Books: The Dispensaries: Healthcare for the Poor Before the NHS: Britain’s Forgotten Health-care System

This is a fascinating and unusual book exploring a widespread but now little known aspect of primary care that existed 200 years before our NHS began.

Dispensaries started slowly. The first ran in London from 1696–1725 but more widespread adoption began from around 1770 and real expansion took place with Victorian philanthropy (and urban population explosion) in the mid- and late 19th century, spurred on by mid-century Poor Law reforms. We’re never told how many dispensaries there were in England, but there were over 100 in London by 1900 and over 1000 in Ireland by 1872.

There were two main funding systems. The first and predominant relied on subscriptions, originally from rich individuals, but by the 20th century funding included from businesses and sometimes parish churches. Patients had to be ‘poor’ and deciding eligibility could be difficult. Many dispensaries started by only accepting patients recommended by subscribers.

By the 19th century a growing view that such charitable care encouraged dependence led to the establishment of Provident Dispensaries. Here, potential patients paid a small but regular subscription themselves to get free care when ill. This was the germ of a health insurance system. However, Provident Dispensaries never replaced voluntary subscriber ones.

But the key moment came with the 1909 Poor Law Commission Report. Although the majority recommended the general introduction of Provident Dispensaries with universal subscription, the dissenting minority report by Sidney and Beatrice Webb prevailed. The nub of their argument was that most dispensaries only provided medicines, whereas most patients needed a good preventive public health service. The next development was thus the setting up of compulsory health insurance and linked GP services for wage-earning men in 1911 (bringing with it the long-lasting ‘Lloyd George’ record envelopes). Even so, with little further expansion, most dispensaries continued to operate until the NHS established GP-based primary care for all in 1948.

Michael Whitfield, an academic GP from Bristol, has developed his interest in local medical history since his retirement. So this book starts with detailed accounts of dispensaries in Bristol before going on to consider London, the rest of England and Wales, and then certain other countries in outline. Interestingly, Scotland is one of these ‘other’ countries, and, although we’re told how dispensaries have contributed to medical student training in the community, there is no mention of how the world’s first academic GP department evolved directly from dispensary practice in the centre of Edinburgh. Starting in the 18th century, this was a compulsory part of the Edinburgh curriculum from 1890!

Many clinical stories are buried in more prosaic reports of accounts and salaries, and how subscriber management committees attempted to control dispensary doctors. I had not realised that dispensary doctors did home visits, especially in the earlier years. One such visit, to a destitute family in appalling circumstances in Greenwich, southeast London, in 1780 is described on page 96. It is illustrated by the doctor himself, John Lettsom, himself on the front cover, with the title ‘A Morning Walk in the Metropolis’ (inset on the front cover).

The book ends by asking what we can learn from the dispensary system today and concludes that it is worth considering as a decentralised, administration-lite, and essentially cheap system. It is always stimulating to look at alternatives to our present-day NHS and avoid the trap of thinking our own system must be best. All the same, I’m with the Webbs in thinking that basing a healthcare system on the consumption of medicines, rather than a wider vision of public health, would have been a wrong turning.

• © British Journal of General Practice 2017