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Annotations

THE CAPITATION FEE

LONG before the war panel practitioners repeatedlyasked for an increase in the capitation fees paid underNational Health Insurance. Their carefully preparedcase was shelved in 1939, but the necessity for reassess-ment of the fee has never been forgotten. During thewar the payment for each insured person was increasedfrom 9s. to 10s. 6d., but much of this increase was toallow for the higher expenses of practice, and some ofit, the recipients were told, was meant to compensatefor the inclusion (without prior consultation) of the£250- £420 income-group in the health insurance range.The increase is widely felt to be trivial, indeed non-existent in view of the change in the value of moneysince 1939, and many practitioners are working undera strong sense of injustice. Latterly, when the InsuranceActs Committee voiced this feeling, it was told that

nothing could be done until the Spens Committee.

reported. On the appearance of the report, therefore, anew approach was made to the Ministry ; and the

resulting correspondence between the Minister and theLA.C. has now been published.

Apparently an impasse arose early because the Minister,not unnaturally, wished to discuss at the same time theremuneration to be offered to practitioners in the NationalHealth Service which will supersede National HealthInsurance in April, 1948. This the LA.C. refused, havingneither the mandate, nor the inclination, to considerthe more permanent arrangements. One of the reasonsfor its attitude was no doubt that the Minister’s plansfor medical remuneration (as set out in the white-paperon the Bill) include basic salaries and variable capitationfees-proposals which are foreign to present insurancepractice and are probably unwelcome to the majorityof the profession. But even though the I.A.C. has beenunable to secure the limited negotiations which it sought,it has at least won an important pronouncement fromMr. Bevan, which he had hitherto refused to make,despite repeated demands in Parliament. It has obtaineda firm statement of his views on the Spens report :" the Minister desires to make his attitude to that

report quite clear. He fully accepts the substance of therecommendations of the committee in their majorityreport." This statement means in effect that the figurefor capitation fees in the new service will be based noton an adjustment of past capitation fees but on therange of incomes suggested by the majority of the SpensCommittee-translated into post-war money.Meanwhile the Minister has also, by accepting the

Spens verdict, tacitly agreed that panel doctors havebeen, and are being, inadequately paid. Having failedto secure the general discussions which he on his sidewanted, he offers, for this- intermediate period, what isno doubt a smaller sum than negotiations would haveobtained : he is willing to pay an extra 2s., making atotal capitation fee of 12s. 6d., from Jan. 1 of this year.To this the LA.C. replies that 12s. 6d. is "gravelyinadequate." It says that it would be willing to recom-mend acceptance of an interim fee of 15s. ; ; or, ifthe Minister prefers, would accept arbitration bythe Spens Committee, whom it now suggests " shouldbe asked to state the implications of its majorityreport in’relation to the current insurance capitationfee."

There at the moment the matter stands, awaiting theMinister’s reply. It will be a pity if no acceptable solutioncan be found, either by negotiation or some form ofarbitration. The preparations for a new era in medicineought not to be marred by the persistence of the sense offrustration and injustice engendered by unsatisfactoryhandling of the problems of an old and passingday.

RADIO-ACTIVE IODINE IN TOXIC GOITRE

IODINE was one of the first elements to be made radio-active artificially (in 1934), and for some years experi.ments have been in progress in the U.S.A. to determineits effects on the thyroid. It is known now that in apatient not under the influence of iodine 80% of a doseof radio-active iodine is taken up in the thyroid within ashort time of ingestion. It there gives off rays whichgenerate high-speed electrons, and these affect neighbour-ing tissues to a distance of a few millimetres. Thiseffect is the same as that ultimately produced by X rays,but the internal radiation has two advantages in that itdoes not have to penetrate the skin and other overlyingtissues, and that it is probably distributed evenly through-out the gland. Theoretically therefore radio-active iodineshould produce better results in toxic goitre thanX-ray therapy, which in the opinion of most clinicianshas not been a success, and this is verified by recentclinical reports.! The radio-active iodine is taken bymouth within a few hours of its preparation, as an almosttasteless liquid. Occasionally there are slight toxiceffects, including pyrexia and nausea for a day or two.The patient must have taken no iodine for several weekspreviously.

Of the 51 cases reported in the two papers it is claimedthat four-fifths were restored to normal, the basalmetabolic rate falling to normal in one to five months,and the gland shrinking in many cases to normal size.Fibrosis is produced in the gland by this method, as shownby biopsy. In 9 cases hypothyroidism or myxœdemaresulted, though in 5 this occurred only after a subsequentthyroidectomy, and in 2- of the others the B.M.R. rose

spontaneously to low normal levels. The dose of radio-active iodine is calculated in millicuries, and the strengthrequired is proportional to the size of the goitre. Mostof the patients required only a single dose, but othersrequired two or three. These results are so good thatmany British workers will hope that radio-active iodinewill soon be available here so that they can confirm them.The method has the advantage, from the patient’s pointof view, of extreme simplicity, and apart from thepossibility of myxcedema it seems to be free from risk.

MENTAL ILLNESS AND SCOTTISH LAW

EARLY treatment offers the best hope of cure in manyconditions, but is nowadays of special importance inmental illness, since many modern therapies give theirbest results only in the early stages. The laws devisedin the past to guard the patient’s interest may nowsometimes prove a handicap to him if they deter hisfriends from seeking proper treatment for him at theoutset. In Scotland, laws concerning the, mentally illand defective are contained in a series of Acts, the mostimportant being the Lunacy Act of 1857, the AmendmentActs of 1862 and 1866, and, the Mental Deficiency andLunacy Act of 1913. The committee, under the chair-manship of Lord Russell, of the Scottish Court of Session,appointed in 1938 by the Secretary of State for Scotlandto inquire into these laws, have- now published theirreport 3 ; and they lay great weight on possible causesof delay. Voluntary desire for treatment has been

recognised as important in Scotland ever since 1857, whenthe Royal Lunacy Commission recommended statutoryprovision for voluntary patients. Local authorities have

1. Hertz, S., Roberts, A. J. Amer. med. Ass. 1946, 131, 81;Chapman, E. M., Evans, R. D. Ibid, p. 86.

2. The committee was constituted as follows : Lord Russell,chairman; the Hon. Mrs. J. E. Hamilton ; Prof. D. K.Henderson, F.R.C.P.E. ; Sir James Irvine, F.R.S. (resigned1938) ; Air. William Leonard, M.P. ; Sir Basil Neven-Spence,F.R.C.P.E., M.P. ; Mr. W. D. Patrick, K.C. ; Lord ProvostJohn Phin ; Bailie Violet Roberton ; Prof. T. M. Taylor(resigned 1944) ; Dr. A. G. W. Thomson ; Mr. George Andrew.The secretary was Mr. J. A. W. Stone.

3. Report of the Committee on the Scottish Lunacy and MentalDeficiency Laws. Department of Health for Scotland. Edin-burgh : H.M. Stationery Office. Pp. 131. 2s.

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no statutory duty to aid such patients, but of late yearssome of them have encouraged suitable patients to enterhospital voluntarily by giving them aid from the rates ;and on Jan. 1, 1946, of 2081 voluntary patients in Scot-land, 374 were rate-aided. That good use is made ofthe provision for voluntary treatment is evident from thefact that, in 1945, out of 4132 admissions to mental

hospitals 1945-nearly half-were voluntary. As thelaw stands, no-one can be admitted as a voluntary patientif his mental condition is such that certificates of insanitycould legally be granted in his case. In practice, it seems,this requirement is not always met, patients sometimesbeing admitted on a voluntary footing even when theymight legally be certified. To get over the difficulty, thecommittee recommend that this part of the law shouldbe redrafted on the lines of the English Mental TreatmentAct of 1930. Prof. D. K. Henderson dissents from thison the ground that, in Scotland, once a patient hasentered a mental hospital voluntarily it has been cus-tomary to let him remain there on that basis regardlessof the progress of his illness ; and that this has provedbeneficent. Merely to accept the English pattern, hethinks, " would convey a very limited benefit to our

patients, and much confusion and irritation to those whowere responsible for administering the Act." Certainlymany with experience of the English Act would feel that,-though it safeguards some of the patient’s interests, it

disregards others. The committee were unanimous,however, in emphasising that, as far as possible, com-pulsory detention should be applied only where thepatient is unable or unwilling to give his consent totreatment. This granted, they hold that procedurefor the admission of people to mental hospitals needssimplifying.

In their study of the mental-deficiency laws thecommittee rejected the suggestion that mental deficiency,like lunacy, should be made a plea in bar of trial. Pro-fessor Henderson, who seems to have had trouble in

persuading his fellow committee-members to share someof his views (he is responsible for all five reservations tothe report, being joined in the last by Lord ProvostJohn Phin), again dissented, arguing that, owing to theirdeficiency, mental defectives are not so well able tocontrol their thought and actions as the better endowed,and in fact never have a normal appreciation and under-standing of the disordered act. When an accused personcan be unequivocally classed as a mental defective, ofwhatever grade, Professor Henderson holds that a pleain bar of trial should be sustained-a view which many ofhis medical colleagues will share. The committee con-cede that where mental defect is proved it should be abar to a punitive sentence; and that any mental defectivecommitting a criminal offence should be sent not to

prison but to an institution. They recommend that anew State institution should be built for mental defectivesof a criminal or violent type, and that a central index ofmental defectives should be set up, so as to ensure thatno mental defective is sent to prison. For adolescents

showing unstable behaviour, " whose mental capacityand conduct touch only the fringe of insanity or mentaldefectiveness or criminality," new legal provisions arerecommended, to bring them under training or super-vision in a colony or institution in which they will bestudied and treated medically and psychologically, witha view to helping them to become useful citizens.The committee are anxious to see mental health

divorced from the scope of the poor-law. The provisionsfor dealing with dangerous lunatics are in the 1862 Act,and authorise a procurator-fiscal or an inspector of thepoor (now a public-assistance or welfare officer) to applyto the sheriff for appropriate action in the interestsof the public, and the sheriff may then commit the

patient-to a mental hospital to be detained until curedor until " caution shall be found for his safe custody."

These provisions are not limited to pauper lunatics, butare applied to any person found by the sheriff, on inquiry,to be insane and dangerous, even though he is not

receiving parish relief or otherwise coming within thedefinition of a pauper. No such stigma attaches to theperson who needs help on account of physical illness,and it seems likely that this provision, perpetuatingthe association of mental illness with the poor-law, hasoften caused delay in treatment of the patient, therelatives naturally being reluctant to have him classedas a pauper lunatic. The committee recommend thatmental health should be removed entirely from the scopeof the poor-law, and that lunatic wards of poorhousesshould be closed down as soon as accommodation inmental hospitals can be sufficiently increased.

Professor Henderson dissenting, the committee decidedthat a study of the position of the mental-health serviceunder the National Health Service scheme was notcovered by their remit, but they express a hope thatfuture administration will safeguard the interests ofmental health and mental patients, and that there willbe a special department of the central health authorityto deal with them.

MEDICAL CARTOGRAPHY

THE value of the familiar spot maps that commonlydecorate the walls of administrative health offices

depends largely on the efficiency of the methods of diseasenotification and collection and correlation of data. The

unreliability of the human factor, in diagnosis for

example, must also be respected. Thus, in the M.E.F.during the war, as soon as sandfly fever was declareda notifiable disease its " incidence " fell dramatically,but many more cases of "

coryza " were diagnosed.Nevertheless, the American Geographical Society believesthat when a geographer rather -than a medical manbrings his endeavours to bear on medical maps hecan show that the influence of environment holds thekey to understanding or control of at least some humandiseases. The society proposes 1 to produce an atlasof diseases; and a geographical analysis of the distribu-tion of fluorine in the water-supplies of the UnitedStates has already been undertaken.2 This subject hasbeen selected because of the relationship of dentalhealth to the fluorine content of drinking-water, and thegrowing public interest in its importance. Outstandingwork on this relationship has been done in the U.S.A.by H. T. Dean, and he has been chosen as consultant forthe investigations necessary to the production of theatlas. The maximum fluorine content known for eachcounty forms the basis of the map and on this has beenplotted, as a regional pattern, the distribution of fluorineby joining values of stated fluorine concentrations byisolines. The sanitary engineers, health officers, and

geologists of every State are said to have cooperatednobly by collecting and providing statistical information,but the difficulties of the undertaking were still weighty.Incompleteness of data was one of the major problems.For example, before 1932 no attention was given to thefluorine content of water-supplies in the U.S.A., andeven today the fluorine test is not universal in wateranalysis. Again, the fluorine concentration in waterfluctuates widely during the year ; other factors requiredfor mapping are also subject to local variations-e.g.,depth of wells and nature of rock strata. The map givesno information on the nature of individual water-suppliesand the number of people affected by them. Thus, themap is not free from defects as an instrument of scientificresearch and a practical expedient in epidemiologicalstudies.

,

The American Geographical Society has furtherchosen ten diseases for representation in the new atlas :

1. Light, R. U. Geogr. Rev. 1944, 34, 636.2. van Burkalow, A. Ibid, 1946, 36, 177.