Lady Almoner

1862/3 – 4 January 1925

Mary Stewart: The First Lady Almoner, by Lynsey Cullen

In 1895, Miss Mary Stewart became the first lady almoner in Britain upon her appointment at the Royal Free Hospital of London.

The first almoners were appointed to charitable hospitals at the end of the nineteenth century. Their purpose was to means- test patients to determine if they should contribute toward their treatment and, when necessary, refer them to charitable aftercare. This role developed over the first half of the twentieth century into what would be recognised today as social work. Stewart’s appointment as the first almoner therefore marked two important introductions to hospital patient payment and welfare before the NHS; the means test and the almoner’s network of assistance.

Very little is known about Stewart’s family or early life. She attended the North London Collegiate School for Girls and later trained as a social worker with the Charity Organization Society (COS) under its secretary, Charles Loch. Stewart therefore possessed local knowledge as to the conditions of the poor in London and the training needed to inspect a patient’s means and refer them to other charitable sources. All accounts indicate that she was single and childless, which is unsurprising given that many professional roles for women at this time excluded married women. There appears to be no reference in the minutes, the Almoners Report Book, or in the surviving correspondence of the time as to why Stewart was appointed and not a different COS employee. In the minutes of the Weekly Board for the year 1894 however, Mr Sheppard (the Chairman of the Board) claimed that the person required for the job must be someone ‘on whose discretion we could rely and in whom the medical staff had confidence’. It can only be assumed that Stewart was thought to possess such qualities by her employers.  At the end of the three-month trial period, Stewart returned to work with the COS while the RFH evaluated her performance as almoner. It was decided that she should be appointed to this position full time. Two members of the COS committee gave half the salary cost of fifty pounds each (twenty-five pounds to the hospital and twenty-five pounds to the society respectively) to which the hospital added a further twenty-five pounds, making the almoner’s total annual salary £125, which was a very good salary at this time, especially for a woman. This would be the beginning of the almoner’s office and Stewart’s chance to reshape social work as we know it.

Upon her appointment, the main purpose of the almoner was deemed to be to interview patients wishing to receive treatment at the out-patient department to determine whether they were eligible to receive free medical treatment at the hospital; whether they were able to make a contribution towards their care; or whether they were better suited to receive treatment through a different means. 

In May 1895, Stewart commented that few patients objected to giving information and no patient complained about these questions. Many patients were pleased to talk about themselves and the position of their families. They spoke about their earnings, rent and children. Others were less comfortable disclosing personal information and there are accounts of patients giving false statements as to their means, albeit some unintentionally. Over the course of Stewart’s time at the RFH, the number of patients interviewed each month increased until this number peaked at over six hundred in the report of the first seven months of 1899.

Stewart’s arrival at the Royal Free was not totally welcomed by the medical staff. The office space assigned to her was only a small corner of the out-patient waiting-room partitioned off by screens. There was no light and if a visitor did not want to stand the only ‘seat’ was the radiator. In her first month no doctor referred any patients to the almoner’s office and so by judging patients on their appearance ‘the particulars as to the means and general circumstances of 150 patients’ were taken at random. The occupations of the head of the families interviewed were recorded in the first report to give ‘a correct an idea as possible as to the positions of each patient’. Over the next two months of her trial period the almoner’s role was acknowledged and accepted. Consequently, two doctors began to refer patients to the office, which enabled Stewart to abandon the method of random selection. The reason why initial objection to the post subsided is not noted in Stewart’s reports but it is likely that the medical staff came to realise that the almoner was not out to challenge their authority. Stewart was hired permanently in October 1895 and the number of patients she interviewed increased steadily each year thereafter. 

In order to develop the methods of inquiry and admissions at the RFH, Stewart visited other hospitals in the London area to compare policies. The out-patient departments of St. Bartholomew’s, The London, The Great Northern and Great Ormond Street hospitals were all inspected.  She found that only at The London Hospital was any method of inquiry into the patients means undertaken. Patients were seen by an inquiry officer ‘when they first attend and before they are prescribed for by the doctors’. After recording this process, Stewart suggested to the RFH Weekly Board that the hospital should take up the same method of inquiry, as it would not interfere with the patient obtaining first aid but would facilitate dealing with unsuitable cases. Notably, however, on account of the large number of patients treated at The London no referrals were made to charitable organisations, demonstrating that the work of the Stewart was unique at this time.

By 1897 the success of the almoner’s inquiries meant that Stewart’s work was extended. She responded to all requests to interview casualty patients and in-patients . The Samaritan Fund Committee referred all cases in which in-patients stated that they could not pay for medical instruments or make contributions towards stays in convalescent homes. Staff was increased to support Stewart. These were two assistants, Miss Brimmell and Miss Davison, and a new office was allocated to the team. Stewart trained these women to assist in the role of almoner, and with them, developed an index system to register all referrals.  By June 1898, Stewart requested a card index from the Hospital Board as the small book which had been allocated to her was now full with details  of over 5000 patients.

Our limited understanding of the role of the Lady Almoner often wrongly evokes an image of a lonely, single, middle-class woman, hidden away in a back office of a hospital means-testing the few patients sent her way. Mary Stewart was not this figure; she was a pioneer. It was Stewart who developed the original role of means- testing patients to determine if they were eligible for free treatment at charitable hospitals in the late nineteenth century.

It was she who became gatekeeper to a wider network of charity beyond the hospitals in which she served and she used that network to actively construct a service in the community which was  the precursor to modern-day social work. Mary Stewart’s appointment as almoner marked a distinct change in the way the voluntary hospital system in Britain operated. Her practice marked the beginning of an important strand of the social work profession which remains with us today.

References

Cullen, L., ‘The First Lady Almoner: The Appointment, Position and Findings of Miss Mary Stewart at the Royal Free Hospital, 1895-1899’, Journal of the History of Medicine and Allied Sciences, Vol. 68, No. 4, (October 2013), 551-582: doi:10.1093/jhmas/jrs020

Baraclough, J, ‘Stewart, Mary’, Oxford Dictionary of National Biography http://www.oxforddnb.com/view/article/75262?docPos=5

See video of talk by Lynsey Cullen given on 12 March 2024: