Life before the GP
MEDICAL MATTERS Dr Muiris HoustonDespite the many changes facing the health service, the general practitioner remains the first point of call for people concerned about their health. Sometimes father-figures, sometimes gate-keepers to the system, they are always a guiding light for the patient. And research shows a high level of satisfaction with family doctors.
It was not always thus. The dispensary doctor, who can be traced back to the late 18th century in Ireland, was the forerunner of the present day GP. A chapter in Medicine and Charity in Ireland by Lawrence Geary offers some interesting insights into the early dispensary system.
Dispensaries were given official recognition in an 1805 Act of Parliament. Defined as "an institution where medicine and advice are given gratis to the poor", a dispensary was different to a county infirmary or a voluntary hospital in that it had no wards or inpatient beds. Supported by voluntary donations, the 1805 Act obliged county grand juries to match this amount from local taxation to finance dispensaries. However, the Act did not specify the location of dispensaries so, irrespective of need, philanthropy determined their establishment.
The Poor Inquiry of 1835 noted that Co Meath had 19 dispensaries, one for every 9,306 people. However, Co Mayo, with a population in excess of 366,000, had only one public dispensary. Dr Martin A Evans, the dispensary medical officer at Clifton, claimed he was the only doctor in the whole of Connemara.
The quality of dispensary premises varied hugely; "miserable cabin", "an out-house" and a "dismal filthy barn" were some of the descriptions recorded at the time.
The patients were hardly ecstatic about the dispensary service. "There appears to have been a fairly widespread attitude among them that the medical service they received was inferior because it was free," Geary writes. "Candy O'Malley, a labourer from Co Donegal, informed the Poor Inquiry that he often heard the peasantry complain that they only obtained cheap medicines, such as salts and senna, at dispensaries." John Keefe, a labourer from Newtownforbes, Co Longford, was convinced he would receive "more attention and better medicine" if he could pay for it.
Moving beyond the period covered by Geary's book, the 1851 Medical Charities Act established dispensary districts to which a dispensary medical officer (DMO) was appointed. The county DMOs served large areas for poor salaries. Private practice (when available) subsidised their dispensary work, although fees were likely to be paid in kind, with gifts of turkeys, eggs or butter.
Sommerville and Ross wrote of weather "fit for only a snipe or a dispensary doctor". Dr Robert Collis in The State of Medicine in Ireland (1943) described the dispensary service as it was in the 19th century: "Each dispensary was governed by a board of guardians. A Carmichael Essayist of the time described these committees as among 'the lowest forms of life'. The guardians in those days elected the doctor; every form of graft, religious fanaticism and nepotism was the rule of these elections. The dispensary doctor had to trudge long miles on foot, and ride through bogs and up watercourses to reach his patients. His pay was hopelessly inadequate and he had no regular pension so that he hung on long after he was fit for work. Many died of overwork and quite a few of drink. It was a hopeless and thankless job, and the bad name 'dispensary doctor', 'Oh, he's just a dispensary doctor', came from those days as, naturally, the patients suffered more than anybody else. The whole system was built on the necessity to bring some medical treatment to those who were too poor to pay for it and, like the workhouse system, its whole basis was pauperism."
The responsibility for running the service changed in 1925 when boards of health and public assistance took charge. Eligibility to attend a dispensary doctor was determined by the issue of a special ticket. My grandfather, a school headmaster in Kerry, acted as honorary assistance officer for the local dispensary doctor.
The pauperist ethos of a century before had not entirely disappeared; in theory, he and other assistance officers had to ascertain whether the person needed medical help before issuing the ticket. Grandad believed this to be a distasteful invasion of privacy and exercised the required "due diligence" with a light touch.
The dispensary system lasted until 1972 when the present General Medical Services (medical card) scheme was introduced. It brought with it a choice of doctor for the patient and was the first attempt to bring together private and public care in the community. The primary care strategy has signalled the next phase of change for general practice: like so much else in health, it now needs proper funding to make it happen.
Dr Muiris Houston is pleased to hear from readers at email@example.com but regrets he cannot answer individual queries