1479 defensive measures now in force. On all these interesting observations are offered, some illustrating the laws which plague obeys in Africa as elsewhere, while others, not the least instructive, are peculiar to the African scene. PUBLIC MEDICAL SERVICES A REPRESENTATIVE CONFERENCE A CONFERENCE of representatives of public medical services was held at B.M.A. House on Dec. 19th in pursuance of a resolution passed by the annual repre- sentative meeting last July. Dr. E. KAYE LE FLEMING occupied the chair. The primary bases of the conference were : (1) the B.M.A. model scheme for a public medical service ; (2) an explanatory memorandum on the scheme; (3) a confidential report on the work and conditions of existing services. Their reception was followed by a statement from Dr. G. C. ANDERSON (medical secretary, B.M.A.), who hoped that the conference would be an annual affair. He outlined the history of the public medical services, mentioning the spread of the idea after the war, beginning with Essex. He said that adequate medical attention for the poorer and working classes involved some form of insurance. There was a tendency throughout the country for contract schemes to start afresh, and to start in a manner detrimental to the profession. The way to stop that was to start in the area a public medical service based on the B.M.A. model. The trouble was apathy ; the doctors failed to see the writing on the wall. Probably the income limit would have to be raised before long ; and ultimately consultant and specialist benefit would have to be included. Transfer of benefits between schemes should be arranged. The wage-earner was accustomed to make a weekly budget ; why should he not be able to include in it provision for medical attendance on his dependants There was nothing degrading in contract practice, and if the B.M.A. did not arrange it, someone else would. Dr. ALFRED Cox, representing the London Public Medical Service, read a paper on public medical services and Encroachments on Private Practice The P.M.S. idea, he said, meant something far more constructive than a mechanism for collecting money. A doctor’s bill might be a very real terror in the working-class home, and the wage-earner might be forgiven if he hesitated to call in the doctor and put up with a medical service far below the ideal. The object of a P.M.S. was to provide for such people a family doctor and medical service which fulfilled modern ideas of what was desirable. Most of the encroachments on private practice of which complaints were made were due to the desire of the local authority to give medical services which the family doctor was not providing. Once established, however, clinics- like hospital out-patient departments-were abused. In areas where there was no P.M.S. the profession could never give a valid answer to these encroach- ments. The public must be convinced that the doctors were willing and able to do the work, and local authorities must be shown that much public money could be saved. At present no P.M.S. could claim to do the work done by the authorities as well as it was now being done, but the difficulties were not insuperable. The first necessity was a well-organised and popular service providing all the benefits through some or other of its members. There must be one family doctor responsible; there was no logical defence for the present system whereby a municipal doctor took charge for a brief period of the patient’s life and then disappeared altogether. Continuity was the trump card of the family doctor. Everyone admitted its desirability in theory. Much leeway had to be made up. The individual practitioner could never compete with the organised Government service, but a P.M.S. could do so. It was no use simply grumbling about encroachments; the pro- fession must show that it had learned its lesson. The doctors must be proud of their contract and make it better even than private practice. Dr. A. MCCARTHY (Birmingham) pointed out that an established P.M.S. could demand representa- tion on all public bodies, and then could nip future encroachments in the bud. Legally, a P.M.S. must be regarded as a collecting agency if the expense and complication of forming a company were to be avoided, but that did not prevent the members from remembering and following their ideal. Dr. Cox reiterated his view that so long as the profession regarded a P.M.S. as a means of collecting money it would do nothing to prevent encroach- ments, but would rather have to meet further encroachments. Dr. S. WAND (Birmingham) spoke on the Necessity for Publicity or Advertisement For the first time, he said, the B.M.A. had laid the word " advertisement " before the profession without explanation, qualification, or apology, and that was very important. The objects of publicity were to bring to the notice of everybody-employers and employees-the value of the P.M.S. and to make the public trust it. To get at those who did not attend doctors’ surgeries Birmingham had an " all or none " rule insisting that families must join and leave en bloc and never as individual members. An energetic subcommittee was the first requirement. The doctors were made keen by showing them the objects of the P.M.S. and by encouraging social intercourse and mutual trust. Recruiting letters could. be sent out with the cheques. Birmingham had devised the slogan that every member should aim at getting one new unit a day. The most important item of all in advertisement was the service rendered by the doctor ; doctors could also help by giving out leaflets, displaying notices, and explaining to patients. Another valuable slogan was : " Get at the women ! " It was the wife who usually had to pay the doctor’s bill. Newspapers could be interested in several ways ; interviews were worth far more than entries in the advertisement columns. A notice thrown on the screen at the local cinema had proved valuable in backward areas. Slips could be put in panel medical cards, and leaflets distributed in hospitals, clinics, factory social services, and local health committees. Small booklets had proved of great value in Birmingham. Withdrawals were being followed up and analysed, but were not regarded as very serious. Four axioms for publicity were :- (1) Lay publicity must not be expected to produce rapid increases but had great value in educating the public and preparing them for the attack of the doctor himself. This was predisposing publicity. (2) Exciting publicity was the doctor himself. (3) Results did not just happen; they were only achieved by hard work. (4) Get at the women. Dr. JOHN YOUNG (Edinburgh) asked if the hospitals had given any undertaking not to take casual out-
interesting observations are offered, some illustratingthe laws which plague obeys in Africa as elsewhere,while others, not the least instructive, are peculiarto the African scene.
PUBLIC MEDICAL SERVICESA REPRESENTATIVE CONFERENCE
A CONFERENCE of representatives of public medicalservices was held at B.M.A. House on Dec. 19th inpursuance of a resolution passed by the annual repre-sentative meeting last July. Dr. E. KAYE LE FLEMING
occupied the chair.The primary bases of the conference were : (1) the
B.M.A. model scheme for a public medical service ;(2) an explanatory memorandum on the scheme;(3) a confidential report on the work and conditionsof existing services. Their reception was followedby a statement from Dr. G. C. ANDERSON (medicalsecretary, B.M.A.), who hoped that the conferencewould be an annual affair. He outlined the historyof the public medical services, mentioning the spreadof the idea after the war, beginning with Essex.He said that adequate medical attention for the poorerand working classes involved some form of insurance.There was a tendency throughout the country forcontract schemes to start afresh, and to start in amanner detrimental to the profession. The wayto stop that was to start in the area a public medicalservice based on the B.M.A. model. The troublewas apathy ; the doctors failed to see the writingon the wall. Probably the income limit would haveto be raised before long ; and ultimately consultantand specialist benefit would have to be included.Transfer of benefits between schemes should be
arranged. The wage-earner was accustomed tomake a weekly budget ; why should he not be ableto include in it provision for medical attendance onhis dependants There was nothing degrading incontract practice, and if the B.M.A. did not arrangeit, someone else would.
Dr. ALFRED Cox, representing the London PublicMedical Service, read a paper on public medicalservices and
Encroachments on Private Practice
The P.M.S. idea, he said, meant something far moreconstructive than a mechanism for collecting money.A doctor’s bill might be a very real terror in theworking-class home, and the wage-earner mightbe forgiven if he hesitated to call in the doctor andput up with a medical service far below the ideal.The object of a P.M.S. was to provide for such peoplea family doctor and medical service which fulfilledmodern ideas of what was desirable. Most of theencroachments on private practice of which complaintswere made were due to the desire of the local authorityto give medical services which the family doctor wasnot providing. Once established, however, clinics-like hospital out-patient departments-were abused.In areas where there was no P.M.S. the professioncould never give a valid answer to these encroach-ments. The public must be convinced that thedoctors were willing and able to do the work, andlocal authorities must be shown that much publicmoney could be saved. At present no P.M.S. couldclaim to do the work done by the authorities as wellas it was now being done, but the difficulties were notinsuperable. The first necessity was a well-organisedand popular service providing all the benefits through
some or other of its members. There must be onefamily doctor responsible; there was no logicaldefence for the present system whereby a municipaldoctor took charge for a brief period of the patient’slife and then disappeared altogether. Continuitywas the trump card of the family doctor. Everyoneadmitted its desirability in theory. Much leewayhad to be made up. The individual practitionercould never compete with the organised Governmentservice, but a P.M.S. could do so. It was no usesimply grumbling about encroachments; the pro-fession must show that it had learned its lesson.The doctors must be proud of their contract andmake it better even than private practice.
Dr. A. MCCARTHY (Birmingham) pointed outthat an established P.M.S. could demand representa-tion on all public bodies, and then could nip futureencroachments in the bud. Legally, a P.M.S. mustbe regarded as a collecting agency if the expenseand complication of forming a company were to beavoided, but that did not prevent the membersfrom remembering and following their ideal.
Dr. Cox reiterated his view that so long as theprofession regarded a P.M.S. as a means of collectingmoney it would do nothing to prevent encroach-ments, but would rather have to meet furtherencroachments.
Dr. S. WAND (Birmingham) spoke on theNecessity for Publicity or Advertisement
For the first time, he said, the B.M.A. had laid theword " advertisement " before the profession withoutexplanation, qualification, or apology, and that wasvery important. The objects of publicity were tobring to the notice of everybody-employers andemployees-the value of the P.M.S. and to make thepublic trust it. To get at those who did not attenddoctors’ surgeries Birmingham had an " all or none "rule insisting that families must join and leave en blocand never as individual members. An energeticsubcommittee was the first requirement. The doctorswere made keen by showing them the objects of theP.M.S. and by encouraging social intercourse andmutual trust. Recruiting letters could. be sent outwith the cheques. Birmingham had devised the
slogan that every member should aim at getting onenew unit a day. The most important item of allin advertisement was the service rendered by thedoctor ; doctors could also help by giving out leaflets,displaying notices, and explaining to patients.Another valuable slogan was : " Get at the women ! "
It was the wife who usually had to pay the doctor’sbill. Newspapers could be interested in several
ways ; interviews were worth far more than entriesin the advertisement columns. A notice thrownon the screen at the local cinema had proved valuablein backward areas. Slips could be put in panelmedical cards, and leaflets distributed in hospitals,clinics, factory social services, and local healthcommittees. Small booklets had proved of greatvalue in Birmingham. Withdrawals were beingfollowed up and analysed, but were not regarded asvery serious. Four axioms for publicity were :-
(1) Lay publicity must not be expected to producerapid increases but had great value in educating thepublic and preparing them for the attack of the doctorhimself. This was predisposing publicity.
(2) Exciting publicity was the doctor himself.(3) Results did not just happen; they were only
achieved by hard work.(4) Get at the women.Dr. JOHN YOUNG (Edinburgh) asked if the hospitals
had given any undertaking not to take casual out-
patients. Other members asked questions bearingon the acceptability of the advertising methodsoutlined.-Dr. R. S. MARSHALL and Dr. J. WELLS(Wolverhampton) stressed the importance of theservice rendered and the difficulties produced byhalf-hearted members. Dr. Wells suggested a panelof doctors to teach girls home nursing, so that theservices of a nurse might be available to membersof the P.M.S.-Dr. A. N. MATHIAS said that Londonhad tried all ways of advertising and had concludedthat the only worth-while method was to satisfy thepatient.-Dr. G. IRVING said that that was the onlymethod used by Stockton, which had done very well.Birmingham had 32,000 units and the much smallerStockton had 6265.-Dr. E. LEWIS LILLEY describeda successful collaboration with nurses in Leicester.-Dr. C. H. PANTING (Leytonstone) said that Essexnever had advertised and did not intend to. Thefirst essential, said Dr. A. K. GIBSON, was a first-classservice.
Dr. WAND, in reply, agreed that the importantpublicity was the doctor, through the services hegave. Lay publicity was only used for a certain typeof patient who did not at present attend a doctor’ssurgery-possibly because of the counter-attractionsof free clinics. The total cost of publicity inBirmingham had been less than :E110.Dr. PANTING opened the afternoon session with a
paper onThe Business Aspects
of public medical services. The new service, hesaid, was going to be a business. Policy wouldbe considered with less anxiety. Instead of takingup much time with its discussion, a scheme shouldbe adopted which had proved workable and onlyamended if local conditions definitely demanded it.In Essex great savings had been effected, especiallyin stationery, by the collection of sufficient capital.The committee had borrowed £ 220 from the doctorsand :.E400 from the National Defence Trust, and thishad all been repaid in six years. It was prudent notto rely on any profits during the first two years.The office could not be run on a 5 per cent. basis.Many services were handicapped at the start by notappointing a capable whole-time secretary. Collectingwas skilled work and the collector must, besides beinghonest, be resourceful and tactful.- Past members of
friendly society staffs were perhaps the best. Salaryshould increase with the amount of work done, withno limit. To retain subscribers it was necessary tocurb the activities of doctors who accepted patientswithout fully explaining to them the implicationsof the scheme. No arrears should be tolerated, andthen the service would be held in respect. Otherfactors in efficient working were the provision andarrangement of doctors’ and collectors’ ledgers, themethod of recording names and details of every bookin use, and that of presenting doctors every quarterwith lists of their subscribers.
Dr. W. DABBS (Coventry) explained details of thescheme which had been administered in his districtfor 40 years.-Dr. MCCARTHY. said that men werebetter whole-time and women better part-timecollectors.-Dr. Cox advised that collectors shouldtreat trivial complaints by tact, but make the patientsubmit serious complaints in writing to the committee.- Dr. LILLEY (Leicester) said that fees must varywith the economics of the area. Services whichprovided dispensaries, grants, and special benefitsmust change correspondingly more.-Dr. S. A.FoRBES (Croydon) described a local scheme wherebychemists did the collecting, getting a 2! per cent. :
commission, and Dr. J. J. DAY said that Kent hada similar arrangement.—Dr. JOHN STEVENSON (Ayr)said that their clerk was paid on a 5 per cent. basis andwas not dissatisfied.
The rest of the day was occupied by a number ofmotions sent up by various districts. Dr. AlfredCox was unanimously elected chairman of next year’sconference and then took the chair.
Essex asked the Association to issue a pamphletdealing with the business side of public medical
services, but Dr. ANDERSON thought it was toosoon for a stereotyped pamphlet and persuadedDr. PANTING to withdraw his motion.
Stockton (through Dr. G. IRVING) asked the B.M.A.to prepare scales of minimum rates so that the capita-tion fee should be kept up to a minimum level.-Dr. A. K. TOWERS supported Stockton’s motion,withdrawing a similar one by Wallsend. In thedistressed Tyneside area, he said, rates based on6d. a week for the first adult were being paid. Sucha rate should, he thought, be standardised all overthe country.-Several members felt that the time wasnot ripe for standardisation and that at presentareas must fix their own rates under some kind ofcontrol from the central office ; they also feared lesta standard minimum rate should become a maximum.-Dr. GIBSON argued that the bulk of the workingpopulation was able to pay for what it wanted andit was no part of the policy of depressed areas tomake depressed doctors in them. He supported theStockton resolution, but Dr. WAND, for the samereasons, opposed it.-Dr. C. HILL (deputy medicalsecretary, B.M.A.) pointed out that the capitationfee did not bear a direct relation to the subscription.A high weekly rate might mean a low remunerationbecause it did not attract enough members. Afterfurther discussion, evidencing some fear that anyfixed rate might in the future be held up against theprofession, the motion was lost by a large majority.
Dr. J. L. O’FLYN (for Barry) then suggested areduced rate for the unemployed.-Dr. F. W. GRANT(Jarrow) said that 70 per cent. of his patients wereunemployed and he knew of no demand for lowerrates.-Dr. W. A. KERR (Swansea) said that temporaryunemployment made the position difficult.-Dr. H. F.WATTSFORD (Newcastle) characterised the motion asdangerous and unnecessary. After further oppositionon the same lines, the motion was lost by a very largemajority.
Barry also wished to raise the income limit to
300, but Dr. WAND pointed out that this had beenpassed-as a local option-by the representativebody and the motion was withdrawn.
Dr. TowExs proposed for Wallsend that the
following additions be made to the list of benefitsnot included in a P.M.S. in the Association’s scheme :-
Miscarriages, inoculations, treatment by injection,specialist treatments (oculist and aurist).
Cod-liver oil, linseed meal, serum (unless supplied bythe public authority), insulin and other medicaments usedfor injection, oxygen, vaccines, and bacteriologicalexaminations.
After the argument had swayed in both directionsDr. ANDERSON pointed out that the B.M.A. schemewas only a model, subject to local option, anddeprecated the inclusion of a long list of specificexceptions.-Prof. R. M. F. PICKEN secured the
approval of the meeting when he said that the resolu.tion required a great deal more thought, and a smallmajority voted against it.
Later the, meeting considered three motions byLondon :-That the conference is of opinion that there should be
some mutual arrangement amongst public medical servicesfor dealing with subscribers to services who are temporarilyresident in areas other than the one in which they aresubscribers.
That the machinery of the B.M.A. ought to be used,in those areas where approved public medical servicesare operating, in order to minimise the offer by municipaland voluntary authorities of medical services which thegeneral practitioner can render, and which it is the objectof public medical services to make available.That in the opinion of the conference there should be
a public medical service committee of the B.M.A. fullyrepresentative of public medical services, on lines analo-gous to those of the Insurance Acts Committee.
The first of these was left to the future committeeto consider ; the second was passed; and the third wasleft as a recommendation to council.
Finally, it was decided that conferences of thiskind should be held annually.
MEDICINE AND THE LAW
The Question of AssessorsON Dec. 13th a London evening newspaper reported
that a coroner had called in the treasurer of theLondon Football Association to assist him at an
inquest on a man who died from injuries receivedwhile playing football. The evidence showed thatthe game was being fairly played and that the injurywas accidental; the verdict was returned accordingly.One does not think as a rule of a coroner sitting withan assessor except in the statutory cases of accidentinquiries--L-e.g., under the railway legislation of1871 which enabled the coroner to apply to the Boardof Trade, now the Minister of Transport, for theservices of an expert.On the same day, as it happened, Lord Dawson
of Penn, speaking at the annual dinner of the Medico-Legal Society, referred to the possibility of placingscientific and medical men as assessors on the Benchwhere a court had to deal with the complex problemsof crime, the prevention of crime, and the closeassociation of crime with disease. The Court of
Admiralty does not disdain the assistance of nauticalassessors ; why should the law be afraid of medicalhelp in medical problems ? The answer presumablywould be that the law fears that the criminal will
escape trial or conviction if the doctors have their
say. Once the accused has been found guilty, theadministration of justice is content that the sentenceshould be commuted on medical grounds which ajudge would probably have rejected during the trial.
A Doctor’s Experiences as a Company DirectorA doctor of medicine has given his name to a
leading case on a curious point of company law.In 1932 Prof. J. W. H. Eyre, M.D., formerly directorof the bacteriological department at Guy’s Hospital,was invited to join the board of directors of MiltonProprietary Ltd., a company which manufacturesa disinfectant preparation. The company’s articlesof association prescribed that one-third of the directorsshould retire annually but should be eligible forre-election ; the directors to retire should be thosewho had been longest in office ; where two or morehad served for an equal period, the retirement shouldbe " decided by ballot." These innocent wordswere ambiguous. Did they mean " decided by lot "or " decided by a secret vote of the directors " ?
When it was necessary lately to determine whichdirectors should retire, there was one with the longestservice who would therefore be the first to retire,and there were two others of equal length of serviceof whom one must be selected for retirement. Thesetwo were the chairman and Prof. Eyre. At a boardmeeting in November the chairman asked Prof.Eyre to sign and hand in his resignation ; the requestwas refused. At a subsequent board meeting thequestion was put to the vote ; Prof. Eyre and twoother directors refused to vote; the remaining directorsvoted that the professor should retire. He then
brought an action claiming a declaration thatdetermination by ballot meant by drawing of lotsand that the decision by a majority vote was illegal.Analogies were sought from the old Militia Act andother statutes. Mr. Justice Eve thought the articlesintended to confine the decision to the directors andthat" ballot " must mean a secret vote. TheCourt of Appeal last week upset the court below.The Master of the Rolls, agreeing that the wordsmight be interpreted either way, found that the word"ballot" was used in the Companies Act of 1862but that " lot " had been used in subsequent enact-ments. The language and the practical considera-tions (since there was no provision for a casting vote)led him to conclude that " ballot " in the defendantcompany’s articles meant " lot." A further pointof construction settled the matter temporarily inProf. Eyre’s favour in any event In calculating thetotal number of directors, " additional directors "(appointed to hold office till the next general meeting)were to be disregarded. It resulted that only onedirector had to retire this month and thus neitherthe chairman nor Prof. Eyre need do so.
CORONER AND THE POISONS BOARD
ON Dec. 20th Dr. Bentley Purchase, coroner forSt. Pancras, sitting without a jury, concluded hisinquest on the body of a woman of 60 who died onDec. 10th. The first hearing, on the 13th, was chieflyoccupied by the evidence of the hospital physician andof Sir Bernard Spilsbury, who performed the autopsy.Sir Bernard then said that the body was that of astout woman ; the skin had a slight yellow tint, withno colour in the mucous membranes. There had beenchronic osteo-arthritis of the spine and rheumatism.There was petechial hsemorrhage on the surface ofthe heart, which was enlarged ; the cavities were alldilated, and there was a good deal of fatty diseaseof the muscle with brown atrophy, probably theresult of the terminal pneumonia. The lungs werecongested, especially the lower lobe, and there wasacute broncho-pneumonia at the bases. The air-
passages were reddened. The thyroid was somewhatsmall. The liver was rather fatty ; there were small
haemorrhages in the spleen ; the kidneys were enlargedand congested, and the suprarenals rather large.The tonsils showed acute inflammation, spreadingover the wall of the pharynx, with some membraneon the surface. There was oedema of the glottis.A certain degree of chronic gastritis was found.The marrow in the shafts of the femora was a deepred. The evidence from the hospital where thewoman died showed that the cause of death hadbeen acute broncho-pneumonia. On admission thered cells had been normal but the white cells