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1279 The Government ConlJession to Approved Institutions. To-day, however, matters have drifted from bad to worse. Instead of pulling up sharply the Chesterfield District’ Medical Association for thus reviving some of the former and worse abuses, it has recently received from the authorities marked and material encouragement. It has always been difficult to deal with the Act apart from politics, but in the present instance this difficulty is naturally and greatly accentuated by the fact that the concessions were made just before the Chesterfield election. Previous to these concessions, approved institu- tions that provided medical attendance before the passing of the Act could only obtain from the Insurance Committee what they could prove had been spent on each individual member. Thus formerly, if the average cost was 5s. a year for all the members, whether insured under the Act or not so insured, the Insurance Committee only gave 5s. a head for each of the insured persons who were under the Act. Now Mr. Masterman received on June 4th last a deputation repre- senting the Chesterfield District Medical Association, and in reply issued during the second week in August a memorandum allowing the Insurance Committees to give to approved institu- tions the full 9s. a head for every insured person who selects the institution to provide his medical treatment, upon the principal officer signing a statement that the average of 9s. per head has been expended in respect of insured persons for medical treatment (including the provision of drugs) and general establishment charges ; treatment to be not inferior to that given by doctors on the panel." This places in the hands of a private association, managed by a lay committee, where there is no medical control, all the money collected by the State, and partially contributed by the State, for medical purposes. Protests Against the Memo’J’andu1n. It is stated, in response to the objections raised, that it is only intended to place institutions on a level with the panel. But this is hardly satisfactory to the many who think such institutions should not be allowed to exist at all. However, they do exist, but modifications of the Act should tend to check and not to extend the abuses, such as the sweating of medical men, to which these institutions are so likely to give rise. It is all very well to say that the 9s. are to be expended in providing medical treatment, but what is the medical attendant himself to get out of the 9s. ? 7 The Government in any case should be careful not to do these things just before an election. As it is, several medical men protested energetically in my presence. They wanted to know whether every time a Liberal seat is in danger Friendly Societies are to get more money for their own purposes, and this at the expense of the panel medical men and the profession generally. If so they promised that difficulties would arise, seeing that the profession was better organised now and would know how to make its influence felt. Dealing with the details of the memorandum, the idea that the mere signature of an official belonging to an approved institution was a sufficient guarantee that the whole of the 9s. allowed would really be spent only on persons insured under the Act was considered absolutely absurd. A proper balance sheet may be insisted upon, but as yet it is not known that anything of the sort will be forth- coming. Even then, and should the medical officers obtain the full 7s. out of the 9s., they will be forced on the strength of this payment to attend to women, children, and other members of the association who are not insured under the Act. For the latter portion of their work they might be paid but little or even nothing. Thus, in fact, if not in form, some of the money paid for persons insured under the Act would help to procure medical treatment for members nf the association who were not so insured. The medical profession is now inquiring whether the Chesterfield election demonstrates that the Government can be squeezed when there is a by-election and induced to make concessions to the voting powers of Friendly Societies. Very strong representations have been made to the Government by authorit-ed representatives of the British medical profession. Such action, as it affects Chesterfield, weakens the position of the panel medical men, and this, too, in a town where all the general practitioners were willing to go on’the panel. To encourage competition against them is hardly a fitting way to reward their readiness to carry out the Act. Unfair Competition and Ino’J’ease of TVork. One cause of great complaint is the unfairness of allowing institutions, such as the Chesterfield District Medical Asso- ciation, the right to dispense for all their patients whether within the mile limit or not. This to many insured persons is a great attraction, as it saves them time. On the other hand, many panel medical men have been in the habit of dispensing, some even keep a qualified dispenser, and have a good stock of drugs. But the Insurance Act puts difficulties here in the way of the panel medical man. Then, when the panel medical man does not dispense and the institution does dispense, the former, of course, does not canvass or tout in any way. But all who have lived in industrial centres know something of the considerable influence exercised by the insurance agents who all day long and every day are in and out of the houses of the poorer classes. These agents may have been told not to canvass but they may, as already explained, give advice on their own personal responsibility. There is nothing of this sort on the side of the panel or in the attempt to help the Chesterfield Public Medical Service. This organisation being started by the members of the profession is obliged to observe medical etiquette, and is therefore put at a very great dis- advantage when competing with an institution run mainly on commercial lines. The Public Medical Service is an attempt to solve the problem of medical service for the dependents of insured persons and deserves every support ; but it cannot compete against methods of advertising and canvassing, whether these be open or disguised. Therefore, the member- ship of the Public Medical Service has only increased slowly. But it allows clubs to join in a body, and they all have free choice of medical attendant. Practically all the panel medical men are also on the Public Medical Service. The policy of this service is to give adequate treatment for adequate payment, and the quality of their treatment is absolutely their only advertisement. The proportion of persons seeking medical advice has con- siderably increased since the passing of the Act, especially in regard to farm workers, domestic servants, women workers, and especially charwomen. That a good deal of this practice is the result of the facilities now enjoyed by the people is proved by the fact that it does not exist where the facilities are not so great. On this question a general practitioner, living in the outskirts of Chesterfield, was able to give me his own figures for the last six months and dating from April lst. During that time he had 600 insured persons on his list, for whom he received 2s. each extra annually, because he had to supply drugs and they lived beyond the mile radius from his surgery. Of these 193 required medical advice during the six months. But within the one mile radius. an easy distance so that it was not much trouble for the patient to attend at the surgery, no less than 237 patients sought advice out of a rather smaller list-namely, 550 insured persons. (To be coKK?MMd.) MANCHESTER. (FROM OUR OWN CORRESPONDENT.) Salford Royal Hospital and its Work. AT the annual meeting of the Salford Royal Hospital it was announced that the gift ’of 5000 promised by the president if a balance of .S5500 required to clear off the deficit on the extension of the hospital could be collected during the year had more than attained its object. It was agreed to open the 34 beds remaining empty, so that the total number of beds in future will be 208. Nearly 30,000 patients were treated at the hospital and at the Pendleton Dispensary during the year. The deficit on the year’s working was £ 2212. An Estate and AS’anatomi2cna for Stockport. The Stockport town council, on the recommendation of the health committee, has decided to purchase the Wood- ville estate, Reddish, in order to provide hospital accommo- dation for consumptive patients. The cost of the estate will be f:6500, and comprises about 20 acres of land and a large mansion which will accommodate from 36 to 40 patients. The
Transcript

1279

The Government ConlJession to Approved Institutions.

To-day, however, matters have drifted from bad to worse.Instead of pulling up sharply the Chesterfield District’Medical Association for thus reviving some of the formerand worse abuses, it has recently received from theauthorities marked and material encouragement. Ithas always been difficult to deal with the Act apartfrom politics, but in the present instance this difficulty is

naturally and greatly accentuated by the fact that theconcessions were made just before the Chesterfieldelection. Previous to these concessions, approved institu-tions that provided medical attendance before the passing ofthe Act could only obtain from the Insurance Committeewhat they could prove had been spent on each individualmember. Thus formerly, if the average cost was 5s. a yearfor all the members, whether insured under the Act or notso insured, the Insurance Committee only gave 5s. a headfor each of the insured persons who were under the Act. NowMr. Masterman received on June 4th last a deputation repre-senting the Chesterfield District Medical Association, and inreply issued during the second week in August a memorandumallowing the Insurance Committees to give to approved institu-tions the full 9s. a head for every insured person who selectsthe institution to provide his medical treatment, upon theprincipal officer signing a statement that the average of 9s.per head has been expended in respect of insured persons formedical treatment (including the provision of drugs) andgeneral establishment charges ; treatment to be not inferiorto that given by doctors on the panel." This places in thehands of a private association, managed by a lay committee,where there is no medical control, all the money collectedby the State, and partially contributed by the State, formedical purposes.

Protests Against the Memo’J’andu1n.It is stated, in response to the objections raised, that it is

only intended to place institutions on a level with the panel.But this is hardly satisfactory to the many who think suchinstitutions should not be allowed to exist at all. However,they do exist, but modifications of the Act should tend tocheck and not to extend the abuses, such as the sweating ofmedical men, to which these institutions are so likely togive rise. It is all very well to say that the 9s. are tobe expended in providing medical treatment, but what isthe medical attendant himself to get out of the 9s. ? 7 TheGovernment in any case should be careful not to do thesethings just before an election. As it is, several medicalmen protested energetically in my presence. They wantedto know whether every time a Liberal seat is in dangerFriendly Societies are to get more money for their own

purposes, and this at the expense of the panel medicalmen and the profession generally. If so they promisedthat difficulties would arise, seeing that the profession wasbetter organised now and would know how to make itsinfluence felt.

Dealing with the details of the memorandum, the ideathat the mere signature of an official belonging to an

approved institution was a sufficient guarantee that thewhole of the 9s. allowed would really be spent only onpersons insured under the Act was considered absolutelyabsurd. A proper balance sheet may be insisted upon, butas yet it is not known that anything of the sort will be forth-coming. Even then, and should the medical officers obtainthe full 7s. out of the 9s., they will be forced on the strengthof this payment to attend to women, children, and othermembers of the association who are not insured under the Act.For the latter portion of their work they might be paid butlittle or even nothing. Thus, in fact, if not in form,some of the money paid for persons insured under theAct would help to procure medical treatment for membersnf the association who were not so insured. The medical

profession is now inquiring whether the Chesterfield electiondemonstrates that the Government can be squeezed whenthere is a by-election and induced to make concessions tothe voting powers of Friendly Societies. Very strongrepresentations have been made to the Government byauthorit-ed representatives of the British medical profession.Such action, as it affects Chesterfield, weakens the positionof the panel medical men, and this, too, in a town whereall the general practitioners were willing to go on’the panel.To encourage competition against them is hardly a fittingway to reward their readiness to carry out the Act.

Unfair Competition and Ino’J’ease of TVork.One cause of great complaint is the unfairness of allowing

institutions, such as the Chesterfield District Medical Asso-ciation, the right to dispense for all their patients whetherwithin the mile limit or not. This to many insured personsis a great attraction, as it saves them time. On the other

hand, many panel medical men have been in the habitof dispensing, some even keep a qualified dispenser,and have a good stock of drugs. But the InsuranceAct puts difficulties here in the way of the panel medicalman. Then, when the panel medical man does not dispenseand the institution does dispense, the former, of course,does not canvass or tout in any way. But all whohave lived in industrial centres know something of theconsiderable influence exercised by the insurance agentswho all day long and every day are in and out of the housesof the poorer classes. These agents may have been told notto canvass but they may, as already explained, give adviceon their own personal responsibility. There is nothing of thissort on the side of the panel or in the attempt to help theChesterfield Public Medical Service. This organisation beingstarted by the members of the profession is obliged to observemedical etiquette, and is therefore put at a very great dis-advantage when competing with an institution run mainly oncommercial lines. The Public Medical Service is an attemptto solve the problem of medical service for the dependents ofinsured persons and deserves every support ; but it cannot

compete against methods of advertising and canvassing,whether these be open or disguised. Therefore, the member-ship of the Public Medical Service has only increased slowly.But it allows clubs to join in a body, and they all have freechoice of medical attendant. Practically all the panelmedical men are also on the Public Medical Service. The

policy of this service is to give adequate treatment for

adequate payment, and the quality of their treatment is

absolutely their only advertisement.The proportion of persons seeking medical advice has con-

siderably increased since the passing of the Act, especially inregard to farm workers, domestic servants, women workers,and especially charwomen. That a good deal of this practiceis the result of the facilities now enjoyed by the people isproved by the fact that it does not exist where thefacilities are not so great. On this question a generalpractitioner, living in the outskirts of Chesterfield, was

able to give me his own figures for the last sixmonths and dating from April lst. During that timehe had 600 insured persons on his list, for whom hereceived 2s. each extra annually, because he had to

supply drugs and they lived beyond the mile radius fromhis surgery. Of these 193 required medical advice

during the six months. But within the one mile radius.an easy distance so that it was not much trouble for thepatient to attend at the surgery, no less than 237 patientssought advice out of a rather smaller list-namely, 550insured persons.

(To be coKK?MMd.)

MANCHESTER.

(FROM OUR OWN CORRESPONDENT.)

Salford Royal Hospital and its Work.AT the annual meeting of the Salford Royal Hospital it

was announced that the gift ’of 5000 promised by thepresident if a balance of .S5500 required to clear off thedeficit on the extension of the hospital could be collectedduring the year had more than attained its object. It was

agreed to open the 34 beds remaining empty, so that thetotal number of beds in future will be 208. Nearly 30,000patients were treated at the hospital and at the PendletonDispensary during the year. The deficit on the year’sworking was £ 2212.

An Estate and AS’anatomi2cna for Stockport.The Stockport town council, on the recommendation of

the health committee, has decided to purchase the Wood-ville estate, Reddish, in order to provide hospital accommo-dation for consumptive patients. The cost of the estate willbe f:6500, and comprises about 20 acres of land and a largemansion which will accommodate from 36 to 40 patients. The

1280

hospital will be used for consumptive persons who are prac-tically incurable and who would prove a source of infection ifleft in their own homes. There will also be erected inex-

pensive shelters for cases under observation and mild caseswhich have not got to a stage for sanatorium treatment.Stockport and Heaton Norris together have 46,000 insuredpersons. During the last 3 ear there were 250 cases of tuber-culosis in Stockport and about 135 deaths from the disease.Nearly 2000 consumptives died during the last decade.

The Smoke Fiend and the 8molte .tbaternent Leagtte.The annual meeting of the Manchester and District

Branch of the Smoke Abatement League was held in Man-chester last week, when Lord Newton presided. The aimsof the society are first to induce manufacturers to abate thenuisance of smoke from their chimneys, and secondly tostimulate the local authorities to use the powers they alreadypossess for putting down the smoke evil. Out of 139 firmswhose chimneys were reported by the inspector 19 had madeor were making alterations in their plant. The progress,however, is very slow. It appears that the factory chimneys iin Manchester are in a fairly good state, but an excessive I’quantity of smoke is emitted from chimneys in the Isurrounding districts. The smoke from domestic chimneysin Manchester is now very much less than it was

some years ago, mainly owing to the substitution anduse of gas fires and gas cookers, of which over 100,000are now in use in the city. According to Lord Newton, aperson who never left Manchester never saw the sun shineas it might, never knew the real colour of a tree trunk, andprobably went to his grave convinced that all sheep wereborn black. His lordship said that any Bill promoted by theLeague should be introduced in the House of Lords, wherea measure brought forward by a private Member was, at allevents, discussed on its merits. He approved as an admirablesuggestion the appointment of a Royal Commission to con-sider the smoke question. Lord Newton offered to introducein the House of Lords any Bill framed by the League.

Oct. 28th.

SCOTLAND.

(FROM OUR OWN CORRESPONDENTS.)

Edinburgh University the Report ofthr, Ge1/eral ConoeilCM an Inolusive 11’ee in Medicine.

Ia the half yearly report of the General Council of theUniversity of Edinburgh recently issued, Principal Lauriesays that from the University point of view the obviousobjection to the inclusive fee in medicine was the conditionof uniformity which would make it very difficult in thefuture for any University to increase its inclusive fee in anydepartment, as it would be necessary to persuade theother Universities to agree to the same. It was evidentlythe intention of those who have been responsible forthis principle of the inclusive fee that the fees of the Univer-sities should not be further extended. In the situationcreated by the establishment of an inclusive fee, any futureadditions to the Universities in the way of endowments fornew chairs, or capital sums for the equipping of newlaboratories, must form a source not of gain, but of seriousembarrassment. A fresh source of revenue must be foundfor the Universities, which must be capable of expansionfrom year to year in order to meet the increasing demandsupon the general University fund. Dr. T. Shennan had saidthat it was evident that the extramural school has played animportant part in establishing the Edinburgh Medical School,and was still a prominent factor in maintaining its position.If an inclusive fee in medicine were established it wouldtend to result in students taking all their classes within theUniversity, and the extramural school would thus, for

practical purposes, cease to exist. Further, the supply oftrained teachers, which has been so well met in the past bythis school, would to a great extent cease. This reportwill be considered at a meeting of the General Councilon Oct. 31st.

The Falling Bi?’th-rate: Meeting in Edinburgh.A paper on the Birth-rate Commission, by the Rev. James

Marchant, director and secretary of the National Council ofPublic Morals, was discussed at the Conference on PublicMorals held in Edinburgh on Oct. 21st. In the course of

the paper Mr. Marchant stated that the council had estab-lished a private commission of inquiry into the decliningbirth-rate, composed of leading representatives of religion,science, sociology, literature, and education. It was signifi.cant, he said. that a Parliamentary Committee had beenappointed in France to inquire into the national, social, andfiscal aspects of their declining birth-rate. These two com-missions should elicit facts of which they might trulysay that the sooner they were faced the better. Dr.J. W. Ballantyne, of Edinburgh, who opened the discus-sion, remarked that Edinburgh and Bradford were thetwo cities which were either rejoicing in or deploring thelowest birth-rate at present, and this fall, as shown byfigures, was beginning to manifest itself by its influenceon the number of children of school age. It looked asif the civilised part of the human race was beginningto experiment with its reproduction, just in the same

way as it had already experimented with its modeof locomotion. With the fall in the birth-rate they werebrought face to face with what one might call in com-mercial language greater appreciation of infant life, andthis was the one saving feature. He thought that greaterefforts should be made in future to save existing life, andto find out how many lives were lost before birth. He

hoped that it would not be long before the Governmentbrought in a Stillbirths Registration Act.

Outbreak of Diphtheria in Galashiels.Galashiels is threatened with an outbreak of diphtheria.

of a somewhat severe type. Up to last Saturday therehad been within the last month 16 cases, of which threehad proved fatal. As the infectious disease hospital at.Eastlands is already fully occupied with scarlet f8ver cases,these diphtheria cases have to be treated in the houses in.which they occur.

The National Instwance Act in St011J, Midlothian.At a largely attended meeting of insured persons held in

Stow on Oct. 25th it was decided to call upon the autho--rities to establish a panel doctor in the place, as they werebeing entirely neglected under the Act. It will be recalledthat the,local medical practitioner, who is still in residence,.did not see his way to go on the panel, and thereforethe medical benefit has been administered from Lauder,a distance of about six miles over hill roads.

St. Andrews University Rectorial Election.The election of a Lord Rector of St. Andrews University

took place on Oct. 25th in the United College Hall. PrincipalDonaldson presided, and the Earl of Aberdeen was electedRector for the ensuing three years. There was no othernomination.

Aberdeen City Insurance Panel.The following statement has been compiled showing the

distribution of insurance patients among medical men in.Aberdeen :-Fewer than 50 patients, 8; 50 to 100 patients,3 ; 100 to 200, 5 ; 200 to 300, 5 ; 300 to 400, 7 ; 400 to 500,3 ; 500 to 600, 2 ; 600 to 700, 1; 700 to 800, 2 ; 800 to 900, 2 ;900 to 1000, 3 ; 1000 to 1100, 4 ; 1100 to 1200, 2 ; 1200 to1300, 1 ; 1300 to 1400, 4 ; 1400 to 1500, 2; 1500 to 1600, 2 ;1600 to 1700, 1 ; 1700 to 1800, 2; 1800 to 2000,4; 2000 to.2600, 1.

Sanatoriiiia Benefit in Aberdeen.During the year July, 1912, to July, 1913, the Aberdeen

Insurance Committee administered sanatorium benefit to134 males and 70 females. 73 were treated in the

City Hospital, where the average stay was 90 days, and,13 were sent to Newhills, where the average duration oftreatment was 84 days. Results of treatment were:

fatal, 39 ; better, 49 ; worse, 1 ; no change, 26; outstanding,89. Costs were : reports, <S51; City Hospital, 112813s. 7d. ;.Newhills, 147 11s. 1d.; domiciliary, R38 Os. 0. ; total,1365 4s. 8d. The number of insured persons treated inthe Royal Infirmary from July 15th, 1912, to July 15th, 1913,were: in-patients, 31 ; out-patients, 28; total, 59.

Insurance Leotures in Aberdeen.It is understood that, subject to the Scottish Insurance-

Commissioners sanctioning the expenditure of 100, underSection 60 of the National Insurance Act, 1911, steps willbe taken to institute a series of simple lectures in differentdistricts of Aberdeen, embracing among other subjects (1)the chief laws of health ; (2) the choice of nourishing food ;.(3) digestion and indigestion; (4) care of insured persons.


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