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Revision of Disciplinary Procedure affecting Insurance
Practitioners.

The remuneration of insurance practitioners and chemists is paid conditionally on their rendering a satisfactory service, and, where it is established, after formal investigation, that a doctor or chemist has failed to discharge his obligations under his agreement with the Insurance Committee, his remuneration is considered not to have been fully earned, and, if the failure is of sufficient gravity, an appropriate part of it is withheld.

During the year the existing Regulations affecting insurance practitioners who are alleged to have failed to discharge their obligations under their terms of service have been reviewed in consultation with representatives of the medical profession, and amending regulations agreed upon after full discussion will be issued shortly. Under the new regulations, before remuneration is withheld in respect of an alleged breach of the terms of service which involves professional negligence, the Minister will seek the advice of an Advisory Committee under the Chairmanship of the Chief Medical Officer of the Ministry of Health, or his deputy. Two Medical Officers of the Department, and three practitioners selected by the Minister from a panel of practitioners nominated by the Insurance Acts Committee of the British Medical Association, will also serve on the Committee. In addition, a practitioner selected from this panel will be associated with the persons appointed by the Minister to hear the oral representations of an insurance practitioner when the question of withholding remuneration from him is under consideration.

Standard of Treatment in 1927.--Reference has been made in previous Reports to the marked decline in the number of disciplinary cases in which it has been necessary to withhold part of a practitioner's remuneration. It is satisfactory to record that this decline has continued. During the year there were only 48 cases in which remuneration was withheld from insurance practitioners, the total amount being £367, as compared with 77 cases in 1926, when the total amount withheld was about £1,000. Only 6 of the 48 cases in which remuneration was withheld were cases of neglect (that is, failure or refusal to visit, unsatisfactory treatment, etc.), as compared with 16 in the previous year. Of the remaining 42 cases, 11 were cases of irregular certification, 3 were cases in which fees had been improperly charged, and 1 was a case of failure to keep proper records. There were 17 cases of failure to make necessary reports or to return record cards to Insurance Committees, and the 10 miscellaneous cases included cases of irregularity in prescribing, unsatisfactory surgery accommodation, and a case in which excessive claims had been made for mileage payments.

The amounts withheld from practitioners ranged in the great majority of cases from £5 to £10, but in one case as much as £50 was withheld. This was a serious case of neglect to visit and render adequate treatment to an insured patient. In two cases sums of £25 were withheld, in one case £20, and in two other cases £15.

The number of cases in which disciplinary action was taken against chemists shows a slight increase on the number for the previous year, but this may be assumed to be due to improvement in the working of the schemes adopted by Insurance Committees for testing drugs and appliances, to the operation of which the Committees have now had more opportunity to accustom themselves. There is no reason for considering that the extraordinarily high standard of accuracy in the dispensing of insurance prescriptions has declined.

Under the schemes referred to, over 4,000 samples of drugs and appliances were tested during the year ended on the 31st March, 1928. So high a figure as 96 per cent. of the samples were found on analysis to be correct or so nearly correct that there was no ground for withholding remuneration.

The total amount withheld from chemists as the result of inaccuracies in the dispensing of test prescriptions was £186, deducted from the remuneration of 139 chemists. In addition, money amounting in all to £3 was withheld from 3 chemists in respect of other breaches of their terms of service. The sums withheld from chemists ranged from £1 to £5, in the large majority of cases the former being the amount withheld.

Inquiries relating to Practitioners and Chemists.

During the year under review only one representation was made to the Minister for the removal of an insurance practitioner from the Medical List of an Insurance Committee on the ground that his continuance on the List would be prejudicial to the medical service of insured persons. An inquiry under Part VI of the Medical Benefit Consolidated Regulations, 1924, was accordingly held, and the Inquiry Committee's report was under consideration at the end of the year.

No inquiries relating to chemists were held during the year, but one firm of chemists was allowed to resign on giving a written undertaking not re-engage in National Health Insurance work without the consent of the Minister.

Appeals against Decisions of Insurance Committees.

There were thirteen appeals against decisions of Insurance Committees on questions relating to the administration of medical benefit. Of these eight were by insurance practitioners, one by a chemist, and four by insured persons and Approved Societies.

Of the appeals by practitioners five were allowed and three were dismissed. In one of the latter cases the Minister withheld £15 from the moneys payable to the Insurance Committee with a view to a corresponding deduction being made from the practitioner's remuneration.

Of the appeals by insured persons and Approved Societies one was allowed and three dismissed.

The appeal by a chemist was allowed.

There were also three appeals by insurance practitioners against decisions of Panel Committees to disallow claims for anesthetists' fees. All these appeals were allowed.

Approved Societies: Expenditure on Sickness and Disablement Benefits.

Reference was made in last year's Report to the general increase in sickness claims that was a marked feature of the experience of 1926, particularly during the period from May to November in that year when there was a stoppage of work in the mining industry. It was hoped that the steps then taken would have resulted in an improvement in 1927, but these hopes were not realized. After taking account of the increase in benefit rates under additional benefit schemes, the payments of sickness and disablement benefits during 1927 were again in excess of those for the previous year. One factor leading to this result was the severe influenza epidemic that prevailed between February and April, 1927, but this does not account for the continuance of relatively unfavourable experience during the latter part of the year.

The Department has watched the position very closely, and every suitable opportunity is taken by administrative action to urge upon Societies the need for adequate supervision of claims by such means as improved sickness visitation and liberal use of the Regional Medical service. In general, however, Societies are believed to be alive to the importance of such measures. Attention has also been directed to the question whether some improvement is needed in the standard of medical certification, and conferences have taken place with the medical profession for discussion of this subject and are still in progress. Some advantage may be expected to result from the new provision of the Regulations that has been operative from October 1, 1927, whereby an insured person wishing to change his doctor is required, unless both doctors consent to the transfer, to give notice to the Insurance Committee of his desire, and the transfer can only take effect after 14 days from the receipt of the notice. The Department has also during the year re-issued a memorandum to insurance practitioners (Memorandum 307/I.C.) which furnishes full guidance as to the considerations to be taken into account in giving certificates of incapacity for work.

It is difficult to assign any particular cause or causes for persistence of the high level of Societies' benefit expenditure, which does not seem to correspond with any similar general increase in the actual incidence of sickness. Some of the additional claims may be due to the greater readiness with which insured persons now consult their doctor on the onset of illness, a tendency which cannot be regarded as other than a desirable one. The energies of the Department will, however, continue to be directed towards. the elimination of possible causes of irregular claims on the funds.

REFERENCES TO REGIONAL. MEDICAL OFFICERS.

The total number of references for advice as to incapacity for work in 1927 was 284,678 (i.e., from Societies 282,444, from practitioners 1,273, and from Insurance Committees 961). Of these references 87,010 (or 31 per cent.) related to men and 197,668 (or 69 per cent.) to women.

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The number of persons actually examined on incapacity references was 160,759, 68,002 having declared off the funds before the date fixed for examination, and 56,219 having failed to attend for other reasons. Of the persons examined, 114,874 were reported as incapable, and 45,885 as not incapable of work. 1,346 "consultation" references were received; 1,131 from Societies, 199 from practitioners, and 16 from 16 from Insurance Committees.

Schemes of Additional Benefits.

The current additional benefit schemes have now been in operation for nearly three years in the case of Societies and branches valued as at the end of 1922, and two years in the case of the 1923 group. The relative importance of the two groups as regards size is approximately as 3 million members is to 10 million. For the purposes of this review the two groups are regarded as one. At the end of the year 1927 the number and nature of additional benefit schemes in operation were as follows:

Nature of Benefits included.

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Total Number of

Total Approximate Membership.

Number of Approximate Number of Approximate
Schemes. Membership. Schemes. Membership. Schemes.

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The total figure of 6,714 includes the schemes of 31 Societies. which were valued separately as regards men and women, and there

fore have a separate scheme for either group. The membership covered by these Societies is :

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During the year under review one large Society with a membership of approximately 2,370,000 (1,370,000 men and 1,000,000 women) has adopted a new Rule to provide for the separation of men's and women's funds for purposes of valuation, with a common Contingencies Fund, as is permitted under Section 81 of the 1924 Act. Proposals for a similar amendment of rules have been made tentatively by several other Societies. As a change of this kind will closely affect the interests of the whole of the members, both men and women, the Department has laid down, as a condition of approval of the new rule, that in all cases where it is adopted each member shall be furnished with a clearly worded statement showing the nature and effect of the change, and be given an opportunity of voting for or against it. The decision as to approval of the rule would depend upon the results of the voting, the votes of the men and the women members being for this purpose recorded separately.

Variations in schemes are continually being proposed by Committees of Management, and are approved by the Department where there is good ground for making them. During the year ended March 31, 1928, the total number of variations made was 229. The great majority of the changes have had the object of securing more money for dental benefit, either by reducing cash benefits or by withdrawing money from other non-cash benefits.

The following statement shows the amounts available for treatment benefits during 1927, excluding balances brought forward from 1926.

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