights reserved.

PII: S 0 2 7 7 - 9 5 3 6 ( 0 1 ) 0 0 3 6 4 - 1

studies aimed at understanding the general impacts of

shifts in mental health care policy through the idio-

graphic study of single institutions. Of particular

significance for the present study are two papers by

Joseph and Kearns (1996, 1999) on the closure of

Tokanui Hospital, a psychiatric facility in the Waikato

region of New Zealand. The first paper (Joseph &

Kearns, 1996) indicates the importance of setting events

focussed on a single institution into their broader

context, both within the health sector specifically

(deinstitutionalization and restructuring) and society

generally (biculturalism). The second paper (Joseph &

Kearns, 1999) emphasizes the need to invoke legislation,

not only on the treatment of mental illness and the care

of the mentally ill but also in the health sector generally

and in related areas of civil administration, as a primary

influence on institutional behaviour. The overall im-

plication that we draw from these papers is that

considerable analytic gains can be had from focused

study of particular institutions in terms of in-depth

contextualized understanding grounded in the real-

world specifics of policy impact.

The research material for our analysis is drawn from a

range of primary and secondary sources. Primary

sources include the various prospectuses, promotional

materials and operating plans of the Homewood, as well

as legislation governing the treatment of the mentally ill

and the operation of facilities for their housing and

rehabilitation. Two histories of the Homewood (Ta-

tham, 1983; Warsh, 1989) constitute our major second-

ary sources. We add value to these sources by drawing

out the theme of institutional positioning from what are

otherwise straightforward institutional histories, albeit

in the case of Warsh, a critical one.

The remainder of the paper is organized in four

sections. The first of these describes briefly the evolution

of the Homewood with respect to legislative constraints

and commercial opportunities and its (re)positioning

prior to the substantive advent of community care as a

treatment modality in the late 1960s. We consider

initially a period from 1883 to 1902 that corresponds

to the early development of the Homewood Retreat,

culminating in its reincarnation late in 1902 as the

Homewood Sanitarium. We then summarize a series of

expansions and consolidations that were brought to a

close by the initiation of public funding for some

Homewood patients in 1967. The second section of the

paper presents a lengthier assessment of the period

1967–2000, an era of endemic change in which the

Homewood came to occupy a recognized role in the

landscape of psychiatric care in Ontario and enjoy a

mixed funding base drawing on both the public and the

private sectors. The third and fourth sections of the

paper presents our reflections on the Homewood

experience, as an example of institutional survival and

as an indicator of more general processes of institutional

adaptation. In considering the latter, we also note

opportunities for further research.

A brief history of the Homewood

The establishment of the Homewood was necessarily

foreshadowed by the acceptance in British North

America of asylums as humane and progressive alter-

natives to the neglect or abuse of the mentally ill and

handicapped in the community (Hurd, 1917; Dear &

Wolch, 1987; Sussman, 1998). In legislative terms, the

first provision for the care of the insane in the then

Province of Upper Canada was made in 1830 when the

House of Assembly passed an act authorizing payments

for the maintenance of lunatics in county jails. The ‘‘evil

of the prevailing state of affairs’’ was clearly recognized

(Hurd, 1917, page 120) and, after several failed attempts,

funds were approved and legislation enacted in 1839 for

the erection of a public provincial lunatic asylum along

the lines of those existing in Britain. However, a

permanent publicly funded ‘model asylum’ was not

completed (in Toronto) until 1850 (Warsh, 1989).

Over the next 30 years an extended network of

publicly funded asylums was established, the public

nature of which stemmed as much from a revulsion with

historical abuses in private asylums in the home country

(see Parr & Philo, 1996) as from the particular

circumstances prevailing in Upper Canada. Indeed, it

is significant that the Private Lunatic Asylum Act, 1853

was passed in anticipation of the development of private

sector asylums. This Act set out strict inspection

requirements and its regulations embraced both the

business and medical aspects of the asylum. The

requirements of the Act were, in fact, weighty enough

to deter prospective entrepreneurs from developing

private asylums for 30 years.

On September 30, 1883, 2825 patients were resident in

the (public) Provincial Asylums of Ontario, which well

exceeded capacity. However, as Tuke (1885) pointed out

at the time, 538 (or nearly 20%) of the 2825 residents

were non-destitute, paying patients who might poten-

tially be housed elsewhere. Furthermore, it had also

become common for affluent families to send loved ones

with mental health problems to private asylum institu-

tions in the neighbouring USA. It was this potential

market niche, the provision of care to a paying middle-

class population, which attracted one J.W. Langmuir, an

immigrant Scot with the business acumen and bureau-

cratic expertise necessary to enter the field of private

asylum provision.

Founding the retreat, 1883–1902

Prior to founding Homewood, Langmuir had

been Inspector of the Ontario Asylums, Prisons and

A.E. Joseph, G. Moon / Social Science & Medicine 55 (2002) 2193–22002194

Charitable Institutions from 1868 to 1882, with respon-

sibility for 10 institutions (Tatham, 1983). In that

capacity he had created a centralized system of public

insane asylums, prisons, orphanages and reformatories

(Warsh, 1989) and (in 1873) advanced unsuccessfully the

proposition that a quota of beds at the Provincial

Lunatic Asylum in Toronto be converted into more

luxurious accommodation for paying customers. After a

short spell in the business world, he returned to the

question of private asylum care provision for those who

could afford it, convincing Dr. Stephen Lett, an

assistant superintendent at the Toronto Asylum, to join

him in the venture to establish Canada’s first private

asylum on the banks of the Speed River in Guelph.

Letters patent for the Homewood Retreat were issued

on May 18, 1883 (Tatham, 1983). Langmuir and Lett

each purchased one-third of the original stock issue

(Warsh, 1989). Family, politics, philanthropy or com-

mercial pursuits connected all the other founding

members of the board of directors to Langmuir. That

board identified the need to secure amendments to the

business aspects of the 1853 Act to ensure the

commercial viability of the venture. Specifically, the

1853 Act permitted private asylums in Upper Canada

(now Ontario) to admit only Upper Canada residents.

Langmuir used his influence and contacts to secure the

passage of an amended Act in 1885. Private asylums

(with the Homewood Retreat being the only one at that

time) would now be able to admit non-residents of

Ontario. This exercise of individual agency allowed the

Homewood to capitalize on the relative proximity of,

and good rail links to, the USA. Of equal commercial

importance was another section in the reformed Act that

permitted the admission, by voluntary application, of

non-insane individuals for the treatment of ‘‘epilepsy,

hysteria, chorea-amentia, or any nervine or physical

ailment’’ (Warsh, 1989, page 12). Together with

inebriates, this group would constitute an important

source of business for the Retreat in its formative years.

The Homewood Retreat opened officially on January

1, 1884 with a capacity for 25 male and 25 female

residents. However, despite Dr. Lett’s efforts to adver-

tise the health benefits and luxury of the Retreat to the

medical profession and the general public, and notwith-

standing the extension of the Homewood’s market to

areas beyond Ontario and the expansion of its clientele

to embrace voluntary ‘nervous’ patients, it was soon

evident that the number of admissions was not meeting

commercial expectations. Capital continued to be

depleted and, by 1887, the financial outlook was so

bleak that the board of directors briefly considered

selling the property to the government. However, they

decided instead to reduce costs, specifically salaries

(including Dr. Lett’s) and staffing levels (Warsh, 1989).

The financial picture improved slightly but admission

rates continued to fluctuate dramatically through the

late 1890s. In March 1900, Langmuir submitted Lett’s

dire prognosis to the board of directors: ‘‘I do not see

how we can continue. You will observe that we have

only nineteen patients at present; of these four will be

going out in a few days and none are coming to take

their place’’ (quoted by Warsh, 1989, page 17). The

board was forced to conclude that a private asylum ‘‘was

not remunerative in the province’’ and opened negotia-

tions with the government and private investors for its

sale (Warsh, 1989, page 17). Neither group showed any

interest but, before the year had ended, an unexpectedly

high intake of female ‘nervous’ patients provided a

financial reprieve.

In looking back over the first 20 years of the

Homewood’s history, the impression is one of key

legislative moments inter-twined with ongoing commer-

cial crises. The early phase in the story of the Home-

wood is characterized by individual agency, principally

by Langmuir, with the securing of the amendment to the

1853 Private Lunatic Asylum Act standing out as a

singular example of perseverance and bureaucratic

acumen. We see such initiatives as proactive strategic

manoeuvres designed to frame a bureaucratic structure

in which private mental health care could flourish. This

securing of a legislative niche through the capture of

bureaucratic structures did not, however, guarantee

commercial success, in part because of the structural

volatility of the market that Langmuir sought to enter.

We see a confrontation between society, the market and

medicine. Prevailing notions of psychiatry ensured the

inclusion within Homewood’s clientele of a significant

fraction of female patients with nervous afflictions.

Market considerations ensured that these patients were

important for commercial success but that overall

viability could not be attained without also attracting

the very different patient groups represented by inebri-

ates and those with severe psychiatric problems. In the

late nineteenth century moral climate, the co-location of

these three groups was socially problematic.

Building the sanitarium, 1902–1967

In 1902 Dr. Alfred T. Hobbs, formerly the assistant

physician at the London (Ontario) Asylum, became the

Homewood’s second medical superintendent. He im-

mediately requested that the name of the Homewood be

changed from ‘retreat’ to ‘sanitarium’ and late in 1902,

and still with far from sound finances, the hospital was

re-registered as the ‘Homewood Sanitarium of Guelph,

Limited’ (Tatham, 1983). Hobbs adopted a strategy of

re-orientation and expansion, initially through distan-

cing the Homewood from its reputation as a centre

for the rehabilitation of inebriates. By 1905, 80%

of patients were either ‘mental’ or nervous cases and

the Homewood was beginning to rehabilitate itself

to the prevailing moral climate. As Hobbs himself

A.E. Joseph, G. Moon / Social Science & Medicine 55 (2002) 2193–2200 2195

stated: ‘‘the less [Homewood] is known as an inebriate

institution, the better its moral atmosphere in the eyes of

the profession and the more attractive (it is) to the

general public’’ (quoted by Warsh, 1989, page 18).

A particular and necessary manifestation of Hobb’s

strategy was the renaming as a sanitarium. This

renaming invokes notions of bodily purification that

can be seen in terms of the contemporary notions of

rehabilitation and (mental) health care. Sanitaria were

then fashionable settings in which the upper and middle

classes could recover their health (Gesler, 2000). They

embodied a particular therapeutic landscape in which

treatment, architecture and setting were linked: the

Prospectus of 1915 reads in part like a holiday

advertisementF‘‘[The] Sun Verandah y One does not

have to dwell upon the glory, the splendour, or the

health-giving properties of sunshine. On such a ver-

andah as this the germs born of dust and darkness have

little chance to develop’’ (quoted by Warsh, 1989, page

181). By recasting Homewood as a sanitarium, Hobbs

was seeking to engage with a fashionable and commer-

cially attractive image. The renaming also signalled a

refocusing of the facility’s mission. No longer was it a

retreat (from society), a place where mental ill-health

could be hidden away; it was a place where the moral

and positive aspects of asylum were coupled with the

prospect of rehabilitation.

These changes were signalled overtly in the recon-

struction of the Homewood’s built environment. In

1907, the opening of two new buildings allowed a

separation of addicts, inebriates and incurable cases

from acute nervous and mental cases (Warsh, 1989),

thereby setting in place divisions that were as much a

reflection of commercial priorities as medical needs.

Physical and social amenities were improved, and new

therapeutic facilities in hydrotherapy, electrotherapy

and massage were introduced. Nevertheless, there was

also commitment to ‘modern’ interventionist psychiatry:

a fully equipped operating theatre was opened in 1907

(Warsh, 1989). The loss of the original building in a fire

in 1911 provided the impetus for further expansion

(Tatham, 1983) and by the middle of the First World

War the Homewood had accommodation for 70 men

and 60 women, a staff of five physicians and 60 nurses,

and a nurse training school (Hurd, 1917). This expan-

sion was necessary to reduce waiting lists, a new and

welcome problem for the Homewood, and to stave off

potential competition from new commercial ventures

seeking to emulate the Homewood’s increasing profile as

a (now profitable) provider of psychiatric care.

When Dr. Hobbs stepped down from the medical

superintendency in 1922 the Homewood was a commer-

cial success. Moreover, the hospital had established its

professional credentials and its place in the Ontario

medical system. To some considerable extent this

improving position can be traced back to the recruit-

ment of Hobbs, a physician with a national personal

reputation in psychiatry, as medical superintendent. As

a consequence, Homewood’s commercial success was

underpinned by a growing institutional reputation with

general and specialized physicians, especially in Tor-

onto, who provided the hospital with regular referrals

(Warsh, 1989). Thus, by the mid-1920s Homewood was

in a secure position, both commercially and profession-

ally. Barlow (1938) reports that the Homewood declared

a dividend in every year from 1923 to 1937, except 1925.

The dividend of 12% paid to shareholders in 1937 is

particularly notable given the general state of the

Ontario economy during the Great Depression. This

success was consolidated, albeit with some perturba-

tions,1 under the guidance of successive medical super-

intendents and boards into the 1950s.

The 1950s and 1960s witnessed an increased tempo of

change. The coming of psychotropic drugs in the 1950s

had a particular and immediate impact. The Home-

wood’s first outpatient services were initiated, there was

a fall in in-patient admissions, and one of the residential

units was briefly closed and then re-opened. Despite

these developments, the Homewood continued to

emphasize its role as an in-patient facility. In 1966,

roughly co-incident with the peaking of institutional

populations in Ontario (Dear & Taylor, 1982), the

Homewood undertook its last major expansion, increas-

ing its capacity to slightly over 300 beds.

The first six decades of the last century were thus

comfortable ones for the Homewood. The commercial

niche was made increasingly secure and there was

limited legislative change. The facility enjoyed a good

clinical and therapeutic relationship with its base of

potential customers in Southern Ontario and the

neighbouring American states. The professional niche

was also made secure. Each of the various medical

superintendents of the Homewood served at least one

term as President of the Ontario Psychiatric Association

(Tatham, 1983). The Homewood emerged abruptly from

this historical ‘comfort zone’ in the 1960s. While in-

patient therapies continued to dominate the Home-

wood’s agenda, considerable momentum was building

up in Canada for deinstitutionalization (Dear & Wolch,

1987; Williams & Lutterbach, 1976). For the Home-

wood, the coincidence of a growing (and radical)

1Though our presentation is linear, we would not wish to

imply that the Homewood’s history in the middle decades of the

twentieth century was completely unproblematic. The ‘McIn-

tosh case’ was a significant perturbation (Barlow, 1938). This

concerned an allegation that, for commercial reasons, the

Homewood was willing to hold patients against their will and at

the behest of unsympathetic relatives. The Sanitarium was

eventually exonerated but reputational damage was incurred at

a time when attitudes to mental ill-health were beginning to

change.

A.E. Joseph, G. Moon / Social Science & Medicine 55 (2002) 2193–22002196

critique of ‘custodial care’ (Dear & Taylor, 1982) and

pressures for the introduction of socialized medicine

(Vayda & Deber, 1992), created a critical moment after a

long period of growth and consolidation.

Sustaining the asylum

The planning and building of the final additions to

Homewood’s in-patient capacity occurred at about the

same time as the foundations for a universal, publicly

insured health care system were being laid down in

Canada. In 1964, the Hall Commission recommended a

comprehensive federal-provincial cost sharing universal

insurance program (Vayda & Deber, 1992) that would

build on the provincial hospital insurance systems

established under the Hospital Insurance and Diagnostic

Services Act, 1957 (Crichton, Robertson, Gordon, &

Farrant, 1997). The Medical Care Insurance Act, 1966

provided for such universal coverage on uniform terms

and conditions across the country (Crichton et al.,

1997). The implementation of socialized medicine served

to emphasize the anomalous position in legislation of

Homewood as Ontario’s only comprehensive private

psychiatric hospital. Commercially, it raised the very

real possibility of patients from the ‘better classes’ being

directed by publicly funded physicians to publicly funded

psychiatric hospitals or psychiatric units in general

hospitals instead of to the Homewood.

In 1967, the Homewood responded to the challenge of

socialized medicine by securing a ‘loose arrangement’

with the Ontario Ministry of Health for the supply of

services to the local community (focussed on Guelph

and the surrounding County of Wellington) (Home-

wood Health Centre, 1998a). It seems that the hospital

mobilized arguments based partly on the lack of

proximate alternative facilities (Wellington-Dufferin

District Health Council, 1996), but probably more so

on its record of achievement and its status as a local and

provincial repository of expertise in psychiatric care.

This agency is reminiscent of that deployed by Langmuir

more than 80 years earlier. A proactive stance was also

displayed in terms of meeting new, more stringent,

licensing requirements. The Homewood was the first

psychiatric hospital in Ontario (and only the second in

Canada) to be fully accredited by the newly established

Canadian Council on Hospital Accreditation (Tatham,

1983).

The securing of access to publicly insured patients

provided a degree of long-term commercial security for

the hospital. Indeed, in the 1997/98 operating year the

Ministry of Health provided 59% of the Homewood’s

total revenue of $35,672,880 (Homewood Health Cen-

tre, 1998b). By not accepting capital funding, the

Homewood retained ownership of its assets and

protected its right to admit private patients. In the

mid-1980s the arrangement between Homewood and the

Ministry of Health was clarified: 124 (40%) of the beds

in the Homewood would be ‘ward rate’ beds available at

no additional charge to provincial residents. Beds

available at ward rates would be available in all

programs, with the greater number located in the

Community and Rehabilitation sections catering in

large part to ‘local residents’ (Central West District

Health Councils, 1996). In 1996, 33% of total dis-

charged patients were from Wellington County and a

further 11% from the remainder of the Health District

(Homewood Health Centre, 1998a). This special finan-

cial arrangement for provincial residents, which con-

stitutes an exception to the universality/portability of

health care insurance in Canada, persists today. Out-of-

province patients are charged $224 per day for

accommodation (but receive treatment at no charge)

and US patients are quoted blended accommodation

and care fees that vary by program (Homewood Health

Corporation, undated).

The Homewood thus emerged in the 1970s and 1980s

as a privately owned and operated component of a

publicly funded and administered system of psychiatric

care. It operates in a very genuine and specific way

within a mixed economy of care. However, in a

legislative sense, its position remains unique. Not only

is it anomalous in the context of legislation on health

care finance, it is singular in its position with respect to

legislation on the regulation of health care. The Home-

wood has operated since 1967 under various iterations

of the Mental Health Act (Government of Ontario,

1998a) as one of 82 Schedule 1 facilities (now mostly

general hospitals) offering in-patient mental health

services. The Homewood is not however governed by

the Mental Hospitals Act (Government of Ontario,

1993a), which only covers publicly owned facilities, or

by the Private Hospitals Act (Government of Ontario,

1993b), which excludes hospitals that receive any public

funding. Furthermore, it stands out as the only Schedule

1 facility that is exempted from the requirement to

provide outpatient and community outreach services.

Nevertheless, Homewood has, since its initiation of the

Wellington-Dufferin Community Mental Health Clinic

in 1967, offered such services. Community programs

have been financed by diverting public funding equiva-

lent to 42 beds to a range of extra-mural preventative,

treatment and research programs (Homewood Health

Centre, 1998a). This strategy can be seen as a response

to public pressure for community care of the mentally ill,

but it is also consistent with the Homewood’s estab-

lished record of embracing new treatment modalities

and responding effectively and with political acuity to

signals from the market place.

The Homewood carried its three-part balancing

actFbetween supplying in-patient care and community

services, between being a local community hospital and

A.E. Joseph, G. Moon / Social Science & Medicine 55 (2002) 2193–2200 2197

a specialized facility operating over a wider catchment,

and between public and private accountabilityFinto the

1990s. In 1992, the Homewood Sanitarium of Guelph,

Ltd. became the Homewood Health Centre, Inc., a

subsidiary of the Homewood Health Corporation

(Homewood Health Centre, 1998b). These changes were

carried out in accordance with the provisions of the

Business Corporations Act (Government of Ontario,

1998b) and facilitated by re-listing in the schedules of the

Mental Health Act (Government of Ontario, 1998a).

The 1992 re-organization did not affect the arrangement

with the Ministry of Health concerning the provision of

no cost in-patient psychiatric services to local people.

Internal re-organization was implemented in 1996

based on an unpublished document entitled Path to the

Future (Homewood Health Centre, 1998c). At the

corporate level, the Centre for Organizational Health

was established in 1998 as an affiliate of the Homewood

Health Centre: ‘‘focussing on both academic and

consultative activities, the Centre is committed to

building awareness of the links between mental health,

wellbeing and economic performance’’ (Homewood

Health Corporation, undated, page 5). Additionally,

the Homewood Health Corporation established a

second wholly owned subsidiary, The Homewood

Behavioural Health Corporation (HBHC), to provide

‘‘behavioural and mental health services on behalf of

private sector payers such as employers, health benefit

insurers and medical disability management companies’’

(Homewood Health Corporation, undated, page 3). The

operations of the HBHC are currently divided into three

areasFEmployee Assistance Programs (EAPs), Con-

sulting Services (for the design and implementation of

health initiatives in the community and workplace) and

the Quitcare Smoking Cessation Program (Homewood

Health Corporation, undated). Taken together, these

developments suggest an active re-engagement on the

part of the Homewood with private markets, namely

through recognition of the market opportunities resident

in the growing culture of corporate health care. Second,

they demonstrate a continued trading upon the reputa-

tion of the Homewood within the psychiatric commu-

nity. Last but not least, they represent a strategy of

commercial diversification within the mental health care

sector.

Just as the Homewood’s final phase of in-patient

capacity expansion in the late 1960s occurred alongside

the implementation of community care and universal

public health insurance, the reorganizations of the 1990s

took place alongside further changes in the policy arena.

In Putting People First: The Reform of Mental Health

Services in Ontario, the Ministry of Health sought to

promote the development of an integrated mental health

service (Ministry of Health (Ontario), 1993, page 5).

While the Homewood’s position was enhanced in 1995

by the newly elected Progressive Conservative govern-

ment’s openness to the private sector, captured in the

aphorism ‘‘the best service at the least cost’’ (Cloutier-

Fisher & Joseph, 2000), the autonomy of the hospital

was simultaneously threatened by the comprehensive

restructuring process articulated through the Health

Services Restructuring Commission (HSRC). The

Homewood was especially ambivalent about the

HSRC’s strategy for developing ‘hospital networks’

with shared administration (HSRC, 1998). While

responsive to calls for greater local co-ordination, the

Homewood has consistently asserted its primary char-

acteristic as a specialty in-patient institution with

provincial responsibilities (Homewood Health Centre,

1998b).

Discussion

In reflecting on the recent development of the Home-

wood we will focus on three themes. The first of these

concerns the (re)positioning of Homewood in relation to

changing treatment modalities and legislative condi-

tions. The second and third themes are subsidiary to the

first. They relate respectively to the position of private

mental health care in a publicly funded health care

system, and to the importance of ‘names’ in the survival

of the Homewood.

For the Homewood, the hegemony of in-patient care

ended abruptly in the late 1960s in the face of demands

for new treatment modalities and the drive for publicly

insured universal health care. Those individuals in

charge of the Homewood at that time were able to

capitalize upon the Homewood’s reputation and net-

works to secure an arrangement for public funding to

provide in-patient services to the local community and

to initiate the first of a series of community care

initiatives and partnerships (Tatham, 1983). We would

contend that the Homewood’s move into community

care was initially founded in recognition of commercial

imperatives. Nevertheless, the move was soon matched

by professional commitment and, by the 1990s, the

professional and the commercial were again in harmony.

The entry of the Homewood Behavioural Health

CorporationFtrading as it does on the reputation of

‘‘the Homewood’’Finto areas of mental health care

that would undoubtedly have once appeared marginal

and problematic can be taken as indicative of a new,

‘corporate’ boldness and a regained concordance be-

tween professional ambitions regarding treatment mod-

alities and the commercial viability of the facility.

To some extent, this renewed commercial confidence

can be attributed to the contemporary rehabilitation of

private health care providers in Ontario: ‘‘We pride

ourselves on our business-minded entrepreneurial ap-

proach and see ourselves as a model for how health care

can work in Canada’’ (Homewood Health Centre,

A.E. Joseph, G. Moon / Social Science & Medicine 55 (2002) 2193–22002198

1998b, page 3). Our second discussion point then is that

the Homewood story provides a benchmark for the

contemporary debate on private health care in Canada.

It reveals how private providers in a publicly funded

health care system can be innovative in service

programming in order to create, satisfy and retain a

market. Being at once commercially and medically

responsive is now less clearly problematic, in part

because, as Rosenthal (1998) relates, the crisis in

Canadian health and social welfare in the late 1990s

has meant the re-emergence of a demand for private care

on the part of people able to pay to circumvent long

waiting times for public mental health care. In the 1990s

the Homewood thus seems to have grown more

comfortable with the stresses and strains of being at

once a publicly and privately funded psychiatric institu-

tion. In addition to the expansion into areas of

organizational and behavioural health that represent

an emerging private-sector commercial niche, the Home-

wood is now openly advocating increased government

funding of its services from the safety of its established

position and with a clear recognition of the rapproche-

ment between the public and private sectors. Signifi-

cantly too, these expansions are in in-patient capacity as

well as community programs. The Homewood’s tradi-

tional emphasis on residential care fits well with

concerns now being expressed about the limitations to

community care (Moon, 2000). Thus, in its 1998/99

Operating Plan, the Homewood requested an additional

15 ward beds in its specialized psychiatry division to

supplement the 21 existing beds, and cited the existence

of a 500 person waiting list and delays of one-to-four

years for admission in the public sector as strong

indications of need (Homewood Health Centre, 1998b).

For our third discussion point, we askFwhat’s in a

name? The Homewood has metamorphosed from the

‘Retreat’, through the ‘Sanitarium’ to the ‘‘Health

Centre’. On the one hand, this represents a paradigmatic

recognition of changing treatment modalities. Seclusion

is replaced by an allusion to the healing power of well-

appointed facilities in tranquil settings. This, in turn, is

superceded by incorporation under the broad label of

‘health’. On the other hand, the various names that have

been used have, over time, become progressively less

identifiable in their association with mental health care.

This deinstitutionalization of nomenclature has been

mirrored in staff titles. The current leader at the

Homewood, Dr. Edgardo Perez, is its Chief Executive

Officer and Chief of Staff, not its Medical Super-

intendent.

Conclusion

This paper has explored the reasons for the para-

doxical survival and even prosperity of a (relatively)

large privately owned institutional facility in a landscape

of publicly funded psychiatric care that is now

dominated by small-scale community programs. We

have dwelt particularly on the ways in which the

Homewood repositioned itself relative to legislative

developments and commercial opportunities, both in

its early years and in more recent times. Our account

has shown overt manipulation of legislation as well

as continuing abilities to both extract preference

from the public health care system and move to

new markets. This responsiveness and reflexivity

suggests an ecological metaphor: the Homewood

adapted and survived because of both luck and good

management in its encounters with dangers in its

commercial and health policy environments. Crucially,

it also enjoyed a long period of quiet growth and

development in the middle period of its history, when

neither its in-patient residential nature nor its private-

sector funding base were particularly unusual or

problematic.

At the start of the paper, we claimed a methodological

location for our work alongside other n ¼ 1 case studies.

Taken together with other such works on the geography

of mental health care (Joseph & Kearns 1996, 1999), the

present study confirms the importance of seeing institu-

tional responsiveness in terms of changing contexts. In

moving beyond the n ¼ 1 situation, we must now re-

express context as system. In this regard we identify

perhaps our most interesting conclusion. Despite ex-

perimentation with treatment modalities and entry into

different markets, the Homewood has remained a

provider of asylum care.

The persistence of significant in-patient provision

suggests that beyond the particular circumstances of

the Homewood lies a residual demand for in-patient

mental health care. This runs counter to prevailing

professional discourses of deinstitutionalization, and it

cannot be understood as a simplistic response to

dangerousness, as might be supposed were parallels to

be drawn with recent developments in British mental

health policy (Moon, 2000). Rather, it suggests that

people (or their relatives) are prepared to pay for in-

patient psychiatric care which the public sector is no

longer able (or willing) to provide. Thus, far from

uncritically supporting the assertion that the private

sector may cater only for less difficult mental health

cases (Anderson, Catterson, Gaudet, & Gautam, 1997),

we see a more complex reality. To us, private-sector

mental health institutions seem to pursue opportunities

that have effectively been discarded, under-funded or

neglected by the public system. These commercial

initiatives are inhibited by neither professional nor

ideological fashion and transcend national contexts.

We are addressing this hypothesis further in ongoing

work on private mental health care provision in Britain

and New Zealand. In so doing, we seek to contribute to

A.E. Joseph, G. Moon / Social Science & Medicine 55 (2002) 2193–2200 2199

what appears to be renewed interest in asylums and

‘asylum geographies’ (Philo, 1997).

Acknowledgements

We are grateful to Lois Lindsay for her diligence as a

research assistant and to the Homewood Health Centre

for access to its library. We also acknowledge the helpful

comments of two anonymous reviewers. This said, the

views expressed in this paper remain those of the

authors.

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