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MEDICAL PRACTICE UNDER THE INSURANCE ACT.
921
MEDICAL PRACTICE UNDER THE INSURANCE ACT. (BY
SPECIAL COMMISSIONER.) (Continued from p. 776.)
OUR
other towns similar complaints have been received. The number of permanent old paupers that used to be on the parish books has decreased, but this is a consequence of the Old Age Pensions Act and not of the Insurance Act. As for sanatorium benefit, it may, and indeed, I presume, will come in good time, but in the meanwhile many tuberculous cases in various parts of the country are being sent to the workhouse infirmary as I have been asked whether these panel doctors who get rid of their troublesome cases by converting their patients into paupers are to receive the money paid by those other insured persons who do not employ any medical man on a panel, but subscribe for medical aid twice over that they may exercise their freedom of choice. Here at Wandsworth I have seen and talked to poor people, very poor people, who, though insured, pay a penny a week, preferring to consult one of the doctors of the Wandsworth Medical Aid Society, for example, rather than go to a panel doctor. But as a doctor of the Medical Aid Society remarked: "If I were to go on the panel, these poor people would come to me, because they are faithful to me. Am I right in compelling them to incur an extra expense they can ill afford ? Perhaps I ought to go on the panel for their sakes." By not going on the panel he had, as a matter of fact, lost about a thousand patients, judging from his previous records of practice. Some of his old patients came and consulted him, though they were insured, and they paid shilling fees, but they were so miserably poor that he often had to remit the shilling. He preferred to attend such persons for a penny a week. A good deal of hesitation exists in different London districts turning upon these points. While some doctors are wondering whether they had not better, after all, go on the panel, others have retired. One of these I hear left the panel after a sending circular to all the insured persons on his list explaining his motives for so doing. The difficulty has been more or less met sometimes by partners, one of whom goes on the panel and the other keeps off, thus striving to please all parties.
XL.-LONDON : MAINLY NON-PANEL VIEWS. THE survival under the Insurance Act of some of the abuses which prevailed under the old forms of club practice is a matter that naturally gives rise to much anxious discussion. Some insured persons complain that they are paying twice as much as formerly for treatment and getting no better service or attention than they did before the Act. There used to be club doctors who could organise for the very rapid treatment of numerous patients, and they sometimes made incomes amounting to as much as £ 1000 a year from subscribers of 4s. annually, and managed to achieve considerable popularity at the same time. To-day, if these subscribers have become insured persons and remain faithful to their club doctor who is now on the panel, the latter may be giving the same sort of attendance to the same people, but is receiving twice the pay. It is reasonably argued that if the situation has to be found fault with, the fault lies at the patient’s own door, and that in course of time he will discover how to get better treatment. But there is the other point of viewnamely, that scrupulous practitioners may discover they are giving themselves more trouble than necessary, and that it pays very much better in contract practice to imitate the methods of the former club doctors. " The club doctors are teaching us to do the work easily and cheaply," has remarked to me more than one practitioner who under the Act was being obliged to do contract practice for the first time. It is the old difficulty of finding the juste milieu-the line between giving an insured person the same attendance as if he were a private patient, which on ordinary business principles may be difficult, and repeating stock mixtures, which may or may not be serviceable in the case, as in the old club days. Under the Act it is a prescription and Absentee Panel Doctors. not a bottle that must now be given, and this I went to Finsbury. Though From Wandsworth in itself constitutes an improvement, for the prethis is a very different part of London in many of treatment and is a witness the adopted scription therefore increases the practitioner’s sense of respects, I found some analogous conditions, and, responsibility. In settling what is the best treat- of course, others quite special to the district. One ment possible to be given there can be no rule. peculiarity of Finsbury is the great reduction of the What the practitioner on his side does and what population and the improvement in their conditions the patient on the other side expects must differ of life. Some 30 years ago there were 166,000 much more in some instances than in others ; theremany of them crowded together in fore in my journeys round I hear nothing but com- appalling slums. Now most of the slums have plaints in one quarter, and perhaps in the next disappeared and there are only 86,130 inhabitants, of whom from 26,000 to 28,000 are insured persons. streets many express themselves as highly satisfied. During the last 10 years the local improvements Insured Persons in Workhouse Infirmaries. have been marked. The poorer section of the At Wandsworth I saw a Poor-law doctor who very community have migrated to Walthamstow and emphatically insisted that his parish was giving more outlying districts, and if those who remain are just as much medical aid as it did before the Act. still crowded according to modern estimates they He is, he said, constantly sending to the workhouse are not so very poor. There is a large lodger class. infirmary insured persons who have fully paid up The principal occupations are the butchering trade insurance cards. Panel doctors, he complained, and general occupation in the meat market, though " cart off their bad cases to the parish doctor." there are many printers and persons employed in The excuse generally given is that the patient the carrying trade. The latter are the worst paid cannot be properly attended in his home. The section of the inhabitants, but there is comparaparish doctor, on his side, clares not refuse tively little extreme poverty in Finsbury. recommendation to the for fear To attend to this population there are 24 medical the patient should die without treatment, and practitioners residing in Finsbury, and in January, there are now insured persons dying in the Poor- 1913, when the Insurance Act first came into force, law workhouse infirmaries. From Edinburgh and only three of them went on the panel. But this
formerly.
,
.
inhabitants,
workhouse
922 does not mean very much, as the area is small and medical men from the surrounding districts attend to patients in Finsbury and are inscribed on the Finsbury panel. To-day of the medical men residing in Finsbury 11 are on the panel, as is also the medical officer of the Finsbury Dispensary. Only Also there seven residents are not on the panel. are not only many doctors on the Finsbury panel who do not live in the district, but some of them reside a very long way off. This constitutes so serious a grievance that its occurrence, if it became frequent, should be prevented, even if for this One of purpose further legislation is necessary. the Finsbury panel doctors, who has a list of about 2000 insured persons, lives at Clapton. A couple of I, partners who have a list between them of 3000 to 4000, live at Stoke Newington. Another firm of two doctors, who also have a long list of patients, live in Bloomsbury. This firm is much nearet, but even they live quite a mile away from their
patients. Of course, the doctors on the panel have surgeries in the Finsbury areas, but what is to happen in a case of emergency and any night call ? Many a patient in the Finsbury district lives too far from his panel doctor to be expected to go to fetch him. Some scandals have arisen in connexion with this sort of thing, if the facts have been correctly reported to me. A doctor who lived some miles off, and who was on a panel at Hampstead, bespoke some rooms in the district where he intended to establish a surgery, but was never present to sign the red tickets of those who placed their names Of course, it is well known, and has on his list. been often stated in THE LANCET, that many doctors put their names promiscuously on various panels presumably on the offchance that something worth having might result. Then when they found but few insured persons elected to be on their list they gave the matter up. Though they did no work, never signed a red ticket or saw a patient, their names increased the length of the list of panel doctors, and the longer the list became the more those who were hesitating felt they had better hasten to join before it would be too late. Thus even broken promises were of use to the advocates of the Act, whose good features have been so obscured by these and similar blemishes.
receipts for 1913 have risen to .:B900, an increase of JE200. Though I was not able to get the precise figures I am assured that the other Finsbury practitioners who have not gone on the panel are not suffering in any way. This remarkable state of affairs is attributed to the fact that the list of insured persons whom the panel doctors of the district have undertaken to attend is far too long. They consequently cannot examine the cases properly. A large proportion of the patients attended by non-panel doctors in the Finsbury district are insured persons. But the work of the non-panel doctor is much more arduous than it used to be when he attended, before the Act, to club patients. There are now for him very few trivial cases. When an insured person comes and pays a fee it is because he is really ill and does not feel that his panel doctor has sufficiently studied the case. Some examples of inefficient treatment by panel practitioners, owing to haste and overwork, were given to me with much detail. These, when substantiated, form very pungent criticisms of the Act in its present form, for one of the great advantages claimed as resulting from the Act was precisely the early detection and nipping in the bud of disease, together with the prevention of infection. But if panel doctors have not time to examine their patients properly the claim becomes of no account. A great number of medical practitioners used to do club work as their contribution towards the relief of distress. They could not afford to have many club patients if they treated them as carefully as private patients, but thought it was right to give such treatment to labourers and others who really could not be expected to pay fees. Now, to-day, these doctors who did the club work well and conscientiously have not hurried on to the panel; on the contrary, it is the club doctor who so arranged matters as actually to make a big profit out of the ld. a week the club member paid who hurried on to the panel, and he saw in the Act an opportunity of getting double pay for the same amount of work. Thus it is that, at least in Finsbury, the public are beginning to draw a line of demarkation between the panel and the nonpanel practitioner, and this I hold to be disastrous to the progress of medical science,
Prosperity of Non-Paneb Doctors. As already stated, on a former occasion, the im(To be contin2ied.) pression prevails that in an industrial district, where nearly all the practitioners are on the panel, there QUEEN VICTORIA’S INSTITUTE FOR NURSES.is an opening for one or two non-panel practitioners. The following members of the medical profession have been in But Finsbury a larger number of practitioners appointed by Queen Alexandra to the council of Queen have found it advantageous not to go on the panel. Victoria’s Jubilee Institute for Nurses to hold office until Calling on one of the most prominent of these non- 1917 : Sir Dyce Duckworth, Surgeon-Lieutenant-Colonel Sir panel practitioners, he told me that with the aid of Warren Crooke-Lawless, Dr. A. H. F. Barbour, Dr. Arthur a partner he used to attend to 1850 subscribers Shadwell, and Mr. Charters J. Symonds. to various clubs. But the when Insurance belonging A RADIUM FUND FOR PORTSMOUTH.-An appeal Act came into force these club patients were largely for procuring a supply of radium for Portsmouth and district scattered among the panel doctors by becoming made by the Portsffl07dh Evening N(}1VS has met with a insured persons. During the first month after the generous response, the sum of .61000 having been contributed Act came into force he consequently experienced a within a week. A conference has been held, under the ,
loss of JE50. But the disadvantages of contract prac- presidency of the mayor, for the purpose of forming a trust tice, as established by the Act, soon became apparent to represent the subscribers, who will obtain the radium as to the population of Finsbury, and the loss at first; soon as possible and make arrangements for its safe custody the Royal Portsmouth Hospital. According to the terms experienced was later turned into a profit. By the: at of the appeal the radium will be available for all classes of as with the end of 1913 the receipts, compared sufferers in the district. The fund is still open, and it is i to the extent of .f:200 had augmented previous year, that any "balance not immediately required shall for the two partners. A neighbouring practitioner proposed be invested by the trustees to form the nucleus of a who earned in 1912 from clubs .f:400, and from permanent fund for the purchase of radium or of any other private practice .f:300, in spite of the loss of all hisi agent for the treatment of cancer which medical clubs when the Act came into force, found that hisi science may discover. ,
.
.
j remedial
’
.,
,.
MEDICAL PRACTICE UNDER THE INSURANCE ACT. (BY
SPECIAL COMMISSIONER.) (Continued from p. 776.)
OUR
other towns similar complaints have been received. The number of permanent old paupers that used to be on the parish books has decreased, but this is a consequence of the Old Age Pensions Act and not of the Insurance Act. As for sanatorium benefit, it may, and indeed, I presume, will come in good time, but in the meanwhile many tuberculous cases in various parts of the country are being sent to the workhouse infirmary as I have been asked whether these panel doctors who get rid of their troublesome cases by converting their patients into paupers are to receive the money paid by those other insured persons who do not employ any medical man on a panel, but subscribe for medical aid twice over that they may exercise their freedom of choice. Here at Wandsworth I have seen and talked to poor people, very poor people, who, though insured, pay a penny a week, preferring to consult one of the doctors of the Wandsworth Medical Aid Society, for example, rather than go to a panel doctor. But as a doctor of the Medical Aid Society remarked: "If I were to go on the panel, these poor people would come to me, because they are faithful to me. Am I right in compelling them to incur an extra expense they can ill afford ? Perhaps I ought to go on the panel for their sakes." By not going on the panel he had, as a matter of fact, lost about a thousand patients, judging from his previous records of practice. Some of his old patients came and consulted him, though they were insured, and they paid shilling fees, but they were so miserably poor that he often had to remit the shilling. He preferred to attend such persons for a penny a week. A good deal of hesitation exists in different London districts turning upon these points. While some doctors are wondering whether they had not better, after all, go on the panel, others have retired. One of these I hear left the panel after a sending circular to all the insured persons on his list explaining his motives for so doing. The difficulty has been more or less met sometimes by partners, one of whom goes on the panel and the other keeps off, thus striving to please all parties.
XL.-LONDON : MAINLY NON-PANEL VIEWS. THE survival under the Insurance Act of some of the abuses which prevailed under the old forms of club practice is a matter that naturally gives rise to much anxious discussion. Some insured persons complain that they are paying twice as much as formerly for treatment and getting no better service or attention than they did before the Act. There used to be club doctors who could organise for the very rapid treatment of numerous patients, and they sometimes made incomes amounting to as much as £ 1000 a year from subscribers of 4s. annually, and managed to achieve considerable popularity at the same time. To-day, if these subscribers have become insured persons and remain faithful to their club doctor who is now on the panel, the latter may be giving the same sort of attendance to the same people, but is receiving twice the pay. It is reasonably argued that if the situation has to be found fault with, the fault lies at the patient’s own door, and that in course of time he will discover how to get better treatment. But there is the other point of viewnamely, that scrupulous practitioners may discover they are giving themselves more trouble than necessary, and that it pays very much better in contract practice to imitate the methods of the former club doctors. " The club doctors are teaching us to do the work easily and cheaply," has remarked to me more than one practitioner who under the Act was being obliged to do contract practice for the first time. It is the old difficulty of finding the juste milieu-the line between giving an insured person the same attendance as if he were a private patient, which on ordinary business principles may be difficult, and repeating stock mixtures, which may or may not be serviceable in the case, as in the old club days. Under the Act it is a prescription and Absentee Panel Doctors. not a bottle that must now be given, and this I went to Finsbury. Though From Wandsworth in itself constitutes an improvement, for the prethis is a very different part of London in many of treatment and is a witness the adopted scription therefore increases the practitioner’s sense of respects, I found some analogous conditions, and, responsibility. In settling what is the best treat- of course, others quite special to the district. One ment possible to be given there can be no rule. peculiarity of Finsbury is the great reduction of the What the practitioner on his side does and what population and the improvement in their conditions the patient on the other side expects must differ of life. Some 30 years ago there were 166,000 much more in some instances than in others ; theremany of them crowded together in fore in my journeys round I hear nothing but com- appalling slums. Now most of the slums have plaints in one quarter, and perhaps in the next disappeared and there are only 86,130 inhabitants, of whom from 26,000 to 28,000 are insured persons. streets many express themselves as highly satisfied. During the last 10 years the local improvements Insured Persons in Workhouse Infirmaries. have been marked. The poorer section of the At Wandsworth I saw a Poor-law doctor who very community have migrated to Walthamstow and emphatically insisted that his parish was giving more outlying districts, and if those who remain are just as much medical aid as it did before the Act. still crowded according to modern estimates they He is, he said, constantly sending to the workhouse are not so very poor. There is a large lodger class. infirmary insured persons who have fully paid up The principal occupations are the butchering trade insurance cards. Panel doctors, he complained, and general occupation in the meat market, though " cart off their bad cases to the parish doctor." there are many printers and persons employed in The excuse generally given is that the patient the carrying trade. The latter are the worst paid cannot be properly attended in his home. The section of the inhabitants, but there is comparaparish doctor, on his side, clares not refuse tively little extreme poverty in Finsbury. recommendation to the for fear To attend to this population there are 24 medical the patient should die without treatment, and practitioners residing in Finsbury, and in January, there are now insured persons dying in the Poor- 1913, when the Insurance Act first came into force, law workhouse infirmaries. From Edinburgh and only three of them went on the panel. But this
formerly.
,
.
inhabitants,
workhouse
922 does not mean very much, as the area is small and medical men from the surrounding districts attend to patients in Finsbury and are inscribed on the Finsbury panel. To-day of the medical men residing in Finsbury 11 are on the panel, as is also the medical officer of the Finsbury Dispensary. Only Also there seven residents are not on the panel. are not only many doctors on the Finsbury panel who do not live in the district, but some of them reside a very long way off. This constitutes so serious a grievance that its occurrence, if it became frequent, should be prevented, even if for this One of purpose further legislation is necessary. the Finsbury panel doctors, who has a list of about 2000 insured persons, lives at Clapton. A couple of I, partners who have a list between them of 3000 to 4000, live at Stoke Newington. Another firm of two doctors, who also have a long list of patients, live in Bloomsbury. This firm is much nearet, but even they live quite a mile away from their
patients. Of course, the doctors on the panel have surgeries in the Finsbury areas, but what is to happen in a case of emergency and any night call ? Many a patient in the Finsbury district lives too far from his panel doctor to be expected to go to fetch him. Some scandals have arisen in connexion with this sort of thing, if the facts have been correctly reported to me. A doctor who lived some miles off, and who was on a panel at Hampstead, bespoke some rooms in the district where he intended to establish a surgery, but was never present to sign the red tickets of those who placed their names Of course, it is well known, and has on his list. been often stated in THE LANCET, that many doctors put their names promiscuously on various panels presumably on the offchance that something worth having might result. Then when they found but few insured persons elected to be on their list they gave the matter up. Though they did no work, never signed a red ticket or saw a patient, their names increased the length of the list of panel doctors, and the longer the list became the more those who were hesitating felt they had better hasten to join before it would be too late. Thus even broken promises were of use to the advocates of the Act, whose good features have been so obscured by these and similar blemishes.
receipts for 1913 have risen to .:B900, an increase of JE200. Though I was not able to get the precise figures I am assured that the other Finsbury practitioners who have not gone on the panel are not suffering in any way. This remarkable state of affairs is attributed to the fact that the list of insured persons whom the panel doctors of the district have undertaken to attend is far too long. They consequently cannot examine the cases properly. A large proportion of the patients attended by non-panel doctors in the Finsbury district are insured persons. But the work of the non-panel doctor is much more arduous than it used to be when he attended, before the Act, to club patients. There are now for him very few trivial cases. When an insured person comes and pays a fee it is because he is really ill and does not feel that his panel doctor has sufficiently studied the case. Some examples of inefficient treatment by panel practitioners, owing to haste and overwork, were given to me with much detail. These, when substantiated, form very pungent criticisms of the Act in its present form, for one of the great advantages claimed as resulting from the Act was precisely the early detection and nipping in the bud of disease, together with the prevention of infection. But if panel doctors have not time to examine their patients properly the claim becomes of no account. A great number of medical practitioners used to do club work as their contribution towards the relief of distress. They could not afford to have many club patients if they treated them as carefully as private patients, but thought it was right to give such treatment to labourers and others who really could not be expected to pay fees. Now, to-day, these doctors who did the club work well and conscientiously have not hurried on to the panel; on the contrary, it is the club doctor who so arranged matters as actually to make a big profit out of the ld. a week the club member paid who hurried on to the panel, and he saw in the Act an opportunity of getting double pay for the same amount of work. Thus it is that, at least in Finsbury, the public are beginning to draw a line of demarkation between the panel and the nonpanel practitioner, and this I hold to be disastrous to the progress of medical science,
Prosperity of Non-Paneb Doctors. As already stated, on a former occasion, the im(To be contin2ied.) pression prevails that in an industrial district, where nearly all the practitioners are on the panel, there QUEEN VICTORIA’S INSTITUTE FOR NURSES.is an opening for one or two non-panel practitioners. The following members of the medical profession have been in But Finsbury a larger number of practitioners appointed by Queen Alexandra to the council of Queen have found it advantageous not to go on the panel. Victoria’s Jubilee Institute for Nurses to hold office until Calling on one of the most prominent of these non- 1917 : Sir Dyce Duckworth, Surgeon-Lieutenant-Colonel Sir panel practitioners, he told me that with the aid of Warren Crooke-Lawless, Dr. A. H. F. Barbour, Dr. Arthur a partner he used to attend to 1850 subscribers Shadwell, and Mr. Charters J. Symonds. to various clubs. But the when Insurance belonging A RADIUM FUND FOR PORTSMOUTH.-An appeal Act came into force these club patients were largely for procuring a supply of radium for Portsmouth and district scattered among the panel doctors by becoming made by the Portsffl07dh Evening N(}1VS has met with a insured persons. During the first month after the generous response, the sum of .61000 having been contributed Act came into force he consequently experienced a within a week. A conference has been held, under the ,
loss of JE50. But the disadvantages of contract prac- presidency of the mayor, for the purpose of forming a trust tice, as established by the Act, soon became apparent to represent the subscribers, who will obtain the radium as to the population of Finsbury, and the loss at first; soon as possible and make arrangements for its safe custody the Royal Portsmouth Hospital. According to the terms experienced was later turned into a profit. By the: at of the appeal the radium will be available for all classes of as with the end of 1913 the receipts, compared sufferers in the district. The fund is still open, and it is i to the extent of .f:200 had augmented previous year, that any "balance not immediately required shall for the two partners. A neighbouring practitioner proposed be invested by the trustees to form the nucleus of a who earned in 1912 from clubs .f:400, and from permanent fund for the purchase of radium or of any other private practice .f:300, in spite of the loss of all hisi agent for the treatment of cancer which medical clubs when the Act came into force, found that hisi science may discover. ,
.
.
j remedial
’
.,
,.