THE DOCTORS AND THE INSURANCE ACT. T HE degree of confusion
which reigns at the moment of bringing the medical scheme of the Insurance Act into operation is a perfect lesson in the art of how not to do things. Month after month Mr. Lloyd George assured us that the opposition of the doctors to his scheme would make no difference, and Englishmen, being constitutionally inclined to wait and see, almost took it for granted that matters would somehow arrange themselves. By a series of events which must have quite bewildered the ordinary reader of newspapers, it has now come about that while some of the medical panels are full some are empty, and many are formed unsatisfactorily..' Meanwhile the bitter- ness between the Government and. the British Medical. Association remains unappeased,- and the doctors are placed by Mr. Lloyd George in the invidious position of appearing to be mere money-grubbers. This is a position which the doctors, to their honour, have never occupied, as every impartial person in the country will gratefully admit. There is no other body of men who habitually do so much unpaid work, often at great personal sacrifice. The assumption that these men have suddenly changed their character and are anxious to throw over the sufferers in the poorer classes in order to put more money than they fairly earn into their pockets, or to gratify a political spite, is, on the face of it, absurd.
The crux of the controversy lies in the resistance of the medical profession to a general change of the con- ditions under which medical work has hitherto been done. Hitherto the doctor has generally given his services to individuals in return for an individual fee. It is now proposed that he shall become a member of a service, receiving a fixed annual stipend in return for undertaking the obligation to attend patients whenever they are ill. If this obligation were purely personal between himself and the patient the professional character of the medical service would still be to a largo extent maintained. The doctor would be directly employed by the person to whom his attendance was given, but instead of receiving a fee for each visit he would receive 8s. 6d. a year for as many visits as might be necessary and for the required amount of drugs. The doctors have now declared their willingness to undertake service on these terms. What they object to is the proposal of Mr. Lloyd George that the relation between doctor and patient should cease to be a personal one, and that the doctor should be in effect the servant of a Committee, who would employ him to attend to so many cases in the course of the year, and would supervise his conduct of those cases. They would not have objected if there had been any guarantee Oa, the local Committee would have a majority of men who understood medical practice and the thousand and one delicate points of medical ethics (to some extent summed up under the head of " etiquette ") ; but Mr Lloyd George persistently refused to satisfy them on this point. The doctors' objections were very genuine. Many insured working men are likely to take an exacting view of the services owed to them by a doctor put abso- lutely at their beck and call. In the past the doctors engaged in contract service have had over and over again to complain of the unreasonableness with which they were called in in cases in which persons more considerate— possibly owing merely to more education or more imagina- tion—would not have dreamed of troubling them. "What I pay for I may as well have," is a principle which may easily lead to real hardship for a doctor. It is most important that when complaints are brought against the doctor under the new system his defence should be examined with knowledge and discrimination. When Mr. Lloyd George increased medical representation on the Committees he at the same time increased the lay element, so that the doctors remained relatively in the same ineffectual position. Everyone must know that such a difficulty as this was capable of settlement, but the Insurance Bill was rushed through Parliament without proper discussion, and the monsoon of uncertainty and muddle which has long been gathering in the sky has at last burst about our heads. The Insurance Act, in this respect as in many others, is a monument therefore of how not to do things. Mr. Lloyd George's supporters are speaking of his " triumph " because many of the panels will undoubtedly be able to work the Act. It is a sorry "triumph," however, to have won at the last moment enough support to swear by from a divided and generally reluctant profession. This is not the spirit in which an Act professedly of humane intentions ought to be worked.
The division in the ranks of the doctors has been extremely unfortunate ; and for our part we cannot think that the policy of the British Medical Association, though we are in entire sympathy with its aims, has been conducted throughout with wisdom. True, the change of policy when the British Medical Association went back on one of its cardinal points, viz., not to "enter into individual or separate agreement with any approved society," was more apparent than real. The "alternative scheme" of the British Medical Association, which was produced a. fort- night .ago,. sanctioned the -change of policy. because the Government had failed after all to -give' adequate repro.. sentation to the doctors on the local Committees. If the Association changed its method it remained quite constant to its one object of securing fair and intel- ligent treatment for the profession. But we think the Association should have taken more precautions against misunderstanding. It may be said that there need have been no misunderstanding, since the doctors pledged themselves to be loyal to the policy of the Association whatever it might be. We do not suppose that the majority of those who pledged themselves understood that they were giving a " blank-cheque " pledge, but on the supposition that they did understand that, we can only say that we cannot approve of this sort of pledge. The British Medical Association is in effect a trade union. As such it has done splendid work for the profession ; hitherto it has had the merits and, so far as we know, none of the defects of a trade union. But if the members are to band their souls into the keeping of an Executive Committee the defects of trade unionism, with its capacity for the oppression of a weak minority, begin instantly to appear. We must remember that in the conduct of such a body as the British Medical Association the tendency is for policy to be directed mainly by eminent men who are themselves little affected, if at all, by contract practice. They hear only at second hand of the sorrows of the obscure local doctor who makes his living with incredible toil among working-class patients. Already the familiar spirit of trade-unionism is in the air when we find some members of the profession calling others "blacklegs." Such a word is not applicable to the conduct of those who con- sidered that the original pledge was made void by the change of policy in the Association, and should not have been used. The local doctor, entirely dependent upon his contract practice for a margin of financial security, was in a terribly difficult position. He saw a vision of himself and his family ruined. If there had been no question whatever as to the meaning of the pledge, he would even then have been exposed to a severe test, though, no doubt, he would have remained loyal to it. But when on all sides he heard dis- cussions as to whether the pledge retained any binding force, it was at least intelligible that he should decide to join the panel in his district if he saw others doing so. He need never have been placed in such a quandary.
As for the alternative scheme of the British Medical Association, it seems to us perfectly sound in itself. It maintains the personal relation of the doctor and his patient, and we may say that in Germany insured persons have actually insisted on this course being followed. As individualists we prefer such a system to any other. Mr. Lloyd George has announced that it cannot be accepted because it ignores the principle that public expenditure must be subject to public con- trol. The principle is excellent, and indeed, indispensable, and we can only wish that Mr. Lloyd George would always act on it. But in this case there is an obvious fallacy. The essence of the Act is that each contributor insures himself, among other things, for medical attendance. He pays so much per week to secure this insurance, and the taxpayer as represented by the State adds to his con- tribution. But if it is agreed that the doctor shall receive a capitation fee of 8s. 6d. per annum for every patient on his list, public control is required only to check the pay- ments by comparing the doctor's list of patients with the number of eight-and-sixpences that be receives. There is no necessity for any public control over the relations between doctor and patient. For the doctor, in virtue of the 8s. 6d., becomes the private professional attendant on the patient, and if the latter is dissatisfied with the treat- ment he receives he can employ another doctor. This direct eoutrol by the patient himself would be more effective than any other form of control. No doubt patients are often ignorant, but at any rate they know more about the way in which their malady progresses and the kind of treatment they receive from their doctor than any outside Committee can possibly know. Moreover the medical benefit funds are passed through the Treasury and paid out by the Treasury to properly appointed Commissioners, so that in this respect, too, there is control of the expenditure. The principle of this alternative scheme, so far from being novel and unacceptable, is contained in the Insurance Act itself, which allows insured persons to receive their share of the benefit fund, and make their own arrangements with doctors even in districts where there is an adequate panel. And. when Mr. Lloyd George feared that his panels would not be formed, he actually said that doctors could send in their bills as before, and the only difference would be that the patients would have a fund behind them to help them to pay. The Insurance Commissioness have also recognized the freedom of insured persons to make their own arrangements. It would be rather hard on the insured persons in a sense to have to take over the negotiations with the doctors which Mr. Lloyd George has failed to carry through. Yet it is not an impossible task, and when completed it would have the great advantage of securing personal freedom.
We do not believe that the country will be content with the present obviously half-hearted arrangements. The " full-time" salaried Government doctors, who will have to take up all the contract work where a panel is not formed, will give insured persons no range of choice, and we can foresee how the working classes, who are notoriously capricious in their choice of doctors, will resent that. The bitterness in the profession itself, moreover, will sound the knell of the ready co-operation that was invariably forth- coming when medical help was needed. This struggle ought not to go on over the bodies of the sick. On January 17th the British Medical Association is to meet again. It will not be too late for the Association to admit that misunderstanding was intelligible in the circumstances, and, so to speak, to grant an amnesty if only for the banishing of bitterness in the profession ; to present a scheme, or rather re-state their present scheme in perfectly precise language, and to submit it to the approval of its members by a Referendum for the simple answer " Yes" or " Nis" If the scheme is approved, the Government will have to offer very good reasons indeed for accepting the grave responsibility of continuing a struggle which ought never to have occurred. The British Medical Association should, in our judgment, prevent all possibility of further misunderstanding as to the feeling of the profession. Then it will rest with the insured themselves to judge between the Government and the profession, and to say whether they mean to have an indifferent and unwilling medical service or a willing and thorough one.
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