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1471 of contracting out. It is understood that of the 1100 members of the L.P.M.S. 400 have expressed willingness to take part in the extended scheme, and it is not known, although it may fairly be surmised, what is the view in general of the 6000 practitioners in the metropolitan area who are likely to be affected. There are now in the country as a whole 53 schemes of public medical service with a membership of over 404,000 subscribers, and during the last four years the numbers have more than doubled. While this is only a small fraction of the population to be provided for, it is admittedly a good start, and it is at the start that the inertia is greatest. The schemes vary in detail, both as to what is provided and what is paid for the provision. It is worthy of note that in Swansea, Ipswich, and Leicester the capitation fee for the service is higher than -that paid under the national health insurance scheme. Public medical services then have been established and, for better or for worse, they have come to stay. The oldest and so far the most successful schemes were those devised to get rid of cheap contract practice. The insurance scheme did this in 1911 for the wageearners and it was the anticipation of the extension of the scheme to the dependants of insured persons that gave the impetus to public medical services. Whether the extension of the scheme to higher income limits will prove as salutary remains to be seen. The income limit of ae550 proposed in the London extension scheme will, it is safe to say, swallow up the whole of most private practices. Would the result be the disappearance of private practice as it is known to-day ? It would be a matter for keen regret if the intimate relationship which exists between patient and family doctor were to be injured. The champions of public medical service claim that in a service which is properly administered the relationship becomes more intimate and practical, for the absence of financial hesitancy encourages the more frequent call on the practitioner’s services. There is no doubt that we must be prepared for great changes in private practice and the methods in which medical services are made available to all classes of society. It would be well if the change to an ideal system were a gentle process of evolution avoiding any open conflict between the voluntary and the compulsory systems. Obviously the national insurance scheme could not have been launched without an Act of Parliament. The public medical services so far arranged follow the lines of the national scheme in allowing free choice of doctor and patient, with greater freedom in the administration of the scheme itself because this has remained in the hands of the practitioners. The success of any voluntary scheme of this kind depends on the degree of cooperation between the doctors who work it. and the voluntary subscribers. It is this cooperation which is so difficult to secure. Perhaps the principles of insurance are becoming better understood by the people generally. The London extension scheme may well meet with more sympathy and understanding from a class of subscribers

liberty

THE LANCET LONDON::

59. T IIRD.9. P, DECEMBER 19, 19366

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manner in which the people of our and of the dominions overseas sustained the country threat of a fundamental shock to the Constitution, noble congratulations have been received from other Powers. To dwell upon our good fortune would Yet national savour much of national pride. pride is just. That the days of deep anxiety had their physical as well as mental influence cannot be doubted, but that influence, which might have had sad sequels, was mitigated throughout by the unanimous view that the anxious situation was being met with justice. It was felt by all-or practically all-that while action had to be taken swiftly, no course, whether indicated by allegiance, sympathy, law, or precedent, had been left unexamined before the King’s momentous decision was received. " I doubt whether under any other system of government, a crisis of this gravity could be solved with as little hurt to the body politic as under our system of constitutional monarchy." These were the words in the House of Commons of Sir ARCHIBALD SINCLAIR, speaking as a party leader, but speaking in fact with the voice of the nation. Members of our ruling House have manifested in unceasing and untiring manner’ their interest in the promotion of health, as the fount of happiness and prosperity ; and the well-being of his humbler subjects lay especially near to the heart of EDWARD VIII. We are convinced that in his successor, who comes over us with universal acclaim, the same warm-hearted impulses will be found.

CHANGING PRIVATE PRACTICE IN our correspondence columns this week Dr. ALFRED Cox describes a new scheme of medical practice which is to be set in motion in the London area in the New Year. Under this scheme families with an income between £ 20 and 550 will be able, by payment in health of a graduated yearly the services of their own doctor in illness without having to worry about

subscription,

to

get

his bill. The London Public Medical Service, which is initiating this scheme as an extension of the existing service, is satisfied that there is a firm public demand for it, basing its belief on the success of the present scheme for medical attendance on the dependants of insured persons. The extension has secured the sanction of the B.M.A. council on the condition that any particular unit of the metropolitan area is to be excluded from it if the practitioners in that area should so decide and rules have been laid down for ensuring this

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