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<seem that the doctors who are to work the Government scheme areessentially the Poor-law Medical Service of that country.

Medical Defenoe Union.At the annual general meeting of the above society on May 18th, the

chairman, in opening the proceedings, gave an address upon the dis-abilities of the profession in relation to the proposed scheme of nationalsickness insurance. The disadvantages of the suggested legislation andits interference with the existing general practice were dealt with fully,and a hope was expressed that strenuous and united resistance wouldbe made to the scheme by the profession.

The Medico-Legal Society.At a meeting of the Medico-Legal Society held at the society’s rooms,

11, Chandos-street, W., on May 23rd. Sir John Tweedy presiding, Mr.J. Smith Whitaker, medical secretary to the British Medical Associa-tion, gave an address setting forth very clearly the medical objections,o the National Insurance BillMr. SMITH WHITAKER traced through the reports of Royal Com-

missions, &c., evidences of a growing feeling in recent years that somebetter provision was necessary for dealing with sickness amongst a verylarge proportion of the population so that the vicious circle of diseaseand destitution might be broken. It was very important that the.medical profession should realisethat the essence of the present Bill,which was based, of course, on German models, was that the working.man should be assigned as important a part as possible in the administra-tion, through societies of which he was a member. The clauses dealingwith the employment of medical men were very indefinite andapparently left the door open for any system that could be conceived.Methods might be adopted-such as the employment by societies incombination of doctors at fixed salaries&mdash;which would have the effect ofexploiting the doctor and makiog a profit out of his services. Theobjections of the medical profession to the scheme were several. In thefirst place, an objection was entertained by a large number which.applied to the scheme as a whole or any modification of it-namely,,public intervention between doctor and patient. This interference,however, was recognised as inevitable if the necessary public objects ofthe Bill were to be secured, but doctors said, " Let there be no moreinterference than is absolutely necessary." One of the objections to the- scheme was that it did carry intervention far beyond what theybelieved to be needful. Many would be included as employed contri-butories who were perfectly well able to provide out of their ownresources the cost of the medical benefits allowed under the Bill. Theworking man earning 35s. to &pound;2 a week could, and did, employ a doctorto attend him privately. The necessity for providing medical benefitsfor voluntary contributors whose incomes exceeded 2160 was cei tainlynot demonstrated. The Bill gave them what they did not need-ordi-B ary medical attendance; but did not give them what they did need-viz.,institutional treatment. The scheme, it was feared, would tend to theemployment of selected doctors; the private practitioner would find aconsiderable proportion of his patients practically compelled to transfer.themselves to doctors officially employed. There was also unwilling--ness to trust the administration of the scheme to the friendly-societies., which had shown themselves in the past shortsighted inthe way they had employed their doctors. Medical men wanted awage limit for medical benefits, free choice of doctor by patient-the gain being that patients would have more confidence inthe doctor, and the danger would be avoided of dividing the pro-fession into two factions. Seeing that it was practically agreed by Mr.Lloyd George that the friendly societies were not to appoint thedoctor, fix his payment or his patients, and that the terms of em-ployment were to be subject to the Insurance Commissioners, whatwas there left ’for the approved societies to administer ? It wouldbe better to place the whole respon,.ibility in the hands of thelocal health committees which already had to deal with institu-tional treatment, and where home treatment ended and institutional.treatment began it would be difficult to say. He believed themedical profession would secure adequate representation on centraland local administrative organisations ; they wanted also the powerto elect in every district a medical committee which should

play a recognised part in the administration of the service. The

.question of payment could not be discussed definitely because the dutieswere undefined, but the work could not be adequately paid for by anysum in sight at present. In conclusion, Mr. Smith Whitaker spoke ofthe magnitude of this experiment, and said the profession would reco-gnise that it owed a service to the public, whose interests must be the-first consideration. But in return they were entitled to ask the public,to bear in mind that it was in the public interest that doctors should be-satisfactorily treated.

In the courS3 ofa discussion some interesting points were raised.Dr. MORISON remarked that if doctors were to serve anyone in the

way proposed in the Bill it must be the State and not middlemen. Thenthey would have some prospect of an intelligent directorate, which,could not be expected from the majority of friendly societies.

Dr. MAJOR GREENWOOD predicted that unless a wage limit wasgranted the medical profession had a serious time ahead. Alreadythe sale of piaetices had absolutely gone-no one could sell or transferone.

Dr. TlRARD cJaime,1 that the Bill would do much to raise the-status of the p ofession by establishing, as it did, the principle thatadvice should be paid for, and that advice and medicine were twodifferent things. It was a great s’epin advance in the education ofthe public.Dr. LAURISTON SHAW urged that it should be made clear to the public

what the terms were on which individual doctors had been willing toaccept capitation grants from friendly societies. There was a danger’that the charity of doctors in the past would be their ruin in the future.’The reason doctors accepted 4s. a head was that years ago it was a pointof charitable honour to do what they could for struggling institutionsjust started to help the working man. Doctors would have treated a.great many of these cases for nothing in the ordinary way, and whenworking men tried to help themselves by their societies themedical profession lent a hand and accepted a nominal capitationfee. Now they were told because they had treated these people formext to nothing they should be willing to treat the whole communityfor a few pounds more. The profession should join in absolutelyrefusing to do any work under the scheme unless properly paid, not

f:om any sordid motive, but because they were trustees of the pro-fession. It was their duty to see that the profession was properlyremunerated, so that an adequate number of men might be secured tcoit in the future.

THE REAL VALUE OF CONTRACT

PRACTICE.

BY Two PRACTITIONERS.

WE have prepared a few statistics illustrating the clubwork done in a mixed practice in London which may be ofuse in the present critical juncture in the history of our pro-fession, and from these a fair estimate may be made of ourposition as a profession in the future.

In the first place it is clear that the friendly societiesbenefit largely at the expense of the more wealthy patients ofa practice-where, as here, they are treated just like any otherpatients-no account being taken in their drugs or dressingsof the fact that they are contract patients. The figures showclearly that they are getting for &pound;318 a year what the otherpatients pay &pound;636 for, and, further, that the contract pay-ments, should they be applied to the whole practice, wouldshow a salary divisible among two partners of &pound;249&mdash;&pound;124 10s. each, or much less than one-half a taxi-driver’searnings.The figures taken are consultations-no account having

been taken of visits-but on investigation we find roughlythat 1 in 4 were domiciliary visits, and taking Group J., fourtimes 7d. 9-lOths, or say 8d. for convenience = 2s. 8d. ;take 2s. away for the visit and this will leave 8d. for threeconsultations at the surgery, or if ls. 6d. is taken as a feefor the visits it will leave ls. 2d., or 42/3d. each consultationother than visits. Again, take the average of the OJdfellowsat 4s., and we get 3s. 6d. for three visits at the surgery andone at home, and taking 2s. for the visit, it will show 6d.each other consultation.

Seeing 65 people a day we find hard work for two men,the distance limit for visits being mostly three miles-in afew cases two miles; taken at the above rates the Odd-fellows will show payments of &pound; 12s. for 16 visits and&pound;1 4s. 6d. for surgery consultations-total &pound;2 16s. 6d. perday, or &pound;1 8s 3d. each partner, plua 6s. 7d. each for Sundays.Total i&456 12s. 6d. per annum each partner in place of thepresent return of &pound;1412 gross.We have endeavoured to take the average payment as

received at present from friendly societies where the membersare selected.

Careful estimate has been made of the likely effect of theBill if passed in its present form (4s. for the doctor as fore-shadowed in Clause 38). We find about 2-9ths will still remain,being work practically outside the limit of the Bill ; one-ninth are now clubs, and if the 6s. rate is reduced to 4s. weshall lose &pound;650 a year on this section ; the remaining 6-9ths =&pound;1882, will be reduced at once to one-half, namely, &pound;941;thus the loss will be &pound;991 per annum. Against this therewill be a saving of about &pound;100 a year on drugs, &c., showinga net loss of &pound;891, or &pound;445 each partner. About one-fourthof this loss may be recovered if the work is taken back ascontract work.Now as to the balance-sheet of work we find, as the Bill

now stands, the following are an additional burden. 1.Diseases owing to the patient’s own fault-this is now a fairsource of income and will be completely wiped away. 2.All the chronic cases-the refuse of the friendly societieswill come in for free medical benefit almost at once.

3. Loss of all fees for attendance on workmen injured byaccident.On the other side we are promised relief from some

attendance on tuberculous cases, and this we fear is a delu-sion and a snare, as Clause 15 (3) clearly indicates that onlycases likely to benefit will be so treated-what a farce to besure. The old chronic cases-the tubercle carriers, if wemay so call them, will be with us still-and do not a greatnumber of the other cases get away for treatment now *!Most assuredly they do.

If this Bill passes, as it promises to do, it will be thegreatest blow any profession has received in history ; it willmean ruin to thousands of the hardest worked class in thekingdom, and, as far as it is possible to see, the Chancellor

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will pass it with the support of both sides of the House, andscant courtesy is being shown to the views of the professionand the men doing the work. The constitution of the

proposed health committees is a scandal on the face of it,and we shall be at the mercy of the leading lights of thefriendly societies backed up by Government support. Verilythe last state will be worse than the first.We have endeavoured to show the effect of the Bill on the

profession. We will now sketch what we think may be doneto avert such a national disaster.

1. A wage limit-possibly &pound; 160-should be made a sinequ&acirc; non. We must refuse absolutely to discuss thematter on any other terms whatever.

2. We should fight hard for a minimum payment beingfixed of 8s. 6d. per member exclusive of drugs,dressings, &c. No less sum will give us a livingwage.

3. Proper and full representation on all the govern.ing bodies, from the Insurance Commissionersdownwards.

4. Free choice of doctor by the insured person.

This raises the question, How can we best secure theseconcessions ? And we suggest that if the profession is loyalto itself, as we believe it is over this matter to such an

Partiezulars of Work done in 1910 by A and B.

Total receipts .................. -62824

" expenses .................. Z1150

Profits ......... &pound;1674

Total number of entries in books............... 21,070 Average: 65 each weekday-that is, 30 for each partner-" " " club entries ............... 4.732 and 15 on Sundays.

Average fee for the whole practice...... 2s. 8d. per entry." "" entries other than clubs 3s. 5d. " "

" 5s. 62d.......... Is. 2 2/3d. " " } This is fairly representative of the great friendly societies.

f 9 ,, ,, same @ 4s.......... 10 &frac12;d. " "

" " " Group J.@ 4s....... 7 9/10d. " " This is fairly representative of what the employed PostOffice contributors will be.

Proportion of club work to the whole practice about ... 2/9ths." 11 income " " " ... 1/9th.

If all the practice were paid for at club rates the total income would be ......... &pound;1399And the net income ... ... ... ... ... ...E249

If A, B, and C are taken out, being nowise representative of usual club work, the average for clubswould be 10 &frac12;d. instead of Is. 4d.

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extent that has never before been known, we can get them,and the best way is-

’

Firstly.-To show clearly, as our figures do, that ourposition even then will not be improved, but, ifaltered at all, worse than it is now.

Secondly.-To make representations to the Chancellorand the Members of Parliament of every divisionthrough deputations.

Thirdly.-To ask for no more than fair play and keepin view the good of the nation and the future of therace.

Fourthly.-For every medical man to sign an agreementthat all question of payment for contract work shallbe settled through a local committee of the medicalmen or a committee of the British MedicalAssociation.

Fifthly.-If we fail utterly to secure fair terms and theBill becomes law in its present form we must to aman follow the example of the German professionunder similar circumstances and refuse to do anycontract work whatever for a time and charge every-body the ordinary fees, thus paralysing the wholeworking of the Act.

Space prevents us touching on the other great defects ofthe Act, such as dentistry and the large amount of diseasedue to defective teeth-not one word being mentioned aboutit in the Bill. In the long run and as a general rule thepublic gets full value for its money, and whatever the pay-ment is in this case it will be the same : if it is mean and

poor the return will also be poor ; if it is anything like fairthe public will benefit. Is it too much to say that the welfareof the nation and the future of the race depend largely onthe medical profession " Treat it fairly and the return willbe enormous ; treat it badly and, like all other human beings,the feeling of doctors must eventually be that they shouldnot give handsomely for niggardly pay. We appeal for unityin this matter, for the sake of the welfare of the public andthe future of our race, as much as for our own protection frompartial, if not complete, ruin.Our books are in existence and are at the disposal of the

British Medical Association and the Chancellor of theExchequer, or any other duly accredited person who canmake good use of them.

THE NATIONAL INSURANCE BILL:THE GERMAN FIGURES COMPARED WITH THE

CHANCELLOR’S ESTIMATES.

(FROM A GERMAN CORRESPONDENT.)

THE Chancellor of the Exchequer’s statement that a sum of&pound;4,200,000 will be provided for medical attendance and

drugs is of particular interest as it affords an indication of theofficial estimate of the cost of this branch of the NationalInsurance scheme, and at last makes a definite criticism ofMr. Lloyd George’s promise, translated into practice,possible. In the first place, it is a matter for regret to hearthat the system of capitation payment is to be retained ; true,it is the easiest and most convenient form of payment from abureaucratic point of view, as well as the cheapest, butit is a feature that is not in keeping with present-day ideas. Under the r&eacute;gime of the voluntary associa-tions it might be defended ; the sick clubs were in a positionto reject doubtful applicants, so that the members mightbe considered to enjoy average health, and thus the medicalattendant was in a position to gauge the amount of work hewould be called upon to perform in the course of a year. Ina national system this provision for selection must neces-sarily be absent ; if a man is able to earn a wage he isliable to compulsory insurance; therefore it naturally followsthat the greatest claims on the practitioner’s services will bemade by the physically less resistant members, who will formno insignificant proportion of the total number of insuredpersons. The influence of these members on the whole systemis at present problematic, but will form an important factor,as this category will provide the weakest links in the chain

and make the relatively greatest calls upon the financialresources of the scheme, so that unwelcome surprises of apecuniary nature must be expected in this connexion shoulda too optimistic view be taken of the cost of working sogigantic a measure of social reform. Under the circum-stances, the proposal to offer a fixed, and at that a very low,amount of payment per individual for an unlimited amountof work reflects adversely on the opinion of the value of pro-fessional services held by the framers of this measure.

It is unbusiness-like and undignified, and the taunt ofbeing "out for fees" hurled at the profession by themembers of a body about to appropriate a proportionatelyhigher indemnity for their services is unjustified andcan only be based on a lack of knowledge of the actualconditions.The author of the Bill has admittedly gone to Germany for

many of the provisions it embodies, but in one point hemight have given due consideration to the experience gainedin that country. The capitation system of payment isthere universally condemned by the profession, and thepayment of 4s. per head of the insured represents the averagerate of remuneration which has hitherto obtained and beenfound to be totally inadequate in view of the increasingclaims made on the practitioner’s services and the alteredeconomic conditions. It is thus evident that the Britishmedical man is expected to begin financially at a level thathis German colleague is about to abandon in favour of amore just remuneration. The term medical attendance stillawaits definition, for it must be remembered that theGerman club doctor in receipt of a capitation grant receivesspecial remuneration in cases requiring greater skill, inaddition to the payments made to specialists and

surgeons.’ Here the German statistics afford interesting and instruc-tive reading, and many of the conclusions arrived at in thatcountry are capable of application to the conditions underconsideration, and should in any event command the greatestattention. We must not overlook the fact that in manyrespects the cost of living in Germany, in the broadestmeaning of the expression, is lower than in England, and thesick clubs being self-governing have been able to make arrange-ments with their medical attendants every whit as advan-

tageous as the friendly societies in Great Britain; both appearto be past masters in driving a hard bargain in this direction.It cannot be assumed that the British worker is to be providedwith a less effective medical service than the German, and yetin 1909 the average cost of medical attendance per insuredperson amounted to 5s. 9d. It is assumed that in GreatBritain there will be 14,700,000 persons liable to compulsoryinsurance against sickness, which would entail an expendi-ture for medical attendance amounting to &pound;4,226,250, or

.f.l,426,250 in excess of the total it is proposed to provideunder this heading. And this result is obtained in acceptinga figure recognised to represent the utmost limit of economy,and, in fact, incapable of further maintenance at this lowlevel.

Some idea of the extent to which the medical man’sservices are in request may be gained from the fact that40’ 3 per cent. of the insured in Germany in 1909 receivedmedical attendance coupled with sick pay, i.e., were duringa period of their illness incapacitated for work-no statisticsare kept of medical attendance granted for minor cases notcoupled with loss of working power-and the average dura-tion of each illness amounted to 20’ 5 days. It is significantto note that since 1885 the expenditure for medical attend-ance and the duration of each illness have been steadilyincreasing; in fact, an enormous increase is recorded. Thecost of medical attendance has increased enormously, as

also for drugs and appliances ; in 1885 the averagecost per member for the former amounted to 2s. 2d. andfor the latter to Is. ’7d, ; in 1909 the amounts were 5s. 9d.and 3s. 7d. respectively. From the latter figure it will beseen that the proposal to allow 2s. per insured person fordrugs is still considerably below the average expenditureunder this heading in Germany.

No better illustration of the calls made upon the sick clubdoctor in a National Insurance scheme can be given than astudy of the experience gained in the actual working inpractice of a measure of this kind ; and as the conditions arein both countries to a very great extent similar or parallel,the official German statistics for 1909 afford some veryinteresting data for serious consideration. The following