403

Sir Holburt Waring proposed the toast of the

guests, reminding them of the. personality of Martinyan Butchell, whose caricature they had seen inBeaumont’s sketches, and whose mummified wifewas in the College Museum. He coupled with thetoast the Speaker of the House of Commons.The Speaker suggested in reply that his presence at

a dinner of surgeons might be due to a conspiracy,for he knew that there were some 600 Members ofthe House of Commons who would like to havean operation performed on his eye. But if anysuch operation were contemplated he thought that

Ithere might be difficulties, because each of the 600Members would demand that the organ should bemade to point in a different direction.The Rev. Dr. Nairn, Headmaster of the Merchant i

Taylors’ School, proposed the health of the Hunterian IOrator, explaining that he did so from the point ofview of personal regard as well as from that of admira- ’,tion of the Orator’s talents, as not only was Sir D’ArcyPower educated at the Merchant Taylors’ School, buthe had sent two of his sons to follow him at thatinstitution. Sir D’Arcy Power, having briefly replied,the company were invited by the President to visit thevarious departments of the College, where greatinterest was expressed in a new portrait lent for the ’,occasion by Mr. Buckston Browne.

A New Portrait of Hu?tter? ?The portrait is attributed, probably with good ’I

reason, to Gainsborough. This is a John Hunterentirely different from the dreamy and noble por-trait by Reynolds, or from the pawky but admittedlyexcellent profile by Holland, yet strikingly like theHunter in a brown coat hanging in the outer hall ofthe Royal College of Surgeons of England. The upperpart of the face, with slightly tilted left eyebrow,and tilted leftward more in the alleged Gainsborough,is fairly identical with the same feature in thebrown Hunter. The right eye in each portraitshows a slight squint. The brown Hunter has akeen brown eye, the Gainsborough a dull grey eye.Moreover, the lower part of the Gainsborough faceis full; nothing suggests the concave conformationof the jaw. Have we indeed here a portrait of IJohn Hunter, physician, the great Hunter’s contem-porary, known for his excellent treatise on anthro- Ifpology and his books on military hygiene in Jamaica ?The Gainsborough man points at the skull of agreat ape, but Doctor John Hunter as an anthro-pologist might have done so, quite as much as John ’,the snrgeon.

___ IPROCEEDINGS OF THE

ROYAL COMMISSION ON NATIONALHEALTH INSURANCE.*

THE PROVISION OF MEDICAL BENEFIT.

Evidence by Mr. Brock and Dr. Smith Whitaker(continued).

Records of Illness. I(App. C. 71-81.) The form of record of illness which ’ I

every insurance doctor is now required to keep isbased on the recommendation of a DepartmentalCommittee presided over by Sir Humphry Rolleston.It provides for a continuous record of an insuredperson’s sickness and is passed, when he removes, tothe doctor in his new district. (Q. 1214, 1215.) TheCommittee considered that the object of helping thedoctor in the treatment of a case was paramount, butthe record is also intended to serve useful statisticalpurposes. It has never been considered that it would

* In previous articles the proceedings of the Commission werereported under the following headings : Introductory Note ;The Scope of the Insurance Scheme (see THE LANCET, Jan. 31st,pp. 247-8); The Provision of Medical Benefit (Feb. 7th,pp. 301-3; Feb. 14th, pp. 355-6). References to the officialstatement which has been issued as an appendix in four sectionsare given thus : Section A, para. 69, is shown as "App. A. 69,"and references to the oral evidence thus—Q. 1369.

be possible, consistently with having a continuousrecord kept by the doctor, to gather up all the recordsperiodically and make a general statistical analysis,but sample investigations are possible, and to somesmall extent-up to the present-this has been done.

(Q. 1243.) In reply to a question it was stated thatofficers of the Ministry could, if required, make a

limited investigation for the purposes—e.g., of theIndustrial Research Board. A further questionrelated to the possibility of a limited number ofdoctors keeping fuller records for the purposes of aspecial investigation. As to this, it was stated :-

(Q. 1288.) We derived some assistance of that kind in theRheumatism Inquiry. There was very little satisfactoryinformation as to the existence of different types of rheu-matism, and, guided by the way in which the records werekept, practitioners were selected whom we could regard asreliable men to keep a special record with regard torheumatism. Forms were issued to them and they kept arecord of all cases treated within twelve months of anykind of condition that might broadly be called rheumatic.Those returns were of great value.

How the Records are Being Kept.(Q. 1282.) When the present records were first

started some difficulties were experienced in gettingthem properly kept; these difficulties were attributedby the witnesses to inexperience, to the agitation bysome people against the records, which prejudicedthe doctors against them, and to the natural reluctanceof most medical men to do any clerical work that theycan avoid. (Q. 1285.) The regional medical officersof the Ministry, who have the duty of examiningrecords, all report a changed attitude on the part of thegeneral body of practitioners towards the records.A large number of doctors say that they find therecords helpful both in the treatment of cases whichhave been in their hands all through and in the treat-ment of cases that come to them from other doctors.

Size of Doctor’s List-Number of Services Rendered.(Q. 1219-1225.) The witnesses were asked to say

on the basis of a list of 2500 insured persons how manypatients a doctor would see in the course of a day’swork. They said that on the 1923 figures it was foundthat a doctor saw about 50 per cent. of the persons onhis list. On the average, actual patients are seenseven times, so that the doctor has to render 3’5services per annum for each person on his list. Witha list of 2500, this works out at about 29 servicesa day. Of these 29 services, probably eight in anurban area would be domiciliary visits; the remaining21 would be surgery attendances. Taking a normalurban practice a doctor could do between three andfour visits an hour. As regards surgery attendance,of those 21 persons attending at the surgery on theaverage, only three are coming for the first time, and,therefore, may be expected to require a fairly carefulexamination ; the remainder are coming back eitherto report progress, or to ask for another bottle ofmedicine, or to obtain a sickness certificate, and thosecases can be worked off pretty rapidly. If an hour isallowed for the three new cases, the others couldprobably be worked off at nine or ten to the hour.These are average figures, and only true of urban

areas. In rural areas the proportion of visits toattendances is quite different.The following figures as to the sizes of lists in

England and Wales are of interest-35 per cent. ofthe total have lists of 600 or under, 30 per cent. havefrom 600 to 1200, 21 per cent. have from 1200 to2000, and only 14 per cent. have more than 2000.Of that 14 per cent. a majority, probably the greatmajority, would be men who employ an assistant.As a broad generalisation, it was stated that thedoctor with a big list was the subject of fewer com-plaints than the doctor with a small list.

Prescribing and Dispensing.(Q. 1311.) The Acts provide that insured persons are

entitled to " proper and sufficient medicines." Thequestions that have arisen have turned partly on

whether particular substances were or were notmedicines. Questions of this kind are those in which

404

common sense seems to meet the matter completely.No such cases under the Act have been put toformal test. The bulk of the questions that arise,however, are those under the Regulations relating toexcessive prescribing. (Q. 1333.) The departmenthas never at any time attempted to dictate to doctorswhat they should or should not order. The questionhas always been referred, in the first instance, to thelocal Panel Committee, and it is they who haveconsidered as a medical question whether the thingsordered in a particular case did or did not exceed whatwas reasonably necessary for treatment. If the doctorwas not satisfied with the decision of the InsuranceCommittee, based on that expression of opinion bythe Panel Committee, he had a right of appeal to theMinistry.

In order to reduce the number of cases arising forformal investigation, and to examine the generalcauses for the recent large increase in expenditure ondrugs for insured persons, the Ministry has beenengaged through its officers in an investigation.

(Q. 1316.) No disciplinary action, however, has beentaken under the new arrangement. It has been

thought more expedient to begin by a comprehensive Iinvestigation of the causes of high cost, and the

regional medical officers are only employed at presentin interviewing the doctors and ascertaining fromthem the reasons for prescribing of which the costappears high.

A uthority for the Regulations.(Q. 1392.) The powers of the Commissioners to make

regulations to check excessive prescribing were testedin the courts as early as 1915, and the regulations wereheld by Mr. -Tustice Rowlatt to be within the powersconferred on the Commissioners. The judge statedthat :-

Experience shows that to carry out the Act you musthave some check on extravagance, and that is what thisrule was made for. In effect it says that if a doctor prescribeswhat is extravagant he must pay for it himself.... AnAct of this kind ought to be construed liberally. The diffi-culties which emerge in the administration of an Act ofthis character are exceptionally great, and I ought to lookat it in a practical way and construe the power with liberality.The making of this regulation, which certainly is a mostbeneficial one if properly administered, is well within thepowers conferred by the Act.

Panel Drug Not Inferior.(Q. 1333.) On the question whether there was

ground for the suggestion that insured persons weresupplied with inferior medicines, the witnesses saidthere was no foundation at all for it. The departmenthas repeatedly drawn attention to the fact that alldrugs and appliances should be made available toinsured persons which, on a liberal view, may beconsidered to be reasonably necessary for the efficienttreatment of sick persons, and that full scope should beafforded for the exercise by practitioners of proper Iindependence of judgment in the treatment of theirpatients. In a circular of May, 1924, the Ministerdeprecated any cheese-paring economy or the stereo-typing of methods of prescribing, while at the sametime pointing out the importance of avoiding waste andextravagance.

(Q. 1353-5.) As to stock mixtures, most PanelCommittees now draw up formulae of preparations thatthey believe the doctors will frequently want tosupply, and which are not likely to deteriorate withkeeping if made up in bulk; and chemists are

encouraged to keep those ready made up in stock forreasons of economy. This has given rise to thesuggestion, quite unfounded, that insured persons areless well treated than private patients. It is a practiceprobably adopted in every hospital in the countryand by all private practitioners who do their owndispensing.

(Q. 1339-46.) With regard to the chemists, purchaseshave been made from time to time with test prescrip-tions and analyses made. This action, however, hasnot been as systematic and widespread as it mighthave been, and the department now has underconsideration with the Retail Pharmacists’ Union

a uniform system of investigation throughout th&country.

A Limited List of Appliances.(Q. 1312-1332.) The Acts provide that only such

appliances are to be supplied as the department mayprescribe by regulation. Such common appliances asspectacles, trusses, and artificial limbs are not includedin the list, and the evidence goes to show that th&main ground for limiting the list is the ground of cost,but also that a distinction would appear to have beendrawn between things which are required in order to-enable the process of medical treatment to be properlycarried out and things which are required to remedyphysical impairments in every-day life.

Special Arrangements for Obtaining MedicalTreatment.

Very few questions were asked as to the systemunder which certain persons may make their ownarrangements for getting treatment instead of gettingit under the panel system, or as to the arrangements forgetting treatment through certain approved institu-tions. (Q. 1375.) With regard to the first class itwas stated that there was no considerable demand atthe present time by insured persons to be allowed tomake their own arrangements and to receive a

contribution towards the cost. The main deterrentis probably the fact that the insured person mayhave to pay some part of his doctor’s bill himself.(Q. 1379.) As to the approved institutions, it wasfelt that the arrangements for the investigation ofcomplaints have not been generally satisfactory, andthat some institutions have been very lax in inquiringinto complaints.

Payments to Doctors.(App. C. 125.) The Minister, after consultation with

the Government Actuary, determines for each year,partly on the basis of the number of insurance stampssold, together with any other information available,the number of insured persons in the country whowould be entitled to medical benefit in that year.This number, multiplied by the agreed capitation fee,makes a central pool. The distribution of this centralpool among Insurance Committees is made by theMinister after considering the recommendations of aCommittee, called the Distribution Committee, setup for this purpose. The insurance practitioners arerepresented on this Committee. The sum allotted toeach Insurance Committee area is divided locallyamong the doctors in such way as they themselvesdetermine. The almost universal system is thecapitation system--that is, a distribution according tothe number of persons on each doctor’s list. (Q. 1383.)In Manchester and Salford the distribution is on thebasis of the number of services rendered, but thedoctors themselves have had to devise so manychecks and safeguards against the risk of unnecessaryattendances that by now the result differs very littlefrom the capitation system. It has probably survivedhitherto because of the strong feeling in both thosecities in favour of free choice of doctor by the patientat any time. Now that free choice at any time isallowable everywhere, it is probably only a questionof time for payment by attendance to disappearboth in Manchester and Salford.The central pool for the whole country is itself

based on a capitation payment as stated.(Q. 1412-14.) This has varied from 7s. a head of theinsured population at the beginning, up to a maximumof lls. in 1920, falling to 9s. 6d. in 1922, and then in1924 to its present figure of 9s. (Q. 1388.) Thewitnesses were asked what was the equivalent of the9s. expressed in terms of services rendered. Theystated in reply that it was calculated that the averagepayment per service was about 2s. 7d. Stated other-wise, it worked out at 2s. 3d. per surgery attendanceand 3s. 4d. for each domiciliary visit. These figures,it was suggested-would compare very favourably with the return from privatepractice among comparable classes, when you allow for thefact that, in the case of the insurance payment, it is a net

405

payment. There is no cost of collection and there are nobad debts. There is also the important difference that thedoctor does not dispense for his insurance patient, whereasin industrial practice he ordinarily has to provide medicinefor his private patient, and his fee in the case of the privatepatient, therefore, covers that as well as the attendance.

Persons Who Do Not Choose a Doctor.The number of persons for whom the doctors

collectively are paid depends, it will be seen, upon anestimate of the whole insured population made by theGovernment Actuary, and not on the number whoactually get on to doctors’ lists. (Q. 1452.) Thedoctors are paid for all such persons because they are atrisk in respect of them, and have to give them treat-ment when they fall ill. For this reason no greatimportance is attached to the question of the actualnumber of such persons, which probably correspondsvery closely with the number of fresh persons (abouthalf a million) entering insurance each year. In thecase of younger entrants particularly there is a

tendency not to take any steps in the direction ofgetting on the list of a doctor until his services areneeded.

Mileage Payment for Country Doctors.(Q. 1463.) I see that the mileage grants have increased

from .826,000 for England in 1913 to ;/3250,000 in 1924,though apparently the latter figure covers Wales also.Can you indicate why such a large increase was made ?-A. Because the whole basis on which mileage was calculatedhad to be revised. We started on the assumption that it wasonly necessary to make provision for areas of very special sparsity and difficulties of locomotion.... It was agreed at the beginning of 1920 that a mileage fund should be set upin order to pay the rural practitioner both for his expensein getting to the patient and also for the time spent intravelling over and above the time that would on the averagebe spent by the town doctor. The mileage fund, as from thebeginning of 1920, had therefore to provide additionalpayments for all rural practitioners, and not only, as in1913, for those practising in exceptionally difficult districts.

(Q. 1465.) In the distribution of the Central MileageFund between areas the Minister has the advice ofthe Distribution Committee referred to above. Thedistribution of the local pool is based mainly on thenumber of persons on the lists of the doctors whoclaim mileage, and their distances from those doctors,with extra provisions for areas in which there arespecial difficulties-for example, where a man livesin the middle of a moor and has to be reached byfootpath instead of by car.

-

Town v. Country.(Q. 1514-17.) Questions elicited the general view

from the witnesses that the town doctor has profitedmore by the Insurance Acts than the country doctor.The country doctor is less well off--partly because now he only gets the insurance capitationrate in respect of a number of people-indoor and outdoorservants of the squire, for instance-for whom before theInsurance Act he used to be paid at a pretty liberal rate.It is difficult to say how far that is due to the Act or how farthe doctor is suffering from the impoverishment of the classthat used to keep up big country places.

Also the country doctor is suffering from theincreased mobility of the town doctor.

ROYAL COMMISSION ON LUNACYAND MENTAL DISORDER.

FURTHER SITTINGS.(Continued from p. 301.)

THE Commission resumed its sittings on Monday, IFeb. 9th, when Mr. Montgomery Parker continued his Ievidence, speaking on behalf of the National Societyfor Lunacy Reform. He said that when patients were too poor to pay for the services of medical men from outside, the Society considered that financial lassistance should be granted, perhaps annually.As to the discharge of lunatics, it was thought byhis Society that the petitioner’s arbitrary power to either discharge or not led to frequent abuse;sometimes members of the family shrank from the

trouble attendant on the return of the patient,and occasionally there was a fear of legal actionbeing taken. Additional power of discharge, heinsisted, should be vested in a judicial authority,without the right of veto now enjoyed by individualauthorities ; for licensed houses and hospitals thejudicial authority should have the right of discharge.Licensed houses, Mr. Parker thought, should not beconducted with the object of making profit; some

of them made larger profits than the public hadany knowledge of. Their number should not beincreased, and in that he was opposed to the BritishMedical Association. There might be a financialmotive for detaining patients in these institutions.He also objected to what he termed the autocraticpowers of medical superintendents of mental hospitals ;he stated that long periods sometimes intervenedwithout a patient seeing the medical superintendentat all. He agreed with the suggestion contained ina question by Lord Russell, that the appointmentof a medical superintendent should not be permanentuntil he had occupied the post three years.

Allegations of Physical Violence.Mr. Parker said numerous statements which his

Society had received from patients did not allowof any doubt that on occasions physical violencewas practised on patients. It was, he said, a featureof the age to substitute chemical violence for physical,and that was more difficult of detection. Someexplanation of the use in these institutions of hyoscinewas, he submitted, called for ; also croton oil, themost painful and powerful purgative known. TheCommission should inform itself of the purchasesof croton oil over a definite period at all mentalinstitutions. The Board of Control could deniind this.

Mr. Parker was again in the witness-chair onTuesday, when he continued his statements con-

cerning the use of drugs in asylums, his main conten-tion being that the disciplinary measures now usualwere cruel. Environment, he said, had the greatestinfluence in the progress of a patient towards normalhealth, and so should receive close scrutiny. Healleged, in regard to treatment, that often the con-trolling factor was not the interest of the patient.but finance. It was a pity that the Board of Controlhad only recently pressed for a more extended useof open-air treatment ; and there should be freerfacilities for exercise. Private asylums should berequired to render returns of recoveries to the Boardof Control. It was not now necessary.A further point which Mr. Parker made was that

the medical staffs in these institutions must beconsiderably augmented. In some asylums therewas practically no trained nursing staff. He pleadedalso for more facilities for recreation and amusementand the use of small libraries.

’

The meeting was adjourned to Feb. 24th.

NOTES FROM INDIA.(BY AN OCCASIONAL CORRESPONDENT.) -

Medical Relief in Rural Areas.THE problem of bringing medical relief within easy

reach of the rural population has been engaging theattention of the authorities for some time. Theexisting facilities in this respect are extremely inade-quate. The great mass of the village populationshave hitherto had no opportunity of coming intointimate daily touch with qualified doctors and havehad to be content to a great extent with the servicesof unqualified men. Schemes for dealing with the diffi-cult situation have been drafted by both the Bombayand Madras Governments. In the latter the only solu-tion possible with the funds at present at the disposalof the Government seems to be on one of the threefollowing alternative lines-namely, (1) the openingof a large number of Ayurvedic and Unani dispensaries,

(2) the starting of a large number of itinerating ortravelling dispensaries, and (3) the encouragement of