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siderable improvement in the standard of book-keeping, the number of audit reports in qualification of accounts shewing a marked decrease. Very few cases of malversation or misappropriation, involving insurance funds to a very small amount, were reported. Scottish Societies and Branches, exclusive of Centralised Societies with Head Offices outwith Scotland, have net administration surpluses aggregating nearly £59,000.

3. The industrial crisis during the later portion of the year reacted very seriously on the National Health Insurance position. The income from contributions, after allowing for the changes in the rates of contribution which took place at the beginning of the year, was £226,000 less than in the previous year. There was also a very disquieting increase on sickness and disablement benefits expenditure, which was found to be some £250,000 in excess of that for 1925, after the effect of increased rates had been discounted. The attention of insurance practitioners was specially directed to the necessity for strict adherence to the statutory condition of incapacity for work on which correct certification of sickness claims depends. References to the District Medical Officers by Approved Societies desirous of receiving a second opinion as to the incapacity for work of their insured members were made in 42,016 cases-almost double the normal number. Of 26,410 cases actually examined by the District Medical Officers, 15,625 were found incapable of work. In view of the estimated increase of refereeing, another District Medical Officer is being appointed.

4. Schemes of additonal benefit following on the Second Valuation are now in operation for the distribution over the next five years of available surpluses totalling £2,453,530, of which nearly £342,000 per annum has been allocated to treatment benefits. The arrangements for dental benefit have been revised with a view to securing greater uniformity of procedure and conditions.

5. The administrative expenditure of Insurance Committees amounted to £47,000. Measures for the reduction of inflation in their Index Registers of insured persons entitled to medical benefit, by comparison with the membership registers of Societies, were begun during the year, and approximately onethird of the work, covering 721,000 index slips, was overtaken.

6. In respect of the medical service of insured persons 1,750,000 capitation fees at the rate of 98. per head, together with a payment of £42,500 for ordinary mileage, were paid to insurance practitioners for the year, a total of £830,000. Payments to chemists for the supply of drugs and appliances amounted to £159,042. The number of prescription forms dispensed was 2,765,433, an increase of about 70,000 on the previous year, at an average cost of about 1s. 13d.

CHAPTER XVII.

ILLUSTRATIONS FROM THE WORK OF THE DISTRICT MEDICAL OFFICERS.

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Introduction. Last year the medical certification of incapacity and the problems arising out of it were dealt with. This year it is possible to present three special medical studies from three regions. The district medical officers have now been at work for more than five years. In this period they have passed through their hands over 83,000 cases. There is thus a great accumulation of material in all districts, but varying conditions have called for special attention to particular aspects of the work in different districts, and more concentrated interest has been given by individual officers to certain problems that have been prominent in their experience. The three studies here presented deal with typical problems. Materials accumulated in the south-western district make it possible to present a special study of the incidence of incapacity and the causes of incapacity in urban as compared with rural patients. The study from the northern district illustrates the evolution of the consultative function of the district medical officer in relation to the insurance practitioners. From the south-eastern district comes a special study of bronchitis as a certified cause of incapacity. All three studies are made strictly from the standpoint of the assessment of fitness for work. The first study throws valuable light on the causative factors of incapacity in the town as compared with the country. The thickly populated mining areas cannot fairly be regarded as " rural," and the miners are left out of the reckoning for this purpose. Again, in the special study of bronchitis, the year 1925 has been selected for analysis in view of the abnormal conditions arising from the prolonged coal stoppage during the year 1926. The omission of the mining industry in both these studies makes them more typical of the average experience. On the other hand, the study from the northern district, being the study of the evolution of a function, is not dependent on the figures of any single season.

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These three studies, read in conjunction with those in the Report for 1925, constitute material for estimating the medical significance of the whole system of National Health Insurance. As these studies accumulate, year by year, they will increase in value. They will form a groundwork of tested medical experience to guide the authorities in the future developments of the medical services.

Examinations by the district medical officers are for one or both of two purposes; first, to determine the capacity or incapacity for work of the persons referred to them by the Approved Societies or by the medical practitioners; second, to consider the

diagnosis, and whether the line of treatment which is being followed is the best for the patients referred to them by the Societies or the medical practitioners. The two purposes differ materially. But from the subjoined studies it is clear that both functions of the district medical officers are steadily called into requisition. In the northern district among the cases referred by the medical practitioners those for the determination of "incapacity " are materially less in number than the cases referred on state of health." This shews an increasing desire among the medical practitioners in that district for the cooperation of the district medical officer, who, of course, has the great advantage of studying cases from the whole of the area and from all the industries. His opinion, therefore, must steadily increase in value, and it is gratifying to see that all over Scotland the tendency to invoke the wider experience of the district medical officers is continuously increasing.

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Since May, 1921, 130,198 medically certified persons have been thus referred for medical re-examination. Of these, 47,153 failed for one reason or another to come before the district medical officer; some because they were declared "off" before the day fixed for examination; some because they preferred not to appear, and some for other reasons. But 83,045 persons, that is 64 per cent. of the total referred, came before the district medical officer. In 53,692 of these cases the medical officers confirmed the certificate of incapacity for work. In 29,353 cases they failed to confirm the certificate.

In the year 1926, 42,585 certified cases were referred; 15,625, that is 37 per cent. of the total, were confirmed; 10,785, that is 25 per cent., were not confirmed; and 16,175, that is 38 per cent., failed to appear. The total number of persons actually examined by the district medical officers in 1926 was 26,410.

REGION I.

Urban versus Rural: Incidence and Causation of Incapacity. -In this statement an analysis is given of practically every case referred by the Approved Societies as to capacity or incapacity for work. The references by medical practitioners have been omitted, as they were almost entirely requisitions for an opinion on" state of health," and the question of capacity for work did not arise. The statement covers only the cases referred in the year 1926.

Cases have been divided into urban and rural. The urban cases include those from towns which form a separate insurance area of their own; the rural embrace the cases from the county insurance areas.

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Percentages are given of each disease in its particular category in the successive age-periods.

The total number of cases examined and analysed is :

Urban, providing 63-36 of the total

Rural, providing 36-63 of the total

1,946.

...

1,125.

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Under "rural" the references of miners (of which there were 1,055) are not included as (firstly) although in this southwestern district practically the locale of all the miners is rural, still by no stretch of imagination could present underground mining be considered a rural occupation; (secondly) the coal strike caused such an abnormal condition in sick certification that figures for 1926 could not be taken as a fair basis for analysis and comparison. Accordingly the references to miners (and the very few references to women connected with coal mining) have been omitted.

As to the proportion of references of cases by Approved Societies in urban as compared with rural areas, enquiry was made of several Societies as to the supervision of cases in receipt of sick and disablement benefit, and while some Societies, especially those with headquarters in Glasgow, stated that they endeavoured by means of their sick visitors to give equal supervision in rural and urban areas, it must be recognised that this is impossible with all Societies, and that use of sick visitors can not be made to the same extent in rural as in urban areas. But the close approximation of rural and urban percentages, as shewn, indicates that a very efficient discrimination is being made in rural areas.

The result of the examination is shewn under the headings Incapable and Capable. Incapable include all those who at the examination are deemed to be not fit or capable of returning to work; those who had been called for examination but were found to have been admitted into hospital, asylum, sanatorium, &c. Those who did not attend, but in regard to whom the report given to the district medical officer by the doctor in attendance gave satisfactory evidence of inability to attend on account of illness or bodily or mental disablement, were deemed incapable.

Capable include those capable of returning to work at time of examination, those signed off the sick list before the date of examination, and those who failed to appear for examination and in the absence of any doctor's report or any other confirmatory evidence to the contrary were presumed to have been signed off.

Without going into a detailed comparative analysis of percentages in the two areas a few points of particular interest may be mentioned.

(a) Comparative percentages of references of T.B. lungs in urban as compared with rural areas.

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Naturally the rural figure would have been expected to have been lower than the urban, and as the reverse is the case, there must be something to account for this. The question of housing and sleeping accommodation immediately suggests itself, but this suggestion is put forward tentatively, as no individual examination of the domicile of those referred cases was possible. The figures for the other T.B. (non-pulmonary) references, though high in the 16-30 period, drop in the succeeding periods.

(b) Apart from what may be designated the functional causes of incapability mainly found in the first period (16-30), viz. pregnancy, anæmia and post-puerperal debility, which gave so many cases to this period, the other great incapacitating causes, rheumatism, cardio-vascular and pulmonary (non-T.B.), shew progressive increase as incapacitating factors in each successive decade.

Age: 16-30. 31-40. 41-50. 51-60. 61-65. 65-70. Rheumatism, rheuma

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Cardio-vascular

Pulmonary (non-
T.B.)

16.8 20.3 29.6 33.7

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8.9 14.5
3.5 4.3

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8.4 7.4

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15.08 16.9 8.2 10.9 4.7 3.9 3.5 5.3

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Gastro-intestinal 6.7 10.6
Nervous

Gastro-intestinal and nervous are included as a contrast, as they maintain a very level figure of incapacity through the various periods.

The seeming anomaly of the great decrease of the pulmonary percentage in the 60-70 decade can be explained by the fact that the bronchitic, asthmatic or emphysematous lung sufferers are in this decade often so apparently, and indeed sometimes vividly and distressingly, incapable that need of reference cannot be entertained.

(c) The 16 to 30 period still shews by far the greatest number of references, and also the largest percentage of "capables." Probably this is in part due to the fact that at this period of life, in both sexes, and especially in the earlier years, the natural effect of an untrammelled adolescence is a revolt against subjection to the organised discipline entailed in work.

In the case of female anæmia many are found on examination not to be anæmic, at least at the time of examination. It is possible that in some of these cases there is a manifestation of

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