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PANEL AND CONTRACT PRACTICE

AN OPENING FOR INJUSTICE

CONSIDERING how easy it is for a patient, or relativeof a patient, to bring a charge against an insurancepractitioner-involving, perhaps, professional honour,or even veracity-the exact means by which justiceis administered are of no little importance.

It is obviously fair and right that any adult patientshould be able to send a complaint to the clerk ofthe insurance committee (which is responsible for theadministration of medical benefit) if he thinks that hisdoctor has done something he ought not to have done,or left undone something that he ought to have done.The procedure in this case is for the clerk to forwardrelevant extracts from the letter of complaint, or

possibly the whole letter, to the practitioner concernedand to ask for his observations. These observations,or extracts from them, are sent to the insured person,whose further comment is invited. If this in turncontains anything which is thought to be importantfor the practitioner to know it is forwarded to him.The whole correspondence, verbatim, is then circulatedto the members of the medical service subcommittee.(This consists of an equal number of lay persons whorepresent approved societies or insured persons andof medical men who represent the panel committeeand the local medical committee-which in these

days often have the same personnel. There is an

independent chairman usually appointed from theneutral members of the insurance committee-i.e.,from those representing the county council or theMinistry of Health.) The medical service sub-committee decides whether a hearing is necessaryand, if so, arranges the time and place. Finally,having heard the case, it decides whether therehas been a breach of the regulations ; whether, if so,there should be a caution or censure ; and whether

money ought to be withheld from the practitioner’sremuneration, and, if so, how much. Its decisionis usually confirmed by the full insurance committee,but must also be confirmed by the Ministry of Health.Either party can appeal to the Ministry when thecase is reheard de novo.There is little to complain of in this procedure,

for the members of the committee are not likely toknow anything about the complainant or the doctorpersonally and justice can be correspondinglyimpartial. ,

It sometimes happens that the insured persondoes not want to make a complaint, but a relativedoes. If on the correspondence it appears to themedical service subcommittee that the complaintis one that ought to be investigated in spite of theinsured person’s refusal to complain, they have thepower to advise either the medical benefit sub-committee or the main committee that this is a

matter which requires investigation. Thereupon a

resolution is passed by one of these committees"that the matter be referred to the medical servicesubcommittee for investigation." This procedureis called "getting a reference." The insurancecommittee (or its medical benefit subcommittee) is

becoming the complainant, before one of its ownstatutory subcommittees, against a particularpractitioner.

In these circumstances it may easily happen thatsome of the lay members of the medical servicesubcommittee-those representing either insuredpersons or approved societies-were present at themeeting at which the reference was passed. Thishardly appears fair from the point of view of

administration of justice, for a complainant can

hardly act with equity as accuser and judge. Onthe other hand, the practitioner may rely upon thesupport of his professional brothers, for these are

not likely to have been involved in getting thereference. The position is reversed, however, underArticle 32 (2) of the Medical Benefit ConsolidationRegulations, 1928, which not only gives a panelcommittee power to send a case to the insurancecommittee for investigation, but also provides thatthe insurance committee must in this case investigate.The only tribunal for this investigation is the medicalservice subcommittee, and this includes severalmembers of the panel committee, all of whom have beensteeped in the details which have resulted in the panelcommittee deciding for a reference. What confidencewill the practitioner have in the impartiality of histribunal when his professional brothers on it belongto the body which has instituted the proceedingsagainst him ; and what hope is there of the laymenon that tribunal supporting him against the advice(as he will think) of their professional colleagues-who now represent his accusers ?The particulars of a recent case have been published

for all and sundry to know. Dr. A. made a complaintto the London panel committee that Dr. B. had triedto secure the transfer of insured persons to his list.The case was heard in the usual way by the attendanceof both doctors before the ethical subcommittee,where Dr. A. submitted six signed statements frompatients all alleging persuasion by Dr. B. to join hispanel. Dr. B. tried to refute the allegations, butthere was no opportunity of examining the peoplewho wrote the letters, since they were not present.At the subcommittee meeting, nevertheless, the

allegation was held to be proved. The subcommitteetook a serious view of the case and decided to ask thefull panel committee to take proceedings underclause 44 of the Medical Benefit Regulations, wherebythey are empowered to make representations to theMinister that the continuance on the medical list of thepractitioner would be prejudicial to the efficiencyof the service. When this request came before thefull committee it was said quite plainly that if thecase was one of canvassing the General MedicalCouncil should deal with it. If it was only a questionof removal from the panel then the proper actionwas to refer it to the medical service subcommittee.The point here is that there was so much discussionof the case that no one present could fail to be

impressed with the opinion of Dr. B. which had beenformed by the subcommittee.

Solicitors were instructed to take steps to carryout the committee’s resolution and to begin proceed-ings with a view to the removal of the practitioner’sname from the medical list. The solicitors, however,at once realised the difficulty and reported their

opinion that unless the committee got further andstronger evidence their case would be unsuccessful.The subcommittee thereupon instructed them to

proceed with the collection of further evidence.The solicitors did so ; and their comments on thestatements obtained from six witnesses were as

follows : (A) and (B) were vague and would notstand up to the cross-examination. (C) Actuallyasked to be transferred. (D) A good witness, butwould not have written had he known that therewould have been any trouble ; therefore doubtfulstrength. (E) Doctor against whom complaint wasmade was specially sent for and there was no mistake.

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(F) This patient was told the doctor he wanted tosee was Dr. A. In view of this report the sub.committee decided not to try to get Dr. B. removedfrom the panel ; but as in the course of the investiga-tions it had been discovered that he gave some ofthese insured persons who are not on his list medicineby prescription on the official form and on one

occasion a certificate without seeing the patient,it asked the panel committee to refer the case to themedical service subcommittee for investigation.This will require the consent of the Minister of Health,for it is technically out of time owing to the delayinvolved in the investigation by the panel com-mittee. The panel committee passed the reference,so that, subject to the Minister’s consent, it now goesto the insurance committee. If the Minister does

give consent then three of the seven men who willhave to hear this case will have been familiar with thedetails of the complaint from its commencement, andif they are the normal medical members of that sub.committee one of them was actually present at theoriginal inquiry whilst another in his capacity ofchairman of the main committee cannot fail to haveall the details of the case at his fingers’ ends.

There is obviously something wrong in theadministration of justice to insurance practitionersas instanced in this case. The decision of the ethicalsubcommittee that this man was guilty of canvassing,for which the panel committee must accept full

responsibility, was based on evidence which wasproved insufficient. The panel committee’s decisionto make representations to the Minister with a viewto the withdrawal of the practitioner’s name fromthe medical list, had therefore to be rescinded.Instead of then letting the matter drop, the panelcommittee decided to put this doctor on trial again

on a minor charge before a tribunal in which its ownmembers have to adjudicate and decide the penalty,if any.The function of the panel committee (through its

ethical subcommittee) should be to try and effecta friendly settlement between two doctors who arein dispute. When evidence is given that somethingquite serious has occurred the matter should bereferred, without details being published, to the

proper tribunal for the hearing of such cases, eitherthe General Medical Council or the Ministry of Healthor the medical service subcommittee. No officersof the committee (since they are ex-officio membersof all subcommittees), and no members of the ethicalcommittee should be eligible to sit as medical membersof the medical service subcommittee. The ethicalsubcommittee has no statutory power to call evidence,it cannot pay the out-of-pocket expenses of witnesses,and by its size also it is quite unsuitable to deal withthis sort of case. It appears to have been overlookedin the regulations under which the panel committeecan refer cases to the medical service subcommitteefor trial that its own members sit upon that sub.committee and may have taken part (as in the presentcase) in adjudicating upon the case previously.This seems to be a more glaring anomaly than theformer method of reference by the insurance com-mittee to its own subcommittee.

One way of getting over the reference difficulty wouldbe to send the case to another medical service sub-committee, where, of course, no one would have hadany previous details that might possibly prejudicetheir minds. It is clear that under the presentprocedure the administration of justice to an insurancepractitioner may not be conducted in the properatmosphere of impartiality.

CORRESPONDENCE

BRITISH HEALTH RESORTS ASSOCIATION

To the Editor of THE LANCET

SiR,-We have been much encouraged of late bythe increasing interest shown in the work of theBritish Health Resorts Association by the medical

profession. Our association is largely medical,not only in personnel but in its objects, which areto awaken and sustain interest in the health side ofour British resorts. At our recent conferences at

Harrogate and Cromer we were supported by leadersof the profession, and I venture to think that thequality of the discussions was something of whichwe may be proud.Though we look in the main for financial support

to the local authorities of the places we are trying tohelp, we are very anxious to secure more of it fromthe medical profession, particularly from thosemembers practising in the health resorts or who takea special interest in climatology, balneology, andphysical medicine. The recent action of the HarrogateMedical Society and the Torquay division of theB.M.A. has therefore given our council great pleasure.These bodies have circularised their members witha view to enlisting their interest in our work, andby this means we have secured a considerable numberof new members. Our medical advisory committeewould be glad to have an opportunity in your columnsof bringing these examples to the notice of similarbodies, in the hope that they may do likewise.

Our subscription is n Is. a year, though we wouldwelcome any donations, small or large. We cannot

offer any direct material advantage to subscribers,

but we believe there are many who would be willingto show a practical interest in a movement which hasa distinctly medical as well as a patriotic aim. Ishall be glad to answer any inquiries.

I am, Sir, yours faithfully,

199, Piccadilly, W., July 2nd.ALFRED Cox,

General Secretary.

JOINT LUBRICATION

To the Editor of THE LANCET

SiR,—In your last issue Dr. Shirley Jones hascalled attention to the importance of the viscosityof synovial fluid in relation to joint lubrication,and has inferred that certain forms of arthritismay be due to alterations in the mucin content ofthis fluid. Very little is known about the physiologyof the mucoproteins, but it does seem fairly clearthat the thyroid gland is concerned. Thus in

myxoedema there is a generalised accumulationin the tissues of a colloid which is, or closely resembles,a mucoprotein, and it is also known that the secretionof the parotid gland in this disease assumes an

abnormally mucoid character. Since this plethoraof mucoprotein is readily corrected by thyroxineit might be anticipated that the opposite conditionof hyperthyroidism would be accompanied by a

paucity of mucin in the tissues, and if the synovialfluids share in these general changes, then arthritis,from defective lubrication, should be commonlyencountered in Graves’s disease. It is rather

suggestive that S. Duncan (Jour. Amer. Med. Assoc.,1932, xcix, 1239) and others regard polyarthritis