889

He preferred to do this rather than deprive theclinic of its valuable atmosphere of freedom. Morethan half the cases treated in this department formental disturbance succeeded in escaping certificationaltogether.

Mrs. Matthews asked the witness whether therewas any alternative available to reporting cases

to the inspector of the poor, and he replied that hewould much prefer that the doctor should reportto the health authority, or, still better, to a mentalboard of health, as suggested by the Medico-Psychological Association. On the suggestion ofSir Humphry Rolleston he agreed to submit a

memorandum on the subject.

PROCEEDINGS OF THE

ROYAL COMMISSION ON NATIONALHEALTH INSURANCE.*

(Continued from p. 840.)

EVIDENCE OF THE JOINT COMMITTEE OF ;APPROVED SOCIETIES.

Mr. F. W. Daniels, Chairman, and Mr. P. Rockliff,Secretary, gave evidence on behalf of this body, whichconsists (Q. 8015) of Associations of a specialisedtype-viz., Deposit Friendly Societies, HollowayFriendly Societies, Dividing Friendly Societies, theGeneral Federation of Trade Unions, the Co-operativeGroup of Approved Societies, the Catholic Groupof Approved Societies, and associations of smallsocieties.

The Oxford Resolittion.

(App. XIV., 3, 4. Q. 8023, &c.) A good deal of theevidence bore reference to a resolution of the NationalConference of Friendly Societies, the Oxford Resolution,from which this Joint Committee dissociated itself.It was summed up by the witnesses (8024) thus: Themerger of all existing forms of public medical service,including medical benefit under National HealthInsurance, into one national medical service, therebycreating one unified organisation for the preventionand cure of disease. The witnesses considered thatthe-extension and administration of medical benefit as outlinedin the Oxford Resolution... would lead ... to an

impression (in the minds of the patients, at any rate)that, as regards attendance, it was of the nature of a

Poor-law medical service, and, as regards drugs, that theywere of the " stock-pot

" variety.The misgivings as to the present medical service

would, in the opinion of the Joint Committee, beconsiderably magnified in the system proposed.

(Q. 8160.) It was suggested that the executive ofthe National Conference of Friendly Societies whichbrought forward the Oxford Resolution were stam-peded by Mr. Alban Gordon (whose evidence beforethe Royal Commission has recently been summarisedin these columns).

The Panel Service and the (,)uestion of Ftension.(Q. 8026-41.) In the opinion of these witnesses,

the panel service in the provinces, whilst not perfect,is reasonably efficient. As regards London, the

* In previous articles the proceedings of the Commissionwere reported under the following headings: IntroductoryNote ; 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 ; Feb. 21st, pp. 403-5) ;Financial Provisions of the Act (Feb. 28th, pp. 454-7) ; MedicalCertification and the Regional Medical Staff (March 7th,pp. 508-9); The Approved Societies and the Money Benefits(March 14th, pp. 564-5 ; March 21st, pp. 623-4) ; Evidence ofthe Hearts of Oak Society (March 28th, pp. 677-9) ; Evidenceof the National Conference of Industrial Assurance ApprovedSocieties and of the Manchester Unity Approved Society(April 4th, pp. 731-3) ; Evidence of Independent Order ofRechabites, of Rational Association Friendly Society, and ofMiners’ Societies (April 11th, pp. 784-6 ; April 18th, p. 839) ;Evidence of Mr. Alban Gordon (April 18th, pp. 839-40).

References to the printed statements issued as appendices tothe reports of the oral evidence are given thus ; Section A,para. 69, is shown as " App. A. 69." and references to the oralevidence thus—Q. 1369.

service, in their view, is very far from being whollysatisfactory. The general trend of their evidenceseemed to be that the London Panel Committee wasto blame, and reference was made to the recentdisputes in London about the action of the MedicalService Sub-committee.The Panel Committee in London seek to protect the

scallywag, who, I have no doubt it will be said, will befound in all professions, and they carry it to extremesm London in changing their representation upon the Com-mittee and in seeking to deprive the Medical Service Sub-committee of the judgment of an independent chairman.Asked whether they would propose to scrap the

Panel Service, and if not, what would be the alter-native, they replied that they were hopeful that itmight be still possible to improve the existing service.With regard to extensions of the Medical Service,the following rather cryptic statement is made :-

(App. XIV., 24, 25.) The Joint Committee desire to seethe benefit given by the Act of 1911 fully conferred uponthe insured-i.e., " adequate medical attendance andtreatment"-and not the restricted form of (domiciliary)medical benefit defined by the regulations. Given theformer, there is no need separately to specify here thenature of the extensions desired in the latter.

No Free Choice under a Whole-time Service: :The Regimentation of Women.

(Q. 8185-8200.) Asked why a whole-time serviceas contemplated by the Oxford Resolution shouldnecessitate an allocation to one doctor without anyfree choice, and therefore involve what was describedin the evidence as the " regimentation " of women,the witnesses said that that seemed to follow fromthe appointment of whole-time doctors for par-ticular areas.

If you are going to have so many whole-time paid medicalmen under a National Medical Service in any area as to give ereal freedom of choice, then you are going to make itfinancially impossible to set such a scheme on its feet.

Medical Benefit to Dependants not Recommended.(App. XIV., 1, and Supplemental Statement.) The

Joint Committee consider it undesirable to press atthis present time for the extension of medical benefitto dependants of insured persons. They do not thinkthat there is a clear demand for it from the insuredpersons themselves, and notwithstanding that " panelmedical opinion has crystallised

" in favour of sucha scheme, they think that it is impracticable onfinancial grounds and also that it would throw anundue burden on the profession, especially in con-gested areas.

Petty Surcharges for Excessive Prescribing.(Q. 8029.) Speaking again particularly of London

Mr. Rockliff said :-As regards drugs, miserable petty surcharges have been

made upon doctors because in their discretion, whichwould be unchallenged when dealing with a private patient,they prescribed a 5-grain pill and it was alleged-I amspeaking from personal knowledge-that a 3- or 4-grainpill would have been as- efficacious. It is a sin, too, for aflavouring essence to be put into an insured person’s medicine.Insurance bandages too-I think it is altered now, butpreviously it was so-were to be drab or grey, not whiteas for a private patient.

Pooling of Fuzds.-Pure Theft.(Q. 8179.) The pooling of societies’ funds would,

said Mr. Rockliff in one answer, be " pure unadul-terated theft." (Q. 8244-8365.) The evidence generallysuggests that there would be a clear breach of faithif any proposals were made to take the surpluses ofthe stronger societies and give them to the weaker.

(Q. 8298.) The fact that by a selection on the part ofthe insured persons different results were going to accruewas patent to everybody in 1911. It was patent to tradeunionists, and if they induced their members to segregatethemselves in occupational societies, that was, at any rate,the result of their wrong advice.

As to this, it was suggested to the witness (Q. 8301)that 14 years’ experience of fact might cause Parlia-ment to alter a good deal of what in 1911 was simplytheory.

890

Additional Treatment Benefits.(App. XIV., 26.) The Joint Committee are pre-

pared to support the extension of the list of additionalbenefits so as to enable Approved Societies to makemonetary grants to enable their members to securemassage, radiant heat, and other electrical treatment,blood tests, X ray, and similar advantages in dealingwith illnesses. They are opposed, however, to anytransfer of treatment benefits out of the hands ofthe Approved Societies.

(App. XIV., 27.) As regards treatment benefits generally,whilst special considerations might be advanced in regardto a benefit given nationally as a normal benefit under theAct, the Joint Committee are opposed to any transfer outof the hands of members of Approved Societies of theadministration of the present system of monetary grantsin aid of treatment.

Dental Benefit.(App. XIV., 28-31 and Supplemental Statement.) IThe only treatment which appears to the Joint Com- I

mittee to justify an effort to secure it upon a nationalbasis is probably dental benefit. Even then it would,it is believed, still be desirable for societies to continueto administer it. Such a benefit, if given nationally,would require to be given free of cost to the insuredto enable the ill-paid, and not merely the well-paid,among the insured to obtain it.

In view of the possibility of the present valuationresulting in the very large surpluses which seemprobable, it would appear that 100 per cent. dentalservice is not an impossibility, if preference is givento it over other additional benefits, and the JointCommittee are not impressed by the suggestion thatthe dentists available are inadequate, although(App. XIV., 43) this " might be true of qualifieddentists."

In their supplemental statement of evidence (35),the Joint Committee say :-

Should the surplus be found to amount (when the 1923valuation results are known) to the figure now suggested,the Joint Committee would doubtless consider the desirabilityof utilising such part of that surplus as is requisite to providea 100 per cent. dental service in priority to (a) a reductionin the weekly contribution, or (b) an increase to a limitedextent in the normal rates of cash benefit, which wereadvocated in their original statement.

The Future of Insurance Committees.(Q. 8724-5.) In later evidence on dental benefit,

the witnesses said that the whole cost of thisbenefit might be estimated from the experience ofsome societies at from 5s. 6d. to 6s. 6d. per insuredperson-more probably the higher figure. If bymaking this a normal benefit is implied meeting thefull cost of the benefit,and a member’s medical card, for example, entitled himto go to both a dentist and a doctor, it certainly could beargued that Insurance Committees might be entrustedwith the work ; but if dental benefit as a normal benefitis anything short of a 100 per cent. service, in our judgmentInsurance Committees are conclusively ruled out.

(Q. 8729.) With regard to the work of InsuranceCommittees generally, Mr. Rockliff said :-We are not here to press for their annihilation, but at

the same time we do not lend any support to the effortto preserve their lives by stealing work which is being betterperformed by other persons at the present time.

EVIDENCE OF STOCK EXCHANGE AND LLOYDS’HEALTH INSURANCE SOCIETIES.

Evidence on behalf of these Societies was given Iby Mr. E. E. England and Lieut.-Commander E. G.Holdway, respectively.

Advocacy of Insured Persons JJI aking OwnArrangements for Medical Benefit.

The principal matter upon which they madesubmissions to the Commission was as to the medicalservice.

(App. XV., 6-8.) The Panel Medical Service has alwaysbeen most unpopular with a large number of our members.We have had many complaints from insured persons whofeel that they are not receiving the attention and treatmentthat was promised to them, that the doctors agreed to give,and for which the members have paid.

The witnesses advocated :-The continuance of the Panel Medical Sarvice with an

amendment of the Medical Benefit Regulations, to allowof the unrestricted right of every insured person to make hisown arrangements for medical benefit with a doctor who isnot on the panel.The witnesses pointed out that although Insurance

Committees have power to allow insured persons tomake their own arrangements, the conditions are sostrict that only a few cases are allowed.

(Q. 8455 80.) The witnesses were asked whethersuch an extension of the " own arrangements 11method, as they suggested, would be consonant withthe idea of insurance. They replied that the memberwould exercise the option, knowing perfectly wellthat only a portion of his doctor’s bill would probablybe met, and that the balance would remain for himto pay.

I can see no reason why the principle of insurance shouldbe incompatible with private arrangements. There are

many insurance companies which issue policies againstsickness, and the insured makes his own medical arrange-ments. There should be obviously a certain scale, and themember would know that he had to cover any excess fromhis private resources.

Although it was agreed that the majority of thedoctors are on the panel, and that many of the doctorsfrom whom members of these societies obtain treat-ment as private individuals, were nevertheless onthe panel, it was thought that the fact of a doctorbeing under a contract of insurance made a markeddifference in his outlook.

(Q.) Your suggestion is that the doctor does not realisehis responsibility to his patient ?-Yes. There is also thepsychological aspect of it. The doctor knows he has a certainnumber of people on his panel for which he is going toreceive a certain sum of money, and any extra privatepatient means extra money for him. He knows very wellthat he has had that income assured to him, and withoutwishing to say a word against the medical profession, thereis the human element that naturally comes in. He maybe tired, he may be overworked, but if a private patientcomes and there is more money coming in, he gives thatperson better treatment. There is no doubt about it inmany cases. I have had cases brought to me, and I amquite satisfied that there are many cases where they havehad different treatment altogether.With regard to the contrary suggestion that as

regards his panel patients the doctor feels a greaterresponsibility, the witness replied:-

I quite agree there is a lot to be said for your argument,but between that degree of neglect which a person mayfeel and the degree of neglect which one can bring beforean Insurance Committee as a complaint, there is a very widemargin.

(Q. 8523.) The witnesses wished to avoid makingsweeping charges against the medical profession and,indeed, they considered that the panel service wasconsiderably improved.

It is getting better and better. When the Act first cameinto force there was very great prejudice against it, and thatstill sticks in the minds of a large number of our members.

Other Treatment Benefits.(Q. 8430-40.) The members of these societies are

mainly selected lives, so that the societies carry smallerrisks, and moreover a considerable number do notclaim the ordinary benefits to which they are entitledduring sickness. This enables these societies to giveother very substantial benefits-e.g., full dentaltreatment, which includes examination, scaling andgum treatment, extraction (with or without anses-

thetic), filling, stopping, crowning, and the supply ofartificial teeth where needed. Also optical treatment;the members go to an optician in the City, and thefull cost of pince-nez or rimless glasses or astigmaticlenses are allowed ; gold frames, however, are notprovided. The societies also provide medical andsurgical appliances, either through the Surgical AidSociety or a private surgical instrument maker.They would resent the loss of these benefits under

a pooling scheme, and pointed out that city clerkshave never yet been favourable to National HealthInsurance, and it was important that nothing shouldbe done to increase their hostility.

891

EVIDENCE OF THE GROUP OF CATHOLICAPPROVED SOCIETIES.

For this group Mr. Joseph Moss and Mr. C. H.Waring gave evidence. (App. XVII.) This evidencecomprised the following points :-

1. That there was an undue drain on the BenefitFunds owing to women members’ claims before andafter confinement, particularly in view of the laxway in which many doctors issue certificates for" pregnancy " and " debility following confinement "when the women to all appearances are not incapaci-tated from work.

2. That surpluses should be applied to treatmentbenefits rather than cash benefits.

3. That in meeting the cost of such treatmentbenefits there should be " voluntary cooperationbetween societies and branches, and that they werestrongly opposed to Insurance Committees havingthe administration of these benefits.

4. That, as most of the cases submitted for examina-tion arise from careless and unsatisfactory certification,the cost of the regional medical officers should comefrom the Benefit Fund.

The Personal Touch in dmtfaoM.

(Q. 8660-1.) The witness was asked what exactlywas the personal touch in branch administration ofwhich a member of the Commission said they had" heard such a lot " during the proceedings, and whatit amounted to, if it could not be translated intoactual cash or treatment. The witness did notattempt a definition. He said, however (Q. 8720),that under the branch system they were in fact incloser touch with the members than under any othersystem.

The Black Sheep.As to the panel system generally, the main complaint

appeared to be with regard to looseness of certificationin certain cases, although (Q. 8676) the society feltsuch difficulty in preparing cases adequately for theMedical Service Sub-committee that they had notmade use of the complaints machinery. It seemedto them that when society representatives got onto an Insurance Committee they lost their interest.By way of illustration, they suggested (Q. 8682) thatmany town councillors would be bankrupt in abouta fortnight if they ran their own affairs as they runthe affairs of the city.

(Q. 8705.) With regard to certification they said :-We have people coming on the funds through chronic

bronchitis who cofjne week after week for the benefit, andthey are able to be out in all kinds of weather. We findthat certain doctors specialise in a particular complaint.We know that in the case of one man nine-tenths of hiscertificates will be for rheumatism, and in the case of anotherman nine-tenths will be for bronchitis.

Generally, however, the doctors are trying to carryout their duties under difficult conditions, and it wasto be expected that there would be some black sheepin the fold.

OPHTHALMIC HOSPITAL OF THE ORDER OF ST. JOHNOF JERUSALEM IN ENGLAND.-The report of this institutionfor the year 1924, signed by the Warden, Lieut.-Col. J. C.Strathearn, M.D., shows that the number of new patientsseen was 16,225, and that of the total consultations 75,560.The number of patients admitted to the hospital was 1676and the number of operations performed 4293. Amongnew cases the percentage of blindness in one eye was 8 percent. and in both eyes 3-8 per cent., acute conjunctivitisbeing the most frequent cause, for during the year undernotice the disease was widespread and virulent, though animprovement, now of five years’ duration, was main-tained. Trachoma, the chief scourge of Palestine, andlargely associated with poverty and squalor, still showsa high incidence, and accounts for much of the workin the out-patient department, where the sufferers formed83 per cent. of new cases. Until the social standards ofthe people are raised very little can be done for them inregard to this disease, but encouraging results follow thesystematic treatment of children at school age. Themajority of operations in the hospital, 66 per cent., was forthe relief of trichiasis. The sanitation of the hospitalis receiving the consideration of Dr. J. A. Henderson, theP.M.O., Jerusalem.

NOTES FROM INDIA.

(FROM AN OCCASIONAL CORRESPONDENT.)

Coöperation and Public Health in Bengal.’ AN interesting method of combating malaria, aswell as kala-azar and cholera, by means of cooperativepublic health societies has been put into practicewith considerable success in the Province of Bengal,where malaria takes a heavy toll. The schemeoriginated with Dr. G. C. Chatterjee, formerly AssistantBacteriologist to the Bengal Government, who in1918 was able, in three villages which had beendecimated by an epidemic of malignant malaria, toorganise three Cooperative Anti-Malarial Societiesand to get them registered under the CooperativeSocieties Act. Subsequently he founded a CentralCooperative Anti-Malaria Society " to devise andcarry out measures based on cooperative principlesfor the eradication of malaria from Bengal," whichwas registered and came into existence on June 5th.1919. The outline of the scheme is as follows.The Central Society exists to organise and create anetwork of Anti-Malaria and Public Health Societieson a cooperative basis throughout the villages ofBengal. Each of these societies is an autonomousbody which raises funds by subscription from amongstits members. The Central Society acts as an advisorybody to these rural societies, and may assist themfinancially. It places at their disposal the result ofrecent researches on malaria, kala-azar, cholera, andother preventable diseases. By February, 1924, asmany as 129 societies had been organised. The anti-malaria measures which a society is required to carryout are : (1) filling up ditches; (2) improvingdrainage ; (3) preparing a map of stagnant poolsand regularly kerosinating them by volunteer help ;(4) clearing undergrowth in the village ; (5) administer-ing quinine to all malaria cases in the village, and(6) keeping the fever index of the village systematically.Each society provides a duly qualified medicalpractitioner on a subsidy basis, whose duty it is notonly to treat cases of illness, but also to instructthe people in preventive methods, and to establisha cooperative dispensary in the village itself or withineasy reach of it. For organising public healthsocieties and for educating their members, the CentralSociety carries out propaganda by means of magic-lantern lectures, leaflets, and a monthly journal, whilethe kinema and the stage are also pressed intoservice. The society is very strongly supported by themedical profession. Not only do the majority ofits members belong to the profession, but it hasalso enrolled about 130 medical volunteers, atleast half of whom are fully qualified practitioners,the rest being senior medical students. It enjoysgood financial support, including a grant fromGovernment, which in 1921 and 1922 was Rs.5000and in 1923 Rs.10,000. The organisers of thissystem are to be heartily congratulated in their effortsto awaken the sanitary conscience of the villagepopulation of Bengal, and to promote the idea ofself-help in local sanitation. It is to be hoped thatsuch methods will in the near future be more widelyextended throughout India.

Administration Report of ]I adms City for1923-24.

I This report is a somewhat belated document, but itcontains details which are even now worth mentioningas Madras is the seat of Government and the premiercity in the Presidency. The number of registeredbirths was 22,925, giving a birth-rate of 44-6 per mille

against an average rate of 38-8 for the previousdecennium. As might be expected, there was thecorrespondingly high death-rate of 37-8 per mille, ascompared with 42-7 for the previous year, and 46-6the mean for the quinquennium ending 1922. In twodivisions in the north of the city the recorded death-