- Email: [email protected]
MEDICAL PRACTICE UNDER THE INSURANCE ACT.
203
MEDICAL PRACTICE UNDER THE INSURANCE ACT. (BY OUR SPECIAL COMMISSIONER.) (Continued from p. 139.)
XXXIV.-BRISTOL : THE REFEREE AND REVISED DRUG BILLS. BRISTOL is one of the towns where there was considerable opposition against the Act and where The some advantage was secured as a result. members of the profession began to hold meetings on the question of insurance two years before the Act was adopted. Then the Bristol delegates at the Birmingham meeting of the British Medical Association complained that the war chest was not full, but sought legal opinion to ascertain whether the Association had the legal right to organise what was practically a strike fund. Though the legal opinion obtained proclaimed that the money was safe, a medical federation was started so as to have a fund more safely secured, and this organisation obtained recognition from the Board of Trade as a limited company, with an existence quite independent from the Association. This was considered safer than
follow suit. This was not formally decided upon, however, until certain special privileges had been obtained for the Bristol Panel Service. With all this it sufficed for one single practitioner to declare on Christmas Eve that he must go on the panel, and thereupon the entire resistance collapsed. Another practitioner announced he would in that event be obliged to follow suit, and so would all the rest.
Constitution of Medical Committees. In the face of this defection, and seeing that they could not hold out, the Bristol practitioners nevertheless managed to obtain special terms. Among the various concessions made by the English Commissioners as a condition for the formation of a panel at Bristol was the appointment of a referee, Also it or medical adviser, as he is here called. was agreed that all matters concerning medical men should be submitted to a medical subcommittee, consisting of five representatives of the Local Medical Committee and five representatives of the Insurance Committee, with a town councillor The referee has an annual income, as chairman. and the great point is that his nomination does not depend on the Insurance Committee, for he is On this chosen by the Medical Committee. registering as a trade union. The scepticism of committee the non-panel practitioners are well the Bristol practitioners did not please the British represented. Medical Association. The latter, deeming that At first there was a great bitterness of feeling their money scheme was good enough for every- between the practitioners on the panel and those body, decided against immediate cooperation with who held aloof, but when it was found that the the Bristol Federation. The Bristol practitioners felt former made room on the Medical Committee for they had an opportunity of going forward and of the latter peace was re-established. To-day, even obtaining considerable sums of money, yet if they on the special Panel Committee to be formed in collected subscriptions at the same time as the Asso- accordance with the amendments to the Act, six ciation, and for the same strike fund purposes, they non-panel practitioners are to be appointed. This would damage both funds. The Bristol Federation, is a clear proof of the friendly feelings that to-day to its regret, reluctantly had to acknowledge it was prevail on both sides. Not many in Bristol among bound to support the general effort. For the sake the extreme opponents of the Act would now of unity and discipline its members abandoned like to see it abolished. Certainly there remains their enterprise and their good opportunity of room for improvement. It is thought, for instance, creating a safe and strong local fund. The Federa- that the Insurance Committee is not sufficiently tion rules were that every member rendered influenced by the Medical Committee. As a local himself responsible for a minimum subscription practitioner exclaimed in my presence : " The of .E2and a guarantee of JE5—this, at least, was doctors sell their labour, but have hardly any voice the figure mentioned to me. In any case, none in the bargain." of the money was called up, and those who had Bristol is divided into seven groups or districts, given promises were asked to transfer their sub- which originated with the British Medical Associascription to the British Medical Association. In tion and were adopted by the provisional Medical doing this it is claimed that the Bristol prac- Committee that emanated therefrom. Ultimately titioners gave more in proportion than the the Insurance Commissioners endorsed this method of election. The rule, roughly speaking, is that practitioners of any other town in England. In November, 1912, when the agitation against there should be one elected out of every ten the Act was at its height, there were in the Bristol medical men practising in the town. There are Division of the British Medical Association 421 34 members on the Local Medical Committee. The practitioners, and of these 276 subscribed. Though Panel Medical Committee is to be elected by groups in November of that year they only actually paid according to the strength of the panel men belongin E293 19s. they guaranteed E4488 5s. The votes ing to these groups, and this will be a much larger given were as emphatic as the money subscribed, committee in proportion to the numbers repreboth proving how strong was the feeling against sented. As for the existing Medical Committee, it the Act. At the meeting held on Dec. 20th, 1912, has had a hard time dealing with financial problems only 3 out of 417 votes recorded were in favour and a great quantity of trifling routine work. of accepting panel service. These three voters The First Referee. were, however, perfectly loyal to the majority, It is in the appointment of a referee, however, maintaining discipline while expressing their individual opinion. Bristol claims that it brought that Bristol stands prominent. The initiative taken forward a greater number of medical men against here has since been followed at Oxford and the panel and subscribed a larger sum for the Plymouth, but to Bristol belongs the credit of strike fund than any town in England, yet when having set the example. Nor was it an easy on Christmas Eve a small group of practitioners matter. Thus each Friendly Society wanted to announced that they felt obliged to go on the panel, have a referee of its own, presumably to quarrel all the others, doubting the adequacy of the avail- one with the other. Then a pertinent question was able " strike funds," found themselves compelled to asked as to who should pay the referee. The
Satisfactory
204 Commissioners said the Approved Societies must but when the Commissioners’ scheme is brought to the money. At first the Insurance Com- light it may change the whole aspect of the case. mittee had offered to pay so as to induce the pracReducing the Cost of PresC1’iptions, titioners to come on the panel. Then it was felt A great deal of thought and attention has been that there were not only cases of malingering, but devoted at Bristol to the drug bill. Basing their doubts might arise as to proper treatment, and prac- calculations on experience, it was found that the titioners found it offensive to have anyone calling sheet for one patient must not cost to inquire about their work. On the other hand, the prescription The term sheet more on an average than 5.
provide
opinion of a properly appointed expert, who was means not one medicament, but all the patient’s not a rival in practice, might be welcome. Thus needs-for instance, some pills, an ointment, and the referee is not merely a referee, but a medical a bandage. If the average cost per sheet perhaps adviser. As a matter of fact, however, the chief is 7td., then the extra 6d. will be absorbed and the amount of work done is referee work, the question drug bill will amount to 2s. per annum per insured being the fitness of persons for sick allowance. But in July at Bristol the average cost Out of about 120,000 insured persons from person. of the prescription sheets was 8d. As this could March 1st to the end of October, 554 cases were sent not possibly continue an inquiry was instituted. to the referee. The first 500 cases were analysed, and good work was at once done in pruning the and showed that there were 210 males and 290 females. The result was that 189 were pronounced prescriptions. Then it was discovered that though the panel to be fit for work, 170 were not fit, and 104 did not had the tariff before them they failed attend, and consequently must have gone back to practitioners to appreciate the financial difference between an work of their own accord ; 20 had gone back to infusion and a tincture. Though a much larger work before the notice could be served on them, of an infusion must be given to get the same and 9 proved to be cases under the Compensation quantity amount of the active agent, it may nevertheless be Act. much cheaper. Then there are the minim, drachm, The referee only reports whether the patient is and ounce rates. To escape the proportionately fit or is not fit to work; no details are given. Yet minim rate it is often cheaper to prescribe higher he keeps for his own use many notes concerning 2 drachms rather than 1 drachms, the higher rate the cases, and these are so stored as to be quickly for quantities under 2 drachms. available for reference. Thus a red tag is affixed being charged Thus 16 doses of 7i minims per dose equal to the card of a patient who has been twice. The 2 drachms, or a quarter of an: ounce, and this trouble is to get hold of cases early enough, this amount of a tincture would cost probably ld. But being due to the difficult position in which the if only 12 doses of this same tincture are premedical attendant is placed. The Friendly Societies scribed this would only amount to 1 drachms, and are trying to get back their control over the be charged at the minimum rate of 1?., thus. medical men who attend on their members. But half as much again for a quarter less. the referee works with the practitioners and notifies costing Then economies could be realised in reducing the them when their patients have been told to present of colouring and flavouring ingredients. themselves. It would never do to allow the quantity The following example was given me as to how Friendly Societies to have sole control of the the cost of a prescription could be reduced :appointment of the referee, for then his bed would indeed be one of thorns. As matters now stand, the Bristol panel practitioner occupies He thinks a position of enviable independence. of his patients is well enough to go one back to work, but the latter very much objects. Thereupon, but after the lapse of a few days, the patient is summoned to appear before the referee. He cannot tell, however, whether it is his medical man or an inspector from the Approved Society to which he belongs who has reported him to the llotv Panel Practice Pays. referee. By this method the panel practitioner does not run the risk of losing his patient because Perhaps the drug bill is high because there wa he has refused to give him a certificate that will an extraordinary run of patients calling, on the panel enable him to remain in receipt of sick pay longer practitioner, especially during the first three winter months during which the Act was in force. One than necessary. The Bristol referee was paid C50 the first two panel medical man assured me that in the course of quarters of the year; then, as the work became six months he had seen and given advice ta 58 per much harder than was at first anticipated, he cent. of the insured persons on his list. But these received C72 for the third quarter, but is only were not the worst months of the year. He had The excuse only been able to make the calculation when the’ to have -E62 for the fourth quarter. reduction is that as the for this Approved card system was adopted, so that the figures given given Societies must contribute to the cost they will cover the period from April 15th, to Oct 15th. take better care and there will be fewer cases. Dividing his receipts by each item of medical Dividing the sums received by the number of attendance, he found he only received l0cb. every Another panel cases seen the referee found that it worked out time his services were required. at 5s. 9d. each case. This raises a big question. practitioner, who had made the same calculaIs the appointment of referees going to lower the tion, was more fortunate, for he received ls. 0 fee generally paid to consultants-is it going to per item. constitute a sort of competition against conInquiring as to how many women were profiting sultants ? Finally, is the Bristol medical adviser by the Act, one popular panel medical man, told! or referee going to be maintained in his post ? The me that 30-40 per cent. of his patients were’ Friendly Societies agree that this should be done, women. He thought, however, that it was dombtfat
205
got more medical treatment in conof the Act than they did before it came sequence into force. In other large towns this was doubtless the case, but at Bristol there was such a number of charities at the disposal of the poor that it was not so likely that the Act would bring to light patients who had previously been neglected. There were two general hospitals appealing for subscriptions by the rivalry of their out-patient departments and extensively advertising the number of patients treated. Then there was, he pointed out, a charitable dispensary, employing a staff of visiting medical officers, and, of course, there were quite a number of hospitals for special diseases. Now all this is reduced. The nine visiting medical men of the dispensary do not attend to insured persons, but they attend to uninsured women and children, and I have nearly as much to do as before the Act. It had been calculated that more than one out of I very three inhabitants of Bristol used to receive I, gratuitous medical aid. Consequently it would be ,difficult to find, even among the poorest paid i, workers, women who had not been able to obtain the medical attendance they needed. The fear is not so much in regard to the amount of .attendance available but rather as to its quality. , The Act, more than one practitioner remarked, ’, did not make for quality. It created a stereotyped practice. The practitioner will not rise because his ,patients will always remain 7s. patients. -Formerly, as a practitioner increased in knowledge and experience, he secured a better class of patients. He obtained better paid work, had more leisure for study, and devoted more time to his patients. Now the object is to give less time to more patients. Then the restrictions as to premust be remembered, and no allowance is scriptions made in Bristol for what in emergency cases must ,be provided. At Birmingham ls. per quarter and per 100 insured persons is allowed, making J62 per annum for each 1000 insured persons, and not ;E50, .as erroneously stated when speaking of that town.1 At Bristol, however, there is no such allowance, so the only way to get a bandage back is to prescribe two when but one is wanted for the second dressing, and the panel practitioner then repays himself for what he had already used. There is a danger that the panel practitioner will lose prestige, and medical men not on the panel are seeing daily as private patients insured persons. At Bristol some .:B3000 have accumulated from the payments effected on behalf of persons who have not enrolled themselves on a panel list. They n(t
women
If
medical
(To be continued.)
1
I have to regret this slip in my article of Nov. 29th, 1913, Your Special Commissioner.
p. 1573.-
WEST LONDON MEDICO-CHIRURGICAL SOCIETY.The annual dinner of the society will take place on Thursday, Feb. 19th, at 7.30 for8o’clock, at the Wharncliffe Rooms, Hotel Great Central, Marylebone.road, N.W. During the evening the society’s triennial gold medal will be presented to Professor Arthur Keith, F.R.S. Tickets, price ’7s. 6d. (exclusive of wine), should be obtained beforehand from the senior secretary, Dr. Alfred C. Warren, 41, Lawsdowne-road, Holland Park-avenue, W.
Home and Foreign Notes. (FROM
OUR
OWN
CORRESPONDENTS.)
MANCHESTER. Medical Men and the National Insurance Acts: a Limitation of Income Scheme. ON Jan. 14th the second year of medical benefit under the National Insurance Act begins, and the medical men in this city and district are considering renewals of their contracts with the Insurance Committees. In Manchester and Salford medical men are paid out of pooled funds for their services. In many ’other places the capitation system obtains. As a result of conferences between all concerned it is proposed to overcome the difficulties attributed in Manchester to over-attendance by a limitation to £800 a year of the income which a practitioner may make out of his insured practiced I am informed that, with a few exceptions, all the medical men whose names were on the panel during the past 12 months have signed agreements including the proviso limiting an individual income earned under the Acts to £800 a year. The list of doctors who will serve on the panel for the forthcoming year will be revised early next week. National Insurance : Reduction of the Drug Bills. The sum of 2s. per insured person has not been found sufficient to meet the drug bills here. The Manchester Medical Committee have now agreed with the Manchester Insurance Committee to reduce as far as possible the expenditure of the drug fund. In future the Medical Committee will inspect all prescriptions, and if necessary deal with them under regulations. Any practitioner ordering drugs or appliances in a manner contrary to the instructions of the Committee will be asked to explain, and failing a satisfactory explanation the cost of such drugs or appliances will be deducted from the sums payable to him by the Insurance Committee and will be transThe Medical Comferred to the drug fund. mittee have issued to the medical men serving under the National Insurance Acts a list of instructions to be observed in prescribing, requiring that prescriptions must be made as simple as possible; that medicine sufficient for four or five daysshould be ordered, and only when the practitioner is satisfied that a supply is required; that practitioners must satisfy themselves that the amount of medicine or appliances prescribed has been used by the patient before a new prescription is given; that extract of malt and cod liver oil are not to be prescribed except in tuberculous cases notified as such, and these should be urged to apply for sanatorium benefit ; that ’flavouring agents must only be prescribed when required for their medicinal or to disguise distinctly nauseous drugs ; and expensive proprietary drugs must not be prescribed. Salford and its Consumptive Children in the
value that
Streets. of the Salford town council a question was asked if it was true that 400 consumptive children who are not permitted to attend the day schools on account of the danger to other children are allowed to run about the streets without being adequately cared for. It was
At the last
1
meeting
For the exact scheme submitted to medical
men see
p. 214.
MEDICAL PRACTICE UNDER THE INSURANCE ACT. (BY OUR SPECIAL COMMISSIONER.) (Continued from p. 139.)
XXXIV.-BRISTOL : THE REFEREE AND REVISED DRUG BILLS. BRISTOL is one of the towns where there was considerable opposition against the Act and where The some advantage was secured as a result. members of the profession began to hold meetings on the question of insurance two years before the Act was adopted. Then the Bristol delegates at the Birmingham meeting of the British Medical Association complained that the war chest was not full, but sought legal opinion to ascertain whether the Association had the legal right to organise what was practically a strike fund. Though the legal opinion obtained proclaimed that the money was safe, a medical federation was started so as to have a fund more safely secured, and this organisation obtained recognition from the Board of Trade as a limited company, with an existence quite independent from the Association. This was considered safer than
follow suit. This was not formally decided upon, however, until certain special privileges had been obtained for the Bristol Panel Service. With all this it sufficed for one single practitioner to declare on Christmas Eve that he must go on the panel, and thereupon the entire resistance collapsed. Another practitioner announced he would in that event be obliged to follow suit, and so would all the rest.
Constitution of Medical Committees. In the face of this defection, and seeing that they could not hold out, the Bristol practitioners nevertheless managed to obtain special terms. Among the various concessions made by the English Commissioners as a condition for the formation of a panel at Bristol was the appointment of a referee, Also it or medical adviser, as he is here called. was agreed that all matters concerning medical men should be submitted to a medical subcommittee, consisting of five representatives of the Local Medical Committee and five representatives of the Insurance Committee, with a town councillor The referee has an annual income, as chairman. and the great point is that his nomination does not depend on the Insurance Committee, for he is On this chosen by the Medical Committee. registering as a trade union. The scepticism of committee the non-panel practitioners are well the Bristol practitioners did not please the British represented. Medical Association. The latter, deeming that At first there was a great bitterness of feeling their money scheme was good enough for every- between the practitioners on the panel and those body, decided against immediate cooperation with who held aloof, but when it was found that the the Bristol Federation. The Bristol practitioners felt former made room on the Medical Committee for they had an opportunity of going forward and of the latter peace was re-established. To-day, even obtaining considerable sums of money, yet if they on the special Panel Committee to be formed in collected subscriptions at the same time as the Asso- accordance with the amendments to the Act, six ciation, and for the same strike fund purposes, they non-panel practitioners are to be appointed. This would damage both funds. The Bristol Federation, is a clear proof of the friendly feelings that to-day to its regret, reluctantly had to acknowledge it was prevail on both sides. Not many in Bristol among bound to support the general effort. For the sake the extreme opponents of the Act would now of unity and discipline its members abandoned like to see it abolished. Certainly there remains their enterprise and their good opportunity of room for improvement. It is thought, for instance, creating a safe and strong local fund. The Federa- that the Insurance Committee is not sufficiently tion rules were that every member rendered influenced by the Medical Committee. As a local himself responsible for a minimum subscription practitioner exclaimed in my presence : " The of .E2and a guarantee of JE5—this, at least, was doctors sell their labour, but have hardly any voice the figure mentioned to me. In any case, none in the bargain." of the money was called up, and those who had Bristol is divided into seven groups or districts, given promises were asked to transfer their sub- which originated with the British Medical Associascription to the British Medical Association. In tion and were adopted by the provisional Medical doing this it is claimed that the Bristol prac- Committee that emanated therefrom. Ultimately titioners gave more in proportion than the the Insurance Commissioners endorsed this method of election. The rule, roughly speaking, is that practitioners of any other town in England. In November, 1912, when the agitation against there should be one elected out of every ten the Act was at its height, there were in the Bristol medical men practising in the town. There are Division of the British Medical Association 421 34 members on the Local Medical Committee. The practitioners, and of these 276 subscribed. Though Panel Medical Committee is to be elected by groups in November of that year they only actually paid according to the strength of the panel men belongin E293 19s. they guaranteed E4488 5s. The votes ing to these groups, and this will be a much larger given were as emphatic as the money subscribed, committee in proportion to the numbers repreboth proving how strong was the feeling against sented. As for the existing Medical Committee, it the Act. At the meeting held on Dec. 20th, 1912, has had a hard time dealing with financial problems only 3 out of 417 votes recorded were in favour and a great quantity of trifling routine work. of accepting panel service. These three voters The First Referee. were, however, perfectly loyal to the majority, It is in the appointment of a referee, however, maintaining discipline while expressing their individual opinion. Bristol claims that it brought that Bristol stands prominent. The initiative taken forward a greater number of medical men against here has since been followed at Oxford and the panel and subscribed a larger sum for the Plymouth, but to Bristol belongs the credit of strike fund than any town in England, yet when having set the example. Nor was it an easy on Christmas Eve a small group of practitioners matter. Thus each Friendly Society wanted to announced that they felt obliged to go on the panel, have a referee of its own, presumably to quarrel all the others, doubting the adequacy of the avail- one with the other. Then a pertinent question was able " strike funds," found themselves compelled to asked as to who should pay the referee. The
Satisfactory
204 Commissioners said the Approved Societies must but when the Commissioners’ scheme is brought to the money. At first the Insurance Com- light it may change the whole aspect of the case. mittee had offered to pay so as to induce the pracReducing the Cost of PresC1’iptions, titioners to come on the panel. Then it was felt A great deal of thought and attention has been that there were not only cases of malingering, but devoted at Bristol to the drug bill. Basing their doubts might arise as to proper treatment, and prac- calculations on experience, it was found that the titioners found it offensive to have anyone calling sheet for one patient must not cost to inquire about their work. On the other hand, the prescription The term sheet more on an average than 5.
provide
opinion of a properly appointed expert, who was means not one medicament, but all the patient’s not a rival in practice, might be welcome. Thus needs-for instance, some pills, an ointment, and the referee is not merely a referee, but a medical a bandage. If the average cost per sheet perhaps adviser. As a matter of fact, however, the chief is 7td., then the extra 6d. will be absorbed and the amount of work done is referee work, the question drug bill will amount to 2s. per annum per insured being the fitness of persons for sick allowance. But in July at Bristol the average cost Out of about 120,000 insured persons from person. of the prescription sheets was 8d. As this could March 1st to the end of October, 554 cases were sent not possibly continue an inquiry was instituted. to the referee. The first 500 cases were analysed, and good work was at once done in pruning the and showed that there were 210 males and 290 females. The result was that 189 were pronounced prescriptions. Then it was discovered that though the panel to be fit for work, 170 were not fit, and 104 did not had the tariff before them they failed attend, and consequently must have gone back to practitioners to appreciate the financial difference between an work of their own accord ; 20 had gone back to infusion and a tincture. Though a much larger work before the notice could be served on them, of an infusion must be given to get the same and 9 proved to be cases under the Compensation quantity amount of the active agent, it may nevertheless be Act. much cheaper. Then there are the minim, drachm, The referee only reports whether the patient is and ounce rates. To escape the proportionately fit or is not fit to work; no details are given. Yet minim rate it is often cheaper to prescribe higher he keeps for his own use many notes concerning 2 drachms rather than 1 drachms, the higher rate the cases, and these are so stored as to be quickly for quantities under 2 drachms. available for reference. Thus a red tag is affixed being charged Thus 16 doses of 7i minims per dose equal to the card of a patient who has been twice. The 2 drachms, or a quarter of an: ounce, and this trouble is to get hold of cases early enough, this amount of a tincture would cost probably ld. But being due to the difficult position in which the if only 12 doses of this same tincture are premedical attendant is placed. The Friendly Societies scribed this would only amount to 1 drachms, and are trying to get back their control over the be charged at the minimum rate of 1?., thus. medical men who attend on their members. But half as much again for a quarter less. the referee works with the practitioners and notifies costing Then economies could be realised in reducing the them when their patients have been told to present of colouring and flavouring ingredients. themselves. It would never do to allow the quantity The following example was given me as to how Friendly Societies to have sole control of the the cost of a prescription could be reduced :appointment of the referee, for then his bed would indeed be one of thorns. As matters now stand, the Bristol panel practitioner occupies He thinks a position of enviable independence. of his patients is well enough to go one back to work, but the latter very much objects. Thereupon, but after the lapse of a few days, the patient is summoned to appear before the referee. He cannot tell, however, whether it is his medical man or an inspector from the Approved Society to which he belongs who has reported him to the llotv Panel Practice Pays. referee. By this method the panel practitioner does not run the risk of losing his patient because Perhaps the drug bill is high because there wa he has refused to give him a certificate that will an extraordinary run of patients calling, on the panel enable him to remain in receipt of sick pay longer practitioner, especially during the first three winter months during which the Act was in force. One than necessary. The Bristol referee was paid C50 the first two panel medical man assured me that in the course of quarters of the year; then, as the work became six months he had seen and given advice ta 58 per much harder than was at first anticipated, he cent. of the insured persons on his list. But these received C72 for the third quarter, but is only were not the worst months of the year. He had The excuse only been able to make the calculation when the’ to have -E62 for the fourth quarter. reduction is that as the for this Approved card system was adopted, so that the figures given given Societies must contribute to the cost they will cover the period from April 15th, to Oct 15th. take better care and there will be fewer cases. Dividing his receipts by each item of medical Dividing the sums received by the number of attendance, he found he only received l0cb. every Another panel cases seen the referee found that it worked out time his services were required. at 5s. 9d. each case. This raises a big question. practitioner, who had made the same calculaIs the appointment of referees going to lower the tion, was more fortunate, for he received ls. 0 fee generally paid to consultants-is it going to per item. constitute a sort of competition against conInquiring as to how many women were profiting sultants ? Finally, is the Bristol medical adviser by the Act, one popular panel medical man, told! or referee going to be maintained in his post ? The me that 30-40 per cent. of his patients were’ Friendly Societies agree that this should be done, women. He thought, however, that it was dombtfat
205
got more medical treatment in conof the Act than they did before it came sequence into force. In other large towns this was doubtless the case, but at Bristol there was such a number of charities at the disposal of the poor that it was not so likely that the Act would bring to light patients who had previously been neglected. There were two general hospitals appealing for subscriptions by the rivalry of their out-patient departments and extensively advertising the number of patients treated. Then there was, he pointed out, a charitable dispensary, employing a staff of visiting medical officers, and, of course, there were quite a number of hospitals for special diseases. Now all this is reduced. The nine visiting medical men of the dispensary do not attend to insured persons, but they attend to uninsured women and children, and I have nearly as much to do as before the Act. It had been calculated that more than one out of I very three inhabitants of Bristol used to receive I, gratuitous medical aid. Consequently it would be ,difficult to find, even among the poorest paid i, workers, women who had not been able to obtain the medical attendance they needed. The fear is not so much in regard to the amount of .attendance available but rather as to its quality. , The Act, more than one practitioner remarked, ’, did not make for quality. It created a stereotyped practice. The practitioner will not rise because his ,patients will always remain 7s. patients. -Formerly, as a practitioner increased in knowledge and experience, he secured a better class of patients. He obtained better paid work, had more leisure for study, and devoted more time to his patients. Now the object is to give less time to more patients. Then the restrictions as to premust be remembered, and no allowance is scriptions made in Bristol for what in emergency cases must ,be provided. At Birmingham ls. per quarter and per 100 insured persons is allowed, making J62 per annum for each 1000 insured persons, and not ;E50, .as erroneously stated when speaking of that town.1 At Bristol, however, there is no such allowance, so the only way to get a bandage back is to prescribe two when but one is wanted for the second dressing, and the panel practitioner then repays himself for what he had already used. There is a danger that the panel practitioner will lose prestige, and medical men not on the panel are seeing daily as private patients insured persons. At Bristol some .:B3000 have accumulated from the payments effected on behalf of persons who have not enrolled themselves on a panel list. They n(t
women
If
medical
(To be continued.)
1
I have to regret this slip in my article of Nov. 29th, 1913, Your Special Commissioner.
p. 1573.-
WEST LONDON MEDICO-CHIRURGICAL SOCIETY.The annual dinner of the society will take place on Thursday, Feb. 19th, at 7.30 for8o’clock, at the Wharncliffe Rooms, Hotel Great Central, Marylebone.road, N.W. During the evening the society’s triennial gold medal will be presented to Professor Arthur Keith, F.R.S. Tickets, price ’7s. 6d. (exclusive of wine), should be obtained beforehand from the senior secretary, Dr. Alfred C. Warren, 41, Lawsdowne-road, Holland Park-avenue, W.
Home and Foreign Notes. (FROM
OUR
OWN
CORRESPONDENTS.)
MANCHESTER. Medical Men and the National Insurance Acts: a Limitation of Income Scheme. ON Jan. 14th the second year of medical benefit under the National Insurance Act begins, and the medical men in this city and district are considering renewals of their contracts with the Insurance Committees. In Manchester and Salford medical men are paid out of pooled funds for their services. In many ’other places the capitation system obtains. As a result of conferences between all concerned it is proposed to overcome the difficulties attributed in Manchester to over-attendance by a limitation to £800 a year of the income which a practitioner may make out of his insured practiced I am informed that, with a few exceptions, all the medical men whose names were on the panel during the past 12 months have signed agreements including the proviso limiting an individual income earned under the Acts to £800 a year. The list of doctors who will serve on the panel for the forthcoming year will be revised early next week. National Insurance : Reduction of the Drug Bills. The sum of 2s. per insured person has not been found sufficient to meet the drug bills here. The Manchester Medical Committee have now agreed with the Manchester Insurance Committee to reduce as far as possible the expenditure of the drug fund. In future the Medical Committee will inspect all prescriptions, and if necessary deal with them under regulations. Any practitioner ordering drugs or appliances in a manner contrary to the instructions of the Committee will be asked to explain, and failing a satisfactory explanation the cost of such drugs or appliances will be deducted from the sums payable to him by the Insurance Committee and will be transThe Medical Comferred to the drug fund. mittee have issued to the medical men serving under the National Insurance Acts a list of instructions to be observed in prescribing, requiring that prescriptions must be made as simple as possible; that medicine sufficient for four or five daysshould be ordered, and only when the practitioner is satisfied that a supply is required; that practitioners must satisfy themselves that the amount of medicine or appliances prescribed has been used by the patient before a new prescription is given; that extract of malt and cod liver oil are not to be prescribed except in tuberculous cases notified as such, and these should be urged to apply for sanatorium benefit ; that ’flavouring agents must only be prescribed when required for their medicinal or to disguise distinctly nauseous drugs ; and expensive proprietary drugs must not be prescribed. Salford and its Consumptive Children in the
value that
Streets. of the Salford town council a question was asked if it was true that 400 consumptive children who are not permitted to attend the day schools on account of the danger to other children are allowed to run about the streets without being adequately cared for. It was
At the last
1
meeting
For the exact scheme submitted to medical
men see
p. 214.