38

THE LANCET.

LONDON: SATURDAY, JANUARY 1, 1910.

The Organisation of the MedicalProfession: Some Lessons

from Abroad.THE Battle of the Clubs, under which heading we have li

often described the struggles of English medical men to obtain a fair remuneration for the contract practice which so ir

many of them are compelled to adopt as the only way of

dealing with their poorer patients, is not waged in England alone, but throughout the continent of Europe the necessity for professional organisation has become apparent in order a

to resist the popular demand that highly-trained professional a

men should perform an enormous amount of harassing, y

responsible, and often hazardous, work at a wage

altogether disproportionate to their services, or even k

to their necessary expenses of life. On the con-

tinent, however, the battle has been joined on grounds tsomewhat different from those underlying the troubles e

of our own medical clubs, for it has arisen out of t

the operation of the laws compelling insurance against sickness upon all men with incomes below a certain standard, tlaws which, ipso facto, create an organised system of contract

practice on an extremely large scale, and a corresponding tnecessity for an increasingly general and loyal professional iorganisation to resist any unjust demands made by the i

community under the instigation of the law. It has been

suggested in many quarters that in certain political con-

tingencies we may yet see a similar system of State

insurance for the working classes enforced in this countryand a review of the conditions which it has forced upon our

foreign brethren is not without significance to us at home,although, as Dr. MAJOR GREENWOOD points out in anothercolumn, the fact that the medical men of another nation

have devised a plan which at first trial seems satis-

factory to themselves by no means ensures that a

similar method of dealing with the sick poor would be

desirable in our own country. The latest and worst exampleof the hardships with which European medical men arethreatened comes from Austria, as anybody will rememberwho read our Vienna correspondent’s recent account of theannual Aerztekammertag, or meeting of Medical Councils,held in that city at the end of last November. The meetingwas chiefly concerned in discussing the scheme for generalinsurance against sickness which has been proposed by theAustrian Government, and which provides that every personearning less than 4800 kronen (.6200) a year should berequired to become a member of a Krankenkassa, or sick-club.Should this proposal be enacted, it is not hard to see that theincomes of private practitioners will suffer terrible encroach-ment, because not only will the clubs employ many fewermedical men to serve their members than now serve the

ame number of private patients, but they intend to payotally inadequate salaries for the work which their officersvill have to do. In fact, for a salary of from £100 to R200a year the medical staff will be expected to look after thelealth of from 1000 to 5000 patients, a proposition which

iardly requires comment. We hope our Austrian brethren willbe able to bring enough pressure to bear on the Governmentto obtain the reduction of the wage limit for compulsoryinsurance to £100, the object at which they are aiming.If they are successful, they will keep at least 73,000 wage-earners and their families who would otherwise come under

the new law as possible private patients. There are said

to be 2000 medical men in Austria who cannot make a

living, and it is small wonder that the need for effective

organisation is urgently apparent to the medical professionin that country.

In Germany, no less than in Austria, the economic position ofthe general practitioner is becoming more and more difficult, sothat very energetic action is needed to save a not inconsider-able number of medical men from actual starvation. Here

action was initiated by Dr. HARTMANN of Leipsic some eightyears ago. He founded a fighting medical union entitled ’’ Der

Verband der Aerzte Deutschlands," but more familiarlyknown as the Leipziger Verband. The members pay annually£1, but they are raising a fund of £25,000. Not only have

ley organised many strikes and found the means of financially)mpensating the victims, but the pressure exercised has

een great enough to effect an affiliation with the Deutscher

.erztevereinsbund, an older and more conservative federa-on. The greatest struggle has taken place at Cologne,nd we sent our Special Commissioner to study the condi-ions on the spot. Under the compulsory insurance lawlie different trades form sick funds and each member payss. to 5s. a year for medical aid. There are about 400 medical

practitioners at Cologne, and about 80 of them were employed’y the local sick funds to attend to 120,000 workmen and

,0,000 families. At five members to a family this makes a popu-ation of about 220,000. The families pay 15s. per annum.

)n these terms 300 medical practitioners were willing toattend these people, and the law, which compels everyonewith less than S100 a year to insure against sickness, leavesthe patient free to select the medical adviser he may prefer.In 1904 a general medical strike was declared, and the 80medical officers in the employ of the sick funds administra-Gion gave up their position so as to establish the principle ofthe free choice of medical adviser. The sick-clubs imported32 to 35 other medical men, but the law stipulates that

no medical officer shall have more than 2000 members of a

sick-club on his list, so the clubs had to give way, a five

years’ agreement was signed with the local medical union,and the free choice of medical adviser established. But now

the five years are terminated and the sick-clubs refuse to

renew the agreement. The struggle has been renewed, andas the clubs have on this occasion imported over 60 medicalmen, it is likely to last a long time, while serious doubt isthrown on the possibility of the previous tactics being againemployed with success.

In France also the struggle is on the same lines-thefreedom of choice by the patient, as was explained in arecent article in our columns. Last year this was raised

39

mainly in regard to accidents to workmen. The insurance com-

panies sought to impose on the medical men they employed,and these were accused of minimising the cost and length of treatment. On the other hand, the practitioners chosen by the i

injured workmen were accused of exaggerating the harm done

by the accident. The law and the medical unions, however, successfully maintained the right of free choice, while givingto the insurance companies and the responsible employers the

right to appoint experts to see that there was no abuse.

This year the struggle has been more especially devoted tothe application of the law of 1893, which gives the poor theabsolute right to free medical aid in case of sickness. The

law, however, does not say how this relief is to be given, andleaves the local authorities to decide as to the best method of

application. Fortunately, the medical profession, throughits local unions or syndicates and its national federation of

syndicates, has from the very first clearly stated how themedical poor relief should be organised. There should be a

minimum poor-relief tariff, and the mayor of each districtshould be obliged to place on the list any fully qualifiedpractitioner who is willing to attend on the poor on these

conditions. The poor, on their side, would have the right tochoose from this list whomsoever they might prefer. The pay-ment, of course, would be made directly by the municipalityto the medical practitioner. Out of the 86 departmentsor counties of France, 63 have accepted the principle of

free choice of medical adviser, though the scale of pay-ment varies somewhat. In a few districts the local

authorities have attempted to establish a system like

club practice in England. Instead of paying a fee

for each time advice is given, the municipalities pay asmall sum yearly for each person inscribed on a

practitioner’s list as entitled to free medical relief.

This creates a staff of medical officers who thus become

municipal functionaries. The medical unions stronglyobject to this tendency to convert medical men into

State or municipal salaried employes. A medical practiceshould, they say, be created by the skill and attention

of the practitioner, instead of being given to him as a

reward for services rendered to the political party in

office. If the principle advocated by the medical unionsin France, and outlined briefly above, is firmly establishedthe medical profession will no longer have to do the

enormous amount of gratuitous work that now falls to its lot.All practitioners will then receive at least the minimum fee.If the medical attendant finds the patient cannot or willnot pay, he may inscribe his name on the free list at the

town hall and claim the money from the municipality. If

the patient is not so very poor, then the local authority canrecover the money in the same way as it collects the taxes.

The money for this medical relief is provided out of the

local revenue and the county revenue, supplemented by sub-ventions from the State.

If we were to continue the discussion of the conditions of con-

tract practice in other countries, in most of them-as regardsItaly especially-we should have to tell the same tale of

hard work and inadequate payment for the rank and file of

the medical profession; but we have given sufficient instancesto show that British medical men are not alone in their

professional disabilities, and that their need of cooperation is

no greater than is imposed upon their European brethren.Yet our readers know well enough that their own

necessity for dignified organisation was never greater thanin the present state of Poor-law upheaval and its possiblerevolutionary consequences to many thousands of medical

practitioners.

The Registrar-General’s Report.IMPORTANT changes have recently taken place in the

personnel of the three General Register Offices of the United

Kingdom. In the course of the year just closed a new

Registrar-General and a new Superintendent of Statistics

have been installed at Somerset House, whilst for Scotlandand Ireland respectively new Registrars-General have enteredupon their duties-the vacancy in the latter case havingbeen filled by the appointment of a member of our own

profession, Sir WILLIAM J. THOMPSON, physician-in-ordinary to the Lord-Lieutenant of Ireland. We are in-

debted to Mr. BERNARD MALLET for a copy of his first

annual report as Registrar-General of England. This docu-

ment, which bears the joint signatures of the Registrar-General and the Superintendent of Statistics, is the seventy-first of a remarkable series, the importance of which in

relation to medical science generally, and as the basis for

sanitary legislation and administration in particular, is

universally recognised. We discuss now only a few of themore salient points of the report, as a detailed examinationof its contents will be necessary, together with such

comments on the incidence of mortality and its causes as

will be helpful to those working in public medicine.In the more noticeable features of the vital statistics of

1908 the Registrar-General takes occasion to foreshadow

certain changes in form and method of presentation whichhe wishes to introduce. Among these he refers at length tosome important modifications which have been urged on the

department by persons engaged in public health administra-tion, and which if adopted would greatly increase their

value for sanitary purposes. Hitherto the official statistics

of Somerset House have been limited to registration districtsand sub-districts, the areas adopted in 1837 being those

prescribed by the Act which authorised the parti-tion of England into unions for Poor-law purposes.

The Public Health Act of 1875 provided for a novel

partition of the country into urban and rural adminis-

trative areas which, unfortunately, were seldom co-

terminous with the older union areas of the Poor-law, so

that the statistics of births and deaths, which under existingarrangements are tabulated for the union areas alone, are

practically useless for the administrative purposes of the

public health areas. The assimilation of these areas is, aswe have frequently urged in these columns, a consummationgreatly to be desired ; and we have no doubt that the sani-

tary authorities of the country will appreciate the endeavourswhich the Registrar-General is making with this purpose inview as far as statistics are concerned. Ever since the

creation of sanitary administrative areas under the PublicHealth Act there has been a strong demand for detailed vital

statistics relating to those areas in particular. In view of thisdemand the Registrar-General has now set forth the nature