reasonably be necessary for the adequate treatment" of the insured person. The body to whom is entrusted the duty of investigating these questions of prescribing is the Panel Committee for the area, consisting entirely of the doctor's fellow practitioners, and they are entrusted with the duty not only of investigating facts but of recommending the amount, if any, which might properly be recovered from the practitioner. This duty has been entrusted to the practitioners themselves at the request of their own representatives, who have undertaken that the work should be fairly performed.

STANDARD OF TREATMENT.

The Exchequer grant which is paid as part of the remuneration of insurance practitioners and chemists is paid conditionally on the Insurance Committee securing a satisfactory standard of service, and where it is established after formal investigation that a doctor or chemist has failed in his duty, his remuneration is considered not to have been fully earned, and a portion of it is accordingly withheld.

During the year Exchequer grant was withheld from seventy doctors and six chemists, the total amount so withheld amounting to £1,118.

In four cases of doctors £50 grant was withheld, and in two cases £40. In four of these cases the doctor was found to have been guilty of serious neglect of patients. In one case the doctor permitted his wife to attend patients, though she held no medical qualifications, and in another the doctor persistently charged the patient fees for services which he was under contract to render free of charge. In the remaining cases smaller amounts varying from £30 to £5 were withheld in respect of less serious breaches of the terms of service.

As regards the chemists, £50 was withheld in respect of one case where the chemist repeatedly supplied smaller quantities of drugs and appliances than those ordered by the doctor.

INQUIRIES RELATING TO MEDICAL PRACTITIONERS
AND CHEMISTS.

No further volume of Reports of Inquiries has been issued owing to the need for economy, but during the year fourteen representations were made to the Minister for the removal of practitioners or chemists from the medical list on the ground that their continuance on the list would be prejudicial to the medical service of insured persons.

Eleven of these cases related to doctors, and three to chemists.

In the case of the doctors three representations were based on the fact of the doctor's conviction for criminal offences. In two cases the doctor's name was removed from the list, and in one case a decision was deferred for twelve months, regard to be had to the doctor's conduct in the meantime.

In two cases the basis of the complaint was neglect of patients. In one case the practitioner died before the inquiry took place, and in the second the practitioner was allowed to resign from the medical list, on giving an undertaking not to resume insurance practice without the

Minister's consent. In three cases the representations were withdrawn, other disciplinary action being taken in one case, while another was dealt with by the General Medical Council.

In the three remaining cases, the grounds alleged were insufficient to justify an Inquiry being held.

Three Inquiries were held in the case of chemists, as a result of which two chemists were removed from the list, and in the third case £50 was deducted from the chemist's remuneration and he was ordered to pay the costs of the Inquiry proceedings.

APPEALS AGAINST DECISIONS OF INSURANCE
COMMITTEES.

In sixteen cases there was an appeal against the decision of the Insurance Committees on matters relating to the administration of medical benefit. In eleven of these cases the appellant was a doctor, and in five cases an insured person or Approved Society. Of the former cases six were dismissed, four were allowed and one was withdrawn. Of the appeals made by insured persons and Approved Societies, the decision of the Committee was varied in one case, the appeal was dismissed in another case, and in two cases insufficient grounds of appeal were shown.

In addition to the above there were ten cases in which the doctor appealed against a decision of the Insurance Committee, following an investigation by the Panel Committee representing the insurance practitioners of the area, to withhold part of his remuneration on the ground of the doctor's excessive and extravagant prescribing, whereby loss was sustained by the Drug Fund.

In two cases the appeal was dismissed, the Insurance Committee having agreed in one case to reduce the penalty imposed; one appeal was allowed, one withdrawn, and in the remaining cases decided, the amount of the surcharge imposed on the doctor was reduced.

MEDICAL CERTIFICATION.

During the year the medical certification scheme which had been in operation since 1914 was reviewed in consultation with representatives of insurance practitioners and Approved Societies, and certain amendments were agreed to be necessary. In particular a new form of certificate was introduced for issue under certain conditions in the case of convalescent insured persons whose condition necessitated a period of absence from home. The new Certification Rules became part of the terms of service for insurance practitioners on the 1st January, 1922; and it is hoped that, with the co-operation of the Societies and doctors, the new rules will result in a smoother working of the medical certification system.

MEDICAL RECORDS.

The new form of record to be kept by insurance practitioners, introduced on the 1st January, 1921, has been found to be acceptable to practitioners generally, and few cases of failure to keep proper records have been brought to the notice of the Department.

National Health Insurance Joint Committee.

In consequence of the Government of Ireland Act, 1920, and by virtue of Article 11 of the Government of Ireland (Adaptation of Health Insurance Acts) Order, 1922, the Minister of Labour for Northern Ireland is now a member of the Joint Committee as the representative of the Government of Northern Ireland.

Sir Alfred Watson, K.C.B., the Government Actuary, and Mr. E. J. Strohmenger, C.B., Accountant-General of the Ministry of Health, have been appointed Joint Financial Advisers to the Committee.

Approved Societies' Administration Allowance.

The Departmental Committee on Approved Societies' Administration Allowance, under the Chairmanship of Sir Walter Kinnear, submitted their Report (Cmd. 1291) on the 9th May, 1921. Provisions. to enable their recommendations to be carried into effect were subsequently enacted by the National Health Insurance Act, 1921, which received the Royal Assent on the 28th July. This Act, which was deemed to have had effect from the 1st January, 1921, amended in some particulars the financial provisions relating to National Health Insurance, so as to enable the maximum sum that may be appropriated by Approved Societies for purposes of administration to be increased from 4s. 5d. to 4s. 10d. per annum in respect of ordinary members, with a corresponding increase in respect of special classes of members. These amounts, which have now been fixed by regulation, are to be reviewed at the end of 1922.

The Act also increased the Societies' contribution towards the expenses of administration of Insurance Committees, and provided for a reduction in the size of Insurance Committees in England and Wales. A net saving to the Exchequer of about £300,000 per annum was effected by the Act and the regulations made thereunder.

In view of the increase in the administration allowance, the Department has adopted measures to secure that Societies in deficiency on their administration account shall take steps promptly to make good the deficiency in accordance with the requirements of the Acts and regulations. Modifications have been made by regulations in the procedure to be adopted where administration deficiencies occur.

Government of Ireland Act, 1920.

A Departmental Committee was appointed in October 1921, under the Chairmanship of Sir Alfred Watson, to consider and report upon the steps necessary to carry out the provisions of the Government of Ireland Act, 1920, in respect of National Health Insurance. The Committee made their Report (Cmd. 1575) on the 7th December, 1921, and effect has been given to their recommendations by the Government of Ireland (Adaptation of Health Insurance Acts) Order, 1922. By this Order, the "appointed day" for the transfer of health insurance services to the Government of Northern Ireland was declared to be the 1st March,

1922. The Ministry of Labour for Northern Ireland have become the Department responsible for the administration of National Health Insurance in that area. The Order provided for establishing a separate National Health Insurance Fund for Northern Ireland, for the apportionment of assets and liabilities, and also for powers to be exercised by the National Health Insurance Joint Committee in respect of Northern and Southern Ireland similar to those exercisable by the Committee before the appointed day in respect of Ireland as a whole. The position in regard to Southern Ireland is, however, subject to adjustment consequent upon the formation of the Irish Free State.

Recommendations of the Committee on National
Expenditure.

The Committee on National Expenditure made recommendations with the object of limiting the liability of the Exchequer in respect of National Health Insurance to the ordinary statutory proportion of the cost of benefits and administration. In order to relieve the Exchequer of (a) the special grants (amounting to approximately £1,700,000 per annum) made towards the cost of medical benefit in excess of the statutory proportion of two-ninths, and (b) part of the cost of the administration of medical benefit (amounting to £100,000 per annum), the Committee proposed that there should be an increase in the weekly contribution by 1d. (d. by the employer and d. by the insured person), and it was contemplated that any surplus moneys arising from this increase in the weekly contribution would be used for the provision of a supplemental benefit. The Approved Societies, however, through the Consultative Council on National Health Insurance (Approved Societies' Work), represented strongly that an increase in contributions was inopportune, and they suggested an alternative scheme under which the whole of the saving to the Exchequer would be secured without any additional contributions. Societies have considerable reserves in their benefit funds (amounting in the aggregate to about £14,000,000) derived from (a) the proportion of surpluses carried forward as non-disposable on the first valuation, and (b) the accumulated balances of Contingencies Funds up to the date of the first valuation. The proposals are that, in view of these reserves, the whole excess cost of medical benefit hitherto met out of special Exchequer grants should, as from the 1st April, 1922, be charged on the existing benefit funds of Societies during the continuance of the present arrangements, which expire in December 1923. A Bill has been introduced into Parliament to give effect to the above proposals.

As a further measure of relief to the Exchequer, the Bill provides for the abolition of the Women's Equalisation Fund, which was set up by the Act of 1918 with the object of assisting Approved Societies in meeting their liabilities in respect of sickness claims of women. The income of the Fund was derived entirely from the Exchequer, involving an annual grant of about £350,000. The necessary financial assistance to Societies will be provided in future by means of an increase in the reserve values in respect of married women. This will have the effect of extending the period of redemption of reserve values by between one and two years.

Number and Membership of Approved Societies.

The number of Approved Societies operating in England on the 31st December, 1921, was 1,136, of which 1,106 are centralised Societies and 30 Societies with branches. These figures include 193 Societies which are approved for more than one part of the United Kingdom.

The following table shows the approximate number and distribution of members of Approved Societies among the various groups of Societies at the 31st December, 1920:

land :Men

Women

1,964,000 1,999,200 2,728,400 987,400 79,000 7,758,000 634,200 814,600 2,556,100 197,950 24,150 4,227,000

Total 2,598,200 2,813,800 5,284,500 1,185,350 103,150 11,985,000

Schemes of Additional Benefits.

In last year's Report particulars were given of the issue to Approved Societies of their valuation reports, and of the initial work in connection with the adoption of schemes of additional benefits. The outstanding feature of the past year has been the inauguration of these schemes, which, with few exceptions, came into operation as from the 4th July, 1921.

The additional benefits, any one or more of which might be selected according to the Society's circumstances, fall into two main groups: (i) increases in sickness benefit and other cash benefits, and (ii) payment for various forms of remedial treatment or other non-cash benefits.