the rock. Bad debts are the bane, the bugbear of medical practice, and they are spawned in this system of payment by fee. What anxiety, what anguish, what forebodings we endure in the period-years long it may be-that may perchance intervene between service rendered and fee paid!

A most pathetic commentary on this system of payment by bills is the letter of A Suburban Doctor's Wife,' which, as regular as the clock' about Christmas-time, appears on a prominent page of one of our most respectable and most widely circulated halfpenny morning journals. In words that would draw tears from a stone, she dilates upon the extreme inconvenience she and her consœurs suffer through the reprehensible habit people have acquired in putting off settlement of their doctors' bills until all else are squared up. She appeals to gentle readers to make efforts to deliver themselves from the evils of this mischievous mismanagement of their affairs. She exhorts them to make solemn resolutions that for the New Year and ever afterwards the doctors shall be placed at least half-way up the list of 'bills to be paid.' In her annual letter one notices that she never gives thanks for past favours, but always, poor thing! goes on hoping, appealing to, and invoking her obdurate readers to pay up-if it is only a little on account. She tells them how bad debts. are being piled up in her struggling husband's books (she knows, because she does' them), and that she really cannot see how she will be able to manage to make ends meet ends if things do not mend soon. Tradesmen, she ventures to point out, expect and exact prompt payment of their bills, so why should doctors, who are at the beck and call of everybody day and night, rain and shine, year in and year out, be thrust to the back region of a patient's memory directly the said patient gets on his feet again? She thinks he has forgotten!

It was thoughts engendered by a contemplation of my ledger that induced me years ago-not to write to the papers-but to make efforts to get my working-class clients to join my surgery club. The labourer or fisherman I knew could not pay his doctor's bill without depriving himself or his dependents of something he or they needed. Many of them were living on too narrow a margin to find money enough for sick benefit insurance. Some would apply for admission to my club whose lives I knew were damaged, and for years I refused entry to these miserables. But gradually it dawned upon me that even invalid and mature applicants could be safely accepted at increased rates. This plan has been in operation in my practice for years now with success, and I doubt whether there are many practices in which such an apparently hazardous venture has been made. In action the work runs quite smoothly and satisfactorily. The premium—

which I fix myself on my own estimate of the health value of the proposer-is paid quarterly in advance, and the payment is entered on a card which the member keeps.

I stated a little while back that in November it occurred to me to investigate my affairs. Having noted the facts previously mentioned with regard to income and falling sickness rate, I was further urged to find out what proportion of my income was yielded by contract work. I cannot, of course, give figures, but I may say that I was astounded at the result of my careful inquiry. I will describe the process followed, but before doing so I must define a term I am obliged to introduce in order to avoid a confusion that one constantly meets with at divisional meetings and in the correspondence of every week's medical journals. The error consists in describing all the people of one's practice as 'patients.' I shall use the word 'client' to connote the person, club or private, who, though not at the moment ill, would if he became ill come to me for treatment. A client becomes a patient when he falls sick. How many of our clients never degenerate into patients it is impossible to say, but there are many such in every practice. One of my old club clients was found dead in his back-yard a little while ago, and his wife testified that he had never had a penny of sick-pay or a bottle of medicine in all his born days.' Other clients only become patients at their latter end, or at rare intervals, for short periods. I have known a household of ten persons which in eight years did not furnish me with a single patient, and for how long after I left the district that family remained a thorn in the side of my successor I am unable to say. On the other hand, of course, a few-very few-clients are perpetual patients, and never off our visiting lists.

To return, the feat in accountancy was accomplished in this wise. I added up the receipts from all my contract appointments-society, slate, and surgery clubs, Post Office and union. Then the names of the persons contracted for were counted. The next business-which involved a little more trouble-was to count the names entered in the ledger of persons now living, to add the members of each household, annexing as well as I could remember the names of all people in the district who I knew would come to me if ill. Finally, I ascertained my income from private practice over the latter group. I found that half my income was derived from contract work, and half from private practice. And now comes the surprise. Most of us would expect the examination to show that it required a much larger number of contract clients to furnish the first half of my income than it would private clients to yield the second half. But exactly the contrary proved to be the fact! One-third (contract) of my

total clients return as much income as the other two-thirds who are private clients! If all my practice were 'private' I should be earning less income by one-fourth than I am now doing; and if, on the other hand, all my work was 'contract,' I should be making more than I am actually doing. The motives which hitherto have caused me to encourage my people to join my surgery club-the endeavour to avoid bad debts; the idea that poor people cannot pay doctor's bills-are now supported by a powerful ally, personal gain. Manifestly the best thing I could do for myself would be to succeed in persuading all my clients to insure for medical attendance.

To prevent any misunderstanding, I will mention that my lowest visiting and surgery fee is half-a-crown, and it is rarely I get a visiting fee as high as half-a-guinea. My people are agricultural and other labourers, artisans, fishermen, farmers, gentry, and visitors. In no way is it different from most other country practices. All fees for midwifery and minor operations are included in the income from private practice. The average premiums I receive from all my club members would work out at five shillings.

This discovery, if it is found to have universal application, must have a far-reaching effect-it completely upsets deep-rooted ideas by which we have all been profoundly influenced. Let us see what it means to us, now that we know the insurance method is more remunerative to us than the method of payment for work done. Hitherto we have all imagined that our club work was a form of charity to the working-classes, inasmuch as we were under the conviction that we were not being paid adequately for what we were giving. My insured are nearly all workers, and the non-insured are workers and masters. The first group pays the same amount in aggregate as the second, though the latter is the larger. Surely it follows that the insured. are at least paying me adequately as compared with the noninsured, unless it should turn out that I do more work for the contractors who form a third of my clientèle than I do for the private clients who comprise two-thirds of the total crowd. I am sorry now that I have not been in the habit of keeping a record of the club work done this omission is due to the delusion I have been harbouring-but I am quite sure there is not more sickness among the insured per head than there is among the uninsured. Why should there be? Probably there is less, though it appears that there ought to be more, as the one class calls soon and the other later. The great majority of the insured have passed the doctor.' A'Rural Practitioner' in the Lancet the other day did not sign his name to his letter, because after relating how little he had done for his Post Office people in five

years, he feared the Postmaster-General might cancel the appointment. Not one per cent. of the whole of my clientèle is at the present moment on my visiting list!

A mistake that crops up frequently in the correspondence columns of the medical journals is shown in these typical questions: Who but a lunatic would expect a doctor to give a year's attendance for the price of a dozen collars?' and 'What value will the patient place on services obtained for six shillings a year?' Now, if a doctor attends a club patient with the idea in his head that he is only being paid six shillings for his present visit and for any further visits in the next twelve months this patient may require, he is making a serious mistake. It is a mistaken idea that affects profoundly the whole of his conduct of the case. With this notion in his head he naturally feels himself in the position of one who is giving a lot for next to nothing that he is being exploited, imposed upon, sweated and victimised; that he need not give more than value for the money'; 'that his sense of honour does not compel him to do more than earn his money.' Thinking so, how can he possibly give his best to his club patient? Is it a wonder that his work should be perfunctorily performed, scamped, rushed through? Visiting a patient this very morning, I was conscious of the great effort it required to prevent the continual obtrusion of the thought This man ought not to be in the club; I ought to have 3s. 6d. for this visit!'

The marvel is that insurance for medical attendance as adopted and administered by clubs and societies has not gone to pieces ages ago. I don't care how kind-hearted a doctor may be, he cannot-it is not natural that, while harbouring such thoughts at the bedside, he could-bestow upon the case all the attention that he is accustomed to give to his private patients. These thoughts are all offshoots of the one mistaken idea. But the same idea is just as prevalent among our club members and in the mind of the public generally. By a curious coincidence on a morning round since commencing this paper, three of my club patients expressed the same feelings: Doctor, I don't like to give you all this trouble for the little I pay you.' One of them actually took half a sovereign from under his pillow and begged me to accept it. This patient has been a client of the practice for over thirty years, paying twelve shillings a year, and has only lately begun to fail. Needless to say, I gave these worthy people an elementary discourse on insurance. Obviously, to the questions above quoted, one answers that though it is true the patient pays only six shillings per annum, the service rendered to the individual is paid for by the combined premiums of all the club members, Once the significance of this answer VOL. LXXII-No. 425

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is grasped it will be easy to see that the larger the number over which the risks of illness are spread the more lucrative the results, pecuniarily stated, are to the doctor.

During a discussion at one of our meetings recently a member stated that he had the names of a hundred working people on his books who had each paid him an average bill of a sovereign during the last year, and he failed to see that he would be better off if those people paid him a premium of six shillings per annum. A practised speaker would have pointed out the fallacy in this argument at once. If the member had taken out a list of the patients who had each paid him a sovereign, not only last year, but for each of the last four or five years, he would have found that he had no two lists alike-that in fact the total number of names would be five or six hundred that the total clients, amounting to perhaps five or six hundred, had furnished him with a hundred patients every year. So that if all these clients had been paying him a premium of six shillings per head, he would have been better off. In another form the answer might be made thus: Let the member take the names of the hundred workmen who paid him a sovereign last year, find out how much these same hundred paid him in each of five previous years; the result, I imagine, would be the same-that he would have gained pecuniarily if there had been paid for each of the hundred a capitation fee during all the five years.

I come now to a consideration of the advantages of this system of payment per capita to the doctor. They are so conspicuous that I will only mention them in brief. They are increase of income in spite of a declining sickness rate; income comes in like a salary punctually at the quarter: no office work is required (most of us would thank heaven for that favour). I don't know what is the money value of this office work, but I believe accountants are required to do the copious bookwork of large practices. No worry with debt collecting; a desire (that no cynic will sneer at) to cure the case as soon as possible; sprightliness in preventing sickness and in cultivating better habits of life in the insured individual; cordial co-operation with health authorities in improving the public health; the position of the doctor in public regard will be greatly enhanced, since the same object is being pursued by every member of the community-the interests of doctors and people are then identical.

Are there any advantages to the insured person which a private client does not get? Several. All the days of his clienthood he has a right to and can have the ungrudging and hearty service of his doctor in directing him in the path that leads to health and long life he will be quite certain of this benefit-and is it a small one? It may be too soon yet to feel certain that the