Emma Jacobs, University of Birmingham

By the turn of the twentieth century, the Bristol Dispensary’s board considered their facility one of the city’s ‘principal medical charities’,[1] and the Dudley Dispensary’s committee congratulated themselves on ‘the progress of the Charity’.[2] However, although both dispensaries continued to provide valuable healthcare services, neither institution retained a great resemblance to conventional medical charities. They had instead become increasingly rationalised organisations, contributing to a wider trend of modernising healthcare institutions, involving greater co-operation across social classes.^[3]

 

Early dispensaries, which have mainly been considered from their eighteenth-century origins to the 1870s, typically provided medical outpatient services, alongside home visiting. Wealthy individuals subscribed to the charity, and subsequently received admission notes. These tickets were distributed to deserving working-class individuals who needed treatment from the honorary medical staff, with voluntary hospitals founded on similar charitable principles.[4] Whilst late nineteenth-century healthcare developed rapidly, with expanding mutual-aid provisions,[5] the evaluation of dispensary reorganisation has been neglected. This is despite the unique viewpoint on the decline of charity that these institutions offer, given that they were generally perceived to be less prestigious adjuncts to hospitals.[6] The Bristol and Dudley dispensaries served areas with differing characteristics, and variable industries, yet both institutions were actively expanding within regional socioeconomic centres, suggesting they are suited to comparison.

The dispensaries moved away from their eighteenth-century incarnations, introducing a central theme of growing accountability to working-class groups. These changes occurred at both establishments to some extent, with increased working-class involvement apparent in the institutions’ funding streams. By 1901, working-class collections accounted for around half of the subscriptions, with a slightly larger proportion at the Dudley Dispensary.[7] Wealthy subscribers were no longer the sole arbiters of admission; similar changes occurred elsewhere, with many hospitals introducing pay-beds, reducing the role of eighteenth-century patronage.^[8] Access to the dispensaries’ services was becoming a business transaction with the patients, reflecting the changing healthcare environment.

A manifestation of the growing working-class contributions was that healthcare became a commodity to be controlled. This resulted in governance demands which further challenged the hierarchical subscriber relationships. The Dudley Dispensary appointed the first working-class representative to their committee in 1899, with the Bristol Dispensary following suit in 1914.[9] The Bristol Dispensary’s slightly higher proportion of private subscribers was a probable obstacle to democratisation, as wealthy individuals often feared working-class involvement, being considered a way to turn charities into co-operatives.[10] The representation and funding differences likely reflect the relative integration of working-class communities within the dispensaries’ localities, although both committees experienced unprecedented co-operation across social classes.

The appointment of doctors in contracted posts further demonstrates the loss of conventional roles within the institutions. Rather than continuing to appoint doctors to honorary posts, where medical gentlemen would offer their expertise for a nominal fee at most, salaried arrangements were introduced. The contracts contained additional restrictions, such as the obligation to live in a certain area, in return for an annual salary.[11] Doctors became employees under the control of the committee, resulting in a substantial loss of autonomy. Such changes created market discipline,[12] which was necessary for the future creation of a centrally contracted labour force.

The contracted arrangements allowed the dispensaries’ committees to make key service decisions without the approval of the medical staff. The Bristol Dispensary’s board felt able to expand into a prior slum area that the medical officers were unwilling to visit, illustrating their increasing authority.[13] Both dispensaries’ committees opted to open branch practices, which were subsidiary departments not associated with eighteenth-century institutions. Traditionally, wider factors affected service provision; doctors developed specialist facilities to benefit their careers, rather than primarily in response to local demand.^[14] However, the practices were established in close accordance with community requirements, with such patient-centred philosophies key to the development of modern organisations.

Whilst local factors influenced certain aspects of dispensary management, both institutions made substantial alterations in response to societal challenges. The dispensaries had restructured, and established consumer-led approaches. Centrally coordinated medical systems, such as national insurance panels, were made possible by a more inclusive healthcare environment.^[15] By developing patient-centred styles, dispensaries were contributing to the wider decline of paternalistic charity, thus aiding the later introduction of central services.

 

[1] The Bristol Mercury and Daily Post, ‘The Bristol Dispensary’, 10^th July 1888, 8.

[2] Dudley Archives (DA), Dudley Dispensary Annual Report 1895, DDIS 1/3/6.

[3] Steven Cherry, ‘Hospital Saturday, Workplace Collections and Issues in Late Nineteenth-Century Hospital Funding’, Medical History, 2000, 44, 461-488, 481-483.

[4] Irvine Loudon, ‘The Origins and Growth of the Dispensary Movement’, Bulletin of the History of Medicine, 1981, 55, 322-342, 322.

[5] Peter Gosden, The Friendly Societies in England, 1815-1875 (Manchester: Manchester University Press, 1961), 215.

[6] Katherine Webb, “One of the most useful charities in the City”: York dispensary, 1788-1988 (York: Borthwick Institute, 1988), 3.

[7] Bristol Reference Library (BRL), State of Bristol Dispensary Report 1901, B7891; DA, Dudley Dispensary Annual Report 1901, DDIS 1/3/8.

[8] Vivienne Walters, Class Inequality and Health Care: The Origins and Impact of the National Health Service (London: Croom Helm, 1980), 35-36.

[9] DA, Dudley Dispensary Annual Report 1899, DDIS 1/3/6; Bristol Record Office (BRO), Bristol Dispensary Minute Book 1914, 33041/BMC/13/2.

[10] Cherry, ‘Hospital Saturday, Workplace Collections and Issues in Late Nineteenth-Century Hospital Funding’, 484-485.

[11] DA, Dudley Dispensary Annual Report 1909, DDIS 1/3/8; BRO, Bristol Dispensary Annual Report 1914, 33041/BMC/13/2.

[12] Martin Gorsky, ‘Mutual Aid and Civil Society: Friendly Societies in Nineteenth-Century Bristol’, Urban History, 1998, 25, 302-322, 304.

[13] BRO, Bristol Dispensary Annual Report 1896, 33041/BMC/13/1.

[14] Lindsay Granshaw, ‘’Fame and Fortune by Means of Bricks and Mortar’: The Medical Profession and Specialist Hospitals in Britain, 1800-1948’, in Lindsay Granshaw and Roy Porter, eds, The Hospital In History (London: Routledge, 1989), 199-220, 202.

[15] David Green, Working-Class Patients and the Medical Establishment: Self-Help in Britain from the Mid-Nineteenth Century to 1948 (Aldershot: Gower, 1985), 2.