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THE MEDICAL PROFESSION AND THE NATIONAL INSURANCE ACT.
118 success with the technique which they have adopted, but they add a note of warning that " the fact that there is nothing in the technique which is beyond the capacity of anyone with ordinary skill and intelligence does not make salvarsan a remedy which can be administered carelessly with impunity." Captain G. J. Keane has some Notes on the Treatment of Syphilis The in Uganda, which will be read with interest. author points out that the natives will be wiped out by syphilis unless energetic measures are taken to enforce more strongly the treatment of the disease. Major M. H. Babington’s article on An Outbreak of Paratyphoid B. In a Fever in Malta is also worthy of attention. note which occupies only two pages Colonel R. H. Firth makes a suggestion which, though perhaps not absolutely novel, comes with striking force from a scientific journal. After referring to the work of Loeb on parthenogenesis and its extension by other investigators, Colonel Firth points out that Bataillon of Dijon has succeeded in mechanically fertilising the ripe eggs of the common frog with the ultimate production of tadpoles as a result. Thus the segmentation brought about by altered environment of the ova of invertebrate animals in which gamogenesis is normal, has been followed by the fertilisation of the ova of a vertebrate animal without the physical contact of the two sexes. This, Colonel Firth suggests with all reverence, may throw light on the story of the birth of Christ. The time was not so very long ago when the Church looked upon science as her enemy, but it is more and more being recognised that the Church and Science may be expounders of two aspects of one truth. " This generation,"says the author, " may not live to see the removal of all the difficulties which stand in the way of a scientific explanation of many things which are still mysteries, yet, in the light of what little glimmer we possess, it is desirable that hasty criticism of unintelligible things should be
this
question, would loyally support the wishes of the Fortunately this is not necessary. As Sir Alfred Pearce Gould points out in his letter,"the Act
great
majority.
vague." It will therefore be possible for us compromise and to support the fourth cardinal point as follows : "The method of remuneration of medioal practitioners adopted by each Looal Health Committee to be according to the preference of the majority of the profession of the dis-
is wide and to
triot
of that committee."
In
some
districts
we
may have
a
capitation grant,"in others a " fee for attendance,"and in yet others, perhaps, we may have a combination of these two methods-a smaller capitation retaining fee combined with a fee for each attendance. It even seems possible that "
in some districts the medical benefit for all insured persons may take the form of a direct contribution to the cost of medical attendance. To secure that these diverse systems shall be set up on a proper basis so as to provide adequate remuneration and other conditions of service satisfactory to the profession, As Sir Alfred medical men must present a united front. Pearce Gould says, the profession must look to the British Medical Association to take the chief part in this work. Valuable help may be given by the Royal Colleges and other institutions. The profession must, however, never forget that the only body in the deliberations of which representatives of every class of practitioner, medical officers of the Royal Household and of Poor-law unions, censors of the Royal College of Physicians and colliery doctors, surgeons who earn 100 guineas in an hour and others who earn scarcely so much in a year, can meet on equal terms and support such of their special privileges and interests as do not clash with the common good, is the British Medical I am, Sir, yours faithfully, Association. LAURISTON LAURISTO-N E. SHAW. Ilarley-street, W., Jan. 8th, 1912.
avoided."
To the Edator of THE LANCET. grateful to you for your endeavours to unite the profession, and as one who feels keenly the need of some strong lead in the direction of practical unity, I venture to ask you to permit me to offer a few suggestions. It seems to me that the profession is absolutely united in "Audi alteram partem." its desires, but hopelessly disunited as to the means by which these should be attained. I take it that we all feel THE MEDICAL PROFESSION AND THE on the one hand that an income-limit of not more than .62aa week is the irreducible minimum under which the profession NATIONAL INSURANCE ACT. could work the Act, and that the financial estimates under To the Editor of THE LANCET. which the Act has been prepared are quite inadequate to SIR,-Sir Alfred Pearce Gould’s judicious letter in your meet the needs of the case, and we are determined that columns cannot fail to have a good effect upon our sadly unless these difficulties can be got over no one should underdistraught profession. The great need now is to search take to give medical treatment under the Act. out our points of agreement and work steadily together When, however, we come to consider how these difficulties for their achievement. No sense of false pride or petty may be met there seem to be three policies advocated by ambition must stand in the way of making use of every different sections of the profession: (a) One section appear individual or institution that may be useful in securing to be of opinion that it is impossible under the Act to In our search for points of agreement, get these demands adequately conceded, and therefore our common aim. points of disagreement, some old and well known, others that the only thing to be done is to refuse to have new and forced to the front by powers outside ourselves, anything to do with the Act, whether in the way of forming will certainly be conspicuous. These latter can only be Medical Committees or accepting posts on Insurance Commet either by a loyal submission of the minority to the mittees, and of course of forming a panel. (b) Another views of the majority or by considered compromise. section believe that it might be possible to obtain the conSir Alfred Pearce Gould and I, I fear, will never agree cessions desired from the Insurance Commissioners, and as to the merits and demerits of "contract practice." I consider that unless the Insurance Commissioners will agree cannot bring myself to believe that my professional upon conditions applicable to the whole Kingdom, which colleagues are so different from mankind in general that would therefore all be on the same scale, no one should it is impossible to obtain from them the best work unless undertake to give medical treatment under the Act. (e) The for each item of added service they receive additionalL third section appear to think that it may be necessary to remuneration. This principle of payment is absent from the have somewhat modified regulations for different districts, remuneration given to the navy, the army, the church, too and that it might even be better that these should be the majority of teachers, and even to Cabinet Ministers. arranged locally, provided that these arrangements come Those who believe that this principle must be an essentiall under the irreducible minimum already referred to, but that feature in professional remuneration in order to secure efficient no one should agree to give medical treatment under the Act service, are in my opinion misreading human character as! unless these arrangements were satisfactorily conceded in badly as are those who assert that surgeons who receive large; every part of the country. I suppose that the third fees for each service rendered are incapable of making theirr alternative would be regarded as practically the policy of the existing Council of the British Medical Association. pecuniary interest subservient to their patient’s welfare. The first alternative appears to be the policy of the I believe that medical men when properly paid, by whatPraotitioner and apparently of the new Manchester assoever system, will give the best service of which they ares capable, even as I rejoice to believe the majority of medical1 ciation. Dr. F. J. Smith’s committee do not seem to have men do now, however inadequate their pay may be. Despite3 committed themselves to any definite policy, and they our fundamental differences, I am sure that if it were 3 probably consist mainly of supporters of (a) and (b), necessary in the interests of the profession Sir Alfredi with a small section of supporters of (o). The object of Pearce Gould or I, finding himself in the minority oni the supporters of (a) appears to be to endeavour to wreck the
SIR,-We
Correspondence.
,
.
.
must all be
119 a difficult and perhaps a dangerous thing to appliance for the proper and efficient practice of modern counter to an Act of Parliament, and to endeavour medicine and surgery. to do so usually brings loss and discredit upon those who Who is to pay for these properly fitted surgeries, with make the attempt. Between (b) and (o) it would seem to me instruments, sterilising baths, electrical appliances, hot and to be difficult to make a decision apart from the best expert cold water, and antiseptic dressings of all kind? Will the advice, and it appears to be between these two policies that Insurance Commissioners make grants to doctors on the the British Medical Association will have to decide, and if a panel, or will the doctors who accept service be required to wise decision is to be made it will, in my opinion, depend not go to large expenditure in providing for the requirements of upon clamorous meetings or violent newspaper letters, but the service ?‘! It must be perfectly understood by the proupon the clear hard thinking of the men of business in our fession that over 15,000,000 people will have to be catered profession. Unfortunately the use of the terms such as for, that there will be no out-patient departments of hospitals "The Great Betrayal" or the accusations of political motives giving free medical attendance, and with thefree choice which have been freely bandied about have done much to of a doctor " the popular man for the time being will be render such careful thinking difficult, if not impossible. overworked, and after having provided proper accommodaMy suggestion certainly would be that the matter should tion for a large number of patients may the next year, the be now left to be decided by the different divisions of the popular favour having gone to others, find himself involved in British Medical Association and by its Representative Meet- heavy loss ; also every medical man on the panel will have ing. It is said that the newly formed bodies are intended to no security of tenure, but will hold his office at the will of support the British Medical Association, but divided counsels an Insurance Commission, not an unbiased, independent are always dangerous, and I hope that we shall all agree to body, but a board composed of Friendly Society officials, with adopt the only constitutional action, at least to those of us but one medical man on it, who could not possibly have who are members, of working through the existing consti- sufficient weight to influence the other members, however tution of the British Medical Association, and that whatever well-disposed to the profession he might be. is decided by the majority after careful consideration may The surgeries must be fitted for the proper treatment of be supported loyally by us all. casualties and urgent cases, but under the Act medicines I have ventured in a letter to the Times of Dec. 26th to are to be provided by pharmaceutical chemists. Are they to recommend that three of the leaders of the profession-the provide waiting-rooms’1 Are their shops to be near the Will they provide expensive medicines on the President of the General Medical Council, the President of the Royal College of Physicians, and the President of the unfettered prescriptions of medical men on any capitation Royal College of Surgeons-should be asked to arbitrate system ?’1 If not, are medical men on the panel to provide between the conflicting sections of the profession. My medicines on terms which others have refused ? Are the medical men accepting service to undertake the meaning was not that they should attempt to settle for us what policy we should adopt, but what method we should treatment of fractures and perform all operations that may adopt for arriving at our policy. I believe that if the be necessary, or are they only to treat ordinary cases, sending different organisations concerned would be willing to be serious or special cases to the nearest hospital ?If the latter, guided by some such impartial authority a great step what arrangements are to be made with the hospitals ? The towards peace and unity would be accomplished. out-patient departments can be turned into clinics for the Apologising for trespassing at so great length upon your treatment of special cases and the beds can be used for insured persons; but injured persons who have paid the I am, Sir, yours faithfully, space, CHARLES F. HARFORD. State for "medical benefit " will not be satisfied with the Livingstone College, Leyton, E., Jan. 8th, 1912. hospital conditions now provided for persons seeking gratuitous aid at the expense of the benevolent. They will demand, and rightly demand, the attention due to those who 10 the Editor of THE LANCET. compulsorily, and in many cases against their will, have been SiR,—The exhaustive article in your issue of to-day, obliged to pay for " medical " benefit to be provided by the
Act, but it is run
surgeries ?
with the instructive letter of Sir Alfred Pearce State. to the profession, and A question therefore arises, Will the voluntary hospitals the question that he has put at the end of his letter-namely, be taken over by the State and the staff adequately paid, or " Shall the scheme ofmedical benefit’ be formulated by the if not are medical men on the panel to attend serious cases Insurance Commissioners or Local Health Committees, or in the homes of the homes in some cases of the most insured, shall it be formulated by the profession and pressed upon and squalid description? When all these questions these bodies ? " can only be answered in one way, that is, as dirty have been considered and decided, then, and not until then, he urges-by the profession. the profession will be able to formulate a scheme of reThe profession, however, has not before it, either in the muneration through a central body having the confidence of Act or from any official or other source, any intimation as to all its members. I trust that no attempt will be made to enter the services which will be required from medical men acceptlocal bargaining with Insurance Committees or Oomupon ing service under the Act, and until their duties and respon- missioners dominated entirely by Friendly Societies. sibilities are distinctly stated I would urge that the amount I venture, in supporting Sir Alfred Pearce Gould’s opinion, or kind of remuneration cannot with any advantage be even to ask him to gather together a strong committee, with a considered. I feel sure that the profession would be glad to view to the of a statement showing the minimum drawing assist in making the Act a success, but it must be assured that the State couldup offer as"medical benefit" to possibly that the interests of the nation will be protected, and that many of them able and willing to self-respecting people, the medical service shall be far above any hostile criticism. pay for medical treatment, but who will have compulsorily It must be remembered that for the first time in the United in the future to pay the State for medical service. With such Kingdom the State has now accepted the responsibility of a statement before them showing the duties, responsibilities, givingmedical benefit "-not to paupers, but to a mass of and requirements of the service, the question of remunerapeople who will have compulsorily to pay for its medical tion would be easy of adjustment, equitably and to the service, and who will naturally insist on having the best. advantage of both the State and the profession. I feel quite sure that the profession will wish to supply an I am, Sir, yours faithfully, up-to-date and splendid medical service to the people under ALBERT BENTHALL. Jan. 6th, 1912. Hampstead, N.W., the segis of the State-a service which must advance with the times and be always efficient on the most scientific lines, To the Editor of THE LANCET. but modern medicine and surgery in their higher forms! recent in of a the SiR,—The correspondence in your contemporary the necessary appointments require heavy expenditure well-ordered clinic. With my intimate knowledge of everyTimes by Mr. Boyton, Mr. Smith Whitaker, Sir Henry Craik, class of practice I am obliged to point out that there arei and Sir Philip Magnus has left an uneasy impression on my many surgeries in crowded neighbourhoods where cheap or’ mind that Mr. Smith Whitaker is not receiving fair treatment. club practice is carried on which are not adequately fittedHe was the paid servant of the British Medical Association, and for the realisation of the above ideal. This statement may7as such conducted a missionary tour to its divisions before be unpalatable, but the present condition of things must be the introduction of the Bill, and also acted as a negotiator faced. I feel very strongly that with free choice of aL during its passage through the Houses of Parliament. He doctor," although the assured may exercise the "free; subsequently received a substantial recognition of his services choice," the State will still be responsible and will have to) from the Government. Under these circumstances appearsee that the surgeries have every possible convenience andi ances favour on the one hand the supposition that in view
together
Gould, should be of the greatest value
120 of the fact that there were numerous official and unofficial interviews taking place between him and the Chancellor extending over the periods both before and after’ the introduction of the Bill, he was the tool of the Chancellor and his political supporters, and on the other hand, the supposition that Government supporters belonging to the Association were instructing him as to his course of procedure. It is incredible to me that the governing authority of the Association did not give him written instructions as to the course which he was to pursue, both during his missionary tour and during the negotiations which he conducted with the Chancellor. It, therefore, appears to me highly desirable, in justice to Mr. Smith Whitaker, that such instructions should be published, and it is also desirable that the country should know how far the Government has conducted the negotiations with the British Medical Association with clean I am, Sir, yours faithfully, hands. LOVELL DRAGE. Hatfield, Jan. 4th, 1912. -
our position every club should be notified that on and afterJuly lst our charge per member would be 8s. 6d. (or thereabout), otherwise all contracts to ceae. I am, Sir, yours faithfully, H. G. DIXON. H. City-road, E.C., Jan. 8th, 1912.
To the Editor of THE LANCET. SIR,—In connexion with recent correspondence in your columns, my attention has been called to By-law 39, Sect. 4, of the British Medical Association regulations, which enacts as follows: "In voting upon any matter upon which a constituency has passed a resolution within the three months immediately preceding such meeting the Representative or Representatives of that constituency shall be under obligation to vote in accordance with such resolution." It is. obviously important that in future the representatives have a clear understanding as to their duties in the matter of voting I am, Sir, yours faithfully, I EDWIN SMITH. London, S.W., Jan. 8th, 1912.
To the Editor of THE LANCET. as we dislike it, the National Insurance Act To the Editor of THE LANCET. has come to stay, and we must make the best of it. Apart from the medical benefits it has many commendable points SIR,-Will you allow me space in your valuable journal for which in time will be appreciated by the public. On the a brief reference to Dr. Eiwin Smith’s letter in your issue of other hand, the clauses relating to medical benefits are most Dec. 30th. I was present as an onlooker at the Representative Meeting to which he refers (Nov. 23rd), and myself unsatisfactory, but they appear to be elastic. The " six cardinal points " of the British Medical Associa- heard Dr. Maclean instruct the delegates that in their voting tion have not been accepted by Parliament, and I feel sure "they were to vote in accordance with their conscientious that it would now be a waste of time and energy to agitate opinion on the subjects that arose for consideration." I was. for their incorporation in the Act. It may be that it is well amazed when I heard him say this, for obviously the delegates for the profession and the public that the " six cardinat were there as representatives of the divisions only to the points" or the most essential of them were rejected, as their extent of expressing the views of the divisions, which hadadoption would undoubtedly have perpetuated the objection- been considered at the meetings held previously throughout able per oapita system of payment. the country, certain definite points to vote on, for or against, We are now free to demand our own terms, and I sincerely having been submitted to them previously for their conhope that we shall be unanimous in demanding paJment for sideration. If, then, the chairman (Dr. Maclean) instructed actual services rendered. I can see nothing in the Act to the delegates to vote in the manner referred to, and assuming prevent the Insurance Commissioners from giving this they did so, the meeting, I submit, ceased to be representative method a trial, and if we give them plainly to understand of the views of the profession. We owe Dr. Smith a debt of that we are determined not to work under the Act unless we gratitude for his efforts to ventilate the matter. Again, as an are paid according to an agreed minimum scale for actual onlooker, I could not help feeling that an attempt was being work done, it is possible that this essential will be conceded. made, as Dr. Smith says, to fritter away the time of the In July last the Imperial Medical Reform Union sent outmeeting in futile discussions. I entirely agree with him that20,000 referendum forms to practitioners in England and the consideration of the member of medical men (i.e., 3, 5, or Wales inviting them to state whether in favour of capitation 8 against 80) on the committees is not worth a thought, as in payment or for services rendered, and of the replies received! either case they would be powerless. Dr. Maclean, according to his own statement, had received more than 95 per cent. were in favour of the latter method of remuneration. The adoption of this method is, in the opinionLthe offer of Mr. Lloyd George of the post of Commissioner of the Council of the Union, the only way to preserve the in- for the secretary of the Association, and in my opinion there would have been no breach of confidence if he had dependence of the profession.-I am, Sir, yours faithfully, GEORGE BROWN, openly explained this to the Representatives instead of talking General Secretary of the Imperial Medical Reform Union. of "smoke-room rumours," &c. Had he done this it is certain B.C., Jan. 9th, 9th, 1912. Basinghall-street, E.C., the Representatives would have voted very differently from the manner in which they did. To the Editor of THE LANCET. I was present at the Battersea town-hall when Dr. Lauristom SIR,-May I ask space in your valuable paper to call the Shaw addressed the Wandsworth division, and was astonished attention of my fellow medical practitioners to the extreme to hear him say that the doctors could have 8s. 6d. or 10a. danger to themselves and to theprofession at large in per annum or 2s 6d. per visit if they preferred it." There rashly signing any pledge or undertaking not to work under may be no legal barrier to this, but there is every other conthe National Insurance Act. It is quite patent that a great ceivable barrier, and when he made this statement he deal of the materials published in the lay press is purely of a should have known this well. It looks as though this general political anti-governmental colour, aimed at increas- statement was made only to prevent those present from ing subscribers to certain papers, and serving np pabulum for supporting the resolution which Dr. Edwin Smith had moved lay readers at the expense of the medical profession, whose calling on the Council to resign, and I at any rate trust that real interests are sacrificed and the profession put out of court no steps will be left untaken that will lead to the comand rendered powerless by their present attitude of I?*!
SIR,—Much
.
.
-
I
I
days"
this
question, would loyally support the wishes of the Fortunately this is not necessary. As Sir Alfred Pearce Gould points out in his letter,"the Act
great
majority.
vague." It will therefore be possible for us compromise and to support the fourth cardinal point as follows : "The method of remuneration of medioal practitioners adopted by each Looal Health Committee to be according to the preference of the majority of the profession of the dis-
is wide and to
triot
of that committee."
In
some
districts
we
may have
a
capitation grant,"in others a " fee for attendance,"and in yet others, perhaps, we may have a combination of these two methods-a smaller capitation retaining fee combined with a fee for each attendance. It even seems possible that "
in some districts the medical benefit for all insured persons may take the form of a direct contribution to the cost of medical attendance. To secure that these diverse systems shall be set up on a proper basis so as to provide adequate remuneration and other conditions of service satisfactory to the profession, As Sir Alfred medical men must present a united front. Pearce Gould says, the profession must look to the British Medical Association to take the chief part in this work. Valuable help may be given by the Royal Colleges and other institutions. The profession must, however, never forget that the only body in the deliberations of which representatives of every class of practitioner, medical officers of the Royal Household and of Poor-law unions, censors of the Royal College of Physicians and colliery doctors, surgeons who earn 100 guineas in an hour and others who earn scarcely so much in a year, can meet on equal terms and support such of their special privileges and interests as do not clash with the common good, is the British Medical I am, Sir, yours faithfully, Association. LAURISTON LAURISTO-N E. SHAW. Ilarley-street, W., Jan. 8th, 1912.
avoided."
To the Edator of THE LANCET. grateful to you for your endeavours to unite the profession, and as one who feels keenly the need of some strong lead in the direction of practical unity, I venture to ask you to permit me to offer a few suggestions. It seems to me that the profession is absolutely united in "Audi alteram partem." its desires, but hopelessly disunited as to the means by which these should be attained. I take it that we all feel THE MEDICAL PROFESSION AND THE on the one hand that an income-limit of not more than .62aa week is the irreducible minimum under which the profession NATIONAL INSURANCE ACT. could work the Act, and that the financial estimates under To the Editor of THE LANCET. which the Act has been prepared are quite inadequate to SIR,-Sir Alfred Pearce Gould’s judicious letter in your meet the needs of the case, and we are determined that columns cannot fail to have a good effect upon our sadly unless these difficulties can be got over no one should underdistraught profession. The great need now is to search take to give medical treatment under the Act. out our points of agreement and work steadily together When, however, we come to consider how these difficulties for their achievement. No sense of false pride or petty may be met there seem to be three policies advocated by ambition must stand in the way of making use of every different sections of the profession: (a) One section appear individual or institution that may be useful in securing to be of opinion that it is impossible under the Act to In our search for points of agreement, get these demands adequately conceded, and therefore our common aim. points of disagreement, some old and well known, others that the only thing to be done is to refuse to have new and forced to the front by powers outside ourselves, anything to do with the Act, whether in the way of forming will certainly be conspicuous. These latter can only be Medical Committees or accepting posts on Insurance Commet either by a loyal submission of the minority to the mittees, and of course of forming a panel. (b) Another views of the majority or by considered compromise. section believe that it might be possible to obtain the conSir Alfred Pearce Gould and I, I fear, will never agree cessions desired from the Insurance Commissioners, and as to the merits and demerits of "contract practice." I consider that unless the Insurance Commissioners will agree cannot bring myself to believe that my professional upon conditions applicable to the whole Kingdom, which colleagues are so different from mankind in general that would therefore all be on the same scale, no one should it is impossible to obtain from them the best work unless undertake to give medical treatment under the Act. (e) The for each item of added service they receive additionalL third section appear to think that it may be necessary to remuneration. This principle of payment is absent from the have somewhat modified regulations for different districts, remuneration given to the navy, the army, the church, too and that it might even be better that these should be the majority of teachers, and even to Cabinet Ministers. arranged locally, provided that these arrangements come Those who believe that this principle must be an essentiall under the irreducible minimum already referred to, but that feature in professional remuneration in order to secure efficient no one should agree to give medical treatment under the Act service, are in my opinion misreading human character as! unless these arrangements were satisfactorily conceded in badly as are those who assert that surgeons who receive large; every part of the country. I suppose that the third fees for each service rendered are incapable of making theirr alternative would be regarded as practically the policy of the existing Council of the British Medical Association. pecuniary interest subservient to their patient’s welfare. The first alternative appears to be the policy of the I believe that medical men when properly paid, by whatPraotitioner and apparently of the new Manchester assoever system, will give the best service of which they ares capable, even as I rejoice to believe the majority of medical1 ciation. Dr. F. J. Smith’s committee do not seem to have men do now, however inadequate their pay may be. Despite3 committed themselves to any definite policy, and they our fundamental differences, I am sure that if it were 3 probably consist mainly of supporters of (a) and (b), necessary in the interests of the profession Sir Alfredi with a small section of supporters of (o). The object of Pearce Gould or I, finding himself in the minority oni the supporters of (a) appears to be to endeavour to wreck the
SIR,-We
Correspondence.
,
.
.
must all be
119 a difficult and perhaps a dangerous thing to appliance for the proper and efficient practice of modern counter to an Act of Parliament, and to endeavour medicine and surgery. to do so usually brings loss and discredit upon those who Who is to pay for these properly fitted surgeries, with make the attempt. Between (b) and (o) it would seem to me instruments, sterilising baths, electrical appliances, hot and to be difficult to make a decision apart from the best expert cold water, and antiseptic dressings of all kind? Will the advice, and it appears to be between these two policies that Insurance Commissioners make grants to doctors on the the British Medical Association will have to decide, and if a panel, or will the doctors who accept service be required to wise decision is to be made it will, in my opinion, depend not go to large expenditure in providing for the requirements of upon clamorous meetings or violent newspaper letters, but the service ?‘! It must be perfectly understood by the proupon the clear hard thinking of the men of business in our fession that over 15,000,000 people will have to be catered profession. Unfortunately the use of the terms such as for, that there will be no out-patient departments of hospitals "The Great Betrayal" or the accusations of political motives giving free medical attendance, and with thefree choice which have been freely bandied about have done much to of a doctor " the popular man for the time being will be render such careful thinking difficult, if not impossible. overworked, and after having provided proper accommodaMy suggestion certainly would be that the matter should tion for a large number of patients may the next year, the be now left to be decided by the different divisions of the popular favour having gone to others, find himself involved in British Medical Association and by its Representative Meet- heavy loss ; also every medical man on the panel will have ing. It is said that the newly formed bodies are intended to no security of tenure, but will hold his office at the will of support the British Medical Association, but divided counsels an Insurance Commission, not an unbiased, independent are always dangerous, and I hope that we shall all agree to body, but a board composed of Friendly Society officials, with adopt the only constitutional action, at least to those of us but one medical man on it, who could not possibly have who are members, of working through the existing consti- sufficient weight to influence the other members, however tution of the British Medical Association, and that whatever well-disposed to the profession he might be. is decided by the majority after careful consideration may The surgeries must be fitted for the proper treatment of be supported loyally by us all. casualties and urgent cases, but under the Act medicines I have ventured in a letter to the Times of Dec. 26th to are to be provided by pharmaceutical chemists. Are they to recommend that three of the leaders of the profession-the provide waiting-rooms’1 Are their shops to be near the Will they provide expensive medicines on the President of the General Medical Council, the President of the Royal College of Physicians, and the President of the unfettered prescriptions of medical men on any capitation Royal College of Surgeons-should be asked to arbitrate system ?’1 If not, are medical men on the panel to provide between the conflicting sections of the profession. My medicines on terms which others have refused ? Are the medical men accepting service to undertake the meaning was not that they should attempt to settle for us what policy we should adopt, but what method we should treatment of fractures and perform all operations that may adopt for arriving at our policy. I believe that if the be necessary, or are they only to treat ordinary cases, sending different organisations concerned would be willing to be serious or special cases to the nearest hospital ?If the latter, guided by some such impartial authority a great step what arrangements are to be made with the hospitals ? The towards peace and unity would be accomplished. out-patient departments can be turned into clinics for the Apologising for trespassing at so great length upon your treatment of special cases and the beds can be used for insured persons; but injured persons who have paid the I am, Sir, yours faithfully, space, CHARLES F. HARFORD. State for "medical benefit " will not be satisfied with the Livingstone College, Leyton, E., Jan. 8th, 1912. hospital conditions now provided for persons seeking gratuitous aid at the expense of the benevolent. They will demand, and rightly demand, the attention due to those who 10 the Editor of THE LANCET. compulsorily, and in many cases against their will, have been SiR,—The exhaustive article in your issue of to-day, obliged to pay for " medical " benefit to be provided by the
Act, but it is run
surgeries ?
with the instructive letter of Sir Alfred Pearce State. to the profession, and A question therefore arises, Will the voluntary hospitals the question that he has put at the end of his letter-namely, be taken over by the State and the staff adequately paid, or " Shall the scheme ofmedical benefit’ be formulated by the if not are medical men on the panel to attend serious cases Insurance Commissioners or Local Health Committees, or in the homes of the homes in some cases of the most insured, shall it be formulated by the profession and pressed upon and squalid description? When all these questions these bodies ? " can only be answered in one way, that is, as dirty have been considered and decided, then, and not until then, he urges-by the profession. the profession will be able to formulate a scheme of reThe profession, however, has not before it, either in the muneration through a central body having the confidence of Act or from any official or other source, any intimation as to all its members. I trust that no attempt will be made to enter the services which will be required from medical men acceptlocal bargaining with Insurance Committees or Oomupon ing service under the Act, and until their duties and respon- missioners dominated entirely by Friendly Societies. sibilities are distinctly stated I would urge that the amount I venture, in supporting Sir Alfred Pearce Gould’s opinion, or kind of remuneration cannot with any advantage be even to ask him to gather together a strong committee, with a considered. I feel sure that the profession would be glad to view to the of a statement showing the minimum drawing assist in making the Act a success, but it must be assured that the State couldup offer as"medical benefit" to possibly that the interests of the nation will be protected, and that many of them able and willing to self-respecting people, the medical service shall be far above any hostile criticism. pay for medical treatment, but who will have compulsorily It must be remembered that for the first time in the United in the future to pay the State for medical service. With such Kingdom the State has now accepted the responsibility of a statement before them showing the duties, responsibilities, givingmedical benefit "-not to paupers, but to a mass of and requirements of the service, the question of remunerapeople who will have compulsorily to pay for its medical tion would be easy of adjustment, equitably and to the service, and who will naturally insist on having the best. advantage of both the State and the profession. I feel quite sure that the profession will wish to supply an I am, Sir, yours faithfully, up-to-date and splendid medical service to the people under ALBERT BENTHALL. Jan. 6th, 1912. Hampstead, N.W., the segis of the State-a service which must advance with the times and be always efficient on the most scientific lines, To the Editor of THE LANCET. but modern medicine and surgery in their higher forms! recent in of a the SiR,—The correspondence in your contemporary the necessary appointments require heavy expenditure well-ordered clinic. With my intimate knowledge of everyTimes by Mr. Boyton, Mr. Smith Whitaker, Sir Henry Craik, class of practice I am obliged to point out that there arei and Sir Philip Magnus has left an uneasy impression on my many surgeries in crowded neighbourhoods where cheap or’ mind that Mr. Smith Whitaker is not receiving fair treatment. club practice is carried on which are not adequately fittedHe was the paid servant of the British Medical Association, and for the realisation of the above ideal. This statement may7as such conducted a missionary tour to its divisions before be unpalatable, but the present condition of things must be the introduction of the Bill, and also acted as a negotiator faced. I feel very strongly that with free choice of aL during its passage through the Houses of Parliament. He doctor," although the assured may exercise the "free; subsequently received a substantial recognition of his services choice," the State will still be responsible and will have to) from the Government. Under these circumstances appearsee that the surgeries have every possible convenience andi ances favour on the one hand the supposition that in view
together
Gould, should be of the greatest value
120 of the fact that there were numerous official and unofficial interviews taking place between him and the Chancellor extending over the periods both before and after’ the introduction of the Bill, he was the tool of the Chancellor and his political supporters, and on the other hand, the supposition that Government supporters belonging to the Association were instructing him as to his course of procedure. It is incredible to me that the governing authority of the Association did not give him written instructions as to the course which he was to pursue, both during his missionary tour and during the negotiations which he conducted with the Chancellor. It, therefore, appears to me highly desirable, in justice to Mr. Smith Whitaker, that such instructions should be published, and it is also desirable that the country should know how far the Government has conducted the negotiations with the British Medical Association with clean I am, Sir, yours faithfully, hands. LOVELL DRAGE. Hatfield, Jan. 4th, 1912. -
our position every club should be notified that on and afterJuly lst our charge per member would be 8s. 6d. (or thereabout), otherwise all contracts to ceae. I am, Sir, yours faithfully, H. G. DIXON. H. City-road, E.C., Jan. 8th, 1912.
To the Editor of THE LANCET. SIR,—In connexion with recent correspondence in your columns, my attention has been called to By-law 39, Sect. 4, of the British Medical Association regulations, which enacts as follows: "In voting upon any matter upon which a constituency has passed a resolution within the three months immediately preceding such meeting the Representative or Representatives of that constituency shall be under obligation to vote in accordance with such resolution." It is. obviously important that in future the representatives have a clear understanding as to their duties in the matter of voting I am, Sir, yours faithfully, I EDWIN SMITH. London, S.W., Jan. 8th, 1912.
To the Editor of THE LANCET. as we dislike it, the National Insurance Act To the Editor of THE LANCET. has come to stay, and we must make the best of it. Apart from the medical benefits it has many commendable points SIR,-Will you allow me space in your valuable journal for which in time will be appreciated by the public. On the a brief reference to Dr. Eiwin Smith’s letter in your issue of other hand, the clauses relating to medical benefits are most Dec. 30th. I was present as an onlooker at the Representative Meeting to which he refers (Nov. 23rd), and myself unsatisfactory, but they appear to be elastic. The " six cardinal points " of the British Medical Associa- heard Dr. Maclean instruct the delegates that in their voting tion have not been accepted by Parliament, and I feel sure "they were to vote in accordance with their conscientious that it would now be a waste of time and energy to agitate opinion on the subjects that arose for consideration." I was. for their incorporation in the Act. It may be that it is well amazed when I heard him say this, for obviously the delegates for the profession and the public that the " six cardinat were there as representatives of the divisions only to the points" or the most essential of them were rejected, as their extent of expressing the views of the divisions, which hadadoption would undoubtedly have perpetuated the objection- been considered at the meetings held previously throughout able per oapita system of payment. the country, certain definite points to vote on, for or against, We are now free to demand our own terms, and I sincerely having been submitted to them previously for their conhope that we shall be unanimous in demanding paJment for sideration. If, then, the chairman (Dr. Maclean) instructed actual services rendered. I can see nothing in the Act to the delegates to vote in the manner referred to, and assuming prevent the Insurance Commissioners from giving this they did so, the meeting, I submit, ceased to be representative method a trial, and if we give them plainly to understand of the views of the profession. We owe Dr. Smith a debt of that we are determined not to work under the Act unless we gratitude for his efforts to ventilate the matter. Again, as an are paid according to an agreed minimum scale for actual onlooker, I could not help feeling that an attempt was being work done, it is possible that this essential will be conceded. made, as Dr. Smith says, to fritter away the time of the In July last the Imperial Medical Reform Union sent outmeeting in futile discussions. I entirely agree with him that20,000 referendum forms to practitioners in England and the consideration of the member of medical men (i.e., 3, 5, or Wales inviting them to state whether in favour of capitation 8 against 80) on the committees is not worth a thought, as in payment or for services rendered, and of the replies received! either case they would be powerless. Dr. Maclean, according to his own statement, had received more than 95 per cent. were in favour of the latter method of remuneration. The adoption of this method is, in the opinionLthe offer of Mr. Lloyd George of the post of Commissioner of the Council of the Union, the only way to preserve the in- for the secretary of the Association, and in my opinion there would have been no breach of confidence if he had dependence of the profession.-I am, Sir, yours faithfully, GEORGE BROWN, openly explained this to the Representatives instead of talking General Secretary of the Imperial Medical Reform Union. of "smoke-room rumours," &c. Had he done this it is certain B.C., Jan. 9th, 9th, 1912. Basinghall-street, E.C., the Representatives would have voted very differently from the manner in which they did. To the Editor of THE LANCET. I was present at the Battersea town-hall when Dr. Lauristom SIR,-May I ask space in your valuable paper to call the Shaw addressed the Wandsworth division, and was astonished attention of my fellow medical practitioners to the extreme to hear him say that the doctors could have 8s. 6d. or 10a. danger to themselves and to theprofession at large in per annum or 2s 6d. per visit if they preferred it." There rashly signing any pledge or undertaking not to work under may be no legal barrier to this, but there is every other conthe National Insurance Act. It is quite patent that a great ceivable barrier, and when he made this statement he deal of the materials published in the lay press is purely of a should have known this well. It looks as though this general political anti-governmental colour, aimed at increas- statement was made only to prevent those present from ing subscribers to certain papers, and serving np pabulum for supporting the resolution which Dr. Edwin Smith had moved lay readers at the expense of the medical profession, whose calling on the Council to resign, and I at any rate trust that real interests are sacrificed and the profession put out of court no steps will be left untaken that will lead to the comand rendered powerless by their present attitude of I?*!
SIR,—Much
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