insurance committee. A comparison of these figures with the figures shown in Appendix XXIX. of the Report for 1921 tends to confirm the view already expressed that the inflation of the index register is generally equally distributed throughout the country. On the recommendation of the Committee appointed under the Medical Benefit Regulations to advise as to the basis for the distribution among committees of the Central Practitioners' and Central Drug Funds, the index register was adopted without adjustment. Medical Benefit. MEDICAL ATTENDANCE AND TREATMENT. Remuneration of Doctors. The capitation fee of 9s. 6d. payable to practitioners during last year continued in force in 1923, and £804,147 in all was distributed among the insurance practitioners under agreement, the number of whom was approximately 1780. The amount of the money available for distribution among insurance practitioners for the year was provisionally based on an estimate made before the commencement of the year by the Government Actuary. Subsequent information having tended in his opinion to confirm that estimate, we determined that the moneys provisionally advised for 1923 should be regarded as final, and we notified committees accordingly. We have, however, found it necessary to augment the funds relating to the years 1920-1922, the sums determined on the original estimates of the numbers of insured persons entitled to medical benefit in these years having been found to be short of what was properly available for the remuneration of practitioners. Advices of the further credits due were issued at the end of the year. Prolonged consideration in conjunction with the Approved Societies' Consultative Council, the Scottish Committee of the British Medical Association, and representatives of approved societies and insurance committees, was given to the question of the remuneration of insurance practitioners as from the 1st January, 1924. The maintenance of the 98. 6d. capitation fee for 1922 and 1923 had been made possible only by the undertaking given by societies to bear for these years the whole cost of medical benefit over and above the statutory sums provided in the Act of 1920. This offer was embodied in the National Health Insurance Act, 1922, the relative section of which, however, ceased to have effect as at the 31st December, 1923. As societies on the one hand were unwilling to continue after that date the payment of any sums additional to the statutory amount, and the medical profession on the other hand were pressing a claim for an advance on the existing rate of 9s. 6d., a situation of peculiar difficulty arose. Throughout the resulting negotiations we acted in close co-operation with the Ministry of Health, and the outcome of our deliberations was a joint offer by the two Departments to provide a capitation fee of Ss. 6d. per annum for three years or 8s. per annum for five years. At the same time intimation was made of the decision to arrange for the appointment of a Royal Commission to investigate the whole question of national health insurance as a preliminary to the framing of future policy in regard to the system, including the terms of service with practitioners. The offer was not accepted by the Insurance Acts Committee, and their rejection of it was confirmed by 94-89 per cent. of the practitioners under agreement with insurance committees, who intimated their decision to withdraw from the panel at the end of the year. Faced with a possible breakdown of existing arrangements for the provision of medical benefit, it was agreed to make a revised alternative offer of (1) a capitation fee of 8s. 6d. for five years, subject to the right being reserved to the medical profession to reopen the question of remuneration should the report of the Royal Commission above referred to suggest any material alteration of the conditions of service, or (2) such capitation fee as may be recommended by a Special Court of Enquiry to be appointed forthwith. The second alternative being accepted, the Court was constituted by the appointment of the following gentlemen, T. R. Hughes, Esq., K.C., Chairman of the Bar Council; F. C. Goodenough, Esq., Chairman of Barclay's Bank; and Sir Gilbert Garnsey, K.B.E. The Court had not com menced its labours at the close of the year. Revision of Conditions of Medical Service. Questions as to the adequacy of the existing service naturally arose in connection with the revision of the fee and matters relating to the administration of medical benefit, and suggestions for the improvement and extension of the insurance service were discussed with the Scottish Committee of the British Medical Association, the Approved Societies' Consultative Council and the Scottish Association of Insurance Committees. The principal alterations effected are as follows: Limitation of Lists.-The maximum number of insured persons who may be accepted by a doctor practising single handed has been reduced to 2500; for partnerships the average on the list of the partnership must not exceed 2500. Where assistants are employed a number not exceeding 1500 may be added in respect of each assistant. Change of Practitioner.-In future an insured person may at any time change from one doctor to another. Range of Service. The treatment now required from a practitioner is defined as comprising all proper and necessary medical services other than those involving the application of special skill and experience of a degree or kind which general practitioners as a class cannot reasonably be expected to possess, and as including the administration of anaesthetics, or rendering of other assistance at operations of certain defined kinds and subject to defined conditions. When a practitioner himself performs an operation, either within or without the Terms of Service, he will be responsible for providing the services of an anesthetist except where the administration of the anaesthetic is itself a service involving special skill and experience. Charging of Fees.-Fees charged to a patient who does not represent himself to be insured but who subsequently applies to the insurance committee for refundment may be recovered from the doctor on the committee being satisfied that the patient was at the time of treatment entitled to medical benefit. The committee may remunerate the doctor for his services on the basis of the payment allowed in the case of temporary residents, and pay for any drugs supplied by the doctor on the basis of the drug tariff. Arrangements for Practice.-It is stipulated that a doctor shall not carry on insurance practice elsewhere than at his residence unless he satisfies the insurance committee that the arrangements made will enable his obligations under the Terms of Service to be carried out adequately. Medical Certification.-Certificates are to be stamped with the name and address of the practitioner by whom they are signed. The obligation is now laid on practitioners to issue certain certificates in respect of exempt persons, and certificates as to the fact of death in the case of insured persons dying while under treatment for an illness in respect of which they are certified to be incapable of work. A voluntary certificate is being provided for use where the regular certificate cannot be given at the time the insured person asks for it. Under certain circumstances, and when asked by the patient to do so, the doctor is required to state on the medical certificate any form of special medical or other treatment he has advised his patient to obtain. Payment to Dispensing Doctors.-Doctors who dispense drugs will not be under obligation to supply out of the capitation payment allowed therefor insulin and any other costly drugs which we may direct. The cost of insulin and such other drugs will be excluded in calculating the capitation payment to be made to those doctors who are permitted or required to dispense drugs. Complaints against Practitioners. It is satisfactory to record that formal complaints against practitioners have been even fewer than in the previous year. The number of cases in which grant was withheld was 11, as compared with 12 in 1922, though, owing to the more serious nature of the offence in one or two instances, the total sum withheld shows an increase. In six instances the complaints were lodged by societies and related to irregularities in certification. Such offences were not generally of a serious nature, and the total sum withheld in respect thereof amounted to £28, 8s. only. The remaining five complaints may be classified as follows, viz.: (a) Failure to attend (including in one case the issuing of pre- Total Removal from Panel. In addition to the cases referred to in the foregoing paragraph, one case was brought to our notice which appeared to us to be of such gravity as to warrant an inquiry being held as to whether the continuance on the medical list of the practitioner concerned would be prejudicial to the efficiency of the medical service of insured persons. An inquiry in the manner prescribed in the Regulations was accordingly held, and on consideration of the inquiry committee's report we directed the practitioner's name to be removed forthwith from the medical lists of the committees with whom he was under agreement. In accordance with previous practice we also reported the facts to the General Medical Council. The offence consisted mainly in the lax issuing of certificates and prescriptions, the filling in of these forms being left on occasion to the discretion of the clerkess employed at the doctor's surgery. Appeals under the Medical Benefit Regulations. Two appeals were taken by medical practitioners against the decision of insurance committees. In the one case the insurance committee held that the doctor was not entitled to charge an insured person on his list a fee for his services as anesthetist while the patient was having her teeth extracted by a dental surgeon. appeal was allowed. In the other case the committee found that the doctor had failed to call on an insured person and treat him when requested to do so. The appeal was dismissed. The Two appeals were taken by societies against the decision of insurance committees on complaints against certain medical practitioners for alleged breaches of the medical certification rules. One appeal was sustained and the other dismissed. One appeal was taken by an insured person against the decision of an insurance committee dismissing a complaint that her panel doctor had refused to issue to her medical certificates. The appeal was dismissed. Persons making their own or special arrangements. The mean number of insured persons making their own arrangements for medical benefit in Scotland in 1923 was 6237. The increase indicated in the previous year's Report has therefore been maintained. New applications for travellers' vouchers, enabling insured persons frequently moving from one area to another to obtain medical benefit, numbered 51 during 1923. The total number of vouchers issued since 1913 is 1101. Of these, only 195 were current at the close of 1923. DRUGS AND APPLIANCES. As a result of negotiations with the Pharmaceutical Standing Committee (Scotland) regarding the terms and conditions of service. for the year, the Committee agreed to recommend that the pharmaceutical service be continued in 1923 on the same conditions as those for the previous year, except that the profit allowed on vaccines and sera supplied by chemists was restricted to a maximum of 5s. on each order. The recommendation of the Committee was H agreed to by the General Council of Panel Chemists, and insurance committees were able to arrange for a satisfactory service. Consideration was also given towards the close of the year to the terms of pharmaceutical service for 1924. The arrangements made with panel chemists since the inception of the Acts have always included the possible liability of discounting their accounts if the amount of the Drug Fund was insufficient in any year to meet the demands on it. We have reconsidered the matter in connection with the new provision to be made for financing the cost of medical benefit, and have decided that the opportunity should be taken to abolish the discounting clause and to guarantee that in future chemists' bills will be paid in full. Drug Fund, 1923. The central drug fund as constituted on the capitation basis of 1s. 10d. per annum was £155,187, one twenty-fourth of which was reserved for the special drug fund, formed for the purpose of meeting any deficits in the drug funds of particular committees. Some time must elapse before the full expenditure of the year (including the amounts payable to the doctors who dispensed drugs for their patients) can be ascertained, but the experience of the first nine months appears to warrant the assumption that the whole of the income provided will not be expended. The increase in the average cost per form is mainly accounted for by the steady upward trend in the prices of drugs during 1923, following on a reduction which had continued almost uninterruptedly from the middle of 1920 to the end of 1922. The rise is probably indirectly the result of the Safeguarding of Industries Act. We anticipate that, when the final figures for the year are known, the drug funds of five committees will be in deficit to the extent of approximately £2000. This is considerably less than the deficit in the previous year, and, as in that year, fully half is applicable to one. committee area. The examination of the prescriptions of a number of doctors in that area is still proceeding. Drug Position, 1922. The aggregate credits to committees in respect of the drug fund amounted to £152,300, and we retained as special drug fund the sum of £6645. The expenditure chargeable to the drug fund, including chemists' bills, dispensing doctors' capitation in respect of drugs, and expenses of panel and pharmaceutical committees, amounted to £136,525, 16s.7d., |