insured person will get the best his doctor can give him when he lapses from a state of physical purity, but once the doctor has shed the prejudices that warp his estimate of the insured patient's 'value,' once he is convinced that the insured has all the rights of the private patient, there will arise a determination to give of his best, and this will govern his every action. The insured knows, too, that his case will receive exactly the amount of attention which his doctor's professional judgment deems necessary; more rather than less, because his doctor can act on his unbiased judgment and cannot be swayed by fear of public comments on his over-zealousness in visiting. Aware as he is that his doctor wants him off his hands, he is assured that he will be given every benefit that medical science prescribes for his case. Another, not mean advantage, that will accrue to the insured-proceeding as it does from the fact that he pays his doctor by easy lifelong instalments and not by a lump sum after a period of sickness and unemployment-is that he will be more able and ready to call in expert assistance should his case require it. Under present conditions of payment by fee, I am confident that a wish for a consultation is often dismissed or disturbed by dread of the coming doctor's bill.' The desire to feel that everything has been done that can be done' prevails in the hearts of the working classes as strongly as among the well-to-do.

I will consider now the drawbacks which this per capita system entails upon the doctor practising under it. Two most pestilent are said to be trivial calls and calls at inconvenient hours. Both these faults are equally common in contract and private practice, and can only be checked by educating our clients if they are contract,' and penalising them if they are 'private.' It is strange but true that some doctors suffer more from these annoyances than do others. The other day, in conversation, I heard it stated that Dr. So-and-So was never out at night, while Dr. S. was up every night in the week. I spoke of temperament a little while ago; can it be possible that 'trivial calls and calls at inconvenient hours' depend not so much on the patients as on the doctors? It is an interesting subject for research.

It has been well remarked by a correspondent in the British Medical Journal that 'private patients, from motives of expense, only call us when they need.' But do they always call us when they need, do they always pay us for the call, and do we only call when they need us? A friend of mine was called once to see a child with measles at the house of one of his wealthiest clients. He wrote a prescription, gave full directions as to diet, &c., was interviewed at length by the mother, and informed on leaving that he need not call again unless he was called, and

that if he should be needed she would call him. Days went by; he was not called, as he rather hoped and expected he would be, and, quite naturally, I think, he concluded he was not needed, so of course he did not-it would not have been proper for him to-call. A few weeks afterwards, on calling at his druggist's, he heard that the whole family of eight children had heroically struggled through measles on the strength of that prescription, those directions, and an intelligent perusal of the Family Physician.

Another objection made against per capita payment is that ' it will give us enormously enhanced work.' Is, then, the nation suddenly going to take on fearsome diseases the while we are turning our private into insured practices; to pick up germs we have never dreamt of; to hurt itself in quantities the profession has never hitherto experienced? The sickness rate is falling steadily, and only a plague or an invasion or civil war would give more work than we have already or are justified in expecting. Busy times there are sure to be in all large practices, be it at west or east end of the town. The work of the insurance doctor is no more, but just as likely to be scuffled and rushed at these times as that of the doctor whose practice is exclusively private. The per capita system is said to foster malingering. Malingering occurs when sick pay exceeds wages, and is not unknown even among well-to-do folks insured against accident. A person, however, insured for medical attendance is not always, and need not be, insured for sickness or accident benefit. Very many of my insured clients are not insured in benefit societies-there is never any malingering in this class of client.

These are all the disadvantages that can attach to a system of payment per capita. Numerous others brought forward have no relevance against the system as such, and any weight they have at all bears only against the system as adopted and administered by the various societies and clubs. An unbiased scrutiny of all the abominations and faults attributed to club doctoring will, I think, result in the conclusion that they are all, every one, due to the doctors themselves. They tumble over each other in their eagerness to secure club appointments—it is the salary, the certain income they want—and is it a wonder that premiums should fall to sweating point, and that club officials and club members should get their heads swelled? Competition for club appointments is the root and origin of all the ghastly evils of doctors' club work-and I cannot suggest a remedy; no remedy can be applied until every qualified man becomes a member of the Association. Lancashire cotton weavers can, and do, kick blacklegs into submission; the only weapon we can employ is ostracism-but if the medical blackleg is already in Coventry, where else is there to send him?

6

It is insurance for medical attendance of our own private clients that I am recommending, not club work. The club' is deservedly in bad odour in the profession, though one must admit the verity of my charge that we are ourselves and alone to blame for the state of things therein existing. Clubs can be, and are in hundreds, paying a fair premium, and the conditions attaching to the doctors' work in them are not in any way irksome. The system of payment by premiums has a sound and scientific foundation in the doctrine of averages, and insurance for medical attendance is no more a gamble than is insurance against death or burglary or sickness or broken windows. It is applicable to all classes of our clientèle, rich and poor. As far as I can see there is no other method by which we general practitioners can maintain or enlarge our incomes in the face of a constantly falling sickness rate.

I have attempted in a poor way in this paper to put every consideration I can conceive, perceive or remember, for and against the system of insurance for medical attendance in its every phase and aspect, and I now leave it to the thoughtful examination of all those of my brethren who have these many years been watching the steady decline of the nation's sickness rate. Insurance is in the air, and the people are awakening to the advantages it gives to them. If we medical practitioners can only convince ourselves of the profit, material and moral, which the system will undoubtedly, in my opinion, bring to the profession, there will be the dawn of a new era.

My own position is somewhat anomalous. I am torn both ways. To be 'busy' brings joy to the half of me that is private practitioner and sorrow to the portion that is insurance doctor. If I were all contract doctor I could smile when the people smiled, and weep when they weep. To pass a day without seeing a single patient-as happens not unseldom-now only generates a feeling that is neither one thing nor the other. I am half-hearted whether I weep or chortle in my joy. If I were wholly a private practitioner I should never be laughing when the people laughed, or crying when they cried so there is no enjoyment for me either way. If I were 'insurance doctor' undividedly, pure and simple, I could join in at any time, whether folks were laughing or crying.

I think it is generally conceded by the profession at this date that the actuaries who framed the financial clauses of the Insurance Act had no alternative but to adopt payment by capitation in preference to payment by fee. Under the latter system the funds needed would be uncertain and incalculable, and most doctors now understand that a Chancellor of the Exchequer

must be able to make an approximate estimate of the funds he will be called upon to provide for the working of the Act. The Council of the British Medical Association was quick to recognise this necessity, and has bowed to it. Unfortunately, until quite lately, it has not been possible to establish any relation between the two methods of payment. All efforts to discover the exact premium that would be equivalent to a given fee per visit have proved futile. For months doctors by the hundred have been struggling to find what premium, paid yearly by members of a group of insured persons, would be of equal value financially to a fee of half-a-crown per visit, charged for attendance on individuals from a group of the same size and class who may be disabled by illness or accident in the course of the same period. The estimates have varied from 25s. down to 8s. 6d. The latter figure is the minimum demanded by the Association, but no one can pretend that it is anything more than a guess— a mere compromise. These efforts have failed for two principal reasons. One is due to the failure to distinguish between clients and patients, and the other lies in the impossibility of standardising the visit.' As doctors vary enormously in their propensity to visit no two are alike in their methods of work or in their temperaments-it is obvious that no two estimates can be alike. Take a group of five hundred employed persons chosen at random, young and old, male or female, sound or damaged. What annual premium should be paid per head, to yield the doctor an income equal to the amount he would receive by attendance on such of the five hundred as would fall sick or lame in the ensuing twelve months? His visiting fee, we will say, is 2s. 6d. The answers to this simple question have had the wildest variance-clear proof that they were arrived at by erroneous calculations upon misused data. The Association, as we know, insists on 8s. 6d. Investigation of the books of my practice shows that an average premium of 5s. gives me better returns than private practice over a group of the same number at fees of which 2s. 6d. is the lowest.

Obviously the relation of premium to fee must depend upon the visiting habits of the doctor and upon the sickness rate. The visiting habit will always vary with the mentality of the doctor, and so far it has proved an incalculable quantity. The sickness rate has not yet been worked out, but it varies with the time. of the year, the weather, the nature of employment of individuals, the amount of employment, the prevalence of epidemics, conditions of housing, and a dozen other factors. But it is, in this kingdom, for ever on the decline. In any two practices working alongside under the same sickness rate the relation of premium to fee will differ, because of the diverse habits as to visiting of the two doctors. Every medical man would like to know what

premium per head would give him the same return of income as do his present visiting fees. He is at a loss in his search for truth in all the maze of conflicting views that confront him at meetings and in the medical journals week by week.

Quite recently I published in the Lancet a method of solving this question of equivalence. My method will give results that approximate very closely to the truth in every practice. Results would be exactly, mathematically correct if, as in my practice, the precise number of persons comprising the clientèle of the practice could be ascertained. A doctor will know, of course, how many contract clients he has, but he can only make the vaguest guess as to the number of private clients he has. No town doctor, and very seldom a country doctor, can tell how many clients it requires to furnish him with his income. Some of his clients-and they are his because they intend to go to him when ill-never become actual patients. There must be thousands of people walking the streets to-day, clients of no one knows whom. They pay no one anything now, but will be premium paying in the near future. Any doctor, however, knows who have been, who are, and who are not his patients. As it is then generally impossible for a doctor to arrive at the total of his clientèle a state of things that accounts largely for erroneous estimates-I have had to adapt my plan to the ledger as it stands now and not as it may stand through the next five years. All that is necessary is to take from the ledger the names of a hundred individual working-class patients now alive, and add up what they have paid to the practice in 1908, again in 1909, 1910 and 1911. They must be the same individuals in each count. Then, by making a total of the sums received from them in the four years and dividing it by 400, we get the average payment of each patient per annum. I am justified from the facts of my own practice in believing that in the majority of practices-notwithstanding excessive sickness rates and the most extreme grades of fussiness-the result of this investigation will show an average figure well below the 6s. offered us under the Act.

I should point out that this plan of taking patients' names instead of clients' is really mathematically against me, inasmuch as it implies that a person will be a patient at least once in five. years. As I said before, thousands of clients, potential patients, are not on the ledger at all, are paying no doctor anything (but will soon be insured persons paying a premium).

Also one would get a truer equivalent with a larger countsay 500. The same method can be carried out with all classes. of patients. For instance, one might wish to know what premium would tally with a 3s. 6d. or a 5s. fee per visit, and so on. It is not probable that the worked-out average equivalent will be