954

MEDICAL PRACTICE UNDER THEINSURANCE ACT.

(BY OUR SPECIAL COMMISSIONER.)(Continued from p. 893.)

XXII.—HULL AND THE FRIENDLY SOCIETIES.

Mr. John Lewenstein, solicitor and clerk to the InsuranceCommittee of the town and port of Hull, expressedto me his great satisfaction with the working of theNational Insurance Act at Hull. Out of a population of287,000 persons 95,000 are insured, although some 6000 ofthese persons, reported by panel doctors as on their lists,had not as late as midsummer been traced back to their

Approved Societies or as Post Office contributors. But thissort of thing has not been peculiar to Hull. ’

The Position of the Friendly Societies. :

In Hull there is a larger proportion of artisans andlabourers than in most towns, and it was supposed to be thestronghold of Friendly Societies. The Druids have theirheadquarters here, the Sons of Temperance are very strong, the National Amalgamated Society, the Refuge, the Pearl, and many other Friendly Societies and speculative insurancecompanies are very active in Hull, and all are now workingunder the Act. Hull consequently seemed to afford a goodopportunity for endeavouring to ascertain what is likely to rresult from allowing two totally different organisations-i.e.,

.

Friendly Societies and commercial insurance companies-to work the Act. Mr. Lewenstein had previously acted as clerk to a County Insurance Committee in Wales. He is vice-president Iof the National Association of Clerks to the Insurance Com- -*

mittees and has just been appointed editor of the organ of that association, and has taken so prominent a part in the cNational Insurance world that he was well able to give me 9

full information on the matter. To my surprise, he took a fdifferent view to what most persons expressed with whom I tdiscussed the question. He thought, contrary to the impres- csion, which he admitted was widespread, that the Friendly tSocieties do their work well. The commercial societies, t

meaning certain life assurance societies, might have excel- 1]

lent business methods, but they did not pay the benefits due t

as promptly as the Friendly Societies. They were working to make money and the smallest pretext was eagerly seized as ’]

an excuse for deferring, perhaps avoiding altogether, the pay- ament of sums claimed. The Friendly Societies, on the scontrary, do not seek to make money, but endeavour to carry out the motto, "Bear ye one another’s burdens."

I

Possible Abolition of the Insurance Committees. a

In the struggle between the two forms of organisation, n

Mr. Lewenstein did not anticipate that the more business- 11like administration of the commercial societies would end by a

sweeping away the Friendly Societies. Rather might such a contest result in the disappearance of both forms of Sorganisation. There would then be created, on the German iimodel, a National Insurance Organisation managed by the a

State and comprising the entire insured population. Such aJFriendly Societies or commercial insurance companies as S1

might remain would provide all supplementary benefits that a]are not given under the Act. e]

Hull is not peculiar in one thing. Throughout the country ojI find that there is undoubtedly much bitterness of feeling n,

and jealousy between the two very different sorts of organisa- n.

tions that have been allowed to carry out the Act. Some ti,means will be attempted to bridge over this antagonism as it engenders so much discord. The present position is

certainly very difficult, for experience, proves that what sr,

occurred among those who voluntarily insured before the d(Act cannot be taken as an indication of what is happening dito-day with the totally different population now under the h:compulsory clauses of the Act and forced to insure. foThese latter come from a different class of peoplealtogether. A member of a Friendly Society is con-

cerned in the prosperity of his society, for he is a

paying partner, and it is to his interest to be careful isnot to occasion a larger expenditure than necessary. deBut the newly insured person, who did not belong to re

a Friendly Society, does not feel that there is a ques- extion of principle involved. He has never conceived that wit might be his duty to pay a weekly subscription in order un

to help in bearing another’s burden, and therefore he ismuch more likely to allow a cold to figure as quite a seriouscomplaint if he can do so without malingering beingdetected. Many diseases manage in this way to expand, andthey form, not only a drain on the funds secured under theAct, but a heavy tax on those extra benefits organised by theFriendly Societies over and above what the Act provides.For, after all, as long as the panel doctor signs thecertificate, there is nothing to be done by the Society but

, to pay. One lodge, I am told, made a public statement thatit had paid in three months as much as it paid during a

, year before the passing of the Act. Then the Temperance, Friendly Societies say that their money is being eaten up by

extra sickness among the intemperate. And over and over

again the point was made to me that Friendly Societies,before the Act, were greatly composed of more or lessselected lives. Under the Act medical examination beforeadmittance has, of course, been abolished. Thus the drainon the funds has greatly increased, while, of course, theamount of work to be done by the medical men on the panelis also enormously greater than that done under the oldsystem of contract practice. Everywhere this is the story-any increase of pecuniary return to the practitioner is accom-panied by a vast increase of labour and of expenditure oftime.

The Rising Generation and the Friendly Societies.The attitude of the rising generation towards friendly

societies is not as sympathetic as was that of their fathers.They will not give themselves the trouble to pay theirsubscriptions. The commercial companies have large staffs ofcollectors, and as these men very often collect for otherpurposes as well it pays them to go their rounds persistently.But this is not the case with the Friendly Societies, andunless the latter organise an equally effective body ofcollectors they will find themselves at a serious disadvantage.The commercial societies do all the work, take all the books,fetch them backwards and forwards; the subscriber has notrouble at all-he has only to leave out the money when thecollector’s call is due. If the young men of to-dav will nottake the trouble to pay in their contributions, still less arethey likely to allow themselves to be elected as members ofmanaging committees. The older generation looked uponthe work of organisation as a matter of duty undertaken soas to better the condition of the class to which they belonged.They thought thus to do their duty towards their neighbour,and put in many hours of gratuitous work for conscience’sake, and their altruistic spirit misled them in one direction.As was shown sufficiently clearly in the articles whichI wrote in THE LANCET now many years ago, entitled " TheBattle of the Clubs," the conscience of these organisersallowed them, nay, appeared to impel them, to sweat theirmedical officers, who in some cases were abominably treated.The lamentable position which prevailed in Hull some 20 yearsago or less is depicted in those articles very clearly, butthat is not the point to which I wish to draw attention now.Such a thing as a Friendly Societies Medical Alliance payingin respect of 4000 members £208 for 27,000 consultations, ora fraction over seven farthings per consultation, cannot occuragain, as it did in 1894. We may not be able to forget thatsuch things happened, but it will be more useful to lookahead. The men who did these things were at any rateenthusiastic in the cause of their clubs. But the young menof to-day have not the interest in their Friendly Societiesneeded to make them attend lodge meetings. They willnot take their share in the monotonous work of organisa-tion. It is true that the old Friendly Societies were managedas a rule by a few public-spirited men, and that the rank andfile of the members confined their energies to paying theirsubscriptions, while the wives who, fearing illness anddomestic disaster, kept the men up to the point of regularlydisbursing their insurance money. But the new membershave not the same incentive to economy, and the prospectfor the clubs is not good.

Lay Influence upon the Insurance Committees.The outlook, so far as the medical profession is concerned,

is far from pleasant to contemplate under certain possibledevelopments in the working of the Act. To begin with, therepresentation of the Friendly Societies on the InsuranceCommittees is much too strong. I found this view, whichwas so clearly foreshadowed in THE LANCET, almost

universally held in Hull. The Insurance Act is valuable to

955

the medical profession because it changes entirely theposition of the club doctor, who was under the beck andcall of a lay committee composed of small tradesmen and ofartisans. The committee that managed the club or FriendlySociety was too often one without the slightest sympathyeither with the aims of medicine or with the lot of the doctorwho was employed by the members-the figures I have

just quoted prove how true this was about Hull. But theseformer managers of clubs and Friendly Societies are re-

suming the control of medical practitioners as members ofthe Insurance Committees, and it seems that if the nomineesof the Friendly Societies disappear from the Insurance Com-mittees they will be replaced by the nominees of theinsurance companies. The profession will then be evenmore directly under the thumb of commercial enterprise.This would be quite intolerable, and the desirabilityof replacing the Insurance Committees by a NationalInsurance Organisation, in accordance with Mr. Lewenstein’ssuggestion, might become evident to the medical profession.At least he believes so, and he is possibly right if events turnout upon the Local Insurance Committees as he foreshadows.But here he, and those who think with him, may have mis-calculated. The panel doctor does not make a contract withFriendly Societies or with insurance companies, but with theLocal Insurance Committee acting under the Insurance Com-mission, which is a State institution. If the State exercisedmore power so that the Local Insurance Committee shouldnot become too much like the management committees ofthe old clubs medical men would probably feel more secure,while difficulties created by the demand of different clubswould disappear. The question of certificates gives anexample of what I mean. Why should not the Com-missioners draw up an official and satisfactory certificate-auniform formula to be used throughout the country ? ApprovedSocieties want to enforce the use of whatever certificate theymay approve. But the Insurance Act is national. Thebenefits come from the State and not wholly from the insuredperson’s individual society. The State and not the ApprovedSociety might well provide the proper or statutory form ofcertificate. The thing needed is that the attending practi-tioner must certify when the patient should be placed on thesick list, whether he should continue on the sick list, andfinally that he is well enough to return to work. Somesocieties want a fresh certificate every other day, and theCommissioners should make the societies accept a uniformrule in this respect. There will be no peace until this questionis definitely settled, and the certificates rendered uniform inall the insurance areas. As it is, some panel doctors repeatthe details on every certificate, others content themselveswith putting ’’ as before." One society at Hull refused topay sick allowance because the medical certificate was

written with an indelible pencil instead of with a pen andink Some societies want the certificates signed only on onespecially selected day in the week. Therefore the patientcomes when he wants advice or medicine, and then hecomes round again a day or two later because that is the dayhis society has fixed for the signing of certificates. This, ofcourse, is a loss of time for both parties. At Hull the feelingis strong that the medical man would not be worried in thismanner if the representatives of the clubs upon the LocalInsurance Committees were less influential.

Tlee Allotment of InStbred Persons.But there is no feeling against the Local Insurance Com-

mittee at Hull as a business organisation. Actually, atHull 80 out of 120 general practitioners are on the panel, anda very good impression was produced when three days aftertheir first quarter’s work all the panel doctors received thefull ls. 9d. to which they were entitled for every insuredperson on their list. This showed good business manage-ment on the part of the Hull Insurance Committee and itssecretary. None of the money was kept back, and the paneldoctors will probably get some 20 per cent. more in respectof those insured persons who have not yet selected theirmedical attendant, and they number more than 15,000.These are to be allotted on the following principle. First,so as to keep the medical adviser near to his patient, Hullhas been divided into three districts. The practitioners in theA or first district will be called together to ascertain howmany panel doctors consider they have already a sufficientnumber of insured persons on their list. The unallottedpersons will then be divided evenly among the panel doctors

who still desire more patients. The doctors of the B and Cdistricts will proceed in the same manner, and it is calculatedthat these three districts are very similar-namely, a mixtureof slums and residential quarters. Some medical men have

already got very large lists. Thus one practitioner has2800 persons on his list and his partner, instead of beingfree to assist him, has 2000 persons on his list. This is a

very large slice of practice under the Act for one firm totake. The insured are told to select a separate member ofa firm and not the firm, and many of them do not knowwhich practitioners have already very full lists, whileall are likely to follow the example of some neighbour oranother with the scriptural result that to him who haththere will be given. The restraining movement will have tocome from the medical men. Those who have already verymany patients on their lists should not desire to add to theirresponsibilities lest they bring medical service into some dis-repute by adopting the old methods of contract practice.Already one of the abuses which the old club system used toencourage made a brief appearance at Hull under the Act.It was discovered that some practitioners issued cards sayingthey were connected with certain Approved Societies andthese were circulated among others than the members of thesocieties concerned. The cards seemed to make capital outof a connexion with certain State Approved Societies andundoubtedly constituted an advertisement. Protests weremade and the cards were promptly withdrawn.

The Pharmaceutical Chemists and the Act.Some if not all of the panel doctors have been prescribing

too freely. During the first quarter 67,000 prescriptionswere made up at an average cost of over 7d. each. The dis-

pensing chemists were promptly paid 75 per cent. on theirclaims. This was the most that could be got out of thefunds allotted for that purpose. But as in the ensuingquarter there was much less sickness and the novelty of theAct was beginning to wear out, the number of prescriptionsthat had to be made up was not so considerable. It is con-

sequently anticipated that by the end of the year theaccount will be balanced or that there will be only a smalldeficit. But the chemists now claim an extra penny for

poisons, and there was some trouble about the inferior qualityof the bandages. However, the Medical Committee dis-covered a manufacturer who supplied good bandagesat a sufficiently low figure and the chemists now knowwhere to get what they require, a facility of which theyreadily make good use. The patients no longer com-

plain that the bandages break. But the difficulty in regardto some of the drugs is not so easy to arrange. After thelast amended list of prices was drawn up quinine rose fromls. 5d. to 2s. ; senna and mustard rose from ld. to lid. theounce. Croton oil and andal oil have also gone up;large quantities of the latter are required in all great sea-ports. Nevertheless, and in spite of these difficulties, theInsurance Committee and its secretary consider that goodheadway has been made and that the Act is working well.

(To be continued.)

CHOLERA IN THE NEAR EAST.

(FROM THE BRITISH DELEGATE TO THE CONSTANTINOPLEBOARD OF HEALTH.)

Cholera in Constantinople and Neighbourhood.THE small outbreak of sporadic cholera mentioned in my

last letter on the subject (published in THE LANCET ofJune 14th last, p. 1697) came to an end, as there stated, onApril 25th. Clean bills of health were issued from May 4th.For the next three months the city seems to have been freefrom the disease; but on August 5th 2 imported cases, 1of which proved fatal, were recorded. From August 20thindigenous cases began to occur. Single cases were reportedon August 20th, 21st, 25th, and 28th and on Sept. 2nd. Onthe 3rd 9 cases with 3 deaths were registered ; of these,7 cases occurred in a lunatic asylum at Scutari, on the Asiaticside of the Bosphorus. It is. of interest to note that thisasylum furnished a considerable number of cases during theepidemic of cholera in 1893. Since Sept. 3rd several furthercases have been seen, both in the asylum and in differentparts of the city. In all, 25 cases with 15 deaths have beenregistered down to the 10th inst. ; 2 have been cured and