1692 THE NATIONAL INSURANCE ACT.-MEDICAL NEWS.

attendance and treatment to the insured ; (3) the panelsystem ; (4) remuneration ; (5) provision of drugs andappliances ; (6) mileage; (7) persons who make theirown arrangements ; (8) income limit in respect ofmedical benefit; (9) administration; (10) provisional arrange-ments. In addition to definitions and explanations theCommissioners’ statement contains certain conjectures. Thus,with regard to the method of remuneration, Paragraph 21 saysthat in practice this will usually be decided in accordancewith the preference of the practitioners on the panels ;while the next paragraph says that for the majority ofpersons entitled to attendance in any one year no treatmentwill be required. Equally open to criticism is the statementat the end of Paragraph 24: " There is nothing to preventsuch modifications being made if locally agreed upon thisbegs the question of local agreement.

In addition to the official statement, which demandsscrutiny from medical practitioners, we have received copiesof printed circulars from Dr. T. Arthur Helme, of Manchester,and from Dr. Charles Buttar, of London. Each of these ’1leaflets examines shortly the alternatives now before theprofession and reviews the Government’s present offer in thelight of medical requirements, and the purpose of each is

c10arly to advocate refusal of service under the conditionslaid down in the Act, in the Regulations, and in thelatest Memorandum of the Chancellor of the Exchequer.Dr. Helme’s circular is addressed in particular to themembers of his own branch of the British Medical

Association, and it essays, firstly, to draw an accurate

picture of what future practice would be under theAct. Under the head of Remuneration, Dr. Helme writes :" Previous calculations of contract work are upset, for in thisflat rate is to be included a combination of male and femalelives, unhealthy lives, those in hazardous occupations andsuffering from diseases of misconduct, lives under 65 yearsof age, and those formerly considered uninsurable." (Weassume under 65 " is a slip for over. ") In consideringthe services required of medical men under the Act he

suggests that the contract made between the practitionersand the Insurance Committee is one in which the remunera-tion is fixed and limited, whilst the services are to someextent indefinite. He argues that if the profession undertakesto give contract work under the Act this will be at the sacri-fice of its independence. As to the right to dispense, ’’ this,subject to a small exception, has been ruthlessly filchedfrom the profession." Summing up, Dr. Helme declares thatthere has been no real attempt to meet the demands of theprofession, that the remuneration differs little from that

originally proposed, that the profession in taking servicewould be under lay control in which Friendly Societies havea preponderating position, and that free medical attendancewould be given to those well able to pay for it as privatepatients, whilst club practice with its worst features wouldbe extended and given recognition by the State. Before

recording their votes he urges all medical men to judge the iquestion, not only from the point of view of individualinterest, but with full and responsible sense that the futureof medicine and the well-being of the public are in theirhands. He concludes with the words, I However the votemay go, our difficulties are capable of solution, if only weremain united and each supports the whole." As an appendix

. to his letter, Dr Helme sets out the following short summaryof the results of the recent conference between the deputa-tion of five, of which he was a member, and the Chancellorof the Exchequer :-

The Chancellor’s Concessions.1. To provide a small sum for mileage in special sparsely populated

districts and places difficult of access.2. To alter the constitution of the Enquiry Committee-now to be

composed of two doctors and one lawyer.3. To amend Act so as to withdraw the right to medical benefit from

those whose income is over £ 160 merely because they had been insuredfor live years.

4. To allow dispensing by doctor where patient resides in a rural areaand is more than a mile from a chemist. This does not affect themain point.

b. To make bookkeeping as little as possible, and not to allow inspectorto come between doctor and patient.

6. To allow 10 per cent. representation of practitioners upon theInsurance Committee, though the additional representatives will not be.elected by the profession.

The Chancellor Refuse :1. To increase remuneration.2. To institute a central fund for mileage with extra allowance.3. To reduce the three-mile limit to two miles.4. To allow practitioner to retain his right to dispense.

5. To withdraw from the Insurance Committee the sole right to fixan income limit.

6. To subject the decision of the Insurance Committee respectingincome limit to the approval of the Commissioners.

7. To abolish the right of the Insurance Committee to exempt personsor classes of persons from income limit.

8. To allow the insured person to make his own arrangements formedical benefit-the decision rests with the Insurance Committee.

9. To allow practitioners the right to decide the method of payment-this rests with the Insurance Committee.

10. To cancel the right of the Insurance Committee to finally allocateto practitioners on the panel against their wish patients who have beenrefused.

11. To allow the profession to deal with unreasonable demands for ’

service, except by complaint to the Insurance Committee (a lay body)or in first instanse to the Committee of Complaints.

12. To withdraw the investigation of complaints against medical menon professional matters from a lay tribunal.

13. To allow a professional man to be judged by his peers.14. To abolish the power of the Commissioners to remove a practi-

tioner from the panel, and to entrust this power only to a MedicalCourt.

Dr. Buttar sets outs out in parallel columns the cardinalpoints" of the British Medical Association and the presentposition of each point under the Act, the Regulations, andthe statements of the Chancellor of the Exchequer. Out ofnine demands he finds that five are not granted, one is partlygranted, one is granted with possible limitations, and twoare granted in actual words. To each decision as to refusalor concession Dr. Buttar adds a few lines of brief, pithyexplanation. He also draws attention at the foot of thetable to the additional conditions imposed upon the pro-fession by the Act, the Regulations, and the Chancellor’sstatement, and adds a short synopsis of the actual modifica-tion obtained by the deputation of five at their conference atthe Treasury. Dr. Buttar concludes his bird’s-eye view of thesituation by saying that these concessions do not seem tojustify either (a) surrendering the freedom of the medicalprofession for what in the end will be a State-controlledservice ; or (b) abandoning the decision that the Regulationsunder the Act are unworkable and derogatory to the

profession. -

THE ACTIO.N OF THE LONDON INSURANCE COMMITTEE.

We are informed that the Insurance Committee for the

County of London have had under consideration the dutiesimposed upon them by the provisions of Section 15 of theNational Insurance Act with reference to the administrationof medical benefit. With a view to making arrangementsfor the medical attendance and treatment of insured personsentitled to medical benefit they have addressed a letter to allmedical practitioners practising in the County of Londoninviting them to confer with the Insurance Committee, eitherpersonally or through some representative committee, as tothe nature of the arrangements to be adopted. The alterna-tive forms of agreement, which are framed on a capitationbasis and on an attendance basis respectively, have beenforwarded with this letter of invitation, and the selection ofone of these alternatives will be a matter for negotiationbetween the Local Medical Committee or, if no such medicalcommittee is formed, the medical practitioners on the paneland the Insurance Committee.

Medical News.UNIVERSITY OF OXFORD.-The following degree

has been conferred :-.D..—W. D. Sturrock.

The following candidates have satisfied the examiners in theundermentioned examinations :-D.P.11. : Part I.-J. C. Barucha, A. J. Macfarland, L. J. J. Orpen,and H. G. T. Truscott Major.

Part 7f.—R. Donald and A. H. Tebbutt.Parts I. and II.-W. B. Hill and A. E. Jerman.

THE Paris Academy of Medicine has electedM. Delezenne by a large majority, the other candidates beingM. Jacob Langlois and M. Rieffel.

HOSPITAL ALMONERS’ COUNCIL.-The annualmeeting of this useful body took place at Caxton Hallon Dec. 6th, Sir James F. Goodhart, Bart., the vice-

President, being in the chair. The report draws attention to thefact that the council now numbers among its members manyrepresentatives of London and provincial hospitals. During

1693PARLIAMENTARY INTELLIGENCE.

the past year almoners trained by the council have beenappointed at two London hospitals, while others have securedposts as assistants. Two candidates are being speciallytrained for posts in the North of England, and nine othersare now in training. The chairman, in moving the adoptionof the report, drew attention to the work of the council instimulating a demand, which it is now called upon to supply,and made a reference to the importance of the recommenda-tions of the Special Committee of King Edward’s HospitalFund as they affect the future of the movement. Particularattention was drawn by various speakers to the necessity ofdefinite training and to the danger of the appointment ofthose who are unable to benefit by the experience of theirpredecessors. The need for this training had been realisedby those hospitals which had sent almoners to be trained bythe council whom they had appointed and who had alreadybegun work.

’

METROPOLITAN HOSPITAL SUNDAY FUND.—Ata meeting of this Fund held at the illansion House on

Dec. 9th it was announced that the collection for the yearamounted to .667.972. The total collection in places ofworship was E1195 less than in 1911. Hospital Sunday for1913 has been fixed for May 25th.

Parliamentary Intelligence.NOTES ON CURRENT TOPICS.

The Chnncellor of the E.1;cheqller and the Jledical Projession.THE statements as to the administration of medical benefit and

correspondence thereon between the Chancellor of the Exchequer andthe British Medical Association have been issued as a ParliamentaryWhite Paper. The documents include the memorandum as to medicalbenefit under the Insurance Act, which was published in THE LANCETof Dec. 7th.

l11ilk and Dairies Bill.Mr. BURNS, President of the Local Government Board, has intro-

duced in the House of Commons a Bill " to make better provision withrespect to the sale of milk and the regulation of dairies." It has beenread a first time.

Scottish Ins!l1’Cmce Committees and Sanatorium Benefit.A deputation representing 15 county and 22 burgh Insurance Com-

mittees in Scotland met the Chancellor of the Exchequer at the Houseof Commons on Monday, Dec. 9th, to lay before him their objections tothe proposal of the Government to allocate to medical men 6d. perinsured person for domiciliary treatment of tuberculosis under the

Insurance Act. Their point was that the rating authorities had beenrelying on the full Is. 3d. per insured person for sanatorium benefit,and the deduction of 6d. would be serious for them. The conditions ofinsured persons in Scotland, they urged, were such as to render themhighly unsuitable for domiciliary treatment, and the proper places fortheir treatment were the hospital, the dispensary, and the sanatorium.Mr. LLOYD GEORGE, in his reply, stated that he must adhere to his

proposal to allocate the 6d. to the medical profession. Insurance Com-mittees must make the remaining 9d. suffice, and rely upon the ratingauthorities to make up half the balance and the Treasury the otherhalf.

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HOUSE OF LORDS.

THURSDAY, DEC. 5TH.

The Neclical Bill.On the motion of Viscount MORLEY OF BLACKBURN, the Medical Bill

(which is designed to simplify certain matters as to the election ofDirect Representatives to the General Medical Council) was read asecond time. On Dec. 9th the Bill passed through Committee withoutamendment.

Postponement oj Jlental Deficiency Bill.Lord RiBBLESDALE asked the Government whether they had any

intention of reconsidering their announced decision not to proceedthis session with the Mental Deficiency Bill. He said that everyonewould regret that the Government had decided to drop this Bill andhad sacriiiced it to party necessities.-Lord STRACHIE replied that hecould not agree that the Bill had been sacrificed to party necessities,but he thought that it had been sacrificed to House of Commonsnecessities. It was quite clear that it could only have been gotthrough by sacrificing other measures to which the Government weremore attached.

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HOUSE OF COMMONS.WEDNESDAY, DEC. 4TH.

West African Medical Appointments.Mr. EDMUND HARVEY asked the Secretary of State for the Colonies

what public appointments in the Gold Coast, Sierra Lsone, and Lagoswere open to coloured medical men of African descent.-Mr. L.HARCOURT said in reply: Three native medical officers are employed bythe Government of Sierra Leone and four by the Government ofSouthern Nigeria. None are employed in the Gold Coast.

THURSDAY, DEC. 5TH.

Negotiations with the Medical Profession.Mr. BOOTH asked the Chancellor of the Exchequer whether he could’

make any statement with regard to his negotiations with the medicalprofession respecting the administration of medical benefits under theNational Insurance Act.-Mr. LLOYD GEORGE said in reply : I made-a statement to the House on Oct. 23rd as to the amount of moneywhich the Government proposed to ask Parliament to grant-namely, JE1 650.000, for the purpose of increasing the funds availablefor the remuneration of practitioners attending insured persons, and Ithen explained the main features of the proposal which I also describedin greater detail in a statement which I made the same day to theAdvisory Committee appointed under the Act. Subsequently theBritish Medical Association, after discussions upon the subject in theirvarious divisional meetings, appointed a deputation of five representa-tives to confer with me in regard to various points on which theydesired further information. The five representatives accordingly sawme on the morning of Monday, Nov. 25th, and again the next day.Various points on which the deputation had been instructed by the’representative meeting to obtain further information were broughtbefore me, and a Memorandum was prepared setting forth fully the’decisions of the Government, together with the explanations 0)T)

points upon which do ubts had existed. The five representatives hadbeen instructed to prepare a report for their Council uporetheir conferences with me, and the Council was subsequently to’circulate a report to all the members of the Association forthe consideration of the profession as a whole. As the deputationinformed me that it would be impossible for that report to be com-pleted for circulation until Dec. 6th, at their request I agreed thatwhat passed between us at the conference and my Memorandum shouldbe kept confidential on both sides until that date. I therefore propcseto lay on the table of the House this evening the Memorandum repre-senting the reply of the Government together with other papers on the-subject, and I have arranged that the White Paper containing theseshall be available for honourable Members at the Vote Office to-morrowmorning. Copies of the medical benefit regulations, revised to carryout the changes that have been decided on, will also be laid uponthe table to-day and published to-morrow.Mr. GINNELL: Will the right honourable gentleman include in his

statement his proposals regarding an equivalent for Ireland in thismatter ?-Mr. LLOYD GEORGE : This has nothing to do with Ireland.It simply has reference to the medical benefit under the Insurance Act.

Medical Remuneration under the Insurance Act.Sir JOHN JARDINE asked the Secretary to the Treasury whether,

unde r the present proposals for medical remuneration under theNational Insurance Act, doctors would have to wait until after the endof each quarter before they were paid in respect of that quarter, orwhether he could arrange for advance payments to be made.-Mr.MASTERMAN answered : Although the exact sums to be paid in respectof any quarter can, of course, only be determined after the end of thatquarter, arrangements wlil be made whereby it will be possible formedical men on the panel to receive payments in advance based on thenumbers of insured persons on their lists at the beginning of thequarter.Mr. GLYN-JONES: Do Friendly Societies pay their medical men in

advance ?-Mr. MASTERXAN : I cannot say, but I think :that it is verydesirable that some payment should be made as soon as possible.

The Possibilities of Sanatorium Benefit.Mr. LANE-Fox asked the Secretary to the Treasury whether, under

the National Insurance Act, a blacksmith, on payment of 4s. 8d. contri-tion, could obtain benefits of the value of £200.-Mr. MASTERMAN answered : Yes, sir. A blacksmith or other insured person sufferingfrom tuberculosis could be recommended by an Insurance Committeefor sanatorium treatment, the cost of which might involve an expendi-ture reaching to £200, even though the amount of contributions paidby, or in respect of, the insured person before the date of his illness didnot exceed 4s. 8d.Mr. LANE-Fox : Is that a case which can honestly be put as a typical

case under the Insurance Act?-Mr. MASTERMAN: It is a case whichactually occurred, and it is a very remarkable one.Mr. LANE-Fox : But is it a fair case to be quoted as typical, or is it

exceptional ?-Mr. MASTERMAN: It is a true case and a perfectly fairone, and I have no means for suggesting that it is a unique case receivingbenefit. The recommendation for sanatorium benefit will continue solong as the patient is receiving benefit from the sanatorium.Mr. J. SAMUEL : Is the right honourable gentleman aware that it is

possible under the Insurance Act for an insured person, say, age 21, afterbeing insured for two years and having paid El 14s. 8d. in premium todraw in benefits £617 10s. ?-Mr. MASTERMAN: Yes, that is one of thebeneficent results of National Insurance.

Sanat01’ia in Ireland.Mr. SWIFT MACNEILL asked the Chief Secretary to the Lord

Lieutenant of Ireland to state what counties in Ireland were availingthemselves of the accommodation, either on a temporary or permanentbasis, of the Peamount, Rossclare, or Allan Ryan Sanatoria, under thecontrol of the Women’s National Health Association in Ireland.-Mr.T. W. RUSSELL (on behalf of Mr. BIRRELL) replied : I am informedby the honorary secretary of the Women’s National Health Associa-tion that the counties in Ireland which have intimated their intentionof availing themselves of accommodation either on a temporaryor permanent basis of the Peamount, Rossclare, or Allan Ryan Sana-toria under the control of the association are Armagh, Carlow, Cavan,Clare, Donegal, Dublin, Fermanagh, Kerry, Kildare, Kilkenny, King’sCounty, Leitrim, Limerick, Londonderry, Louth, Meath, Monaghan,Roscommon, Tipperary North, Tipperary South, Tyrone, Waterford, Westmeath, and the county boroughs of Dublin, Limerick, andLondonderry.

Sir J. LovsDar,E: Is the Peamount Sanatorium ready for occupatio,,- Mr. T. W. RussELL : It is already occupied.

MONDAY, DEC. 9TH.

Hospitals and the Insurance Act. Writing in reply to Sir HILDRED CARLILE, Mr. MASTER-M-AN said:

Melical benefit under the National Insurance Act includes that servicewhich can ordinarily be given by general practitioners who have come onto the panel. I know of no reason why the present treatment of the