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PANEL AND CONTRACT PRACTICE

A Discussion on Insurance ProblemsA CONFERENCE between representatives of approved

societies and representatives of the medical profes-sion was convened by the London insurance com-mittee and held at the County Hall on Oct. 5th.There were 16 representatives of approved societieswho were members of the insurance committee andfour others. The London panel committee sent20 of its members, many of whom had never beforemet any of the members of the insurance committee.The chairman of the insurance committee said hewas sure everyone had come to try to help on theadministration of the Act, to try to see the otherman’s difficulties, and to do what he could to helpto avoid them. Sir Thomas Neil also spoke in thesame sense.

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MARRIED WOMEN AND PREGNANCY

The first subject of discussion was certificationof pregnancy and other problems involved in themedical certification of married women. The approvedsociety representative said that many women comeup for a certificate because they think they shouldnot have to work during pregnancy; others becauseemployers refuse to employ them when pregnant;others, again, because their appearance is abnormal.He asked doctors not only to resist certification onthese grounds but also to stick to the legal criterionof whether the woman is incapable or not withinthe meaning of the Act. The patient’s occupationwas of course important; many of them could notdo their usual work but could do their housework.Could that be considered as a temporary alternativeoccupation ? It would help societies if some periodof gestation, or the date of expected confinement,could be put on the certificate, with a statementwhether there was any associated abnormality, suchas varicose veins. Societies were not anxious torefer such cases to regional medical officers, forreferences pleased nobody.The answer from the medical side was that the

certification of pregnancy was causing more difficultythan anything else ; no two societies treated theircases alike ; some referred every case, some alwaysallowed a month’s sick pay without hesitation.There were cases in which pressure was put on thedoctor to grant a certificate by agents of societiesas well as by relatives or friends. Nobody-doctor,patient, or society-really knew where they stood.A suggestion was made that there might be a

pregnancy benefit for every pregnant insured persondating from a specified time, such as four or eightweeks before confinement; or alternatively there

might be an increase in maternity benefit ; but no

pregnant woman should then be entitled to sicknessbenefit for pregnancy, or for any complication arisingout of it. It was also pointed out that doctors differabout the desirability of rest. That part of the

Ministry which dealt with sickness benefits formarried women issued pamphlets on capacity towork when pregnant which were very differentlyworded from those issued by the part of the Ministrywhich dealt with infant welfare. The latter stronglyadvocated rest, and sick visitors were sent to insiston it if possible. There were professional difficultiesabout putting the period of gestation on a certificateform, not excluding the possibility of resultant

proceedings before the medical service subcommittee.There was not so much discussion of the certi-

fication of married women in general, but in reply

to one suggestion that married women should notbe insurable at all it was pointed out that one ofthe principles of the Act was that any wage-earnershould receive recompense if he or she becameincapable of work through illness. Another proposalwas that doctors should be asked to certify whethera woman was fit to do housework. This is frequentlydone by regional medical officers but never by theinsurance practitioner..

CERTIFICATES ON A PARTICULAR DAY

The next discussion was introduced by the medicalside, on the demand for certificates on a particularday of the week. The speakers said they realisedthat in some areas the agent had many miles totravel, and it was convenient for him to get thenew certificate on the day he paid out sick pay.But was the system of book-keeping so inelastic thatthese agents must pay up to the full week t Thedemand was impracticable from the doctor’s pointof view ; it led to waste of time and even of medicine,for the patients often asked for a new bottle whenthey came for a certificate, and wasted the remainsof the old bottle in order to get a refill. The replyfor the societies was that each day was very importantfinancially, and yet about 40 per cent. of people" declared off " on Saturday. The pay day at theend of the week originated with the old friendlysocieties, to enable their members to get moneyfor their Sunday dinner. Agents were dealt with

firmly if evidence in writing could be obtained show.ing that they had demanded certificates on a parti-cular day. It was thought more use might be madeof that part of the certificate which says, "Youshould come to see me again on ...."

NATURE OF INCAPACITY

From the next discussion it appeared that whatthe societies want is an indication, as early as possible,of what is the matter with the patient-chiefly,it seemed, so that compensation might be obtainedwhere it is due. Incomplete information puts thelay official in a difficult position, and practitionerswere asked not to rely too much on a patient’sstatement as to the cause of his illness. One casewas certified as gas poisoning on the patient’s state-ment, yet on investigation it was found he did notwork in or near gas. The other instances given werenot happy from the societies’ point of view, for thecertificates contained quite clear medical indicationsof the sequence of events. The societies’ repre-sentatives pointed out that venereal disease is knownto occur among a number of workers, but is hardlyever mentioned on a certificate. The medical replyto these criticisms were, first, that alteration of

diagnosis on certification led the society to thinkthe doctor was doubtful; hence the original diagnosiswas often persisted in. Secondly, doctors were

not detectives and often had to accept a patient’sstatement, e.g., as to where he was working. Thirdly,most patients with venereal disease got free treat-ment from a clinic or else went to another doctor;moreover these diseases were not as a rule incapacitat-ing. Both sides agreed that very little use was nowmade of the special certificate form Med. 40 D whichenables a practitioner to state less precisely on thecertificate the cause of incapacity. This, of course,goes to the local agent, but when it is used the doctorhas also to write to the regional medical officer givingthe facts of the case. Both sides, again, attackedthe Ministry about its suggestion in a memorandum

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that cases of catarrh, gastritis, menorrhagia, andother disorders should be referred as soon as possibleto the regional medical officer ; but it was

subsequently pointed out by a representative of theMinistry that this procedure was advised only if thereport of the sick visitor was unsatisfactory.

CONTROL OF SICKNESS BENEFIT

In the last discussion the opening statement ofthe societies’ representative showed the extent of thecontrol of sickness benefit in an ordinary case. Thedoctor’s certificate practically amounts to a chequeon the funds unless the member’s record is bad orunless something suspicious happens-in which casethe patient is sent to the regional medical officer.Claims are still excessive, and the cooperation of theprofession was asked to find ways and means to stopthe loss. Another speaker pointed out that 613doctors in London, out of 1983 principal doctorsunder agreement with the committee, have lessthan 250 patients each on their list. These menwere not likely to have much knowledge of, or interestin, the Act, for the bulk of their practice was notconnected with it, and consequently they mightinadvertently contribute to excess claims. Anotherapproved society member had investigated claims

among 10,000 of compulsorily insured persons in1932. There had been 1816 claims-i.e., just over18 per cent.-and if repeat claims were includedthe proportion was 21 per cent. In the old dayspeople were aghast at 9 per cent. claims. Comparingthe compulsorily insured with the voluntarily insuredin the same society there were 9 per cent. moreclaims by the former. It was thought that the

voluntary member has a greater sense of responsibilityand therefore less pestering incapacity, though heis not less subject to illness than the State member.Another society member thought it would help

if certificates showed whether they were given athome or at the surgery ; he thought there was anincrease in short claims. Why were different formof words used by the regional medical officer and theinsurance practitioner ? ’? The former says " notincapable of work, the latter says " fit to resume " ;they hardly meant the same thing. The time mightarrive when, as in Germany, the patients had to payfor their first attendance or for medicine.

In the course of medical replies it was pointed outthat certification had a bad start under old club

system, where, however, members looked better aftereach other and did not feel that there were unlimitedfunds to draw on. Certification was much betterthan it was.

THE POSSIBILITY OF ACTION

Having dealt with only four out of ten items onthe agenda, the meeting adjourned after a short

speech by Dr. William Duncan, a divisional medicalofficer of the Ministry of Health. The Englishsystem, he said, was very good when the rules werefollowed, and it had been largely copied in othercountries. Both sides had said they would like todeal with each other directly : how different it hadbeen in 1912 when the profession would have nothingto do with societies at all !

It will be observed that many interesting and attimes new suggestions were talked over in a friendlyway. The question arises as to how results can beobtained. A conference has no locus standi, andmust therefore set up some body or refer the pointsto some committee that can take action. The mainnegotiating committee for the medical side of contro-versial questions is the Insurance Acts Committee.The approved societies have more than one negotiating

body, but probably the National Association ofInsurance Committees would be their strongest andtheir most representative body. It is probablethat this conference will refer all matters fordiscussion first of all back to their own respectivecommittees-the panel and the insurance committeesfor London. These have a joint consultative com-mittee, and if an agreed proposition could be obtainedit would then go to the Insurance Acts Committeeand the National Association for their approval witha view to incorporation in regulation, if approvedalso by the Ministry.

The UnemployedAt a meeting last week the Middlesex insurance

committee decided to oppose any proposal for retain-ing under the National Health Insurance schemethose who have fallen into arrears by reason of

unemployment. It was argued that the unemployedhad been secured in their right to medical benefitwithout payment of contributions for at least threeand a half years, and that this concession was a

departure from the principles of the Act. If it werepersisted in it would inevitably lead to reduction ofbenefits to those who did pay their contributions.The alternative was a special subvention to theNational Health Insurance Fund, for which, thecommittee held, there was no justification. No hard-

ship, it was suggested, would be inflicted on thoseaffected if they had to seek medical benefit throughthe public assistance committees, inasmuch as manymore had to look to the same source for such help.The number concerned, estimated at 80,000, did notjustify a departure from the vital principle thatbenefits depended on the payment of contributions.One speaker, however, urged that medical benefitshould be continued to the unemployed so that whenthe depression lifted-perhaps in two years’ time-more of them would be physically fit to take upemployment.

The Future of Health InsuranceThe possible extension of benefit to the dependants

of insured persons was the topic which aroused mostinterest at the twenty-first annual conference of theScottish Association of Insurance Committees, heldat Aberdeen on Sept. 29th and 30th. Mr. A. Clark,in his presidential address, said that in certain quartersthere was a growing feeling that the ultimate solutionwould be found in what was called an " all-in "

insurance scheme, embracing the whole range of socialinsurance. The subject was vast and complicated,but a survey of the international position led to theconclusion that although social insurance was nowalmost universally recognised it was far from havingattained its maximum force. Curiously enough,however, even during the period of persistent unem-ployment the number of insured persons in Scotlandhad been steadily increasing. The past eight yearsshowed an increase of 240,000, and the total numbernow entitled to medical benefit was 1,904,000, whichwas equal to 40 per cent. of the whole population.In any extension to dependants the receiver of thebenefit ought to pay for it; the employer alreadybore a sufficient share of the burden by contributingtowards payment of the workman’s premium. The

probable number of dependants was at least equalto the number of the insured, and assuming that theinsured persons and their dependants account for80 per cent. of the total population, the benefitsof the panel system ought to be extended yet furtherso as to include, first, the legal poor, including thedestitute able-bodied unemployed, estimated at5 per cent. of the population, and, secondly, that

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large class of shopkeepers, artisans, and others whoare at present without the benefit of insurance,although their economic position may be no betterthan that of the insured.Whether this new benefit should be on a com-

pulsory or on a voluntary basis is a matter for argu-ment, said Mr. Clark. It was agreed, however,that the general practitioner scheme must be extendedso as to provide hospital treatment and specialistservices. The demand had become clamant, and was

only partially met by the voluntary hospitals and thevarious contributory schemes now in existence.Under a complete coordination scheme the servicesof panel doctors could be utilised to a far greaterextent than at present in discharging various dutiesunder the Public Health Acts such as those connectedwith nursing, tuberculosis, child welfare, and schoolinspection, much of which is now done by speciallyappointed officials. The family doctor would thusbecome an important worker in general public health.

CORRESPONDENCE

LETTERS BETWEEN CONSULTANT ANDPRACTITIONER

To the Editor of THE LANCET

SiR,—I do not know Mr. C. Robinson, the rhino-logist to the Loamshire Hospital, but I think it is

rough luck on him that you should pillory his badreport on a case by publishing it (Oct. 7th, p. 837),especially when it is clearly stated to be confidential.

I wonder whether it is a coincidence or by intentionthat out of the thousands that must now be availableyou choose a letter in reply between family doctorand consultant which illustrates one of the disadvan-tages of this form. It is possible that the nose rivalseven the abdomen to-day as an area of the body onwhich unnecessary operations are performed, and thegreatest cause of this is that they are advised withoutdue consideration. It is very rarely that we shouldplump for operation on the nose at a single examina-tion, or without seeing first how much relief can beobtained by some applicational or general treatment.The conditions under which we work in London atrhinology and otology tend to compel us in thatdirection. We cannot have the patient up daily orseveral times a week for some treatment that cannotbe applied by the family doctor or by the patienthimself, but needs the attention of a junior assistantor specially trained nurse working under the super-vision of, or instruction from, the chief of the clinic.This class of work is best seen in a small centre suchas Munich, and is very difficult to follow out in

London, with the result that we all tend to adviseoperation against our better judgment at the firstexamination of the patient, instead of seeing himonce or twice more first. This is particularly liable tohappen in cases of suspected sinus disease sent up bya doctor, because in a busy clinic it is so hard toremember to send him the second note when theinvestigation is concluded ; and then the patientdrifts into that group of cases coming up weekly orfortnightly, having the medicine and treatment

changed, and being converted into the chronic invalid.These cases are just as worrying to the head of theclinic for their presence as they are annoying to thefamily doctor for their absence.

Mr. Robinson is evidently young. Otherwise hewould have known that he should have given Dr.Smith the opportunity of disagreeing with theoperation before making arrangements for thepatient’s admission. It would have been better hadhe added the words " subject to your approval."Two things, however, show him to be a good fellowand therefore worth the trouble of this letter. Hemakes his decision as a result of anterior rhinoscopy,and not by a guess after transillumination andradiography, and he crosses out the Sir/Madam ofthe form and puts in Dr. Smith’s name. The personaltouch between practitioner and consultant is of valueto the patient, and tends to be lost by the use of

these forms instead of the old-fashioned notes. MayI suggest that when they are reprinted a row of dotsreplace the Sir on one side and the Sir/Madam on theother. Incidentally, why not Sir/Madam on both.Are we to assume that the panel committee forLondon does not require the woman consultant ? f

I am, Sir, yours faithfully,London, W., Oct. 7th, 1933. T. B. LAYTON.

TUBERCULOSIS OF THE LARYNX

To the Editor of THE LANCET

SiR,—On reading in your issue of Sept. 23rd thereport of the discussion at the B.M.A. meeting inDublin on Tuberculosis of the Larynx, I find myselfin entire agreement with the remarks of Dr. F. R. G.Heaf, but must differ from the statement attributedto Mr. H. S. Barwell. He is reported as saying"that the high altitude of Swiss resorts made theseunsuitable for laryngeal cases, which in the earlystage might give rise to no symptoms."

It is, of course, possible that a fuller account ofMr. Barwell’s paper would show some qualificationof this assertion. As it stands, however, it is directlyopposed to my experience and to that of the Swisscolleagues with whom I have discussed the matter.It is certainly contrary to the opinion of our visitingconsulting laryngologist, Dr. 0. Gentinetta, of Sierre,who, for nearly ten years past, , has followed thecourse of laryngeal tuberculosis in hundreds of

patients, both in the Rh6ne Valley and at Montana-a difference in altitude of approximately 3500 feet.Dr. Riiedi, the well-known laryngologist of Davos,who has had exceptional opportunities of observingresults in this complication of pulmonary tuberculosis,should be able to disprove authoritatively the reportedaccount of Mr. Barwell’s views.

Since Montana Hall was opened at the end of 1930,excluding those at present in residence, 29 patientswith laryngeal tuberculosis have been treated here.In 13 of these the disease appeared clinically healedon or before discharge. One of these developedlater intestinal tuberculosis, with aggravation ofthe pulmonary condition and subsequent death, butthere was no recrudescence of laryngeal activity.This is in conformity with Dr. Heaf’s observations.In eight patients, on departure, the disease in thelarynx was improved but not yet completely healed.In two advanced pulmonary cases the laryngeallesions remained stationary. In three very advancedcases, all of whom died after leaving this institution,the laryngeal disease was worse, and the three

remaining patients died in the sanatorium shortlyafter arrival. With regard to those patients whodid badly all were sent here in a toxic state, andwith extensive and destructive lesions of the lungs.They would, in my opinion, have done equally badlywherever treated.

Fishberg, with his vast experience of the effect