759PANEL AND CONTRACT PRACTICE

been given protection from air attack and additionalequipment has been supplied by the Ministry ofHealth. Their medical staff are not all full-time,some being still in practice in the neighbourhood.The Willesden general, for instance, has 6 full-timeand 4 part-time men and 14 Middlesex students ;the Harrow general 5 full-time men living out,2 resident house-officers, 6 part-time men and 12students. These hospitals have also been cleared ofpatients except for a nucleus of about a fifth of theircomplement. In addition there are five casualty-clearing hospitals " class 1B "-Paddington Green,the Western Ophthalmic, the Samaritan Free, theRadium Institute, and Northwood and Pinnerhospital-special or small hospitals that will onlychange over from their ordinary work to the receptionof casualties when the organisation is hard-pressed.Next come the two advanced base hospitals, the

Mount Vernon and the Royal Bucks at Aylesbury.The Mount Vernon has been greatly enlarged and isnow equipped and staffed to deal with all kinds ofinjuries. Before the war it contained 100 beds forcancer patients ; now it has 520, 300 being in tentson the lawn, and when its hutted annexe is finishedit will have 620. It has an entirely full-time staff of29 as well as 24 students, mostly drawn from theMiddlesex. The Royal Bucks has had some 35 bedsadded to its pre-war 115, and also has some students

attached. The casualty-receiving hospitals will sendtheir patients when they are fit to move to one ofthese two, the intention being that the Mount Vernonwill take patients from the Middlesex and its neigh-bourhood and the Royal Bucks from hospitals furtherout, though this must necessarily depend on where themain brunt of an air-raid falls.

In most sectors the base is situated well away fromLondon and arrangements have been made for thereception there of a large number of patients. AtArlesley, for example, the base hospital for sector III,the Three Counties mental hospital has been extendedto take 1200 casualties in addition to its 1100 mentalpatients. Similarly, the base for sectors VIII and IXat Horton will have over 2500 beds. In sector V,however, no comparable institution capable of rapidconversion was available, and the base is placed atAylesbury close to the advanced base hospital.For this purpose the Aylesbury public assistanceinstitution is being enlarged and up-graded by theerection of tents and huts and the addition of theatreand other equipment to hold some 700 patients.The three remaining hospitals in sector V-Cheshamcottage hospital, St. Monica’s children’s hospital andthe London lock hospital-may be needed later forthe reception of chronic or convalescent cases.

Meanwhile, like the casualty-receiving hospitals inclass IB, they will go on with their ordinary work.

PANEL AND CONTRACT PRACTICE

Regulations SuspendedTHE Ministry of Health have informed insurance

committees that the regional medical service has beensuspended and the regional medical officers assignedto other duties. Insurance practitioners cannot,therefore, now refer cases to the R.M.O. either toassess incapacity for work or for consultation. Otheractivities under the medical benefit regulations whichhave been suspended until further notice are :

(a) The routine testing of drugs and appliancessupplied to insured persons. Special tests may,however, be made where there are good grounds forthinking that tests are desirable ; (b) Proceedingsunder regulation 43 for alleged excessive prescribing ;(c) Proceedings under regulation 44 for the investiga-tion of certification ; (d) Proceedings under regulations42 and 45 for failure to keep medical records. TheMinistry are not enforcing the obligation to keeprecords during the war, but are leaving practitionersto keep such records (especially clinical notes) as theycan in the pressure under which they will be working.It has been suggested that where the absenteepractitioners’ records are deposited with insurancecommittees they should be redistributed among theacting practitioners who have these patients on theirtemporary lists, for their information and completion.This course also seems desirable from the point ofview of the safe keeping of the records to avoid theirconcentration longer than is necessary in the officesof committees ; (e) Proceedings under regulations 47and 48 for substances alleged not to be drugs orprescribed appliances ; (f) The routine checking ofprescriptions against practitioners’ lists. The com-mittee, however, is given discretion to deal with aparticular case.

More Cooperation and Larger ListsThe Ministry have suggested that for the period of

the emergency insurance practitioners should agreeto forgo payment from the local practitioners’ fundfor emergency treatment and anaesthetics. It has

long been the policy of some. panel committees to

discourage claims for emergency treatment on theground that practitioners should act for one anotherin case of necessity on the principle of give and take.

In view of the smaller numbers of practitionersavailable for civilian (including insurance) medicalservice some latitude will be found necessary in themaximum number of insured persons permissible onpractitioners’ lists. General approval has been givenin allocation schemes for an additional 500 to themaxima prescribed for practitioners with and withoutpartners or assistants, and a similar increase in theaverage for a partnership. This relaxation will beexamined in the light of experience and the extensionnow allowed may even be increased.

Prescriptions and CertificatesThe Minister has been approached about insurance

practitioners’ surgery hours and insurance chemists’shops’ hours of opening, in view of the blackout.

Though early closing would be convenient to doctorsand chemists, and even many patients, it must beremembered that national needs will not permit allworks and offices to close before nightfall. TheMinister has recommended insurance committees toreview the position in consultation with the local paneland pharmaceutical committees and make suggestions.The Minister has also said that it would help ifpractitioners always make a practice of issuingprescriptions and certificates to patients at the timeof visiting them. It is a little surprising to find thatthe Minister has found it necessary to make thissuggestion.

Absentee Practitioners

Large numbers of insurance practitioners have beencalled away. Some have arranged for partners ordeputies to carry on their practices on their behalf,but many have taken advantage of the B.M.A.scheme for the protection of practices. So far asinsurance practice is concerned, 50 per cent. of the

760 GRAINS AND SCRUPLES

remuneration of the absentee practitioner is creditedto him and the other 50 per cent., less an amountto be determined in respect of the cost of administra-tion, forms a pool from which acting practitioners areremunerated for their services. The bureaus toadminister this arrangement are as a rule the localinsurance committees. During a practitioner’s ab-sence his list will be reduced in respect of deaths,cessations from insurance and removals outside thearea of his practice ; the ordinary end-of-quartertransfers will also operate, but he will continue to beremunerated in respect of those of his patients whohave placed themselves provisionally under the careof acting practitioners.

So far as acting practitioners are concerned, accep-tances during the war will be provisional and after-wards all patients will be given the option of exercisinga fresh choice. Insured persons accepted for the firsttime, that is to say, new entrants and removals intothe district, will carry 100 per cent. capitation valueto the accepting practitioner, but provisional accep-tances of the patients of absentee practitioners willof course rank only towards the distribution of thebureau pool. Acting practitioners would be welladvised, when accepting patients of absentee practi-tioners, to take care that part " B " of the medical

card is completed and that the word " provisional "is endorsed in that part of the medical card as well astheir signature. Insurance committees in theircapacity as local bureaus will have to keep a separaterecord of this type of provisional acceptance, andpractitioners will find that a little extra trouble inindicating the type of acceptance will be amply repaidin reducing misunderstandings.As already indicated, the keeping of medical records

will not be obligatory during the war, but somebureaus are arranging to supply specially markedcontinuation cards for -provisional acceptances of

patients of absentee practitioners, so that the actingpractitioner may readily recognise the war-timepatient and make any clinical note he may feeldesirable. Practitioners who are leaving their civilpractices to take up national service are remindedthat they must communicate with the insurancecommittee and indicate the nature of the arrangementsmade for the conduct of their insurance practice.It is difficult to believe, but we are told that somepractitioners have gone on full-time national servicewithout making any arrangements to secure thetreatment of the patients for whom they are respon-sible and for whom they are being paid by theinsurance committee.

GRAINS AND SCRUPLES

FROM D.P.M.

V

Now that we have leisure to exchange views, I amfinding out how different people prepared for war.One friend of mine bought herself a pair of ski-ingtrousers and some sherry, and another laid in aneighty-pound cheese. Some have bought bicyclesand some bedsocks, and one unearthed a piece ofcrochet she had begun in her first year as a medicalstudent. When I reviewed my own preparations, Ifound I had chosen a pair of gum-boots and a Chippen-dale chair.Amateur philosophers, luckily for everybody, are

nearly as common as amateur generals in war-time.It is an old observation that an ordered routine makespeople disgruntled whereas a crisis mellows them.You have only to compare the savage conduct ofthe average man and woman catching a bus in therush hour with the cooperative, gay and unselfishbehaviour of the same people during a transportstrike ; their humanity is delightfully stimulated bya little misfortune. The same genial atmosphereprevails in any large railway station on the eve of apublic holiday, when trains loiter off irresponsibly,hours behind their time, and good-humoured passen-gers sit round upon their luggage cracking jokes.I suppose the truth is most of us welcome a changeand are prepared to believe that provided things aredifferent they might be worse. Still even philosophycan be carried to extremes-or so I thought afterhearing two of our more tranquil critics discussingthe situation the other day. The conversation ran asfollows :

" Terrible business, their sinking this warship."" Yes-well-but it’s war, I mean, isn’t it ?

"

" Yes ; I suppose we mustn’t grumble."* * *

The trouble about golf, an enthusiast tells me, isthat the clubs face the wrong way. I cannot under-stand the finer points of his sorrow, but he seemed tobe complaining that all the real work has to be done

by the left hand-and backhanded at that. Anybodybut a fool, he says, would use his right hand for such aridiculous stroke ; and, following the example of theOldest Member, tells this illustrative story. A parsi-monious acquaintance of his who decided to take upgolf went round the junk shops pricing secondhandclubs ; finally he found a complete set going for asong and quickly bought them-only to find, of course,that they were left-handed. But the annoying fellow,anxious to get his money’s worth, decided to playleft-handed ; and found his golf much easier in

consequence.The unjust moral makes one wonder whether we

are all more ambidextrous than we think. Left-handed people, of course, are commonly ambidextrous,no doubt because the general right-handedness forcesthem to conform to many right-handed actions. Indigging most people seem to be almost ambidextrous.I call it right-handed to hold the handle of the spadewith the right and the shaft with the left hand ; thismeans that you stand with the left foot advanced anduse a right-handed drive and a left-handed lift. Mostmen claim to prefer this stance, but add that they canreadily use either hand. Women seem to favour theleft-hand stance, perhaps because lifting is accom-plished more readily with the right hand ; on theother hand, left-handed people also seem to prefer theleft-hand stance. It seems curious but not veryinteresting.

* * *

Psychologists have done us all a service by insistingthat an adult state of mind is proper to adult people.That this notion was summed up long ago in thephrase " Ripeness is all " is no fault of theirs. Weknow well enough by now that nothing new is to befound in the human mind, and they have done theirpart in bringing the idea once more to our notice.Moreover, they have reminded us that the maturestate is becoming to every grown person-to womenas well as men.

Of course, one may argue, a mature state is notaccessible to mankind. Human intelligence is strictly