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MEDICAL PRACTICE UNDER THEINSURANCE ACT.

(BY OUR SPECIAL COMMISSIONER.)(Continued from p. 139.)

XXXIV.-BRISTOL : THE REFEREE AND REVISEDDRUG BILLS.

BRISTOL is one of the towns where there wasconsiderable opposition against the Act and wheresome advantage was secured as a result. Themembers of the profession began to hold meetingson the question of insurance two years before theAct was adopted. Then the Bristol delegates at theBirmingham meeting of the British Medical Asso-ciation complained that the war chest was not full,but sought legal opinion to ascertain whether theAssociation had the legal right to organise what waspractically a strike fund. Though the legal opinionobtained proclaimed that the money was safe, amedical federation was started so as to have a fundmore safely secured, and this organisation obtainedrecognition from the Board of Trade as a limitedcompany, with an existence quite independent fromthe Association. This was considered safer than

registering as a trade union. The scepticism ofthe Bristol practitioners did not please the BritishMedical Association. The latter, deeming thattheir money scheme was good enough for every-body, decided against immediate cooperation withthe Bristol Federation. The Bristol practitioners feltthey had an opportunity of going forward and ofobtaining considerable sums of money, yet if theycollected subscriptions at the same time as the Asso-ciation, and for the same strike fund purposes, theywould damage both funds. The Bristol Federation,to its regret, reluctantly had to acknowledge it wasbound to support the general effort. For the sakeof unity and discipline its members abandonedtheir enterprise and their good opportunity of

creating a safe and strong local fund. The Federa-tion rules were that every member renderedhimself responsible for a minimum subscriptionof .E2 and a guarantee of JE5—this, at least, wasthe figure mentioned to me. In any case, noneof the money was called up, and those who had

given promises were asked to transfer their sub-scription to the British Medical Association. In

doing this it is claimed that the Bristol prac-titioners gave more in proportion than thepractitioners of any other town in England.In November, 1912, when the agitation against

the Act was at its height, there were in the BristolDivision of the British Medical Association 421practitioners, and of these 276 subscribed. Thoughin November of that year they only actually paidin E293 19s. they guaranteed E4488 5s. The votesgiven were as emphatic as the money subscribed,both proving how strong was the feeling againstthe Act. At the meeting held on Dec. 20th, 1912,only 3 out of 417 votes recorded were in favourof accepting panel service. These three voterswere, however, perfectly loyal to the majority,maintaining discipline while expressing theirindividual opinion. Bristol claims that it broughtforward a greater number of medical men againstthe panel and subscribed a larger sum for thestrike fund than any town in England, yet whenon Christmas Eve a small group of practitionersannounced that they felt obliged to go on the panel,all the others, doubting the adequacy of the avail-able " strike funds," found themselves compelled to

follow suit. This was not formally decided upon,however, until certain special privileges had beenobtained for the Bristol Panel Service. Withall this it sufficed for one single practitioner todeclare on Christmas Eve that he must go on the

panel, and thereupon the entire resistance col-

lapsed. Another practitioner announced he wouldin that event be obliged to follow suit, and so

would all the rest.

Satisfactory Constitution of Medical Committees.In the face of this defection, and seeing that they

could not hold out, the Bristol practitioners never-theless managed to obtain special terms. Among thevarious concessions made by the English Com-missioners as a condition for the formation of apanel at Bristol was the appointment of a referee,or medical adviser, as he is here called. Also itwas agreed that all matters concerning medicalmen should be submitted to a medical subcom-mittee, consisting of five representatives of theLocal Medical Committee and five representativesof the Insurance Committee, with a town councilloras chairman. The referee has an annual income,and the great point is that his nomination doesnot depend on the Insurance Committee, for he ischosen by the Medical Committee. On thiscommittee the non-panel practitioners are well

represented.At first there was a great bitterness of feeling

between the practitioners on the panel and thosewho held aloof, but when it was found that theformer made room on the Medical Committee forthe latter peace was re-established. To-day, evenon the special Panel Committee to be formed inaccordance with the amendments to the Act, sixnon-panel practitioners are to be appointed. Thisis a clear proof of the friendly feelings that to-dayprevail on both sides. Not many in Bristol amongthe extreme opponents of the Act would nowlike to see it abolished. Certainly there remainsroom for improvement. It is thought, for instance,that the Insurance Committee is not sufficientlyinfluenced by the Medical Committee. As a local

practitioner exclaimed in my presence : " Thedoctors sell their labour, but have hardly any voicein the bargain."

Bristol is divided into seven groups or districts,which originated with the British Medical Associa-tion and were adopted by the provisional MedicalCommittee that emanated therefrom. Ultimatelythe Insurance Commissioners endorsed this methodof election. The rule, roughly speaking, is thatthere should be one elected out of every tenmedical men practising in the town. There are34 members on the Local Medical Committee. ThePanel Medical Committee is to be elected by groupsaccording to the strength of the panel men belong-ing to these groups, and this will be a much largercommittee in proportion to the numbers repre-sented. As for the existing Medical Committee, ithas had a hard time dealing with financial problemsand a great quantity of trifling routine work.

The First Referee.It is in the appointment of a referee, however,

that Bristol stands prominent. The initiative takenhere has since been followed at Oxford andPlymouth, but to Bristol belongs the credit ofhaving set the example. Nor was it an easymatter. Thus each Friendly Society wanted tohave a referee of its own, presumably to quarrelone with the other. Then a pertinent question wasasked as to who should pay the referee. The

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Commissioners said the Approved Societies mustprovide the money. At first the Insurance Com-mittee had offered to pay so as to induce the prac-titioners to come on the panel. Then it was feltthat there were not only cases of malingering, butdoubts might arise as to proper treatment, and prac-titioners found it offensive to have anyone callingto inquire about their work. On the other hand, theopinion of a properly appointed expert, who wasnot a rival in practice, might be welcome. Thusthe referee is not merely a referee, but a medicaladviser. As a matter of fact, however, the chiefamount of work done is referee work, the questionbeing the fitness of persons for sick allowance.Out of about 120,000 insured persons fromMarch 1st to the end of October, 554 cases were sentto the referee. The first 500 cases were analysed,and showed that there were 210 males and 290females. The result was that 189 were pronouncedto be fit for work, 170 were not fit, and 104 did notattend, and consequently must have gone back towork of their own accord ; 20 had gone back towork before the notice could be served on them,and 9 proved to be cases under the CompensationAct.The referee only reports whether the patient is

fit or is not fit to work; no details are given. Yethe keeps for his own use many notes concerningthe cases, and these are so stored as to be quicklyavailable for reference. Thus a red tag is affixedto the card of a patient who has been twice. Thetrouble is to get hold of cases early enough, thisbeing due to the difficult position in which themedical attendant is placed. The Friendly Societiesare trying to get back their control over themedical men who attend on their members. Butthe referee works with the practitioners and notifiesthem when their patients have been told to presentthemselves. It would never do to allow the

Friendly Societies to have sole control of the

appointment of the referee, for then his bedwould indeed be one of thorns. As mattersnow stand, the Bristol panel practitioner occupiesa position of enviable independence. He thinksone of his patients is well enough to goback to work, but the latter very much objects.Thereupon, but after the lapse of a few days, thepatient is summoned to appear before the referee.He cannot tell, however, whether it is his medicalman or an inspector from the Approved Societyto which he belongs who has reported him to thereferee. By this method the panel practitionerdoes not run the risk of losing his patient becausehe has refused to give him a certificate that willenable him to remain in receipt of sick pay longerthan necessary.The Bristol referee was paid C50 the first two

quarters of the year; then, as the work becamemuch harder than was at first anticipated, hereceived C72 for the third quarter, but is onlyto have -E62 for the fourth quarter. The excuse

given for this reduction is that as the ApprovedSocieties must contribute to the cost they willtake better care and there will be fewer cases.

Dividing the sums received by the number ofcases seen the referee found that it worked outat 5s. 9d. each case. This raises a big question.Is the appointment of referees going to lower thefee generally paid to consultants-is it going toconstitute a sort of competition against con-

sultants ? Finally, is the Bristol medical adviseror referee going to be maintained in his post ? TheFriendly Societies agree that this should be done,

but when the Commissioners’ scheme is brought tolight it may change the whole aspect of the case.

Reducing the Cost of PresC1’iptions,A great deal of thought and attention has been

devoted at Bristol to the drug bill. Basing theircalculations on experience, it was found that theprescription sheet for one patient must not costmore on an average than 5. The term sheetmeans not one medicament, but all the patient’sneeds-for instance, some pills, an ointment, andperhaps a bandage. If the average cost per sheetis 7td., then the extra 6d. will be absorbed and thedrug bill will amount to 2s. per annum per insuredperson. But in July at Bristol the average costof the prescription sheets was 8d. As this couldnot possibly continue an inquiry was instituted.and good work was at once done in pruning theprescriptions.Then it was discovered that though the panel

practitioners had the tariff before them they failedto appreciate the financial difference between aninfusion and a tincture. Though a much largerquantity of an infusion must be given to get the sameamount of the active agent, it may nevertheless bemuch cheaper. Then there are the minim, drachm,and ounce rates. To escape the proportionatelyhigher minim rate it is often cheaper to prescribe2 drachms rather than 1 drachms, the higher ratebeing charged for quantities under 2 drachms.Thus 16 doses of 7i minims per dose equal2 drachms, or a quarter of an: ounce, and thisamount of a tincture would cost probably ld. Butif only 12 doses of this same tincture are pre-scribed this would only amount to 1 drachms, andbe charged at the minimum rate of 1?., thus.costing half as much again for a quarter less.Then economies could be realised in reducing thequantity of colouring and flavouring ingredients.The following example was given me as to how

the cost of a prescription could be reduced :-

llotv Panel Practice Pays.Perhaps the drug bill is high because there wa

an extraordinary run of patients calling, on the panelpractitioner, especially during the first three wintermonths during which the Act was in force. One

panel medical man assured me that in the course ofsix months he had seen and given advice ta 58 percent. of the insured persons on his list. But thesewere not the worst months of the year. He hadonly been able to make the calculation when the’card system was adopted, so that the figures givencover the period from April 15th, to Oct 15th.Dividing his receipts by each item of medicalattendance, he found he only received l0cb. everytime his services were required. Another panelpractitioner, who had made the same calcula-

tion, was more fortunate, for he received ls. 0per item. Inquiring as to how many women were profitingby the Act, one popular panel medical man, told!me that 30-40 per cent. of his patients were’women. He thought, however, that it was dombtfat

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if poor women got more medical treatment in con-sequence of the Act than they did before it cameinto force. In other large towns this was doubtlessthe case, but at Bristol there was such a numberof charities at the disposal of the poor that it wasnot so likely that the Act would bring to lightpatients who had previously been neglected. Therewere two general hospitals appealing for subscrip-tions by the rivalry of their out-patient depart-ments and extensively advertising the number ofpatients treated. Then there was, he pointed out, acharitable dispensary, employing a staff of visitingmedical officers, and, of course, there were quite anumber of hospitals for special diseases. Now allthis is reduced. The nine visiting medical men ofthe dispensary do not attend to insured persons, butthey attend to uninsured women and children, and Ihave nearly as much to do as before the Act. It Ifhad been calculated that more than one out of Ivery 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 obtainthe medical attendance they needed. The fear isnot so much in regard to the amount of medical.attendance available but rather as to its quality. ,

The Act, more than one practitioner remarked, ’,did not make for quality. It created a stereotypedpractice. The practitioner will not rise becausehis ,patients will always remain 7s. patients.-Formerly, as a practitioner increased in know-ledge and experience, he secured a better class ofpatients. He obtained better paid work, had moreleisure for study, and devoted more time to hispatients. Now the object is to give less time tomore patients. Then the restrictions as to pre-scriptions must be remembered, and no allowance ismade in Bristol for what in emergency cases must,be provided. At Birmingham ls. per quarter andper 100 insured persons is allowed, making J62 perannum for each 1000 insured persons, and not ;E50,.as erroneously stated when speaking of that town.1At Bristol, however, there is no such allowance, sothe only way to get a bandage back is to prescribetwo when but one is wanted for the second dress-

ing, and the panel practitioner then repays himselffor what he had already used.There is a danger that the panel practitioner

will lose prestige, and medical men not on thepanel are seeing daily as private patients insuredpersons. At Bristol some .:B3000 have accumulatedfrom the payments effected on behalf of personswho have not enrolled themselves on a panel list.

They n(t<W ask by what right should a panel practi-tioner receive money from a person who has never.asked for or obtained anything from the panel, buthas paid full fees for whatever medical assistancehe needed. The right of the individual to contractout of the Act is therefore insisted upon in variousquarters .at Bristol.

(To be continued.)

1 I have to regret this slip in my article of Nov. 29th, 1913, p. 1573.-Your Special Commissioner.

WEST LONDON MEDICO-CHIRURGICAL SOCIETY.-The annual dinner of the society will take place on

Thursday, Feb. 19th, at 7.30 for8 o’clock, at the WharncliffeRooms, Hotel Great Central, Marylebone.road, N.W. Duringthe evening the society’s triennial gold medal will be pre-sented to Professor Arthur Keith, F.R.S. Tickets, price’7s. 6d. (exclusive of wine), should be obtained beforehandfrom 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 themedical men in this city and district are con-

sidering renewals of their contracts with theInsurance Committees. In Manchester and Salfordmedical men are paid out of pooled funds for theirservices. In many ’other places the capitationsystem obtains. As a result of conferences betweenall concerned it is proposed to overcome the diffi-culties attributed in Manchester to over-attendanceby a limitation to &pound;800 a year of the income which apractitioner may make out of his insured practicedI am informed that, with a few exceptions, all themedical men whose names were on the panel duringthe past 12 months have signed agreements in-

cluding the proviso limiting an individual incomeearned under the Acts to &pound;800 a year. The list ofdoctors who will serve on the panel for the forth-coming 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. TheManchester Medical Committee have now agreedwith the Manchester Insurance Committee toreduce as far as possible the expenditure of thedrug fund. In future the Medical Committee will

inspect all prescriptions, and if necessary deal withthem under regulations. Any practitioner orderingdrugs or appliances in a manner contrary to theinstructions of the Committee will be asked to

explain, and failing a satisfactory explanationthe cost of such drugs or appliances willbe deducted from the sums payable to himby the Insurance Committee and will be trans-ferred to the drug fund. The Medical Com-mittee have issued to the medical men servingunder the National Insurance Acts a list of in-structions to be observed in prescribing, requiringthat prescriptions must be made as simple as

possible; that medicine sufficient for four or fivedays should be ordered, and only when the practi-tioner is satisfied that a supply is required; thatpractitioners must satisfy themselves that theamount of medicine or appliances prescribed hasbeen used by the patient before a new prescriptionis given; that extract of malt and cod liver oil arenot to be prescribed except in tuberculous casesnotified as such, and these should be urged to applyfor sanatorium benefit ; that ’flavouring agents mustonly be prescribed when required for their medicinalvalue or to disguise distinctly nauseous drugs ; andthat expensive proprietary drugs must not beprescribed.

Salford and its Consumptive Children in theStreets.

At the last meeting of the Salford town council aquestion was asked if it was true that 400 con-sumptive children who are not permitted to attendthe day schools on account of the danger to otherchildren are allowed to run about the streetswithout being adequately cared for. It was

1 For the exact scheme submitted to medical men see p. 214.