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THE PAYMENT OF MEDICAL MENSUMMONED BY MIDWIVES TO

THEIR ASSISTANCE.

THE attention of medical men has frequently been calledto the grave defect in the working of the Midwives Actof 1902, caused by the fact that although a midwife isbound by the Act to summon a medical man to take

charge of a case of difficult labour, yet no provision ismade under the Act for the payment of his services. Incases of poverty, where the patient is entitled to charitablerelief, the difficulty has not been so serious, but in manyinstances medical men have attended knowing fullwell that no fee would be recoverable and have giventheir services as charity with the knowledge that if theyfailed to do so they would risk public censure for heartless-ness. Certain boroughs, such as Liverpool and Cardiff,have adopted schemes by which, in some circumstances, theborough became responsible for the fees due ; in this theyhave more freedom than the county councils the accountsof which are under strict central control. The latter have

only been able to suggest that medical men should seek torecover from local boards of guardians, a very feebleguarantee of repayment. The latest council to take actionis that of the borough of St. Helens which has adoptedthe scheme which we print below, the power for which itfinds under Section 133 of the Public Health Act :-The council of the county borough of St. Helens is prepared to make

certain payments to medical practitioners called in under Section E 18and E 19 of the rules framed by the Central Midwives Board, underSection 3, I., of the Midwives Act, 1902. (2 Edw. 7.c.17.) These pay-ments will be made only on the written application of the medicalpractitioner after consideration and investigation by the health com-mittee of the council. In determining which cases shall come underthis scheme the health committee will take into consideration: 1.Nature of case. 2. Inabilitv of medical man to recover his fee.

1. Nature of the case.-The expenses of medical attendance will bepaid only when there is great urgency, and under Section E the casesof urgency will include : 19 (1) The whole sub-section; 19 (2)b whenthere is loss of blood; 19 (3, the whole sub-section; 19 (4) secondarypost-partum haemorrhage; 19 (5) dangerous feebleness of the child ; butall other cases when there is undoubted urgency and danger to eithermother or child shall be included whether mentioned in the foregoinglist or not.

2. Inability of medical man to recover his fee.-The medical man isrequired to take reasonable means to secure his fee before applying tothe health committee. The fee will be paid only on the writtendeclaration of the medical attendant that he has been unable to obtainthe whole or any part of it from the patient, and shall be wholly orpartly repayable by the medical attendant to the council if

subsequently whole or part payment be made by or on behalf of thepatient. The medical attendant shall also be required to give a

description of the case, and the treatment adopted, on a prescribedform. (Copy attached.) The fee for attendance on all cases of urgencyand danger to either the mother or the child shall be on the scale of6s. for a visit, or El Is. when operative interference is required and hasbeen carried out. The fees are not cumulative and the fee in any onecase shall not exceed 5s. when operative interference is not requiredand .El ls. when an operation has been required and carried out. Anyclaim for an additional fee must be made in writing, and will beconsidered by the health committee on its merits. Nothing in thisscheme shall be held to bind the health committee or the council topay the fees of any medical attendant in cases which they, afterinvestigation, shall for any reason whatsoever deem unsuitable. Thehealth committee reserve to themselves the right of withdrawing oramending the scheme. W. H. ANDREW, Town Clerk.Town Hall, St. Helens, June 5th, 1907.

The following is the form that must be filled up andreturned to the council by the medical man who makes theclaim.

THE MIDWIVES ACT, 1902.To the-Health Committee ofthe Cozsnty Borough oj St Helens.I hereby certify that on.....................................................................

at.................. ’*’ I was called in at the instance of a midwife ............

to attend.......................................at ...................................................The reason given on the paper furnished by the midwife for calling

me in <,3.............................................................................................The case was one of urgency and I found the following conditions

requiring medical assistance :&mdash;............................................................

The treatment which I adopted was briefly as foltows :&mdash; ..................

I hereby declare that I have failed to obtain my fee in whole or partfor this attendance, and that I have taken reasonable means to secureit. I further undertake to refund to the council any payment made tome with respect to this attendance, should whole or part payment bemade to me by or on behalf of the patient.

.............. Address................................................Address ...................................................Date..........................................

This form duly filled up and signed by the medical practitioner mustbe sent to the Medical Officer of Health, Town Hall, St. Helens, withinsix months of the date of the attendance.

THE HAMPSTEAD GENERAL HOSPITAL.

RECENT events in connexion with the constitution of thestaff at the Hampstead General Hospital have led to a

situation that threatens to become almost an impasse and asthey involve principles of the greatest importance to allsuburban hospitals and to medical men a short statement ofthe facts will be useful.The Hampstead Hospital was founded in 1882 as a small

nursing institute, with the title of the Hampstead HomeHospital. The late Dr. Heath Strange associated with him-self several local medical men as a staff and until his recentdeath took the greatest interest in the affairs of the institu-tion. There were no free beds until 1893, when a fewwere added, and three years later an out-patient depart-ment was started which was the first step that broughton the institution the criticism of practitioners in theneighbourhood who were not on the staff. In 1905 thehospital was moved into a fine new building that had beenerected on Haverstock-hill with 64 beds but the move hadnot the cordial support of the local profession, many ofthe members of which consider that Hampstead does notrequire so large a hospital. In spite of this feelingthe council of the hospital-as the board of manage-ment is styled-during 1906 proceeded with the erection oftwo new wings, which was made possible by a donationof <820,000 from Sir Henry Harben, and one of R6000from King Edward’s Hospital Fund for London, and newout-patient buildings were also erected. The hospital isadministered by the council, on which all the six membersof the medical staff have seats, although of course the layrepresentation has a strong majority. The staff consists offour medical officers and two assistant medical officers, all ofwhom are local practitioners and make no claim to what isgenerally known as a purely " consultant " practice. It mustbe said at once that on all sides it is admitted that thesegentlemen carry out their duties in an exceedingly efficientand skilful manner and the question at issue is one of

principle entirely and not of personality. Up to thepresent time they have had exclusive charge of thefree beds and the out-patients but have shared the rightof treating their own private cases in the dozen or so payingbeds with any other practitioner who chooses to apply forsuch a bed in which to treat a private case, preferencebeing given to patients coming from Hampstead, Highgate,Hendon, or the neighbourhood. The new wings when openwill give a total accommodation of about 110 beds and thenumber of paying beds will be increased.

It is about the free beds that the chief trouble is centred.When the hospital was moved to its present site a good dealof local feeling arose on several counts ; one was that thestaff derived an undue local prestige from their official

position, but the chief trouble was the hostility of the localprofession against the out-patient department. During May,1906, the local branch of the British Medical Associationconvened a meeting of neighbouring practitioners who

carried the following motions and a committee was formedto promote their enforcement :--

1. That an out-patient department in Hampstead is unnecessary.2. That the casualty department be kept distinct from any other

department and that casualty patients, if not suitable for admission,! be seen once, and thereon be referred to private practitioners, provident

dispensaries, or Poor-law authorities.3. That there be greater facilities for general practitioners of the

neighbourhood to attend in-patients.4. That there should be a service limit, as well as an age limit, to

appointments to the medical staff.5. That the outside medical profession be adequately represented on

the board.6. That it is desirable, both in the interest of the district and of the

. hospital itself, that the Hampstead Hospital be carried on as a purely.

local institution, and not as a large general hospital, and that there-; fore an acting staff of consultants is not in accordance with the spirit,

of its constitution.

These were forwarded to the council of the hospital but they. did not receive the support of the hospital staff and they; cannot be said in themselves to have carried much weight., Neither can the indefinite expression of opinion in answer to) a circular sent out by the council to the local profession3asking for an expression of opinion on the constitution of the

staff be said to have influenced the result materially. It. will be seen that the last resolution deals with the. introduction of a staff of consultants, and it is over

that point that the present critical position has arisen;it is the point that makes the situation a test-case for

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similar hospitals. Up to the present there have been a few .1consultant members of professional eminence on the Hamp-stead staff, but their office has been just as much of a sine-cure as that of a consultant member of the staff of anyLondon general hospital. The King Edward’s HospitalFund for London had intimated to the council of the

hospital when it attained its present importance that itwould be well advised to change the constitution of itsstaff from local practitioners to "consultants," althoughit is noteworthy that the Fund has never committeditself to the definition of a consultant. During 1906 thecouncil considered the matter and it was this event that

brought about the meeting and resolutions to which wehave referred above. The council appointed a special com-mittee to consider the subject, which reported on Februarylast " that this committee is of opinion that it is desirableto appoint a staff of four consultants of high standing (twosurgeons and two physicians), but that under the specialcircumstances of the Hampstead General Hospital it is

important to retain the cooperation on the medical staff ofmedical men residing in the neighbourhood of the hospital."At the end of last year matters were hurried on by anew factor. The North-West London Hospital was insuch severe financial difficulties that it was suggested toclose it. The King’s Fund, however, took the matter in handand proposed to the Hampstead Hospital that they shouldamalgamate and carry on their out-patients department atthe North-West London Hospital, where there had beenan out-patient practice of about 123,000 a year, whilst theHampstead attendances of out-patients did not much exceed21,300. The Fund promised the Hampstead Hospital 1500a year and other benefits resulting from the amalgamation,but the offer was absolutely conditional on the replacementof the staff by the undefined "consultants" and the inclusionof certain members of the North-West London Hospitalstaff. After much negotiation the Fund agreed to retain thepresent medical officers for a period of 18 years from the timeof their original election, giving them terms of from five toseven years to run, but it would not agree to the subsequentpromotion of the assistant medical officers, although one ofthese gentlemen holds the Fellowship of the Royal College ofSurgeons of England. In fact, it laid down the absoluterule that in future the staff must be " consultants " and notlocal practitioners, however capable these may be. The

hospital council, without referring the matter of amalgama-tion or staff constitution to the general body of governors,has accepted the terms, including the appointment ofthree members of the North-West London Hospital staff.The condition precluding the present assistant officers frompromotion was the last concession made to the King’sFund and was only carried by one vote, and subsequentevents have proved that the council was divided on

many points. Meanwhile the local profession as repre-sented by the British Medical Association had been active ;a conference was held between its 1906 committee andmembers of the staffs of the two hospitals concerned, whereit was agreed that there was no objection to amalgama-tion under certain very clear conditions regulating the out-patients and insuring a good local professional representa-tion on the staff and the committee. A meeting of the pro-fession was convened on May 24th to consider these recom-mendations and so far from supporting them unanimously amotion that the amalgamation was undesirable was onlylost by the casting vote of the chairman. At this time thestaff of the hospital were trying to support their council asfar as they reasonably could in a most trying and delicateposition and the local profession were handicapped in theirendeavours by not having the staff with them. When,however, the council made its final surrender to theKing’s Fund the staff decided to make common cause withtheir outside brethren and at a well-attended professionalmeeting on July 3rd, under the auspices of the local branchof the British Medical Association, Dr. E. CollingwoodAndrews on behalf of the staff rehearsed the position andannounced that his colleagues and he had decided to supportthe motion before the meeting :-That this meeting considers the Hampstead General Hospital should

always have a staff of local practitioners, and in consideration of thisopinion calls upon the members of the medical profession to refuse toaccept any office on the staff on terms which are net consideredsatisfactory by the local profession.

He, moreover, announced that a special meeting of governorsand subscribers of the hospital had been convened forJuly 16th who would be asked to rescind the council’s

decision and to vote for the continuance of an acting staff oflocal men with an increased consulting staff. Dr. Andrews,it is suggested, minimised the financial support broughtby the North-West London Hospital to the amalgamationscheme, but though an important matter it does not affectthe position brought about by the proposals. If these are-not carried the staff will resign in a body ; if they arecarried it appears that the amalgamation scheme will fallto the ground, but we understand that the hospital will notthereby lose the support of the King’s Fund. The meetingreceived the attitude of the staff very favourably, althoughone or two gentlemen tried to confuse the issue with the out-patient controversy. The resolution was carried nemine con-tradicente and there the matter rests until the meeting ofhospital governors has been held. We have only had spaceto indicate the outline of the matter and shall acquaint ourreaders with the issue in due course. It is impossible toforetell what this may be as the situation is one of ex-

treme difficulty. There is no doubt, however, that the localprofession has had its influence greatly strengthened by thesupport of the hospital staff. We trust that the governors atthe approaching meeting will not be swayed by personalconsiderations but will record their decision in what theyconceive to be the true interests of the hospital’s welfare.

MEDICINE AND THE LAW.

attempted Suicide and the Policeat Chelmsford.A CURIOUS and unaccountable attitude appears to have

been adopted by the police authorities at Chelmsford, accord-ing to the evidence given at an inquest held there recently.The deceased, a carpenter, had become insane and had cuthis throat in the street. He was taken by the policewhile still alive to the Chelmsford Infirmary and waathere attended to, but was not allowed to remainas an in-patient because the police authorities atChelmsford refuse to permit a constable to remain inthe infirmary in charge of a person who has attemptedsuicide and the authorities of the Chelmsford Infirmarynaturally and rightly decline to entertain such patientswithout police assistance. On the occasion in question thedeceased, after receiving surgical aid at the infirmary, wastaken by the police to the workhouse infirmary, but there hewas refused admission, equally rightly, because he was not aproper subject for poor relief. A medical man who appearsto have been summoned to attend him at his homefound that his condition required that he should betreated in a hospital, and interesting himself vigorouslyin the matter persuaded the guardians to stretch a.

point and to allow him to be admitted to the workhouseinfirmary. The guardians passed a special resolution thathe should be taken in, but an hour after his arrival he died.The jury at the inquest had before them correspondencebetween the infirmary board and the police which passed in1904, in which the board intimated that it could notundertake the care of those who had attempted to commitsuicide without the assistance of the police, to which thechief constable had replied that he could not instruct thepolice not to take a patient whose life was in dangerto the infirmary if that was the nearest availableplace, but that it would be detrimental to the public

service to allow his men to remain there. They hadalso evidence to the effect that the institution hadno male attendants to take care of such cases as that, described and that would-be suicides were admitted toI London hospitals only because the police always remainedL in charge of persons for whose safety they were directlyL responsible. In reply to this the deputy chief constable isL reported to have made the statement that " there is no powerl to put the police in charge." The jury at the conclusionL of the inquest returned a verdict of suicide during; temporary insanity, with a rider that the guardians

should have been notified of the correspondence betweenthe police and the infirmary, that the guardians were greatlyto blame, and that the relieving officer was not to blame ashe had only done his duty. Such censure seems to be unl deserved and misplaced. The guardians of the union appear

to have acted with humanity and to have done their best fors the deceased when they were fully informed that his life wasr in danger, although, strictly speaking, he would not in other circumstances have constituted a case for treatment under