SANATORIUM BENEFIT

Probably the most popular feature in the National Insurance *Act was the scheme for the treatment of Tuberculosis. Undoubtedly the crusade against the ravages of the white plague caught the imagination of the nation, and the efforts to arrest this disease evoked the hearty goodwill of the medical profession, public health authorities, and generally the mass of the nation. Most people were not too closely concerned with discussions as to methods. What aroused and dominated public feeling was the idea that sustained attention would be given to the essentials of public health with regard to housing, drainage, the abundant supply of water, fresh air, and good food, as well as to the application of medical remedial measures to endeavour to arrest and, if possible, stamp out this disease. Compared with other portions of the country, Scotland has suffered severely from this devastating scourge. The dimensions of the evil may be gathered from the following facts :—

(a) The total number of deaths from the various forms of Tuberculosis in Scotland during the five years 1907 to 1911 inclusive was 44,933.

(b) Of these 28,037 were due to pulmonary Tuberculosis.

(c) As contrasted with other infectious diseases during the same time, pulmonary Tuberculosis alone caused more deaths than resulted from the whole of the following, namely :—

Smallpox, Diphtheria, Scarlet Fever, Typhus Fever, Enteric Fever, Measles, and Whooping Cough.

(d) Every death from pulmonary Tuberculosis represents several existing cases of the disease.

(e) Whilst the incidence of other infectious maladies is mainly on childhood, that of pulmonary Tuberculosis is mainly on adults at the working period of life, many of them being fathers or mothers with families to maintain.

The following- statement of the position in Scotland is taken from the report of the Scottish Insurance Commission. With regard to the number of approved institutions and the number of beds available in these institutions, it may be said that each bed represents accommodation for three or four persons in the year as the average time of treatment may be taken tc» represent three or four months. Thus 1,600 beds would roughly accommodate some 6,000 persons per annum. It may further be said that the sustained attention of the Central and Local Authorities is being given to the provision in every district of a complete organisation to cope with the preventive and remedial measures which are desirable in order that organised scientific effort may be applied to fight this terrible plague. In most districts some provision is available, and more complete organisation will be speedily forthcoming where it is required.

Sanatorium Benefit is the second of the benefits named in Section 8 (1) of the Act. It is there defined as “Treatment in sanatoria or other institutions or otherwise when suffering from tuberculosis or such other diseases as the Local Government Board, with the approval of the Treasury may appoint.”

The following is a brief review of the main provisions of the Act with respect to this benefit :

Sanatorium benefit was not subject to a waiting period ; it became current on 15th July, 1912, the date on which the Act came into operation. It is administered in all cases by and through Insurance Committees, who are required, for the purpose of its administration, to make arrangements to the satisfaction of the Commission with a view to providing treatment for insured persons suffering from tuberculosis in institutions or otherwise.

The sums available under the Act for defraying the cost of the benefit in each year are one shilling and three pence in respect of each insured person resident in the Insurance Committee’s area, payable out of the National Health Insurance Fund, and one penny in respect of each such person payable out of moneys provided by Parliament, but the whole or any part of the latter sum may be applied by the Commission to research. Unless recommended by an Insurance Committee, an insured person is not entitled to sanatorium benefit. An Insurance Committee may defray in whole or in part the expenses of the conveyance of an insured person to or from any sanatorium or other institution to which he may be sent for treatment.

An Insurance Committee may, if it thinks fit, extend sanatorium benefit to the dependants of insured persons or to any class of such dependants. If in any year the amount available for defraying the expenses of sanatorium benefit is insufficient to meet the estimated expenditure on sanatorium benefit for insured persons and such dependants, the Insurance Committee may, through the Insurance Commission, transmit to the Treasury and the Council of the County or Burgh an account showing the estimated expenditure for the purpose, and the amount of the sums available for defraying the expenses of sanatorium benefit, and the Treasury and Council may, if they think fit, sanction such expenditure.

The Treasury and the Council of the County or Burgh sanctioning such expenditure as aforesaid will thereupon each be liable to make good, in the case of the Treasury out of moneys provided by Parliament, and in the case of the Council of the County or Burgh, out of the County General Purposes Rate, or Burgh Public Health General Assessment, as the case may be, one-half of any sums so sanctioned by them and expended by the Insurance Committee on sanatorium benefit for insured persons and their dependants in the course of the year in excess of the amount available for defraying- the expenses of the Committee on sanatorium benefit.

Provision is made for the expenditure of a sum of ^1,500,000 made available by the Finance Act, 1911, for the provision of sanatoria and other institutions for the treatment of tuberculosis. The sum was to be apportioned between England, Wales, Scotland and Ireland in proportion to their respective populations at the 1911 census, and is to be distributed by the Local Government Board with the consent of the Treasury, who, before giving their consent, are to consult with the Commission. Any County Council receiving a grant may be authorised by the Local Government Board to provide and maintain institutions, and Joint Committees and Joint Board may be constituted by Order of the Board for this purpose. An Insurance Committee, with the consent of the Commission, may, under certain conditions, contribute out of its Sanatorium Benefit Fund, by annual or other payment, towards the maintenance of an institution or the provision of treatment available for persons recommended by them for sanatorium benefit.

Up to the time of the passing of the Act, efforts had been made by Local Authorities in Scotland, and also through private benevolence and enterprise, to make provision in some measure for the treatment of tuberculosis, but these efforts tended to be restricted and inco-ordinate. Although much had been done by the local extension of the Notification Act of 1889 to pulmonary tuberculosis and in other ways, there were few local government areas which, in respect of treatment either in residential institutions or elsewhere, were meeting the needs of their population in a complete and adequate manner.

With the passing of the Act, a new prospect was opened— a prospect with far-reaching possibilities. The treatment of tuberculous insured persons was obligatory on Insurance Committees; the treatment of their dependants was suggested, and the grants in aid of buildings were seen to be available, not for the benefit of insured persons only, but for the whole population.

In order that progress from existing conditions to those outlined by the Act might be guided along reasoned and uniform lines, the Treasury, by Minute of 22nd February, 1912, appointed a Departmental Committee, of which Mr. Waldorf Astor, M.P., was Chairman, and the Deputy Chairman of the Commission a member, to report at an early stage upon the considerations of general policy in respect of the problem of tuberculosis in the United Kingdom in its preventive, curative, and other aspects, which should guide the Government and local bodies in making or aiding provision for the treatment of tuberculosis in sanatoria or other institutions or otherwise.

The Committee in their Interim Report stated that the scheme for dealing with tuberculosis which they desired to recommend was based on the establishment and equipment of two units, the first of which is the tuberculosis dispensary or equivalent staff, and the second the sanatorium or similar institution.

In the Scottish section of the Committee’s Report, the view is expressed that certain recommendations of the general portion of the report may not be applicable or suited to Scotland, owing to the different position, legal and otherwise, existing in that country. It is stated that the Local Government Board for Scotland have power to require Local Authorities to provide out of rates for practically every variety of treatment included under the term sanatorium benefit. In respect of the units which should constitute a scheme, the Scottish portion of the Report is in agreement with the remainder.

On 29th May, 1912, the Local Government Board issued a circular which drew attention to the powers and duties of the Board and of Local Authorities, suggested that Councils of Burghs of more than 20,000 inhabitants, and of Counties, should instruct their medical officers to prepare a report on the requirements of their area with respect to a tuberculosis scheme, and desired information before 1st July as to progress made.

On the 18th June, 1912, the Local Government Board made their Public Health (Pulmonary Tuberculosis) Regulations (Scotland), 1912, rendering the notification of pulmonary tuberculosis compulsory throughout Scotland as from the 1st August, 1912.

All these steps in the way of progress were directed towards the evolution of permanent schemes. But the 15th July, on which sanatorium benefit was to come into operation, was now close at hand, and it was necessary that provisional arrangements should be adopted to begin with.

The Commission accordingly issued a circular for the guidance of Insurance Committees during the transitional period. It was suggested that in the beginning the work of enquiring as to the best course to be adopted by an Insurance Committee with regard to insured persons suffering from pulmonary tuberculosis should, with the necessary sanctions and under proper terms and conditions, be undertaken by the Medical Officer of Health. At the same time the attention of Committees was drawn to the necessity of entering on the careful consideration of permanent schemes for the administration of sanatorium benefit.

SANATORIA HOSPITALS AND DISPENSARIES.

Inception of Sanatorium Benefit.

In order that Insurance Committees, under Section 16 (1) of the Act, might make arrangements with persons or Local Authorities (other than Poor Law Authorities) for the treatment of insured persons in sanatoria or other institutions under their management it was necessary that the institutions should be approved by the Local Government Board. The Board had instructed their Medical Inspectors to make local enquiries and inspections, with the result that, on loth July, there were 46 institutions in Scotland approved and ready for the treatment of insured persons suffering from tuberculosis.

Institutions as at 15th July, 1912.

Of the 46 institutions approved by the Local Government Board as at 15th July, 1912, 36, with upwards of 883 beds, were sanatoria or hospitals. Three of these, with a provision of upwards of 41 beds, were reserved for non-pulmonary cases. There were in addition 10 approved dispensaries, situated in the Burghs of Dundee, Glasgow, Greenock, Inverness and Leith.

Institutions as at 31st March, 1913.

Following the 15th July, 1912, the work of inspection and approval by the Local Government Board continued to be carried on, with the result that at 31st March, 1913, the total number of institutions available for insured persons had risen from 46 to 101. Of the 101 institutions, 87 were sanatoria or hospitals, containing upwards of 1,533 beds in all, of which 109 were for non-pulmonary cases only. The 10 dispensaries had been increased to 14, by the addition of one in Edinburgh, one in Paisley, and two in the Glasgow area.

Since the above facts were published, the dispensaries have been increased to 15. The approved institutions have risen from 101 to 109, and there has been an increase of beds from 1,533 to 1,656.

NUMBERS TREATED FOR TUBERCULOSIS.

Between the 15th July, 1912, and the 31st March, 1913, Sanatorium Benefit was received in Scotland by 1,557 insured persons. The approximate total expenditure chargeable to the Sanatorium Benefit Fund to the 31st March, 1913, was £17,963 18s. 7d.

The persons actually in receipt of sanatorium benefit at the 31st March, 1913, numbered 1,177 in all, of whom 735, or 62.1 per cent, were in sanatoria or hospitals, while 19.5 and 18 per cent, respectively, were receiving dispensary and domiciliary treatment.

Of the total 1,177 cases, 344 were derived from the areas of the 31 County Insurance Committees, and 833 from the 25 Burghs with a population of 20,000 and upwards.

COUNTIES.

Of the 344 County cases, 276, or 80.2 per cent., were undergoing treatment in sanatoria or hospitals, while 68, or 19.8 per cent., were in receipt of domiciliary treatment. There was no dispensary treatment in the county areas. The counties of Fife, Ayr, Lanark and Renfrew had each over 20 persons in sanatoria. Of the County Committees which had recommended more than a single case, nine were able to procure sanatorium treatment for all their patients. The Committees in question were those of Argyll with 6 cases, Dumbarton with 14, Dumfries with 9, Lanark with 48, Linlithgow with 5, Midlothian with 13, Renfrew with 24, Selkirk with 9, and Stirling with 19. Twelve of the thirteen Perthshire cases were in sanatoria. Of three cases in Shetland, two were in receipt of sanatorium treatment. The Wigtownshire Committee had the pleasing-experience of total exemption from claims upon their Sanatorium Benefit Fund.

BURGHS.

The percentage of the 833 Burghal cases which were receiving treatment in sanatoria at 31st March, 1913, was 55.1, as contrasted with 80.2, the corresponding figure for Counties. This difference, however, is not in general association with a higher incidence of domiciliary treatment in Burghs, for the proportion of home cases in Burghs is, in fact, somewhat less than in Counties, being 17.3 per cent., as against 19.8. The cause is to be found in the prevalence in Burghal areas of dispensary treatment, which accounted for 230 persons, or 27.G per cent, of the total.

Of the four great cities, Edinburgh, with 79.5 per cent., had the highest proportion of sanatorium treatment; Glasgow, Dundee and Aberdeen follow in order with 47, *13.3 and 29.5 per cent, respectively.

No Burgh which had recommended 10 cases or over for sanatorium benefit had the whole number in sanatoria at the 31st March.

The highest dispensary figures, 74.2 per cent., was reached by Greenock; Glasgow occupies the second place, with -18.8 per cent, of cases so treated, and is succeeded by Leith and Inverness with percentages of 39.4 and 25 per cent, respectively.

Domiciliary treatment was under 5 per cent, in Glasgow and Leith. At the 31st March no cases were being treated exclusively at home in Airdrie, Dumbarton, Dumfries and Max-welltown, Dunfermline, Greenock, Kilmarnock, Motherwell, Paisley, Perth, Rutherglen or Stirling. Wishaw, alone among the Burghs, had no insured person in receipt of Sanatorium benefit either at home or e-lsewhere. The following table shews the comparative figures for all four countries. It will be observed how much better Scotland has dealt with this problem than her sister countries :—

SICKNESS BENEFIT.

Sickness benefit, or sick pay as it is commonly called, is defined in the Act as “ periodical payments whilst rendered incapable of work by some specific disease or by bodily or mental disablement, of which notice has been given, commencing- from the fourth day after being- so rendered incapable of work, and continuing for a period not exceeding twenty-six weeks (in this Act called ‘ Sickness Benefit A reduced

rate of benefit is payable in respect of young persons under 21 who are unmarried or who have not any members of their family wholly or mainly dependant upon them. There are also some special provisions relating to special married women contributors and to members of the mercantile marine, to soldiers-and sailors, and to some insured persons who come under section 47. With these exceptions under the new Act, when it operates, and subject to qualifying waiting periods and to the three waiting days and to the operation of any arrears, the rate of sickness benefit is a flat one, and all British employed contributors over 21 who insure before 13th October, 1913,. will be entitled to 10s. per week if men and 7s. 6d. per week if women, and incapable of work.

MATERNITY BENEFIT.

Maternity benefit, while, comparatively speaking, a new benefit, has been most popular. Definition has already been made of this benefit. Various questions relating to administration in Scotland have arisen.

One of the chief points of difference in Scotland in relation to the administration of maternity is raised by the fact that the Midwives Act, 1902, does not apply to Scotland. By the proviso to Section 18 (1) of the National Insurance Act it is laid down that “ the mother shall decide whether she shall be attended by a duly qualified medical practitioner or by a duly certified midwife.” Section 80 (17) of the National

Insurance Act 'meets the different situation by saying that certified midwife ” shall be held to mean any midwife possessing such qualifications as may be prescribed. Accordingly the Scottish Commission have made a regulation which enacts that the qualifications of a midwife for the purposes of Section 18 of the Act as applied to Scotland by Scction 80 of the Act shall be either

(a) Bond fide practice in Scotland as a midwife for a period of at least one year prior to 15th January, 1913; or

(b) Regular or due attendance at a course of training in midwifery ajt such hospital, infirmary, or other institution as may from time to time be approved in writing by the Commissioners.

It is laid down by paragraph three of these regulations that “if any question arises as to whether any woman possesses the prescribed qualifications the same shall be determined by the Commissioners, whose decision shall be final.”

The Amending Act modifies in certain directions the conditions attached to the administration of maternity benefit.

VOLUNTARY CONTRIBUTORS.

Voluntary Contributors in Scotland have turned out to be a very small class. According to the official figures, there are less than 2,000 in the whole of Scotland.

The voluntary contributors are defined in the principal Act as :—

“All persons who either

(a) Are engaged in some regular occupation and are wholly or mainly dependent for their livelihood on the earnings derived by them from that occupation, or

(b) Have been insured persons for a period of five years or upwards provided always that no person whose total income from all sources exceeds one hundred and sixty pounds a year shall be entitled to be a voluntary contributor unless he has been insured under this part of this Act (Part I.) for a period of five years or upwards. Persons upwards of 65 are not authorised to become voluntary contributors.”

Some important alterations referring- to voluntary contributors are made under the Amending Act.

Doubtless one of the reasons why so few persons have entered into voluntary insurance is the effect on the public mind of the campaign against the Act. Instead of insurance being represented as a good thing and desirable in itself, the suggestion made has been that it was bad and a thing to be avoided.

Persons who are entitled to enter insurance as voluntary contributors should very carefully consider the scheme on its merits. More especially does this hold good with regard to those persons who are entitled up to 13th October, 1913, to enter on the flat rate of contribution. This advantage is one that should not be lightly cast aside, and an immediate decision should be made.

THE DEPOSIT CONTRIBUTOR.

No part of the National Insurance Act has been subjected to so much criticism as that part which relates to the Deposit Contributor. Metaphorically speaking, gallons of ink have been spilt over the woes of the poor depositor. Like other parts of the Act, the actual situation has turned out to be totally different from that anticipated.

It is well to bear in mind that under the Insurance Act every Society was given the right to reject any applicant on any ground except that of age. It was expected that a considerable number of persons would be unable to find entrance into any Society by reason of their state of health. As a matter of fact, few Societies held a medical examination of those applying for membership, and little difficulty was experienced by average persons in securing entrance into some kind of approved Society. The Deposit Contributors are not only very much fewer in number than was expected, but they appear to be of a different class from that anticipated. All the information available from approved Societies and from official sources tends to shew that deposit contributors as a class are quite good “ lives ” and that they could find entrance into .Societies if they so desired. As a matter of fact, deposit contributors in Scotland at first numbered about -15,000, or something like 2½ per cent, of the total insured persons. The numbers of this class and the district to which they belong are given in the table relating to number of insured persons in Scotland. From official sources one learns that nearly 10,000 bave either transferred to some Society or given notice that they intend to transfer. One also learns that two of the largest approved Societies have offered to take over en masse the entire body of deposit contributors. As every effort is being made to induce deposit contributors to transfer to approved Societies, and as it is obviously to their advantage to do so, it would appear that the educative effect of the payment of restricted benefits will drive more and more depositors to join some Society. Although the figures are only available for a few months, and it is therefore unsafe to draw too strict conclusions from them, it would appear that the deposit contributor is drawing sickness benefit at a much lower rate than that claimed by members of Societies who are enjoying the lowest sickness experience. On the basis of the figures obtaining during the first six months, it is evident that there will be a substantial surplus on the total of the deposit contributors’ accounts taken as a whole. In other words, if the Deposit Contributors’ Fund were a Society, it would appear on present experience to be a good sound business proposition.

The question, therefore, arises whether the deposit contributors should not be formed into a Society under the management of the Insurance Commissioners on the insurance basis with such safeguards as might be required by the special necessities of the class as experience determined. In any event the Deposit scheme is a temporary one, and in a year’s time sufficient data will be available for the treatment of a question which appears to be one of comparatively easy solution.

CASUAL WORKERS.

The case of the regular worker presents few serious difficulties in Scotland. The position of the casual worker is one of the most difficult in National Insurance. Indeed, here and elsewhere, in all kinds of social reform the casual worker is always attended by a train of administrative and financial difficulties. Among these obstacles to successful administration is the straitened circumstances of the worker, his irregularity of work, his numerous employers, his migratory habits, his frequent changes of address, and his lack of education and dislike to anything approaching routine or system. There is, of course, the outstanding difficulty of the casual worker avoiding arrears and keeping himself in benefit. Casual labour is employed in a vast variety of industries and numerous plans have been advocated and many experiments tried to adapt the payment of contributions so that no undue burden should fall on the employer or employee. Thus there have been instituted pooling systems, grouped employers, arrangement of payment by employers in turns, as, for instance, in connection with charwomen and cleaners. The new provisions with regard to arrears and schemes for treating casual labour should prove helpful to the casual worker.

It should always be noted that it would be impossible to exclude casual workers from the scope of compulsory insurance, as to do so would encourage the employment of casual labour, a result which would be deplorable in itself and one which might operate against the interests of regular labour.

It is to be observed that in Scotland during the past year or two regular labour has been well employed, and casual or seasonal labour has tended to become more fully employed than hitherto. In fact, during such prosperous times labour tends to become decasualised and as, for example, in agricultural work labour begins to shew itself not so much as casual but as part of a series of operations covering a variety of seasons, such as the preparation of ground, the planting of seeds, the cleaning of ground, and the picking or gathering of the fruits or harvest of the soil.

It may be that the operation of the new arrears clause and schemes adopted to meet casual or irregular labour will partly solve the problem, which is a serious economic one. The exigencies of a necessitous class may make it necessary to charge the employer of casual labour with a contribution on a scale sufficiently high to give the casual worker a reasonable chance to keep in insurance and to enable him to join a Society, and thus secure the benefits of real insurance, even if such a Society is a specially managed or subsidised one as indicated in the paragraphs on Deposit Contributors.

“MALINGERING”

The financial basis of the National Insurance Scheme is that contributions have been fixed to meet the cost of certain benefits. The cost of these benefits has been estimated by actuaries to be a certain weekly figure for sickness, disablement and the other benefits. The cost of sanatorium benefit is calculated at a fixed amount per person per annum ; medical benefit is computed at a certain figure per person ; maternity benefit is estimated on the basis of a number of births per annum and a sum of 30s. being paid for each birth in connection with an insured person or the wife of such.

Various investigations have been made in this country with regard to the sickness experience of members of Friendly Societies. The Government actuaries have adopted sickness tables derived from an extensive investigation made on behalf of the Manchester Unity of Oddfellows by Mr. A. W. Watson. The problem of the actuaries was to assess the cost of providing certain benefits for a lad of sixteen and then to fix a rate of contribution sufficient to cover the cost of such benefits.

The actuaries took into account that contributions would not be paid during- sickness or unemployment and that the average number of payments per person would be 48 per annum, or at a 7d. rate a sum of 28s. per annum.

On the basis of calculations adopted by the actuaries the contributions necessary to provide the various benefits for persons entering insurance at 16 years of age would be as follows, the cost of medical benefit being taken at 6s. per annum :—

It should be remembered that there is a scheme of reserve values. The “reserve value” of an insured person is the liability which a Society undertakes by accepting him at the moment of his entry into insurance. It is thus possible to adopt a flat rate of contribution for all ages.

It must be kept in mind that the rate of sickness increases with advancing years. The following table gives the rates of sickness experienced at each age by the Manchester Unity as derived from their investigation during the years 1893-97 :—

One main question that will require to be answered in connection with the working of National Insurance in this country is the vital one of whether the basis of the Government actuaries is a safe one or whether it will be found that sufficient margin is not allowed for lives which represent the mass of the nation and are, therefore, not selected, such as many of the members of the Friendly Societies were. Even the Manchester Unity figures might be said to be in some respects an investigation of the experience with reference to selected lives. It has also to be remembered that few Approved Societies instituted a medical examination of those who applied for membership of the State Section of Societies, and that, therefore, some Societies may be loaded with a large proportion of bad lives. For it must never be forgotten that only a certain fixed number of days of sickness is allowed in the calculations for each member of a Society per annum, and the contributions and interest on reserve values only provide the funds which are sufficient to meet the expected amount of sickness per member per annum. If that expected amount of sickness is exceeded the result will be a deficit in the funds of the Society. That deficit must be met in certain ways, either by receiving a portion of such deficit from associated members, or by levy on members, or reduction of benefits payable to members of the Society. It should be kept in view that the State does not guarantee the payment of benefits. All that the State guarantees to do in connection with benefits is to pay 2/9ths or 1/4th of such benefits as are paid. If there is a deficit in the funds of a Society due to excessive claims on the sickness funds that deficit must be met by the members. It will not be met by the State.

The question of the actuarial calculations of the basis of the National Insurance Scheme is important. Moreover, if a Society has been unfortunate enough to admit too large a proportion of bad lives the effect is obvious and deficits are certain.

Behind the whole scheme lurks this grim spectre that in the judgment of some critics threatens the whole superstructure of National Insurance. Apart from real sickness, or excessive claims on particular Societies due to a large proportion of bad lives, there arises another vital question as to whether the introduction of a State Insurance Scheme will lead to increased claims for sick pay, not because of real illness, but because of sham illness, or whether it may not foster a class of “illness” which is more or less imaginary. This, in the opinion of many students of insurance, is the most difficult and dangerous of all questions involved in the administration of National Insurance. It is the question that is troubling the minds of the Administrators, it is perplexing the medical profession, and it is already causing grave anxiety to the executive officials and working committees of the approved Societies. Although the British experience under the State is too limited to yield reliable data, it is admitted by students of voluntary insurance under the old Friendly Societies that malingering did exist and that checks were necessary in order to prevent and limit and, if possible, prevent fraud on the funds. It is admitted that there is a certain amount of malingering in connection with claims under the Workmen’s Compensation Act.

It is further admitted and proved that the great German insurance scheme has been productive of much malingering and that checks have had to be set up in order that frauds on the sickness funds may be reduced and, if possible, eliminated.

All these facts point to the necessity for close scrutiny of claims, for care in administration and for attention to the main features of good business management of the sick funds. It may further be found necessary to institute special checks in the shape of the employment by Societies of special sick visitors. This system is not novel, and it has been found to work well where faithful and efficient visitors have been organised in connection with the payment of sickness claims to members of Societies. The “ doctor’s line,” or certificate of illness, will be a great protection if certificates are only granted to members who are truly incapable of work. A great responsibility lies upon the insurance doctors. On them rests the important duty of seeing that genuine applicants are duly certificated as being “ incapable of work.” On the other hand, it is their plain and obvious duty to refuse to give certificates to those who are not entitled to receive them. Medical men must keep in view that their certificate is equivalent to a cheque to bearer. If these cheques are given carelessly or wrongfully no Society on the present basis can stand the burden, and deficits and bankruptcy will be the inevitable result. One of the most important checks on malingering that may operate advantageously and powerfully will be the effect of the healthy public opinion of the general body of insured persons shewn in their attitude to those who are beyond doubt defrauding Societies by making claims for and receiving sick pay on improper grounds. The insurance doctor’s sphere is a most important one, the sick visitor may be a powerful bulwark to the sick fund, but as important will be a healthy public opinion unaffected by any spurious feeling of sympathy for the malingerer.

It will be a matter of vital importance for the members of Approved Societies to understand that any individual who is robbing the sick fund of a Society is robbing his fellow members, and probably depriving some members who are truly necessitous from receiving benefit. The State does not make good any deficit. The members themselves must defray any balance that is on the wrong side. Thus, improper claims do not fall on the State, but their burden really falls upon the members of each Society. Undue claims and bad management are thus penalised. Good management is rewarded.

It is desirable to make the above perfectly clear, for it must be recognised that many people take one view with regard to transactions with individuals and another and totally different view of transactions with the State, corporate bodies, insurance and railway companies and societies. However difficult it may be to defend such action, it is a matter of common knowledge that many persons think it rather clever than otherwise to escape due payment of income tax, or to seek relief from the payment of rates and taxes even when they are able to pay them. In the same way numbers of people view with somewhat lukewarm indignation any attempt to get the better of an 'insurance company or to defraud a railway company. Irregularities or offences in any of the above directions are often regarded as venial and the detection of such frauds, or conviction related thereto, does not carry the degredation or loss of social status that it ought, nor does it signify any very great change in public opinion with regard to the delinquents. This point requires to be emphasised because so much has been heard of the State and State Insurance that it is to be feared that many insured persons have been imbued with the idea that a benign Government with a bottomless purse invites all to claim money. And the loose and vague talk one hears in certain quarters is that there is money in National Insurance and it is the business of some people to secure their share of it. The popular idea seems to be that they are paying for benefits and are entitled to receive them. It is overlooked that benefits are only payable on certain we'll defined conditions. If these conditions do not exist, no benefits are payable.

The next few years will be a searching time for the administrators of National Insurance, but the test will apply to the people as well as to their governors. I have belief in the character and good sense of the great majority of Scottish people. For the minority who may require education and oversight in a new field, it may be said that the national ability to grapple with difficulties will be likely to solve any knotty problems, and that stern adversity may guide the way over any obstacles that may beset the path of the well-wisher of National Insurance. Moreover, the triennial valuation will exert a very healthy discipline and, where necessary, provide a salutary lesson.