DOCTORS BY CONTRACT
I N recent . times the problem of the black-coated worker has increasingly interested society. Events in. Germany and Italy have warned us with what violence. ,a class. may react when ground between the wage-earners and their masters ; in America black7coated unemployment has been one of the greatest problems of the depression. In our own country, the new Bill which the Government is to introduce, extending unemployment insurance to the black-coated worker, is again a recognition that he enjoys no greater economic security than the wage-earner. It is interesting therefore that in London anew medical service is about to be introduced which. :extends to this same class benefits which previously have been confined to wage-earners and their dependents. The new service, it is instructive to observe, has been described and commented on with approval in the columns of the Lancet.
In 1911, the system of National Health Insurance was introduced for wage-earners ; and later a number of public, medical services were established for the dependants of insured persons. There are now 53 sehemes of public medical.,, service. in existence, with 404,000„snbscribers, the latter figure having more than 4ç4led in the last four years. The Principle of these services, as of National Health Insurance, is that, by regular payments when in health subscribers secure for themselves medical attendance in illness, without .further outlay. Such an arrangement is so far only open to wage-earners and their dependents ; on January 1st, of next year the London Public Medical Service will inaugurate a scheme by which the same principle will be applied to families with incomes of between £250 and £550.
Payments are to be made annually and, have been calculated, on the basis of the income which practitioners have . been accustomed to make from this .class :. of practice ; they rise from El 10s: a year, for. a single person with an income of £250- £375 to £5 10s. for a family of five or more with an income of /475-1550. For these payments the subscriber is entitled to medical attendance, at home or in the surgery, and to the usual medicines—that is, to, the services given in the ordinary course of practice . by the family doctor. The subscriber is also entitled, if he wishes, to an annual overhaul. The scheme has been made possible by the voluntary co-operation of general practitioners. It is understood that 400 of . the, 1,100 doctors who are members of the London Public Medical Service have expressed their willingness to take part in it ; and it has the sanction of the Council of the British Medical Association, provided that any particular unit of the metropolitan area is excluded from it if the general practitioners of the district so desire.
After the success of existing public medical schemes, there is thought to be an assured public demand for this new service. Certainly anyone acquainted with the fear of medical expenses in families in this income*roup cannot doubt its value. Such families are excluded from National Health Insurance. When illness comes, doctors' bills are heavy in relation to income ; the common practice is to avoid medical attendance until it is absolutely necessary. Illness in the family is the harder to bear because of the inevitable financial burden it entails ; it means in many cases that medical advice is not sought till the point at which illness can still be avoided is past. For this reason, indeed, it is hoped that the new scheme will avoid one disadvantage which might seem unavoidable. The family doctor is normally much more than a paid consultant. He is a friend and adviser, with a personal relationship to his patients. It might be feared that under the new scheme this relationship might be weakened or lost. But patients will still be entitled to choose their own doctor, as before—provided that he accepts the scheme ; and it is likely that, with fear of expense removed, they will ask for medical advice and attendance .more fre- quently .and. more regularly. Under these' cOnditions the personal relationship can only he .strengthened.
.Thus in. the doctor's interest as well as the patient's the London scheme must be wished all success, and a success calculated to inspire imitation elsewhere. For the scheme implies a change of attitude towards questions of health, and a change in the organisation of medical services ; and it is essential that these changes should be general. It is by now recognised that further improvement in .the health of the nation depends .largely on the development of preventive as opposed to curative medicine ; it depends equally on a greater nieasure of co-ordination' between existing services!, and especially, perhaps, on bringing the general .practitioner into closer contact with 'centres of research. These points were emphasised by Sir Farquhar Buzzard when, in a speech earlier this year to the British Medical Association, he described a . plan for establishing in every city a Health Centre which should co-ordinate all the medical services of the district. That is, unfortu- nately, a very distant ideal. But the condition of attaining it is that, at least, all members of the population should be brought under some kind of regular medical attendance and inspection ; and that a close degree of co-operation should exist both between general practitioners themselves and between them and specialists -and research students. The National Health Insurance system provides a firm basis for such development, so far as the wage- earners are concerned,. One of the most important aspects of the London Public Medical Service's new scheme may be that, if successful and widely imitated, it will provide a similar basis of development for the middle-class.
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