MEDICAL PRACTICE UNDER THE INSURANCE ACT.

1142 The National Insurance Practitioners’ Associasome order where so much disorder prevailed ; but London stood at a special disadvantage, because the opposition to the Act was so strong that it was not possible until a (Continued from p. 1069.) few weeks ago to elect a London Medical Committee as laid down by the law. This difficulty, XLIII.-LONDON: ADMINISTRATIVE DIFFICULTIES AT however, it was anticipated by supporters of the Act, would be overcome by the new enactment which DENMARK HILL. had brought into existence the Panel Committees MY next visit was to a successful panel doctor who officially representing doctors on the panel. In lives at Denmark Hill. He did not commence by provincial and country districts this sort of com. eulogising the Act, but, on the contrary, was soon mittee was not so much needed. In many parts of quite busy describing some shortcomings. Thus, the country a Local Medical Committee exists and the Act had just been amended, so that men up to is fairly representative, but it was argued that had the age of 70 were accepted. Before, the limit was a Medical Committee been elected for London the 65 years. These old men have a voucher given to panel doctors’ interests would hardly have made them. The doctor signs the voucher, the Insurance themselves felt. Committee then stamps it, and sends it back to the The Cel,tificate Trouble. insured person, so that it now bears the doctor’s Yielding to the universal feeling that simplificasignature and the committee’s stamp. All this con- tion is absolutely necessary, the Approved Societies stitutes more routine than the persons concerned have now all agreed to adopt the same form of quite like, but it has served to show that a consider- certificate. Still there is trouble. The Insurance able number of these old men who were excluded from the Act before it was amended have never- Committee gives a book of certificates, and the theless been receiving medical benefits all the latter, when signed, entitles the bearer to be put on time, for they had somehow obtained the red the sick list. The panel doctor hands over one of tickets to which they were not entitled. Also, these certificates to his patient, and he at once some insured persons have been found in sends it to his society. But the next day the patient panel doctor and present his possession of several red tickets. Others have may return to his form which has on it a certifiSociety’s called on panel doctors without any red ticket Approved like the cate one the doctor had given exactly to show but their at all and no evidence This second certificate the insurance card. As the panel doctor on whom I him the day before. The following or third called has a list of 3500 insured persons whom he doctor has also to sign. is that on which the agent of the day probably attends with the aid of an assistant, he has had makes his round of visits, and Society Approved of of with irregularities plenty opportunities dealing of this description, and the mechanism of adminis- he wants yet a third certificate for the week’s contration is of great importance when there are so tinuation of the sick allowance. This apparently dates according to the agent’s visits and not in many persons needing attendance. accordance with the patient’s illness. Thus the Since Jan. 12th a new form replaces the old same statement may have to be signed three times red ticket, but some of the approved societies in the course of three days. It is the small continued during the month of February issuing Societies that give the most trouble. The forms that should not have been used after Friendly commercial insurance companies do not usually big the 12th of the previous month. This naturally insist on such complications in regard to the caused a great deal of confusion, particularly I signing of certificates. To add to the confusion as there has been such a number of forms issued. societies have persisted in using up their many The panel doctors began working the Act on " stock of literature " even when it was no longer Jan. 15th, 1913, and they had then reached the Thus insured persons present themform relating to medical affairs No. 20. By the appropriate. selves and make some application only to be told month of February, 1914, they had received form that their procedure, though perfectly correct No. 50. These forms relate to transfers, to medical to the old rules, is to-day no longer benefits at the Post Office, to change of doctor during according applicable. the year when the signatures of both doctors are Financial Aspects of Panel Practice. Then there are changes of address, needed, &c. and, again, when a doctor has joined the panel In answer to some of my questions, the popular after most of his colleagues administrative complica- doctor to whom I have referred said that many of tions arise. In Form 20 the insured had only to the 3500 insured persons for whom his assistant state the name of the Approved Society to which he and himself were responsible had belonged to belonged. This has caused an appalling amount clubs for which he was the medical officer before of confusion. No one seems to have foreseen that the Act. These patients had not changed in any such a declaration in no wise sufficed to trace the way. Their behaviour and attitude had not individual. It is very little use if John Brown or changed at all now that they came to him as George Smith merely states that he belongs to the insured patients instead of members of clubs. He But if they give felt assured that patients, whether club patients or Oddfellows or the Foresters. their number, the name and address of the lodge to insured persons-it did not matter who they might which they belong, they can be traced, and their be-if treated courteously and statements verified, without the slightest difficulty would always behave back in a similar way. The In consequence of this form thousands of doctor should be able to get on with all sorts. A or delay. insured persons could not be traced back to the certain number of his patients, he said, showed a societies to which they belonged. My informant great readiness to declare themselves sick. But declared that he was now attending a considerable they had been trained to do this and to rely on number of persons without knowing whether they 1 See THE were entitled to such attendance. LANCET, Jan. 31st, 1914, p. 346.

MEDICAL PRACTICE UNDER THE INSURANCE ACT. (BY OUR SPECIAL COMMISSIONER.)

tionl worked very hard to put

I

sympathetically

1143 bottle of medicine. It would take years to teach such persons that a bottle of medicine is but a small part of the treatment. Very few of his insured patients had more than JE100 a year. I have come to the conclusion from all I heard that the insured persons whose incomes range from £ 100 to JE160 are likely to occasion a little The feeling more trouble than the poorer classes. which made people imagine it was not good form to be insured is now wearing off. Fees certainly can be obtained from persons whose income is aboveJE100, but there was previously much trouble in getting paid and many bad debts, and many persons removed leaving no address, so that even with this section, and right up to the income-tax limit, the capitation system may be found to pay better. Two panel doctors in the Dulwich and Denmark Hill district have calculated what they made per item from patients on their panel lists. The one received ls. 3’2d. per item and the other ls. 7d. As this included the mere signing of a certificate it was really quite as good as the ls. 6d. or 2s. fee for consultation at the surgery and the 2s. 6d. for a visit if all the bad debts are deducted. Another panel doctor, reckoning from April to the end of December-that is, cutting off the three worst months of the year-found that he had received 2s. per item. This, while it lasts, is certainly better than private practice was at minimum fees. My first informant said that he was not anxious for an income limit, and that right up to the incometax mark he thought practice on the capitation a

principle paid better. Hospital for

not possible that they should immediately begin to order their professional lives on a higher standard. But at Denmark Hill, as elsewhere, I gathered the impression that bad work would be found out and that the lists would limit themselves in time to the most competent workers. (To be continued.)

Home (FROM

OUR

and

Foreign Notes.

OWN

CORRESPONDENTS.)

LIVERPOOL. Annual

]1,[eeting of the Liverpool Stanley Hospital. Liverpool Stanley Hospital held its fortyannual seventh meeting in the Town-hall, Liverpool, on April 7th, under the chairmanship of the Lord Mayor, Mr. H. R. Rathbone, J.P. The chairman, in moving the adoption of the report and accounts, deplored the decrease in the annual subscriptions, and appealed for a more widespread sympathy with the work of the hospitals. The president of the hospital, Sir Percy Bates, Bart., seconded the resolution, and pointed out that the effect of the recent legislation had been to increase the work of all hospitals, which needed more Mr. Oswald Dobell, and more financial support. THE

honorary treasurer, submitted the balancesheet, which showed a deficit on the year of -E931,

the

the total debit balance up to JE4462. Whilst somewhat disheartening, he had been greatly encouraged by the spontaneous response to his appeal for funds to build a much-needed nurses’ home. This was now ensured, and would be a great boon to the nursing staff. Mr. W. M. King, seconded by Mr. W. Bagshaw, moved the re-election of the honorary medical staff. The Rev. Stanley Rogers, in moving the reappointment of the committee and officers, eulogised the good work which the Stanley Hospital was doing, and of which he heard so much when going about the populous and poor districts of the north end of Liverpool. The resolution was seconded by the The proceedings Rev. S. Barrow and carried. terminated with a cordial vote of thanks to the Lord Mayor. Treatment of Tube1’Clllosis. The administrative officer of the Liverpool Insurance Committee (Mr. Gill Hodgson) has just issued his report on the treatment of tuberThe report, which was adopted at the culosis. meeting of the committee, gave the exact number of applications for sanatorium treatment in the 18 months ending Jan. llth as 1829, of whom 1557 were recommended for medical treatment, the pulmonary cases being 1317. Of the 1495 who had received treatment 782 were men, 338 The cost of treatwomen, 194 boys, and 181 girls. ment had been : Sanatorium and hospital (1029),

bringing this

was

the Insu1’ecl. Since the Act came into force it has been found difficult in this district to get patients into hospitals, and the creation of many State or municipal hospitals is freely spoken of as a possible solution. As it is, the Insurance Commissioners have retained beds for the reception of tuberculous patients in various hospitals. Why should not this principle be extended ? But if this plan were pressed to its logical consequence, side by side with the extension of the Act to include the dependents of insured workers, the whole system governing the organisation of hospitals would have to be If remoulded on an entirely different basis. everybody is to be brought under the scope of State insurance, then it would only be logical to anticipate that the hospitals must also be brought under a scheme of State management. Perhaps when the State is thus gradually led to provide medical aid for nine-tenths of the entire population it will better realise the importance of removing the obvious causes of preventable diseases. For though Denmark Hill is a favoured district to some extent, a very earnest protest may be entered against the awful housing conditions which many of the patients under the National Insurance Act there have to endure. It is said that these very poor and ill-housed people are often neglected or carelessly treated by JE14,487; dispensary (150), .S270; domiciliary (704), the practitioners on the panels-the statement is JE6913; total, JE21,671. The results of treatment regularly made, among others, by those who desire were as follows: Discharged fit for work, or if to see a multiplication of medical aid institutes such juveniles " disease arrested," 152; improved, 448 ; found not tuberculous, 15 ; unimproved, 106 ; worse, as have come into being in Chesterfield, and the control of medical practice falling again into the 6 ; died, 210 ; treatment discontinued for other than Let medical reasons, 37 ; total, 975 ; under treatment hands of clubs managed by lay committees. The apparently large number of it be granted that among the first medical men to Jan. llth, 520. deaths was due to the fact that many advanced serve on the panels were medical men whose habits and routine of practice had been learned in cases were treated where the hope of recovery was cheap dispensaries. They were doing the work but small, the committee desiring to secure conbefore the Insurance Act came in force, and it was stant attention and to avoid the great risks of