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MEDICAL PRACTICE UNDER THEINSURANCE ACT.

(BY OUR SPECIAL COMMISSIONER.)(Continued from p. 1211.)

XLV.—SOUTHEND-ON-SEA.

IN the course of my peregrinations over EnglandI had by the end of March worked across the

metropolis to the border of Essex, and my startfor a brief tour in the Eastern counties was madeat Southend-on-Sea.

In honour of its rapid growth in population andpopularity, Southend-on-Sea has just been promotedto the status of a county borough. Though so nearto London and so accessible, it is only duringrecent times that its advantages as a place of resi-dence or a resort have been appreciated in anymarked way. In 1866, or but half a century ago,there were 3400 residents at Southend. Even so

recently as 1892 the population was only estimatedat 12,500. To-day it has reached the imposing totalof 82,000.The railway companies have contributed to bring

about this increase, and have so improved thefacilities of communication that many families whose earning partner has business in London I

nevertheless reside at Southend. This means thatthere are many and good opportunities for privatepractice. It is not an industrial town, but a

pleasure, health, and holiday resort. The particularlocal and economic conditions so created do notseem to the medical profession suitable to a largeincrease of contract practice, and doctors were nota little alarmed to find that a National InsuranceAct, which on the whole was planned to suitworking-class and industrial centres, would be

applied to their very different and special locality.Therefore the Insurance Bill inspired sinister fore-bodings and general mistrust. During the year1912 the local practitioners gathered together veryfrequently, and as the critical Christmas in the

history of the legislation approached they metevery night.

It was my privilege to be received by quite alarge number of local practitioners when I wentdown to Southend recently, and I found many ofthem still congratulating themselves on havingbeen very unanimous in the view which they tookduring the most trying periods. That they gave upthe struggle with the unanimity which they hadshown in combating the scheme cannot be denied;and now it is probable that not only at Southendbut throughout the whole county of Essex 90 percent. of the available practitioners are on the panel.Yet it would be a great mistake to look upon this asa manifestation in favour of the Act. It simplymeans that the Essex practitioners thought that ifthey did not yield worse would happen to them.

Early Dislike of the Act.It would have been easier, as a matter of fact, to

resist the Act in Southend than in many other

places because the town is especially free from anycompeting connexion in the surrounding country.Southend is embraced on three sides by broad waters.The insured population could not have e crossedthis water conveniently to get medical advice in aneighbouring medical area. Previous to April lst,1914, when Southend became a county borough,and thus secured an Insurance Committee of its own,the locality was under the Insurance Committee of

the county of Essex. The only county borough thatthen existed was West Ham, and East Ham wasapplying to be recognised as a county borough.The population of the county of Essex is put downat 1,300,000, and 290,000 of them are insured. Thereare many districts where the population is so sparsethat it is not practicable to give prescriptions topatients, and the actual number of insured personsfor whom the panel doctors have to dispensemedicine amounts to 54,000. In Southend itselfthere should be 19,000 persons insured, but on

recently adding up the lists of the panel doctorsit was found that the payments effected onlycovered an insured population of from 14,000 to15,000. As there are 34 practitioners on theSouthend panel this means an average of less than500 persons per list. It will be seen, therefore, thatthe Southend practitioners are not so dependentfor their living on the classes that come under theInsurance Act as is the case in large industrialcentres. But like many averages the figures do notrepresent what actually occurs. In practice somelists are so small that to lose the patients theyrepresent would not much matter, while others, onthe contrary, represent the better part of the prac-titioner’s income. The stout resistance set upagainst the Act remains justified in the eyes ofmany doctors by subsequent events.The resistance, here as elsewhere, broke down

through the want of organisation. It was im-possible to find out what was happening in otherparts of the country. What publicity did take

place favoured the partisans of the Act, for itconsisted, in the main, of an ever-growing list ofplaces that had given in. Such news, on itsrecurrent appearance, was very discouraging, andthere were no means available of testing thefeeling of the :profession in other places. Then

the Southend practitioners sadly felt the needof a proper fund on which they could rely to backup the victims. "Am I to break my word or

am I to be ruined’? was a question raised by someof the practitioners who were most involved.It was very difficult to counsel men to hold outwhen it was obvious they would lose half their

practice and were not likely to receive any com-pensation. Nevertheless the practitioners had atSouthend the advantage of having very few medicalaid clubs or societies. So they held out after allthe other parts of Essex had accepted the Act, butthree or four days before the pledge was withdrawnthey did surrender, and they all yielded together.Thus to-day no one can say:

"

I held out and you didnot."

The Expenses of the Committees.What finally brought the resistance to an end, so I

was told, was the news given that Mr. WorthingtonEvans, M.P., had telephoned that it was no use

holding out any longer because the Governmenthad parcelled out Essex among a staff of medicalmen who were ready to establish a sort of StateMedical Service for the county. The chairman ofthe Essex County Insurance Committee having con-firmed the news, the South end practitioners werecalled together and given this information. There.upon it was agreed to accept the Act, and this wasdone unanimously. Therefore the profession isnot divided into two camps; but, as I havealready said, it would be a great error toconclude that because all have accepted, there-fore all approve of the Act. On the contrary,when I found myself in the midst of some 10 or12 Southend practitioners it soon became apparent

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that they had many grievances to ventilate.Naturally, I asked if there was a Medical Com-mittee that might deal with at least some of thesegrievances, but I soon became aware that the MedicalCommittee was in itself a grievance. The CountyMedical Committee had to meet in London and to

pay for the hire of its own room and the travellingexpenses of its own members. The secretary had anenormous amount of work to do, but received

nothing for his trouble. A voluntary levy wasattempted, but met with a very poor response.The present proposal is that the expenses

of this County Medical Committee, as also thoseof the Pharmaceutical Committee, are to be paidby a deduction of one halfpenny out of the

floating sixpence for each committee, counting,of course, the halfpenny for each person on thelists of the panel doctors, thereby decreasing theclaim of the practitioner from this source. To spendthus their own money in carrying out the Act byestablishing a Local Medical Committee they hadto obtain special permission from the Commis-sioners, and some soreness is accordingly felt.

No New Story.As to the results of the Act, some of the Southend

practitioners have recognised that under it they areearning more than before ; but if the amount ofwork they have to do is taken into consideration,then they said that they were earning less in pro-portion. In the old club practice the patients feltreluctant to take the money of others unless therewas really something serious the matter. Nowno one has such scruples, and the result is thatthe panel doctors of Southend are so worried by theimportunities of those who have nothing much thematter with them, that they can with difficulty findtime to examine properly those to whom, if theexact conditions were realised, they should devotemuch more time. Not only is this injuriousto the patients, but it destroys the value ofthe cards, for the information which theyshould supply for statistical purposes is notreliable. Yet no one at Southend, I was assured,has more than 900 persons on his list. What, then,would have happened if the Government had putinto this town, as it was proposed, only four prac-titioners to do the work that is divided to-dayamong 34 practitioners?One practitioner, in explaining how the Act had

somewhat reduced his income, said that most of hispatients belonged to a lowly paid class of clerks.They used to pay small fees and were now nearlyall insured persons. And they are not the profitableclientèle that they should be in a place as healthyas Southend with a death-rate of about 9 per 1000.

Capitation fees should be very profitable, for thereis so little sickness. But this extension of contractpractice has affected many doctors. The realgrievance here, as in so many other places, is theinsuring of the employed sons and daughters ofwealthy persons. One case related to the son of alarge contractor. On his father’s wage sheet heappears as earning 35s. a week, but he also receivesa bonus of J620 a month. The family doctorrefused to treat on insurance terms the son

of this contractor, and as a consequence helost the whole family. If he had acceptedhe could not have treated the son differentlyfrom the rest of the family, yet for the smallsum insured persons pay he ought not to expect somuch personal attention.

.At Southend, I am sorry to report, it was evident

to me that contract work in many instances meantinferior work. The panel doctor must not acceptanything above the grant as by law established forfear that to do so might bring about a system ofpreferential treatment, and yet when he knows thesubstantial position of some of his patients or

their children he naturally feels sore. Formerlyit was contemplated charging some insured patientsordinary fees, but deducting from their bills thesums accumulated by the annual payments of 7s.Any arrangement of that sort has, however, beendeclared irregular. "The Act," one Southend practi-tioner exclaimed, and others approved his observa-tion, " is glorified club practice. No one wouldcome if he had to pay a panel doctor for such treat-ment." If partly this was a self-condemnatoryremark, partly it was a proof that a very big pro-portion of the population are resorting to paneldoctors-a far higher proportion than had beenanticipated. Consequently the old club bottle ofmedicine method was revived. Any amount ofmedicine was needlessly given, because the patientwould complain if he did not get at least one bottleof medicine.

In8ul’ed Women at South end.Servants are perhaps difficult to keep at

Southend, and mistresses fortunate enough tohave them are unduly solicitous about theirwelfare. Anyhow, the mistresses of domesticservants are, I was told by several doctors, con-stantly telephoning when there was the least thingthe matter with their servants. They used to bemore careful when they had to pay for medical

advice, as to their credit they very usually did. Butthe practitioner must not resent being thus troubledor else he may lose the servant’s mistress, who isa private patient and pays good fees. I should nothave thought servants are difficult to get; indeed,there are so many women domestics and charwomenat Southend that several panel doctors were of theopinion that some 40 per cent. of the insured withwhom they had to deal were women. The female

patients under the Act always take up much moretime than the men, and this has proved the case atSouthend, where, also in accordance with generalexperience, their principal complaints are ansemia,gastric trouble, constipation, and rheumatism.These patients go far to prove that it was a greatmistake on the part of the promoters of legis-lation to have calculated the probable amount ofsickness on the experience of the FriendlySocieties, particularly when these societies hadbut few women members. As a matter of fact,panel doctors are now treating " arrears of sick-ness " among their female patients-namely, womenwho were ill before the Act was passed, but whohad never before been either insured or treated.Such neglected people naturally give more

brouble than the former members of FriendlySocieties, and they are as frequent at Southend asjhe smiling lass who turns up after a mile walk andbegins negotiations by the statement that she is in’ an agony of pain." To add to the extra trouble itlas been discovered that insured servants are some-iimes sent out to describe their mistress’s symptomsmd get medicine or ointment, not for themselves,mt for the family they serve. Others give theirnedicine to non-insured dependents.

The Temporary Population.Then there is at Southend the special trouble

hat applies to holiday resorts-namely, the treat-nent of strangers who are insured visitors. Last

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season the green vouchers were in force, but themajority of visitors were so worried by formalitiesthat they gave the matter up as hopeless and foundit less trouble to pay the usual fees. Daring theforthcoming season it is feared the surgeries willbe filled with insured strangers just when a

little profitable private practice might be obtained.The attending to these strangers must necessitatea separate system of bookkeeping and cause moreclerical work than the probable financial resultwarrants. On the other hand, it is thought thatthe conversion of Southend into a borough with itsown Insurance Committee will improve the situa-tion. A certain hostility was felt by the EssexInsurance Committee against the doctors becausethey had given trouble and had so stoutlyresisted the Act. Now a smaller and purelylocal Southend committee, drawn from peoplewho are personally acquainted with the doctors, ismore likely to be free from any such prejudice.The Commissioners, however, did not view thematter in the same light. They feared there mightnot be money enough forthcoming to pay for theworking expenses of the Local Insurance Com-mittee. It appears they have calculated that unlessthere are about 50,000 insured persons the receiptswill not cover the expenses of an Insurance Com-mittee ; and it has been seen that unless strangersare included there is not half that number ofinsured persons at Southend. However, the diehas been cast, and the best must now be made ofthe situation.

(To be continued.)

MOTORING NOTES.

(FROM A SPECIAL CORRESPONDENT.)

Insignificant Tr{fles.DURING my 14 odd years of motoring I have come in

contact occasionally, either personally or in correspondence,with a few unlucky individuals. As far as their automobile

experiences went, they seemed to have had the sorrows ofWerther, while other owners of similar cars have expressedthemselves completely satisfied. Analysis of the cause of

many of these troubles leads to the conclusion that themotorist was more often to blame than the car. Looking atthe car of a satisfied owner revealed frequently, byjinference,the reason of the worries of the dissatisfied motorist. Inone the engine was kept clean, the bearings were alwaysadjusted, nuts subject to vibration were kept tightened,lubricators were charged with grease or oil, water jointswere not allowed to leak, springs were kept greased, shacklebolts were lubricated and tightened, the sparking plugpoints were clean and correctly adjusted, and the ends ofthe valve lifters were separated only by the thicknessof a thin visiting card from the stems they had to lift,while the petrol needle valve was true, and there wasan absence of the clatter noticeable in the slovenly keptengine. Most of these details are in themselves insignificant,and the attention they need would probably not occupy morethan five or ten minutes a day ; but the few minutes savedby ignoring their claim to this slight attention are usuallyfollowed by a day of reckoning, in which hours may be

spent on the roadside and pounds in the repair shop. I Itrust, however, that these suggestions will not be an excusefor the other type of owner : I mean the over-careful,fussy one, who also exists, and who likes to look at the

piston rings once a week, to grind in the valves almost asfrequently, and even to attend to the big ends " at equallyshort intervals. There is, of course, a happy medium.

The Cost of Repairs.Disputes regarding accounts for car repairs are best

obviated by first obtaining an estimate. Generally speaking,the repairer is not in a position to give an estimate withoutfirst dismantling the engine ; but most motor engineers will i

give a price for dismantling and re-erecting, and then, whenthe engine is taken down, the actual requirements can beascertained and demonstrated to the owner, and the priceand need for each specified. It may be enough if valves areground in, new valve springs fitted, and big ends taken up,or bearings may require renewing and timing or other gearsreplacing. These are points for consideration, and can bediscussed when the parts are asunder. In some cases

relining the bearings with white metal will suffice, whilst inother cases it may be advisable to replace them with newones. This depends on the amount of wear and the qualityof the material originally used. On well-constructed and

carefully fitted cars the life of a bearing is longer than onthe cheaper and less carefully built ones. In coming to adecision it is well to remember that though loose parts mayrun, still they cause loss of power, and when once loose theywear rapidly. A little extra trouble spent in the overhaulmay postpone the need of a second one for some con-

siderable time, and moreover may obviate an undesirableroad stop.

The Object of Lubrication.In order to obtain efficiency from an engine and from all

moving parts any undue friction must be overcome. Lubri-cation does this by interposing a film of oil, which keeps thesurfaces of all moving parts from coming into contact witheach other. As these parts move they throw and squeezeout the lubricant. However well the moving parts are

made, when examined under the microscope they are seen tobe rough, and when two rough parts work on one anotherthey grind each other and thus cause wear. The film of oilinterposed prevents this wear. As already remarked, thetendency is to squeeze this film out, therefore to obviatewear the lubricant must be supplied frequently and in smalldoses. Car owners who bear this in mind will obtain themaximum life from their engine and working parts, with aminimum expense in the matter of upkeep. A point also tobear in mind is the quality of the lubricant. Though cheapoils may not always be considered the most satisfactory, ifmade by a good firm they frequently answer as well as

the more expensive ones. It is better to buy the oil in bulk,by which method the price is greatly reduced. If when

ordering the make of engine is mentioned, the manufacturerwill see that a suitable oil is supplied.

A Novelty in Change Speed apparatus.When an internal combustion engine is used for the pro-

pulsion of a vehicle change speed gears are a necessary evil,and a part of the evil has been the quadrant or gate on thedriver’s right, which usually interferes with easy access tothe seats of the car from that side. A recent Americaninnovation is the electric gear change apparatus, in whichthe external actuating levers are replaced by an electricdevice worked from the steering column. In the place ofthe gate or quadrant there are merely some four or five pushbuttons. A solenoid-that is, a hollow magnet surroundedwith insulated wire-is fitted, and when the button is

pushed and the electric circuit i5 completed by depressingthe clutch pedal an electric current circulates through thesolenoid, which then becomes a powerful magnet drawing ina rod, and thereby bringing the gear into mesh. All thedriver has to do when desiring to change speed is to pressthe appropriate button. Nothing then happens, however,until the circuit is completed by taking the clutch out.Then the magnet so formed draws the gear into mesh. Iunderstand that the consumption of electric current is smalland that this method has been found to answer exceedinglywell in America, where it is now largely used. Of course,there is a danger of short circuits, but if this methol is welldesigned and constructed they are not likely to occur.

The Causes oj Oue.-heatzn..Over-heating may be due to one of the following causes :-

(1) Insufficient lift to the exhaust valve ; (2) backwardpressure from a choked or partly choked silencer ; (3) too-rich a mixture ; (4) too late an ignition ; and (5) some blockin the water circulation. A diagnosis is easily arrived at bya process of exclusion. Examine the valve-lifters at work,and note if there is too much clearance between the lifterand the valve stem. The thickness of a thin visiting cardshould be an ample gap. If there is too much clearance thevalves will lift late and the exhaust gases will not be

thoroughly clea1’e(l out by the time the piston descends forthe induction stroke. With the engine accelerated note if