visional societies operating within the other country. Precise instructions were conveyed to British societies by circular as to disposal of members resident in the Free State on 1st July, 1923. Generally speaking, every society with such members had to get into touch with a Free State society willing to accept them en bloc, and had then to carry through a transfer of engagements in respect of them as at the appointed date by a modified procedure involving simply the passing of complementary resolutions by the respective committees of management, the one disposing of the engagements and the other accepting them. The rights of the individual members, however, were safeguarded by provision that each had to be notified of the proposed transfer and to be allowed opportunity to object. Unless at least 10 per cent. of the members in question raised objections the transfer became effective. The same procedure applied in the case of Free State societies in regard to disposal of members resident outwith the Free State, and, so far as has been ascertained, the separation as it affects Scotland is complete. It is important to note that all members affected retain the fruits of their society membership prior to the appointed day, including their title to the equivalent of such additional benefits as are provided under the additional benefit scheme, if any, of their old society.

In view of the separation, arrangements have been entered into by the Joint Committee and the Irish Insurance Commissioners for securing continuity of insurance of insured persons who may move from one country to the other. Under these arrangements a member of a British society who becomes resident and takes up employment in the Irish Free State will remain entitled to benefits from his British society until the end of a specified period unless, meantime, he has joined a Free State society. He may apply for admission to a Free State society at any time after he has taken up employment in that country and will become entitled to benefits from that society from the beginning of the half year following his admission thereto. If he has failed to join a Free State society within the specified period he becomes a deposit contributor in the Free State. In either case membership of his British society will be treated as if it were Free State Insurance, but he will not carry with him the right to any additional benefits he may have enjoyed in his British society. The specified period referred to above is determined as follows:-Where a member of a British society has been employed in the Free State during each of two consecutive half years without return to employment in Great Britain, the British society must terminate his membership at the end of the third consecutive half year unless in the meantime he returns to employment in Great Britain. For this purpose weeks of incapacity in the Free State are to be regarded as weeks of employment there. Further, so that the member concerned may not be in ignorance of his position, the society must give him at least eight weeks' notice of the compulsory termination of his membership as at the end of the specified period.

The above procedure relates to the normal case only. Special provision is made for special cases such as temporary residents, deposit contributors, men serving in the armed forces of the two countries, etc.

SICKNESS, DISABLEMENT AND MATERNITY BENEFIT CLAIMS.

The average expenditure per member in pence per week on these benefits, in respect of the Scottish membership of approved societies, is given in the following table -~-~

* The increase of benefits under the 1920 Act as from July, 1920,

affects these figures.

+ These figures are affected by additional benefits payable as from

July, 1921.

It should be noted that the 1922 figures relate to a year during which for the first time additional benefits have been continuously payable. From a comparison with previous years, therefore, it may be said that sickness and disablement benefit claims do not show any appreciable increase. There has, however, been a marked decrease in maternity benefit claims.

Expenditure figures for 1923 are not yet available, but we believe that they will show a slight decrease in payments in respect of sickness benefit, accompanied, however, by an increase in disablement benefit.

Further particulars of approved societies' expenditure are given. in Appendix VII.

DISTRICT MEDICAL OFFICERS' SCHEME.

References to the District Medical Staff.

During the year an increasing number of societies have taken advantage of the district medical officers' scheme with beneficial results. Whereas, in 1922, 137 societies referred cases to the district medical officers for examination, the corresponding number during the past year was 149, and the number of cases referred by

societies has increased from 16,618 in 1922 to 19,040 in 1923, an increase of 146 per cent. These figures indicate that the large majority of societies are realising the advantages of obtaining a second medical opinion in the day to day administration of benefit as soon as a reasonable doubt as to incapacity emerges, not merely after benefit has been paid for a prolonged period.

The following table shows the total number of cases examined under the scheme during the past year, with particulars of the opinions expressed thereon:

:

* Includes 13% declared-off before examination, 16% failed to attend,

and 4% other cases.

The examination of cases in the remoter and less populous districts of the Highlands and Islands is excluded from the scheme, the work being undertaken by our headquarters medical officers as and when opportunity arises for them to do so without undue expenditure of time and money. The total number of such cases examined during the past year was 240. These cases are included in the total given above. While every endeavour is made to secure the examination of these excluded area cases as quickly as possible, it is impossible to dispose of them with anything like the promptitude with which cases in the rest of Scotland are dealt with. Not infrequently the insured persons to be examined are resident in remote and inaccessible places, necessitating trying journeys by road and water, and to send one of our medical officers for the sole purpose. of conducting examinations would involve an unjustifiable expenditure. Generally speaking, however, it has been found possible to dispose of references within a month of the date of reference.

Organisation of Districts.

In accordance with the provisions of the National Health Insurance Act, 1922, the cost of the district medical service is now refunded from the benefit funds of societies, who are, however,

recouped out of the Central Fund to the extent of 7/9ths of 1/3rd of the amount charged against their benefit funds. We think it desirable, therefore, to outline briefly the organisation of the service, which we have from time to time adjusted in the light of experience, but which can now be regarded as practically stabilised.

Apart from the excluded area, to which reference has already been made, Scotland is divided into five districts for the purposes of the scheme, each with a full-time medical officer. Central medical inspection rooms are located at Edinburgh, Glasgow (2), Dundee and Aberdeen, and all cases which can conveniently be so treated are examined at these centres, necessary travelling expenses being refunded to the insured person. In addition, other medical inspection rooms are available throughout the various districts and examination sessions are periodically conducted at these out-stations. Payment at a fixed rate per session is made for the use of these rooms, and by their use the travelling-and the travelling expenses -of insured persons are reduced to a minimum. Out-stations are now available at the following places :

Western District:-Dumbarton, Falkirk, Stirling.

S.-Western District:-Ayr, Dumfries, Greenock, Kilmarnock,
Paisley, Stranraer.

S.-Eastern District: Motherwell, Coatbridge, Galashiels,
Hawick, Duns, Lanark.

Eastern District:-Forfar, Perth, Kirkcaldy, Dunfermline,
Alloa.

Northern District:-Fraserburgh, Keith, Banff, Elgin, Inverness,
Invergordon, Peterhead.

A fair proportion of cases necessarily fall to be examined at the patient's residence.

During the year the district medical officers have made progress' in establishing friendly and helpful relations with panel committees and with insurance practitioners. A growing desire has been manifested by practitioners to obtain the advice of district medical officers on medical questions, and there has been an increase in the number of references made by practitioners, although the number continues to be small. Some of the smaller societies also from time to time have invited assistance on medical matters, and guidance as to the type of case most suitable for referring. Generally, it may be said that societies are now fully alive to the type of case which calls for a second medical opinion, and it is only infrequently that the district medical officers decide, on an examination of the insured person's record as furnished by his medical practitioner, that an examination is unnecessary.

The following general inferences may be drawn from the combined experiences of our district medical officers during the year:—

(1) The standard of certification by insurance practitioners is improving, but numerous cases of laxity still come under notice. Some practitioners do not realise, for example, that where hospital treatment is necessary but admission to the institution is likely to be delayed, the patient should not be certified during the waiting period as incapable of work if in fact he is not so incapable.

(2) There is a great diversity in the range of treatment given to

their insurance patients by practitioners. The work done by many practitioners is of the very highest quality, sometimes comparing not unfavourably with that of specialists attached to hospitals. In few cases are special fees demanded for exceptional services. In some isolated instances, however, it would seem that the care and attention given to their patients by certain doctors is definitely below the average of the insurance service.

(3) There is an urgent need for increased hospital accommodation for the insured. The fullest advantage is not always taken by practitioners of the availability of specialist advice at these institutions.

SOLDIERS, SAILORS AND AIRMEN.

The scheme for the recoupment of societies in respect of the excessive benefit expenditure due to heavier sickness claims received from men discharged invalided or from men who but for demobilisation would have been so discharged was closed down during the period.

There has been no change in the general arrangements regarding discharged and disabled members of societies who are receiving highest degree disablement pensions or industrial training allowances. All awards of 100 per cent. pensions to Scottish members are now notified to us direct instead of, as formerly, via the Ministry of Health.

Up to the 31st December, 1923, we had received notification from the Ministry of Pensions of 538 awards of 100 per cent. disablement pensions for periods in excess of four weeks and of the cancellation. or reduction of 331, leaving 5716 awards of 100 per cent. disablement pensions still in force. By the same date the Ministry of Labour had notified 6042 grants of training allowances.

Reference was made in our last Report to the fact that a final opportunity was to be afforded to societies at the 1922 audit for submission of claims for credit in respect of war-time contributions of members who served in the Forces. There remained in the case of most societies a varying number of members, touch with whom was lost during the war and in respect of whom it was reasonable to believe that a proportion died on service, although societies had not been able to establish the fact of death to the satisfaction of the auditor. As the financial loss to societies in respect of each such death unestablished is considerable, involving as it does loss of transfer value and army contributions, the departments have arranged that the lists of such untraced members for each society will be compared with the index of notifications of army deaths supplied by the War Office to the Ministry of Health. This comparison is now proceeding.

ADDITIONAL BENEFITS.

Schemes under Section 37 of the National Insurance Act, 1911.

The administration during the past year of additional benefits schemes arising out of the first valuation of societies, which was made as at 31st December, 1918, calls for little comment. Several societies submitted to us various minor amendments of their schemes