Editorial - Dispensaries in London.
During the discussions upon the Reform Bill, the case was often put of an intelligent foreigner being the spectator of our political proceedings.... Now let us suppose that the intelligent foreigner be a physician and before sympathising with the more confined circle of our medical interests. Let us imagine him to take up a newspaper, and find an advertisement for a dispensary physician, who must, as usual, be a member of the Royal College, and possess satisfactory testimonials.
He might learn, on farther inquiry, that it was a common thing to spend a deal of time, and some money, in canvassing for such a situation; and that there have been occasions when candidates, stimulated by the desire of high preferment, have laid down Bank-notes against each other - that is, have paid in subscriptions in the names of imaginary governors, and have thus gained their election at the Grub Street Dispensary, in the same way that they might their election as M.P. at Leicester or Liverpool. The intelligent, but not naturalized foreigner, knowing that a professed philanthropist cannot always be had for advertising, and that a nation boutiquiere must contain many cautious men who are unwilling to exchange solid sovereigns for empty titles, necessarily supposes that the office gained with much expense, and held with infinite trouble, is very lucrative. What would be his surprise on hearing that the place is almost always a gratuitous one ? Or, to drop the foreigner, how significant are the quiet inquiries of sensible people, when they see their medical friends canvassing for a place of nothing per annum. They naturally want to know why the candidate is so eager to obtain zero. Because it leads to practice replies the abashed canvasser. But then, rejoins the friendly doubter, we do not see why this snatching at a shadow should be more necessary in physic than in the other learned professions. In the law, for instance, we sometimes hear of a cause being pleaded gratis; legal opinions, like medical advice, are no doubt occasionally given without a fee to the needy client; but the barrister who should set up a legal dispensary where he doled forth his advice to all comers without a fee, with the avowed intention of getting into practice, would, we more than suspect, be speedily sent to Coventry by his brethren.
It may be replied, of course, that medical advice is more often necessary than legal counsel to the indigent, and should therefore be provided for them gratis at the expense of the community. This we readily grant - at the expense of the community ; but that this be done, the medical officers should be well paid, for at present the charitable bestowal is chiefly at their expense....
In the case of the dispensaries, it must be confessed that if the medical officers are somewhat slow in discerning certain unpalatable truths before their election; they find them out quickly enough afterwards; a few months are usually sufficient to teach that no pay is attended by another stern negative - no increase in practice to which are added the uncomfortable positives; much work, and plenty of squabbling. The consequence is that places are thrown up with wonderful readiness; service is found to be no inheritance.
At a worn out dispensary (a ci-devant respectable one) we have known four vacancies occur in the post of physician in less than 3 years. This dispensary, like others of the old school, once enjoyed the services of stipendiary officers; but when its income declined, and it became necessary to curtail its expenditure, the most obvious way of doing so was to cut off their salaries; for as druggists, leech- venders, messengers and the like, insist on being paid, and as this
is a matter of indifference to physicians and surgeons, the natural conclusion was, stop these useless salaries, and thereby add so many hundreds to the income, and consequently to the efficiency of the dispensary.
This is the short-sighted principle on which almost all dispensaries are now conducted, or mis-conducted; but we confess our astonishment that so respectable institution as the St Marylebone Dispensary should have lately fallen into the common error, and passed a law - that no physician or surgeon hereafter appointed will receive any salary or gratuity from the funds of this charity. Any one who is acquainted with the subject, and has the interest of the poor really at heart, will allow that all that is done in London by 20 or 30 ill-conducted dispensaries, might be infinitely better done by 6 or 8 good ones, with ample funds, and well-paid medical officers, devoting the greater part of their time to the institutions. The saving in house-rent, taxes and other items, which would be effected by such a coalition would at least balance the increased expense caused by the salaries. One of the most obvious improvements which would necessarily follow a reform of this kind, would be in the arrangement of the houses intended to be used as dispensaries. At present they are commonly unfit, architecturally, for the use to which they are put. Then it would be absolutely requisite that the hours of attendance should be considerably extended. How inconvenient it would be for the public if a medical practitioner were to be found at home for one hour only every day, or if a government office were to be open only from 12 until 1.
It continually happens, too, that the patients are thrown out by the accidental punctuality of the medical officer. Suppose that, as usually happens, he is habitually half an hour later than his printed hour; to-day he comes to the minute; his tail, or late patients, presuming on his lack of punctuality, miss him altogether. But it is often said, all patients should be there at the hour printed on the letters; if so, many will have to wait an hour, and some much more, a serious loss for a patient who, though labouring under a chronic disease, still continues to work; while it is also an injury to the health of many. As, in consequence of such a coalition, the remaining institutions would be of far greater importance, we should expect to see persons of more weight in society, both lay and medical, interest themselves in their interior economy. It is almost needless to particularise the reforms to which this valuable superintendence must lead. The quality of the drugs would be improved, when the druggists were informed, quite in earnest that trash and pulveres redacti must be sent elsewhere, and not to persons competent to judge of them.
The same cause would quite alter the system of dispensing medicines. No more substitution of gentian for cascarilla - no more verbal directions, no more lumping of six powders into one. We must conclude with the painful reflection, that most of these charitable institutions in London, as at present managed, are in bad odour among the poor, and produce more discontent than gratitude. As for their supposed effects upon the fortunes of the physicians and surgeons connected with them, the truth must come out in this age of
expositions, confessions, and eclaircissements of all kinds, the bubble must soon burst, and we shall not be sorry to see it do so.
The London Medical Gazette 1837-8 Vol 21 1053 pp
p 260 11th November 1837
Submitted by Alan Longbottom
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