464 CHANGES IN THE E.M.S.-VOLUNTARY HEALTH INSURANCE IN U.S.A.

CHANGES IN THE E.M.S.

THE terms of service in the Emergency Medical Servicehave lately been modified to suit the unexpected courseof the war. The group officers of the London sectors,while retaining their present title, have taken over someof the former duties of hospital officers ; they will arrangemovements of patients, staff and equipment, control theuse to which the various hospitals are put and advise onupgrading. Problems of transport between hospitals,however, remain in the hands of the hospital officers andtheir deputies, the medical officers of health in thevarious districts, who will also retain their control overfirst-aid posts and other A.R.P. activities.The hospital officer for London will continue to super-

vise the first-aid and ambulance service and the work ofthe casualty bureaux in the region, as well as inter-hospital transport. The outlying sector hospitals willbe primarily under the control of the group officer of thesector, who will discuss with the regional hospital officersconcerned plans for the use of these hospitals, and forthe transfer of patients from sector to sector or to neigh-bouring regions. Mr. C. H. S. Frankau, F.R.C.S., hasthe task of coordinating the work of the London sectorsand the regions round London ; he is assisted by Dr.W. J. Gill, on behalf of the L.C.C. and other municipalbodies, and Dr. R. E. Bonham Carter, on behalf of thevoluntary hospitals. Group officers will still work inclose touch with the municipal medical officers, and anyinstructions to municipal hospitals will normally beaddressed to the M.O.H, rather than the medical super-intendent of the hospital concerned. When urgencymakes it necessary to send instructions to the super-intendent the M.O.H. will be informed as soon as possible.

The following changes in the terms of service of class-3officers have been approved by the Minister :The limit of two sessions daily and the maximum quarterly

fees of 120 and 75 guineas have been withdrawn ; the maxi.mum consultant fees for six months will be 240 guineas andfor general practitioners 150 guineas, computed on the basicsessional fees which remain unaltered.The advisory emergency hospital medical service committee

have undertaken that practitioners will give service as may benecessary for the remainder of the half year after the maximumfees have been earned.When a practitioner normally attends a hospital which is

on the occupied-bed basis whenever there are patientsrequiring treatment within his specialty his fee will be derivedfrom the pool provided by the capitation fees. Where he is sum-moned only when required he will be paid on a sessional basis.

Administrative work undertaken at the request of thehospital officer will be paid for at the appropriate sessional rate.The separate sessional fee and mileage rate is to be replaced

by a combined fee covering medical attendance and travellingcosts. A scale has been drawn up beginning at 2t guineas forspecialists and It guineas for general practitioners per sessionwhere the hospital is within two miles of the doctor’s home andrising by 6d. per session for every extra mile up to eighteen.The terms of service for class-1 and class-2 officers have

not yet been decided, and their appointments are for themost part being extended on existing terms until thebeginning of December.

VOLUNTARY HEALTH INSURANCE IN U.S.A.

(FROM OUR OWN CORRESPONDENT)

A YEAR ago (Lancet, 1939,2,447) I described the genesisof a national association of medical groups concernedwith the distribution of medical care on a voluntaryinsurance basis. At a conference in New York thatJuly all those experimenters met for the first time andconsidered the difficulties of organising for group practiceunder existing state laws. At this conference Prof. J. P.Peters and Dr. Hugh Cabot upheld the ideal of goodmedical practice which the latter suggested they wouldnot get so long as the emphasis was on age, experience andwhiskers. The charter members of these groups were :

Civic medical center, Chicago, Ill. ; Farmers union coopera-tive hospital, Elk City, Oklahoma ; Group health associationof Washington, D.C. ; Greenbelt health association, Green.belt, Md. ; Group health association of New York; Group

health mutual, St. Paul, Minn.; Milwaukee medical center,Milwaukee, Wis.; Ross-Loos medical group, Los Angeles,Calif.; Trinity hospital, Little Rock, Ark. ; Wage earnershealth association, St. Louis, Mo.At the first meeting of the new association, which is

called Group Health Federation of America, the follow-ing officers were elected : Dr. Mahlon D. Ogden (LittleRock), president, Dr. H. Clifford Loos (Los Angeles)and Dr. Michael Shadid (Elk City) vice-presidents,Charles A. Marlies (New York), secretary-treasurer, andMartin W. Brown asst. secretary. It was decided thatthe officers and some other members should define anddevelop standards for cooperative medical practice andthese standards have now been published.

1. The plans must provide medical care and preventivemedicine given by and built around the general practitioner.

2. The operation of the plans shall not impose restrictionson the physician as to methods of diagnosis or treatment andshall not interfere in the physician-patient relationship.

3. The plans must have available equipment and facilitiesadequate to ensure full performance of the services arrangedfor or provided, and in general to provide a high quality ofmedical care.

4. The compensation of the physicians must be adequateand commensurate with accepted standards for the com.munity served. ,

5. All plans shall be equitable and consistent with respectto the rights and obligations of subscribers and physicians,and shall describe specifically the types and amounts ofhealth services to which the subscribers are entitled.

6. All medical services shall be rendered by or under thedirection of graduates of recognised schools, duly licensed topractise medicine and where possible members of appropriateprofessional societies. All specialists’ services shall berendered by physicians qualified in the particular field. Allnursing services shall be rendered by or under the direction ofgraduates of recognised training schools, duly licensed topractise nursing.

7. The plans must be economically sound and havefinancial status and operations which adequately protect theinterests of subscribers and physicians.

8. The rates must not be excessive or inadequate.9. After the first year of membership, statistical records

must be maintained and reports must be submitted currentlyas prescribed by the federation.

10. A profit-making sales organisation shall not be givenresponsibility for promotion or administration. Promotionand administrative policies shall be dignified in nature andin a manner consistent with professional ideals.The enforcement of these standards is in the hands of

a group of visiting experts. The final decision of theboard of directors as to whether a particular organisationmay be accredited within the federation is made on therecommendation of this accrediting committee of expertsafter consideration of their report. It is interesting to seehow careful these reformers are to eliminate the risks ofgroup practice described so eloquently by your specialcommi.ssioner in his " Battle of the Clubs " forty years ago.

BiGGEB AND BETTER SHELTERS.—The A.R.P. CoordinatingCommittee, under the chairmanship of Prof. J. B. S. Haldane,was one of the first consultative bodies to propose heavilyprotected shelters, and the Government’s technical expertsrecently approved the committee’s designs for communalshelters which could be rapidly constructed. On Sept. 17 adeputation from the committee was received at the HomeOffice, and put forward a plan to secure a large and immediateincrease in the production of cement. The Haldane shelters,advocated by the committee, would entail the use of largequantities of cement, the output of which could be increased by50% if the committee’s recommendations are adopted. Noaction has so far been taken, but to be useful these measuresmust be initiated soon. The committee also suggest that tunnelshelters could be used to supplement the Haldane shelters,and propose that bunks should be put up in the undergroundstations to increase their capacity; these bunks could be trans-ferred to the shelters as they are completed. Additional tunnels,they think, could be driven with the help of unemployedminers,from the tubes or into hillsides, and existing tunnels could beconverted, as at Southwark and Ramsgate. They suggest asurvey of steel-framed and reinforced concrete buildings, whosebasements and lower floors could readily be made safer thanthe standard forms of communal shelter now available.