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To these figures payments to dispensing doctors in respect of drugs supplied, and to Pharmaceutical Committees in respect of administration expenses, aggregating about £11,000 and £2,000 respectively annually, fall to be added in arriving at the total annual expenditure from the Drug Fund.

15. Control of Prescribing. The policy in this matter has continued to be one of endeavouring to ensure that insured persons receive proper and sufficient medicines and the prescribed medical and surgical appliances to which they are entitled under the Act, while directing attention to the elimination of wasteful and unnecessary expenditure. In normal circumstances expense by itself should never be a bar to the supply of appropriate medicine under National Insurance. The tendency, however, for expenditure on drugs to move upwards whenever administrative control is relaxed has been noticeable, particularly since the provision was introduced whereby an insured person can change his practitioner at any time. Investigations conducted by the Medical Officers, and reports of local investigations, continue to shew that a portion of the expenditure from the Drug Fund is still unnecessary from the point of view of the health of the insured population. The great majority of experienced practitioners are able to meet the needs of their patients satisfactorily at a cost well within the funds provided, and experience goes to indicate that the reason for a heavy expenditure on drugs in any particular case over a prolonged period is rather to be found, with some exceptions, in the prescribing habits of the doctor concerned.

During the year we have continued to co-operate with the local committees in supervising the prescribing of insurance practitioners. Reference was made in the last Report to a Joint Committee representative of the Insurance Committees and the medical profession which was preparing a scheme of suggested procedure to be followed by local panel committees in connection with their duties towards prescribing in their areas. The scheme was issued by its authors to Panel Committees and Insurance Committees early in the year. It was recognised that the adoption of the procedure outlined would bring the control of prescribing throughout the country into co-ordination with that in the relatively few areas which have consistently maintained an effective supervision, and accordingly no opportunity has been lost of impressing on local bodies the need for examination of the position, wherever that appeared to be called for. provision in the scheme whereby the preliminary clerical work entailed in an investigation of prescribing would be undertaken by the Central Checking Bureau at the expense of the Special Drug Fund was largely taken advantage of by panel committees. There is no doubt that these measures had a useful effect in providing organised methods of scrutinising drug expenditure, although there are certain committees which still fail to appreciate fully their responsibilities in the matter. There is no reason to anticipate that such measures for the economical

administration of insurance funds by checking waste and eliminating excess in prescribing should react unfavourably upon the treatment provided. In the course of their duties in connection with the control of prescribing, fifteen Insurance Committees found it necessary to surcharge some fifty-nine practitioners sums aggregating £763, 16s. 11d. In five cases the practitioners appealed against surcharges, and in four of these it was found, on considering the facts, that the surcharge was justified, while in the fifth case the amount of the surcharge was reduced.

16. Lowlands Mileage and Necessitous Districts Funds.-For the year under review a mileage fund of £42,500 was made available as in 1925 for the purpose of compensating rural practitioners in the Lowlands area of Scotland for the additional outlays and time involved in travelling to visit insured patients residing beyond two miles from their residence. The allocation of the Fund between the various County Committees was on the same basis as last year.

A further sum of £3,500, as in the previous year, was reserved for disbursement with a view to the improvement of the medical service in areas in the Lowlands presenting exceptional difficulty, and grants were made on the existing basis to doctors working in sparsely populated districts, and allowances given towards the cost of running a motor car, for removal of insured persons to hospital, for improved telephone facilities, &c. Eight doctors from outlying practices received contributions from the Fund during the year towards the expenses incurred in taking a postgraduate course of study.

17. Questions of Insurability.-The practical and popular advantages of the conjunction of widows' and old age pensions insurance with health insurance appear to have awakened the keen interest of a number of persons who were formerly content to remain uninsured notwithstanding unresolved doubts whether they were employed within the meaning of the National Health Insurance Act. Indeed it may be said that persons who could put forward a colourable case for their exclusion from health insurance and who contrived to do so with every argument in their possession are now demanding admittance to the health and pensions scheme, and are abandoning altogether their former arguments in support of their exclusion. For example, the Glasgow slaughtermen, who in the early days of the National Health Insurance Act willingly acquiesced in the decision that they were not employed under a contract of service and were therefore not compulsorily insurable, made very strong representations during the passage of the Contributory Pensions Act that they should be brought within the scope of the health and pensions scheme. Unless, however, the conditions under which they work are changed it is impossible to give effect to their desire, employment under a contract of service being the broad basis of compulsory insurance.

From the outset difficulties arose respecting persons who were alleged by their widows to have been insurably employed though no contributions had been paid. As the award of a widow's pension depends upon the insurance of her husband, it was necessary to enquire very closely into these allegations of insurable employment. With the lapse of time it was exceedingly difficult to ascertain precisely what the conditions of the husband's employment had been. Sometimes the employer was dead as well as the husband; at best only the employer's version of the facts was obtainable, supplemented in some cases by thirdparty evidence which was not always well-informed. There was always the possibility of collusion between parties with a view to presenting a favourable case for a pension. If satisfied on enquiry that the husband's employment was of an insurable character, we invariably collected the arrears of contributions due before allowing the widow's pension claim. On the other hand the natural desire on the part of the widow to obtain a pension often led her to put forward a history of insurable employment which subsequent enquiry failed to substantiate. For example, it was alleged in one or two cases that the husband had been in receipt of a weekly wage, whereas it appeared from later evidence that he had worked under partnership conditions, and that he was not in receipt of wages under a contract of service. Again, claims put forward by widows of barrowmen, i.e. men employed by commercial travellers to carry samples of goods, had in some cases to be refused because of the impossibility (in the absence of stamping) of obtaining the necessary evidence of employment. While their employment is of a casual nature, it is not excepted from the scope of compulsory insurance, inasmuch as the exception relates only to casual employment otherwise than for the purpose of the employer's trade or business. In practice, however, it has been found that the payment of contributions has often been ignored, the barrowman apparently preferring to dispense with health insurance rather than risk the loss of employment or the loss of tips which might result from the presentation of a card for stamping. Non-compliance of this kind is difficult to check both on account of the number of employers of the same barrowman and the inability of the latter to give the names of their employers, and the necessary dates and other particulars. We have recently brought the matter to the notice of the Commercial Travellers' Association, and have recalled their attention to the requirement that casual employment of this kind is insurable, and that it is the duty of the commercial traveller first employing a barrowman in any week to stamp his card. We have further endeavoured by all practical means to make it clear to such barrowmen that it is their duty to present cards for stamping purposes, and that, if they fail to do so, loss of pension rights to themselves and their dependants may result.

The loss of pension rights which may result from failure to pay contributions when due, will act as a strong inducement

to many persons to look after their insurance interests more carefully than they have done in the past. Wives have now an enhanced and close personal interest in insurance, and may be trusted to see that their husbands' cards are stamped and surrendered. Already there are signs of activity in that direction on the part of the wives.

Similar insurance difficulties were experienced in the investigation of claims to old age pensions free from the "means test by persons who had reached the age of 70 before 2nd July, 1926, who alleged that they were in insurable employment up to the time when they attained the age of 70 although no contributions had been paid, and who demanded that they should be treated as having been continuously insured since 29th April, 1925. The non-payment of contributions was prima facie evidence of non-insurability, but subsequent enquiries frequently shewed that the claimants had been in insurable employment although no contributions had been paid. It was possible to obtain in these cases evidence from both the employer and the employee, but before arriving at a decision we had to consider the likelihood of collusion between the parties.

18. Formal applications for decision in regard to liability to insurance.-Under the provisions of Section 89 of the National Health Insurance Act it is open to any person to ask us to determine any question that arises in regard to liability to insurance. Normally our informal opinions on such matters are accepted, but as the applicant has no right of appeal unless and until a formal decision is given under the above section, formal questions are from time to time submitted for determination. The decisions are final on questions of fact, but appeal may be made to the Court of Session on any question of law in relation to the facts as established.

During the year nine such questions were received under the above section. Of these three still remained under action at the close of the year. Particulars of the questions decided are as follows:

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It will be observed that of these applications the third and fifth related to the insurability of the applicants' deceased husbands. The third application arose out of an appeal against the refusal of a widow's pension under the Contributory Pensions Act. In the case of the fifth application, it was pointed out to the applicant that before proceeding with a civil action which she proposed to bring against her husband's employers for loss of benefit sustained through their failure to pay contributions, it might be advisable for her to obtain and submit to the Court our formal decision whether or not her husband was insurably employed. Question No. 4 was remitted to us in terms of Section 97 (4) of the National Health Insurance Act by the Sheriff before whom the employers were being prosecuted for failure to pay contributions.

19. Employment during the General Strike.-In a few isolated cases we were asked whether contributions should be paid in respect of persons employed on emergency work during the general strike. Our attitude has been that where persons, who were normally not employed within the meaning of the Act and therefore not insured, took up emergency work of an insurable character, we did not press for the payment of contributions. Voluntary workers were, of course, not employed within the

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