1 |- : K a % 1 1 1 1 •x 1' 1 1 1 1 'i' 4" 1 UC-NRLF B e OOCtJMENTS DEPT. NATIONAL INSURANCE ACTS, 1911 to 1913. REPORT FOR 1913-lJi ON THE ADMINISTRATION OF NATIOML HEALTH INSURANCE ptcscntc^ to both ir?oii6C6 of iparUament bs Commant) ot Ibts /Bbajeat^. LONDON: PBINTBD UNDER THE AUTHORITY OF HIS MAJESTY'S STATIONERY OFFICE Bt HARRISON AND SONS, 45-47, St, Maktin's Lane, W.O., Printers in Ordinary to His Majesty. To be purchased either directly or through any Bookseller, from WYMAN AND SONS, Ltd., 29, Breams BxiiLDiNas, Fetter Lane, E.G., and 28, Abingdon Street, S.W., and 64, St. Mary Street, Cardiff; or H.M. STATIONERY OFFICE (Scottish Branch), 23, Forth Street, Edinblkgh E. PONSONBY, Ltd., 116, Grafton Street, Dublin; or from the Agencies in the British Colonies and Dependencies, the United States of America, the Continent of Europe and Abroad of T. FISHER UNWIN, London, W.O. 1914 [Cd. 7496.] Price 2s. 6d fm^^^tm ^m%'^Wm^ NATIONAL INSURANCE ACTS, 1911 to 1913. REPORT FOR 1913-14 ON THE ADMINISTRATION OF MTIOML HEALTH INSURANCE. ' . ■ 1. ■ k Ipreeentet) to botb tomce ot parUament bg Command ot tyie Aaje6tB. LONDON: PRINTED UNDER THE AUTHORITY OF HIS MAJESTY'S STATIONERY OPPICB By HAERISON and SONS, 45-47, St. Martin's Lane, W.O., Printers in Ordinaby to His Majesty. To be purchased either directly or through any Bookseller, from WTMAN AND SONS, Ltd., 29, Breams Buildings, Fetter Lanb, E.O., and 28, Abingdon Street, S.W., and 54, St. Mary Street, Cardiff; or H.M. STATIONERY OFFICE (Scottish Branch), 23, Forth Street, Edinburgh ; or E. PONSONBY, Ltd., 116, Grafton Street, Dublin; or from the Agencies in the British Colonies and Dependencies, the United States of America, the Continent of Europe and Abroad of T. FISHER UNWIN, London, W.C. 1914. [Cd. 7496.] Price 2s. 5d. A- (B254) Wt. 4348-g3161 4000/90 7/14 H&S GP. 5 s . iii — » CONTENTS PART I. INTRODUCTION. fAGE. Introduction 1 The scope of National Health Insurance ... ... ... ... ... 2 The National Insurance Act, 1913 8 Medical and sanatorium benefits... ... ... ... ... ... 9 Sickness and disablement benefits ... ... ... ... ... 10 Maternity benefit ... ... ... ..^ ... .,. ... ... 12 Miscellaneous ... ... ... ... ... ... ... ... 14 PART II. NATIONAL HEALTH INSURANCE JOINT COMMITTEE. 1.— GENEKAL. Constitution of the Joint Committee .. . ... ... ... * ... ... 17 Scope of the Joint Committee's work... ... ... ... ... ... 17 Medical research '.. 19 National and International Societies ... ... ... ... ... ... 21 Section 16 (1) of the Act of 1913 — Valuation and transfers in the case of International Societies ... 22 Section 16 (2) of the Act of 1913 23 Section 16 (3) of the Act of 1913 — International Societies relinquish- ing approval for one or more Countries 23 Section 16 (4) of the Act of 1913— Branches 24 The continuance in insurance of emigrants ... ... ... ... ... 25 Advisory Committee to the Joint Committee 25 Other Committees assisting the Joint Committee ... ... ... ... 26 Actuarial Advisory Committee ... ... ... ... ... ... 26 Investments Advisory Committee 26 Postal Payment of Benefits Committee ... ... ... ... ... 27 2.— ACTUAKIAL. Tables of transfer values ... ... ... ... ... ... ... 29 Crediting of reserve values 31 Claims by Approved Societies for reserve values ... ... ... 32 Checking claims for reserve values ... ... ... ... ... 33 Central records 35 The basis of valuation 36 Employment under the Crown 36 Actuarial work in connection with the National Insurance Act, 1913 ... 37 Arrears 39 The new scheme of arrears ... ... ... ... ... ... 41 Actuarial basis, of the scheme ... ... ... ... 42 Suspensions under the new scheme ... ... ... ... ... 44 Modifications for special classes ... ... ... ... ... ... 45 Arrears of voluntary contributors .... ... ... ... ... 45 General conclusion ... ... ... ... ... ... ... ... 46 Proposed grant in aid of arrears 46 (B254^Gp.5) 334288 ""^ IV PAGE Benefits for exempt persons — the actuarial aspect ... ... ... ... 47 Scheme for Great Britain 47 Scheme for Ireland... ... ... ... ... ... ... ... 48 Amalgamation, transfer of engagements, and dissolution of Societies ... 48 Variation of reserve values ... ... ... ... ... 51 Deposit contributors ... ... ... ... ... ... ... ... 53 Special investigation 53 Examination of statistics ... ... ... ... ... ... ... 53 The financial position of Approved Societies . ... ... ... ... 58 Information at present available 58 The actuarial basis of sickness benefit ... ... ... ... ... 59 Future provision 61 (i) Sickness among married women 61 (ii) Sickness among women generally 61 (iii) Eisks special to particular Societies ... ... ... ... 61 Other causes of excessive claims 62 PART III/ NATIONAL HEALTH INSURANCE COMMISSION (ENGI^AND). INTEODQCTOEY. Introductory 65 Advisory Committee 65 APPKOVED SOCIETIES. Organisation. Approval of new Societies 66 Membership of Approved Societies 66 Amendment of rules ... ... ... ... ... ... ... ... 67 Adaptation of machinery to the requirements of the Act of 1913 ... 69 The work of Associations ... ... ... ... ... ... ... 70 Disputes and appeals 71 Special arrangements for assisting particular Societies ... ... ... 76 Deficiencies on administration account 77 Approved Societies and Branches of Approved Societies ceasing to transact business under the Acts 78 Regulations as to amalgamation, transfer of engagements, and dissolution 79 (1) Amalgamation 79 (2) Transfer of engagements ... ... ... ... ... ... 80 (3) Dissolution 80 Sickness Benifit. Rate of expenditure 81 Incapacity for work .... ... ... ... ... ... ... ... 83 Systems of administration ... ... ... ... ... ... ... 84 Issue and use of uniform medical certificates ... ... ... ... 84 Medical referees 86 Special arrangements by Insurance Committees 87 Maternity Benefit. Changes effected by the Act of 1913 88 The "mother's benefit" 88 Double maternity benefit ... ... ... ... ... 89 Other changes effected by the Act of 1913 90 Method of administration ... ... 91 Special Problems. Compensation under the Workmen's Compensation Act, 1906 ... ... 91 Subscriptions by Approved Societies to hospitals, dispensaries, nursing associations, &c. .. 92 PAGE Agreements between Approved Societies and hospitals of which members of the Society are inmates 93 The insurance of married women ... ... ... ... ... ... 94 Aliens ... ... ... ... ... ... ... ... ... 94 Transfers of insured persons between Societies 95 Persons ceasing to be insured 96 THE COLLECTION OF CONTEIBUTION"S, THE KECEIPT AND ISSUE OF FUNDS, AND INVESTMENTS. CJOLLECTION OF CONTRIBUTIONS. General 99 Introduction of six monthly contribution card ... ... ... ... 99 Distribution and surrender of cards ... ... ... ... ... ... 100 Payment of contributions at the end of the period of currency of the cards 101 Refunds of contributions paid erroneously ... ... ... ... ... 101 New insurance books ... ... ... ... ... ... ... ... 103 Condition of quarterly returns 104 Receipt and Issue of Funds. Security to be given by Approved Societies ... ... ... ... ... 105 Issue of Funds to Approved Societies ... ... ... ... ... 105 Accounts of the National Health Insurajice Fund 106 Investments. Temporary investments of balances 106 Permanent investments... ... ... ... ... ... ... ... 107 INSUKANCE COMMITTEES. Constitution, Powers, and Duties of Insurance Committees, &c. Constitution of Insurance Committees on a permanent basis 110 Formation of new Insurance Committees ... ... ... ... ... 112 Travelling expenses, subsistence allowances, and compensation for loss of remunerative time 112 Associations of Insurance Committees 113 District Insurance Committees ... ... ... ... ... ... 113 Local Medical Committees ... ... ... ... ... ... ... 114 Panel Committees 115 Pharmaceutical Committees 117 Administration of Sanatorium Benefit. Events leading up to the present position •. 118 The present aim of Insurance Committees ... ... ... ... ... 119 Participation in comprehensive schemes ... ... ... ... 119 The nature of a comprehensive scheme 121 Comprehensive schemes in actual working ... ... ... ... 123 Liverpool 123 Manchester 125 Birmingham 126 Progress made in the establishment of comprehensive schemes ... 127 Agreements between Committees and local authorities 130 Provisional arrangements where no comprehensive scheme exists ... 132 The administration of sanatorium benefit in the County of London... 134 Number of persons receiving sanatorium benefit 136 Summary of arrangements made by each Insurance Committee 137 1. Administrative Counties 137 2. County Boroughs ... ... ... ... ... ... ... 146 Administration of Medical Benefit. Special arrangements for change of residence and modifications in procedure 156 Temporary residents 156 The special " travellers " arrangements .. . ... ... ... ... 157 VI PAGE Approved institutions 168 Medical benefit in relation to the Act of 1913 159 Ee vision of Medical Benefit Kegulations 1 60 Allocation and doctors' credits 160 Procedure in dealing with complaints ... ... ... ... ... 161 Revision of doctors' agreements ... ... ... ... ... ... 161 Chemists' agreements and the drug tariff ... ... 162 Applications under Section 15 (3) of the Act of 1911... ... ... 162 The commencement of the 1914 medical year 163 Special mileage ... ... ... ... ... ... ... 163 Administrative machinery 164 The medical card system ... ... ... ... ... ... ... 166 Tlie settlement of accounts for the 1913 medical year 167 Inquiries relating to the continuance of practitioners upon the panel ... 170 Medical benefit. — General review 171 The Insurance of Deposit Contributors. Initial difficulties 178 Transfer of deposit contributors to Approved Societies ... ... ... 179 Benefits of deposit contributors during 1914 18% Statistics 181 QUESTIONS EESPECTING LIABILITY TO INSUEANCE AND PARTICULAK CLASSES OF INSURED PERSONS. Exempt Persons. Additional qualification for exemption 182 Number of exempt persons 183 Provision of benefits for exempt persons under Section 9 of the Act of 1913 183 Scheme for medical and sanatorium benefits.— How administered ... 184 Machinery for the administration of benefits ... ... ... ... 185 Number of exempt persons receiving benefits 186 Collection of contributions in respect of exempt persons ... ... ... 186 Numbers of exemption certificates issued ... ... ... ... ... 187 Exceptions. Exceptions under paragraphs (6) and (c) of Part II of the First Schedule to the Act of 1911 187 Exceptions under paragraph (^) of Part II of the First Schedule to the Act of 1911. — Employments classed as subsidiary 188 Questions Determined under Section 66 of the Act of 1911. General 189 Public Hearings 190 Question submitted to the High Court ... ... ... ... ... 191 Questions determined otherwise ... ... ... ... ... ... 193 Employees of Local and other Public Authorities. Employees of local and other public authorities 194 Questions as to who is the Employer of an Employed Contributor. Questions as to who is the employer of an employed contributor ... 196 Exemptions under Section 51 of the Act of 1911. Exemptions under Section 51 of the Act of 1911 197 Questions under Section 47 of the Act of 1911. Special Orders under subsection (1) ... ... ... ... ... ... 198 Special Orders under subsection (7) 198 Special Orders relating to employment under the Crown 198 Employers' notices 199 General 199 Vll PAGE The Insurance of Outworkers. The unit system 199 New units of work 200 " Normal " rate of remuneration 201 Questions as to who is the employer of an outworker or class 3 of outworkers 203 The Insurance of Persons in the Mercantile Marine. Amendments of Section 48 of the Act of 191 1 204 Payment of contributions by employers in respect of seamen neither domiciled nor resident in the United Kingdom 205 The Insurance of Seamen, Marines, and Soldiers. Seamen, Marines and Soldiers in Approved Societies ... ... ... 206 Maternity benefit (Navy and Army Insurance Fund only) 206 Discharged men re-admitted to the Navy and Army Insurance Fund under Section 46 (3) (A) of the Act of 1911 207 Benefits received by re-admitted members of the Navy and Army Insurance Fund 207 Advisory Committee ... ... ... ... ... ... ... ... 208 Amendments affected by the Act of 1913 208 Casual Labour in the Port of London. Casual labour in the Port of London ... ... ... ... ... 209 THE WOKK OF THE OUTDOOK STAFF, Organisation 212 Duties of the Outdoor Staff 213^ Northern Division 215- North- Western Division 217 North-Eastern Division 219 Western Division 222 Central Division 224 Eastern Division 227 Metropolitan Division 230 South- Western Division 232 South -Eastern Division 235 COlsrCLUSION. Conclusion ; 238 PART IV. NATIONAL HEALTH INSURANCE COMMISSION (SCOTLAND). INTEODUCTOEY. Introductory 239 I.— THE STKUCTUEE OF THE SYSTEM OF NATIONAL HEALTH mSUEANCE. 1.— The Commission and the Advisory Committee. The Commission 241 The Advisory Committee 241 VIU 2. — Population under the Acts. Numbers of insured persons ... ... ... ... ... ... ... 242 Exempt persons 243 Persons entitled to exemption 243 Procedure in regard to contribution cards 244 Henewal of exemption certificates ... ... ... ... ... 244 Numbers of exemption claims, &c. 245 ^Exemption certificates for institutions 246 Exceptions 247 Exceptions under paragraphs (6) and (c) of Part II of the First Schedule to the Act of 1911 247 Exceptions under paragraph (i) of Part II of the First Schedule to the Act of 1911. Subsidiary employments 247 Questions as to liability to compulsory insurance submitted for decision under Section 66 of the Act of 1911 and Section 27 (2) of the Act of 1913 and other exceptions under Part II of the First Schedule to the Act of 1911 248 Formal hearings of questions ... ... ... ... ... 248 Questions submitted to the Court of Session 250 Appeal case ... ... ... ... ... ... ... ... 252 Other important decisions 252 Rates of contribution ... ... ... ... ... ... 253 Agricultural employments 254 Manual labour... ... ... ... ... ... ... ... 255 Employment under a local or other public authority 255 Casual labour 258 Deposit contributors 258 Persons insured under Section 47 of the Act of 1911 260 Married women 263 3. — Approved Societies. Number of Approved Societies 264 Small Societies and amalgamation ... ... ... ... ... ... 264 County Society 265 Movement towards larger units of administration .. . ... ... ... 265 Amendments of rules ... ... ... ... ... ... ... ... 267 Membership questions 267 Transfer questions 268 Meeting places of Approved Societies and Branches 269 Section 16 of the National Insurance Act, 1913 ... • 269 Voting of collectors and agents 270 Disputes and appeals ... ... ... ... ... ... ... ... 271 4.-— Insurance Committees, Local Medical Committees, &c. Representation of insured persons on Insurance Committees ... ... 271 Local Medical Committees ... ... ... ... ... ... ... 274 Panel Committees 274 Pharmaceutical Committees ... ... ... ... ... ... ... 276 Index register 277 Miscellaneous admininstrative questions ... ... ... ... ... 280 Administrative expenses ... ... ... ... ... ... ... 280 Subsistence allowance and compensation ... ... ... ... 280 Insurance Committee contracts with members ... ... ... 281 Other questions 281 1.- II.— THE WOEKING OF THE SYSTEM. -Contributions. Contribution cards and books Introduction of half-yearly cards Special cards for low- wage earners Deposit contributors cards New insurance books Lost cards ... 283 283 283 284 284 285 PAGE Quarterly and half-yearly stamping arrangements for employers ... 285 Special arrangements for the stamping of contribution cards during the week after payment of wages ... ... ... ... ... ... 286 Refunds and adjustments ... ... ... ... ... ... ... 287 Refunds of contributions paid in error ... ... ... ... ... 287 Allowances for lost and destroyed cards 289 Refunds and adjustments of contributions paid at the wrong rate ... 289 Normal rate of remuneration ... ... ... ... ... ... ... 291 Outworkers ... ... ... ... ... ... ... ... ... 292 Cheap birth certificates . . . ^^'TTT 293 Cheap marriage certificates 294 Prosecutions for non-payment of contributions ... ... ... ... 294 2. — Sickness Benefit. Enquiries by insured persons 295 Medical certificates 296 Donations to hospitals ... ... ... ... ... ... ... ... 298 Misapplication of benefit 299 Medical referees ... ... ... ... ... ... ... ... ... 299 Benefit when in hospital 300 Workmen's compensation ... ... ... ... ... ... ... 300 3. — Maternity Benefit. Changes introduced by the Act of 1913 301 Midwives and Approved Institutions 303 Maternity hospitals 304 Increased employment of doctors 30 4 Direct payment for attendance 306 4. — Medical Benefit. Confirmation of provisional arrangements ... ... ... ... ... 306 Changes due to the Act of 1913, and the issue of new Regulations ... 308 Medical benefit and the insured person 310 General 310 Medical card 310 Change of residence 311 Case value 311 Scottish fishworkers 313 Travellers 315 Own arrangements 315 Allocation of insured persons 316 Post Office Medical Service 317 Medical records 317 Drugs and appliances 318 Negotiations with chemists 318 Prescription forms ... ... 320 Dispensing by doctors 320 Emergency drugs 321 Expenditure on drugs ... ... ... ... ... ... ... 322 5. — Sanatorium Benefit. Medical Advisers of Insurance Committees 322 Approved Institutions 323 Numbers treated for tuberculosis under sanatorium benefit ... ... 324 Extension of sanatorium benefit to dependants 325 Treatment by local authorities ... 326 Schemes of local authorities ... .... 328 Schemes provisionally approved ... ... ... ... ... ... 330 Schemes under consideration 331 Joint sanatorium schemes... 332 Summary of schemes 332 Health lectures ... ... 333 6. — Benefits of Exempt Persons. Benefits of exempt persons 334 (B254-~Gp. 5) a 3 III.— ACCOUNTINa AND FINANCE. PAGE 1. — Approved Societies. Changes in system of accountancy 337 Issue of funds ... ... ... ... ... ... ... 337 Condition of accounts 338 Affiliated Orders 338 Investments 338 Banking arrangements 339 Administration account 340 Security 341 2. — Insurance Committees. Advances 342 Mileage 342 Grant-in-aid of Insurance Committees' administration expenses ... 343 3. — Accounts of the Scottish National Health Insurance Fund. Accounts of the Scottish National Health Insurance Fund 344 IV.— THE WORK OF THE OUTDOOR STAFF. 1, — Introductory. Introductory ... 345 Strength of the staff 346 Organisation of districts ... ... ... ... ... 346 2. — The Contributory System. General features 346 The situation in the towns ... ... ... ... ... ... ... 346 The situation in rural areas 347 The condition in particular areas 347 Sources of information ... ... ... ... ... ... ... ... 348 The number of complaints 348 3. — The Benefits. General ... _ ... 349 Sickness benefit ... ... ... ... ... ... ... ... ... 349 . Maternity benefit , 349 Medical benefit 350 Sanatorium benefit 350 Procedure for dealing with enquiries as to benefits 351 4.— Miscellaneous Duties of Inspectors. Claims for exemption ... ... ... ... ... ... ... ... 352 Questions of insurability 353 Outworkers 353 Section 47 applications 355 Election of Insurance Committees and Panel and Pharmaceutical Committees 355 Mileage 355 Co-operation with Insurance Committees and Approved Societies ... 356 Accounts Branch enquiries ... ... ... ... ... 357 Enquiries under Section 25 of the 1913 Act 357 Transfers 358 Deposit contributors ... ... ... ... ... ... ... ... 359 5. — Special Problems. {a) Casual Labour 359 General ... 359 Classification of casual labour ... ... ... ... ... ... 360 Insurance difficulties 361 Conclusions 362 XI (i), Casual labour in agricultural occupations Classification of agricultural casuals General conditions Varieties of agricultural casual work ... Wages and sources of supply ... Payment of contributions Subsidiary Employment Orders Conclusions (ii) Casual Dock Labour The Clyde ports TbeTay The Forth The Nortli-Eastern ports The Highland ports (iii) Charwomen Charwomen in Aberdeen Types of employers Rate of remuneration and periods of employment Actual earnings ... Working of the Act Enquiries in other towns (6) Maternity Benefit West of Scotland South-East Dundee The North PAGE 362 362 363 363 364 365 366 366 367 367 370 371 371 372 372 372 372 372 373 374 374 374 375 375 375 376 PART V. NATIONAL HEALTH INSURANCE COMMISSION (IRELAND). Introductory I.— INTKODUCTOEY. TI.— ADVISOKY COMMITTEE. 377 377 Advisory Committee III.— APPEOVED SOCIETIES. Numbers of Approved Societies 378 Steps taken to assist Societies in administering the Act of 1913 ... ... 379 Method of payment of benefits 379 Eevised Handbook 379 Transfers of members between Approved Societies 380 Persons ceasing to be insured 380 Linked-up illnesses 380 Suspension of married women .. . ... ... ... ... ... ... 381 Model agreements under Section 12 of the Act of 1911 381 Administration expenditure ... ... ... ... ... ... ... 381 Sickness benefit claims 382 Operation of sickness and maternity benefits ... ... ... ... 382 Disputes and appeals 384 Workmen's Compensation 384 IV. ACCOUNTING AEEANGEMENTS AND MANAGEMENT OF THE lEISH NATIONAL HEALTH INSUEANCE FUND. Working of the system for distribution of cards 385 New insurance book 386 Accounting for contributions 387 Lost cards 388 Special arrangements for stamping contribution cards at the end of the period of currency 389 PAGE Receipts into and payments out of the Irish National Health Insurance Fund 389 Issue of funds to Societies ... ... ... ... ... ... ... 390 Issue of funds to Insurance Committees ... ... ... ... ... 390 Security given by Approved Societies 391 Investments 391 V. INSITRANCE COMMITTEES. Constitution, Powers and Duties of Insurance Committees. Terms of office of members of Insurance Committees 393 Staff of Insurance Committees 393 Travelling expenses, &c., of members ... ... ... ... ... ... 394 Exchequer Grant in aid of i*50,000 394 Changes of residence and the provision of benefits 395 Index register 395 Local Medical Committees 396 The Administration of Sanatorium Benefit. Co-operation between Insurance Committees and local authorities ... 396 Institutional treatment 397 Dispensary treatment ... ... ... ... ... ... ... ... 398 Domiciliary treatment 398 *' After care " of patients who have undergone treatment... ... ... 399 Expenditure of the capital grant 399 The Insurance of Deposit Contributors. Numbers of deposit contributors 400 Transfers from Approved Societies and the Navy and Army Fund ... 401 Transfers to Approved Societies ... ... ... ... ... ... 401 New procedure as to issue of cards 402 Charges for sanatorium benefit and Insurance Committees' administra- tion expenses 402 Administration of sickness and maternity benefits 403 VI. QUESTIONS AS TO LIABILITY TO INSURANCE AND PARTICULAR CLASSES OF INSURED PERSONS. Exempt persons ... ... ... ... ... ... ... ... ... 403 Number of exempt persons ... ... ... ... ... ... ... 403 Benefits for exempt persons 404 Exempt persons fund - 404 Exemption of Irish migratory labourers under Section 81 (3) of the Act of 1911 405 Exceptions 405 Employments excepted under paragraphs (6) and (c) of Part II of the First Schedule to the Act of 1911 405 Employments excepted as subsidiary 406 Questions determined under Section 66 of the Act of 1911 406 Questions under Section 47 of the Act of 1911 408 Insurance of outworkers ... ... ... ... ... ... ... 408 Contributions due by bankrupt employers 410 VII. THE WORK OF THE OUTDOOR STAFF. General 410 Casual labour 411 Outworkers 412 Deposit contributors 413 Staff 413 Xlll PAGE District Keports 414 Nortii- Eastern District 414 North- West District 415 The Cork District 416 The Limerick District 417 The Connacht District 418 PART VI. NATIONAL HEALTH INSURANCE COMMISSION (WALES). I.— INTRODUCTORY. Membership of the Commission 419 Staff and accommodation ... ... • . . . ' ... ... ... • • • 419 "Welsh Advisory Committee ... ... ... ... ... ... ••• 419 Nature of the work ... ... ... ... ... ... ... ... 420 Industrial features of Wales 421 The alleged excessive claims for sickness benefit ... ... ... ... 423 II— APPROVED SOCIETIES. Number of Approved Societies ... ... ... ... ... ••• 425 Scope of the work 425 Steps taken to assist Societies in connection with the Act of 1913 ... 425 Amendment of rules ... ... ... ... ... ... ... 426 Extensions of time ... ... ... ... ... ... ... • • • 426 Maternity benefit 426 Other steps taken to assist Societies 427 Medical referees ... ... ... ... ... ... ... ... 427 Administration account deficiencies ... ... ... ... ... 428 Payment of contributions for disablement benefit 428 Expulsions 428 Amalgamation of Branches ... ... ... ... ... ... 429 Associations 429 Persons over 65 years of age at the commencement of the Act ... 429 Transfers between Approved Societies ... ... ... ... ... 430 Issue and use of uniform medical certificates 431 Married Women ... ... ... ... ... ... ... ... 431 Meeting places of Approved Societies 431 III.— THE COLLECTION OF CONTRIBUTIONS, THE RECEIPT AND ISSUE OF FUNDS, AND INVESTMENTS. Collection of Contributions. Distribution of cards ... ... ... ... ... ... ... ... 432 Changes in the system of collection ... ... ... ... 432 New insurance book ... ... ... ... ... ... ... ... 433 Quarterly and half-yearly stamping of contribution cards • ... 433 Stamping during week after payment of wages ... ... ... ... 434 Condition of Societies' contribution registers and quarterly returns . . . 435 Refund of contributions paid in error 436 Allowances for cards lost or accidentally destroyed 438 Receipt and Issue of Funds. Security to be given by Approved Societies 439 Issue of funds to Approved Societies 440 Book-keeping by Afiiliated Orders 441 Audit certificates... ... ... ... ... ... ... ... ... 441 Accounts of the Welsh National Health Insurance Fund 442 Investmfj^ts. Investments ... ... ... ... ... ... ... 442 XIV IY._INSUEANCE COMMITTEES. PAGE Constitution, Powers, and Duties of Insurance Committees, &c. Appointment of Insurance Committees 444 Statf of Insurance Committees... ... ... ... ... ... ... 446 Index registers ... ... ... ... ... ... ... ... ... 446 Income of Insurance Committees ... ... ... ... ... ... 447 Association of Insurance Committees 448 District Committees 448 Panel Committees 448 Pharmaceutical Committees 449 The Administration of Sanatorium Benefit. The participation in sanatorium benefit of the King Edward VII. Welsh National Memorial Association 450 The position of local authorities ... ... ... ... ... ... 450 The administration of the " Hobhouse Grant " 451 The administration of the capital grant under the Finance Act, 1911 ... 452 Domiciliary treatment 454 The Administration of Medical Benefit. Issue of new Eegulations 454 Ordinary method of selection of doctor 455 Travellers' vouchers 455 Mileage ... 456 Chemists' accounts 458 Certification of illness ... .^. ... ... ... ... ... ... 458 Approved institutions 459 The Insurance of Deposit Contributors. Special inquiry 460 Special difficulties • 461 Numbers of contributions paid by deposit contributors ... ... ... 462 Charges for medical and sanatorium benefits and for administration expenses ... ... ... ... ... ... ... ... ... 462 Sickness and maternity benefit claims ... ... ... ... ... 463 Payments to (a) married women suspended from ordinary benefits, (6) emigrants, and (c) the representatives of deceased deposit contributors 463 Variation in numbers 463 Transfers to Approved Societies ... ... ... ... ... ... 464 International transfers 464 Y.— QUESTIONS AS TO LIABILITY TO INSUEANCE AND PAETICULAE CLASSES OF INSUKED PERSONS. Exempt Persons. Exempt persons .. . ... ... ... ... ... ... ... ••• 464 Questions under Section 66 of the Act of 1911. Questions under Section 66 of the Act of 1911 ... i 465 Application op the Provisions of Section 47 of the Act of 1911. Application of the provisions of Section 47 of the Act of 1911 466 Casual Labour. Casual labour 466 YL— THE WOKK OF THE OUTDOOR STAFF OF THE COMMISSION. Staff 468 The position in rural areas ... 468 Special investigation in Cardiganshire 468 Inquiry, at workhouses 469 XV PAGE Barrowmen ... ... ... ... ... ••• ••• ••• ... 470 Sandwichmen 470 Inspections at theatres, &c 471 School cleaners 471 Boatmen and riggers 471 Sett-maker apprentices at quarries 471 Outworkers 472 Seasonal vocations 473 Assistance to shipowners 473 Nursing 473 Employers using cards for ulterior purposes 473 Prosecutions ... ... ... ... ... ... ... ... ... 473 Compliance with the Act 473 APPENDICES TO PART II. NATIONAL HEALTH INSURANCE JOINT COMMITTEE. I. Statement showing the dates on which the various Sections of the National Insurance Act, 1913, came into operation, otherwise than on the 1st September, 1913 476 II. Membership of the Medical Research Committee and the Advisory Council for Research 477 III. Return as to the administration of sanatorium benefit from 15th July, 1912, to 11th January, 1914 .^ 479 IV. Return as to the administration of sanatorium benefit for the twelve months from 15th January, 1913, to 11th January, 1914... 484 V. Report of the Actuarial Advisory Committee on the basis for the calculation of transfer values 488 VI. Tables showing the results of an investigation made into the experience of 26,015 established deposit contributors in London, of 51,528 established deposit contributors in England, outside London, and of all established deposit contributors in Wales, Scotland, and Ireland 491 APPENDICES TO PART IIL NATIONAL HEALTH INSURANCE COMMISSION (ENGLAND). VII. Table showing the approximate distribution of members of Approved Societies among the various types of Societies for the quarter ended 13th April, 1913 498 VIII. List of circulars issued to Approved Societies since the publication of the last Report ... ... ... ... ... ... ... 499 IX. Table showing number of members of Approved Societies whose contribution cards for the quarter ended 13th April, 1913, have been forwarded to the Commission, with particulars of the contributions paid at each rate and in each class 500 X. Table showing particulars as to the security given by Approved Societies under Section 26 of the Act of 1911, as at 11th January, 1914 502 XL Table showing as regards the period from 15th July, 1912, to 11th January, 1914, the number and amount of claims in respect of losses (and expenses) arising out of malversation or mis- appropriation of State Funds by officers of Approved Societies which have given security under Section 26 of the Act of 1911 502 XII. Statement showing receipts into and payments out of the National Health Insurance Fund (England) from 15th July, 1912, to the 11th January, 1914 503 XVI PAGE XIII. Draft model agreement between County or County Borough Coimcils and Insurance Committees for the provision of institutional treatment of persons suffering from tuber- culosis... 504 XIV. Account of the General Medical Fund for the year ended 11th January, 1914 ' 506 XV. Medical benefit. — Case value results 508 XVI. Deposit contributors. — Table showing number of con- tributors who entered into insurance during each quarter 510 XVII. Deposit contributors. — Table showing number of insured persons, not members of Approved Societies, who sur- rendered cards for each quarter 510 XVIII. Deposit contributors. — Particulars as to the number and amount of benefit payments in the year ended 11th January, 1914 511 XIX. Particulars relating to the issue of certificates of exemption 513 XX. List giving particulars of the Authorities, &c., to whom certificates of exception have been granted under para- graphs (6) and (c) of Part II of the First Schedule to the Act of 1911, from 1st April, 1913, to 31st May, 1914, by the Joint Committee acting jointly with the Commis- sion, and also the approximate number of persons to whose employment such certificates apply 514 XXI. List of official publications of the National Health In- surance Joint Committee and the National Health Insurance Commission (England) and of publications of other Departments relating to National Health Insurance 516 APPENDICES TO PART IV. NATIONAL HEALTH INSURANCE COMMISSION (SCOTLAND). XXII. Number and classification of insured persons (based on first quarter cards) ... ... ... ... ... ... ... 528 XXIII. Particulars relating to the issue of certificates of exemption 528 XXIV. Questions submitted to the Commission for decision under Section 66 of the Act of 1911 ... 531 XXV. Statement showing the classes of employment (other than in Government Departments) specified in Special Orders under subsection (1) of Section 47 of the Act of 1911, in respect of which employers have adopted the special provisions of the Section, and the nnmber of employers who have given notice in respect of each such class . . . 532 XXVI. Deposit contributors. — Table showing the number of con- tributors who entered into insurance during each quarter 533 XXVII. Deposit contributors. — Table showing the number of in- sured persons, not members of Approved Societies, who surrendered cards for each quarter 533 XXVIII. Deposit contributors. — Particulars as to the number and amount of benefit payments in the year ended 11th January, 1914 534 XXIX. Classification of Approved Societies 536 XXX. Table showing the approximate distribution of members of Approved Societies among the various types of Societies for the quarter ended 13th April, 1913 536 XXXI. Table showing the number of representatives of insured persons on each Insurance Committee ... ... ... 537 " XVll PAGE XXXII. Statement showing the number of doctors and chemists on the lists of Insurance Committees as at 12th January, 1914 538 XXXIII. Statement of drug accounts— January, 1913, to January, 1914 540 XXXIV. Administration of sanatorium benefit for the period from 15th July, 1912, to 11th January, 1914 642 XXXV. Table showing the number of institutions approved in Scotland for the treatment of tuberculosis, the number of beds therein, and the number of approved dispensaries, in 1912, 1913, and 1914 543 XXXVI. Table showing the number of institutions in Scottish Civil Counties approved by the Local Government Board for Scotland for the treatment ot tuberculosis as at 11th January, 1914, the number of beds therein, and the number of approved dispensaries ... ... ... ... 544 XXXVII. Table showing the number and classes of exempt persons who were entitled on the 12th January, 1914, to medical and sanatorium benefits, and the number and classes of exempt persons who have sent in declarations in con- nection with medical and sanatorium benefits under Section 9 of the Act of 1913, but who have not yet the requisite number of contributions standing at their credit to qualify for benefit ... ... ... ... ... ... 545 XXXVIII. Table showing the sums paid over to Insurance Committees for medical and sanatorium benefits and administration expenses within the financial year from 12th January, 1913, to 11th January, 1914 546 XXXIX. Statement showing the distribution of the special grant for mileage for 1913 ... ... ... ... ... 547 XL. Statement showing receipts into and payments out of the Scottish National Health Insurance Fund from 15th July, 1912, to 11th January, 1914 548 APPENDICES TO PART V. NATIONAL HEALTH INSURANCE COMMISSION (IRELAND). XLI. Table showing the approximate distribution of members of Approved Societies among the various types of Societies for the quarter ended 13th April, 1913 550 XLII. Statement showing the number of firms, with the number of their employees, under the different methods of quarterly stamping, for certain periods 551 XLIII. Statement showing receipt* into and payments out of the Irish National Health Insurance Fund from 15th July, 1912, to 11th January, 1914 552 XLIV. Deposit Contributors. — Table showing number of contai'ibutors who entered into insurance during each quarter 553 XLV. Deposit Contributors. — Table showing number of insured persons, not members of Approved Societies who sur- rendered cards for each quarter 553 XLVI. Deposit Contributors. — Particulars as to the number and amount of benefit payments in the year ended 11th January, 1914 554 XL VII, Statistics relating to exempt persons 556 XL VIII. Statement showing the number of certificates of exemption granted to Irish migratory labourers under Section 81 (3) of the Act of 1911 559 xvm APPENDICES TO PART VI. NATIONAL HEALTH INSURANCE COMMISSION (WALES). PAGE XLIX. Table showing number of Approved Societies operating in Wales arranged according to class and Welsh membership 563 L. Statement showing particulars relating to security given by Approved Societies under Section 26 of the Act of 1911 ... 563 LI. Analysis of members of Approved Societies in Wales for the quarter ended 12th January, 1913 ... ... ... ... 564 LII. Table showing the approximate distribution of members of Approved Societies among the various types of Societies for the quarter ended 13th April, 1913 565 LIU. Quarterly stamping. — Statistics for the year ended Uth January, 1914 565 LIV. Statement showing receipts into and payments out of the Welsh National Health Insurance Fund from 15th July, 1912, to Uth January, 1914 .'.. 566 LV. Stamping during week after payment of wages. — Statistics for the year ended Uth January, 1914 ... ... ... 567 ' LVI. Statement showing the number of members of each Insurance Committee ... ... ... ... ... ... ... 567 LVII. Summary of scheme of the King Edward VII. Welsh National Memorial Association ... ... ... ... 568 LVIII. Extract from agreement between County and County Borough Councils and the King Edward VII. Welsh National Memorial Association ... ... ... ... ... ... 571 LIX. Statement showing the number of non-insured persons (other than dependants of insured persons) being treated by the King Edward Vll. Welsh National Memorial Association in residential institutions, or who have been treated therein, during the period from 15th July, 1913, to Uth January, 1914 571 LX. Systems and institutions for which approval has been granted under Section 15 (4) of the Act of 1911 572 LXI. Statement, compiled from the index registers, showing the number of insured persons (members of Approved Societies and deposit contributors) in Insurance Committee areas as on 12th January, 1914 573 LXII. Statement showing the number of doctors and chemists on the panels for each Insurance Committee area on 12th January, 1914 574 LXIII. Deposit Contributors. — Table showing contributions paid and charges made against deposit contributors' accounts for each of the first four quarters ... ... ... ... ... 574 LXIV. Deposit Contributors. — Table showing number of contributors who entered into insurance during each quarter ... ... 575 LXV. Deposit Contributors. — Table showing number of insured persons, not members of Approved Societies, who sur- rendered cards for egich quarter ... ... ... ... 575 LXVI. Deposit Contributors. — Particulars as to the number and amount of benefit payments in the year ended Uth January, 1914 576 LXVII. Analysis of replies obtained by officers of the Outdoor Stafi" from a representative group of deposit contributors ... 578 LXVIII. Statement showing the ages and occupations of a repre- sentative group of deposit contributors ... ... ... 579 LXIX. Statistics as to exemption certificates 580 LXX. Statement as to payment of contributions m respect of exempt persons ... ... ... ... ... ... ... ... 580 LXXI. List giving particulars of the Authorities, &c., to whom certifi- cates of exception have been granted under paragraphs (6) and (c) of Part II of the First Schedule to the Act of 1911, by the Joint Committee acting jointly with the Commission, and also the approximate number of persons to whose employ- ment such certificates apply 581 PAET I. INTEODUCTION. 1. The administrative duties which have fallen to the National Health Insurance Joint Committee and the Insurance Commissions since the publication, last year, of the first Annual Eeport on the administration of National Health Insurance differ considerably in scope and character from those which formed the subject matter of that first Eeport. During the period between the passing of the National Insurance Act, 1911, and the issue of the first Eeport, administration was mainly concerned with the establishment on broad general lines of the necessary machinery for bringing National Health Insurance into operation. 2. The first Annual Eeport had therefore to contain a general account on the contribution side of the manner in which these arrangements were set up, including details of the system of collection of contributions by means of stamps and cards, and, on the side of benefits, of the manner in which Societies were approved and assisted in undertaking their new work, and of the provisional appointment of the first Insurance Committees. This account of the work which had to be carried out before the Act came into operation developed naturally into a general account of the measures taken to meet the problems in connection with the commencement of medical, sickness, and maternity benefits in January, 1913. Finally, as regards the period between January, 1913, and the issue of the first Eeport in July of that year, it was possible to furnish some estimate, though necessarily limited and tentative, of the actual effect of the Act's working upon the insured persons for whose benefit it had been devised. The material which has now to be dealt with does not admit of the same broad treatment that was possible in the first Eeport, being necessarily concerned in the main with questions of detail which, though they have all arisen in con- nection with the working of the Acts, may not appear to be bound together in the same close inter-relation which characterised the problems connected with the establishment of the original machinery, and which require separate treatment. (B254— Gp. 5) A 2 Introduction. 3. In this connection two points require to be specially emphasised. In the first place, it must be borne in mind that in many cases, perhaps in the majority of cases, the provisions of the Acts have not been operative for a sufficient period to enable any accurate pronouncements or forecasts to be made. Secondly, in the administration of benefits under the Acts, an intermediate authority is interposed between the Government Departments concerned and the recipients of the benefits. This inter- position of an intermediate authority must clearly affect to a considerable extent both in general the account which can be given by the Departments of the machine in its operation, and in particular the statistics and figures as to benefits which can be furnished. 4. The interposition of these intermediate authorities has a further very important influence on the character of the admin- istration. The principle that the existence of an intermediate authority cannot be justified unless the intermediate authority is Left with a due share of discretion and consequent responsibility, holds good in this as in other spheres of British administration. The work of the Commissions in relation to Approved Societies and to Insurance Committees has been (except where the Acts definitely require Eegulations to be made) advisory rather than executive; and, consistently with the provisions of the Acts, the advice which has been given, whether in the shape of general circulars or of letters on individual points, has consistently aimed at laying down general principles of guidance, rather than at dictating any particular course of action in particular cases. The Scope of National Health Insurance. 5. The experience already obtained, while insufficient to admit of precise scientific treatment, has been amply sufficient to indicate generally the very wide scope which the system of National Health Insurance embraces, and the very great variety of general social questions which the administra- tion of it must touch. Those responsible for the administration of National Health Insurance have constant recourse to in- formation and advice from authorities and bodies working in the most diverse fields, and, reciprocally, they are themselves con- stantly approached by such authorities and bodies seeking to secure the fruitful application of the provisions of the National Insurance Acts to the particular social activity in which they are interested. Thus, almost every type of social question is in- volved, directly or indirectly, in the administration of National Health Insurance ; and not the least interesting feature of the work already accomplished has been the bringing of the resources arising under the scheme of National Health In- surance into co-operation and co-ordination with forms of Introduction. 3 organisation already set up, apart from insurance, for dealing with the immense variety of questions and problems with which National Health Insurance is concerned. In many cases, these problems are such that the system of National Health Insurance directly affords additional facilities to their solution; and even where this is not so, yet the comprehensive and far-reaching machinery which has been established must necessarily result in the elucidation of new facts and new condi- tions which may prove to be of great value in the further institu- tion of various social reforms. It would be difficult to set a limit to the types of question on which National Health Insurance may have this secondary and indirect bearing; directly, however, it would seem that the types of question with w^hich National Health Insurance, in its full development, is likely to be most concerned are those which may be conveniently summarised, to use accepted and well-understood terms, as questions concerning Public Health, and questions concerning economic conditions. 6. In the sphere of Public Health, both on the preventive and the curative side, the questions which arise in connection with National Health Insurance are of the greatest possible diver- gence, and may vary from such a purely scientific question as ihe value of a new cure for tuberculosis to such a purely adrninistra- tive question as the drafting of an agreement between two local bodies co-operating, e.g., for the administration of sanatorium benefit. Naturally, in view of the past history of Public Health reform, there is in this sphere a wide scope for the closest co- operation between National Health Insurance and Local Govern- ment ; and this has been particularly the case in the administra- tion of sanatorium benefit, the account of which given in para- graphs 343 to 404 below affords a striking example of the compre- hensive and far-reaching machinery which has gradually grown up in connection with Public Health, and of the wide possi- bilities of co-operation between central authorities, local authori- ties, and voluntary bodies which are presented by this gradually evolved machinery. The development of sanatorium benefit, indeed, even though it has been in operation for less than two years, seems to indicate that much may be done towards the solu- tion of particular problems of PubHc Health by the considered and scientific concentration of all the available resources, includ- ing those new forces provided by the National Insurance Acts, on a particular question. 7. It is not only in connection with sanatorium benefit that general questions of Public Health arise in connection with National Health Insurance. Medical benefit also contributes its share. The working of medical benefit has already revealed, more clearly than had previously been possible, the loss which the country has suffered through the past inability of large sections of the community to obtain adequate treatment of the (B254— Gp. 5) A 2 4 Introduction. diseases from which they suffered. It is true that in certain areas, and for certain types of disease, the great voluntary hospitals made readily available, for even the poorest of the popu- lation , the most perfect forms of treatment known to science ; but the greatest services performed by the hospitals have been in connection with illnesses and accidents forming suitable cases for institutional treatment. The work of the out-patients' de- partments is necessarily limited, and further, there are large areas where there are no hospitals treating persons otherwise than as residential inmates ; practically throughout the country there has existed no organisation of the provision of medical treat- ment for the mass of illnesses which require to be treated in the patient's home. Many such cases, if so treated in good time, may often be prevented from becoming serious ; a consummation which, if once generally attained, must obviously reduce incal- culably the suffering, pain, and loss of the whole community. The institution of Insurance Committees, and of the panel service of medical practitioners treating practically the whole of ihe working population in their homes, seems to have provided not only actual treatment by general practitioners for cases suited to home treatment, but also a foundation on which extended provision can suitably be based. And the co-ordination of the machinery for medical benefit with any steps that may be taken in the future towards the improvement of the medical service 'of the country may well aff'ord other interesting examples in addition to that provided by the working of sanatorium benefit, of the relation between National Health Insurance and the :general improvement of the Public Health service. 8. Not less interesting is the intimate connection of National Health Insurance with general economic problems. The question of arrears of contributions, for example, is imme- diately connected with the whole problem of unemploy- ment, and with the incidence and causes of unemployment ; and it is possible that, as the scheme of arrears comes into operation, statistics may be obtained which should supplement, possibly with the most interesting results, the Board of Trade returns upon the subject. 9. The working of National Health Insurance has, however, been particularly remarkable for the manner in which it has brought into prominence the problem of under-employment. The position of a worker who is in full employment- during many weeks of the year, and altogether out of employment during other weeks, is in many cases no harder than that of the man who seldom or never gets more than three or four days' employment in any week, even though this limited employment may be fairly continuous. Chronic under- employment of this kind presents problems that are in some respects the most difficult of all ; it has been shown to be par- Introduction. § ticularly acute among outworkers, and among casual labourers. In the actual application of the Acts to outworkers, much has been done to reHeve the difficulties and hardships by the institu- tion of the unit system, and, as regards casual labour in the London docks, an Order expressly designed to remove the diffi- culties arising from chronic under-employment has now been published in draft. 10. What, however, has specially to be pointed out on this subject in this introductory Part of the Eeport is that the opera- tion of National Health Insurance has forced into prominence the problem of under-employment and given it a new aspect compelling public attention. The investigations made in con- nection therewith have resulted in the accumulation of a mass of information which may be most valuable towards the discovery of a general solution of the problem. The position of outworkers has been elucidated in this way to an extent that has probably never been achieved before. Further, in connection with their statutory duty of determining, on appli- cation, whether any particular employment is employment within the meaning of the Acts, the Commissions have collected a great mass of information as to the conditions obtaining in many specialised and hitherto little known forms of employment. 11. The two* questions, however, of Public Health and of economic conditions are inextricably interwoven.' Indeed, their intimate connection has been brought home most clearly by the operation of National Health Insurance ; and it is perhaps in this respect that the most interesting deductions can be made from the experience already gained. These deductions present themselves particularly when consideration is given to the admin- istration of sickness benefit and maternity benefit, these being the two cash benefits at present in operation. 12. In connection with the payment of weekly sums of 10^. or Is. 6d. as sickness benefit, the whole experience, so far as it can at present be judged, confirms the theory that the provision of curative facilities is of little avail unless they are accom- panied by financial provision to relieve the economic conditions of distress which would otherwise arise while the head of the family is away from work. Indeed, the experience already gained has substantially proved that any attempt to divorce the two factors leads to a vicious circle. Where, in the days before the Insurance Act, the individual whilst ill was receiving no cash payments from Friendly Society or otherwise (and this was the case, it must be remembered, with the majority of the working population) , the results achieved by the provision of facilities for medical treatment through provi- dent dispensaries or otherwise were in many cases neutralised or even wholly foregone by reason of the fact that the recipient of the treatment could not afford to give up work (B254— Gp. 5) A3 6 Introduction. for more than a very limited period ; and such improvement as was effected was often undone by his premature return to work. Conversely, the fact that a worker in many cases could not afford to lose wages for the purpose of submitting himself to a course of treatment, even though the course of treatment itself might be given him entirely free, tended not only to make the provision of facilities for free treatment abortive, where such facilities were actually made, but also to discourage the idea of providing such facilities where they had not been made. A most interesting example of this point arises in connection with the shortage of doctors which was found to exist, before the Act came into operation, in many industrial areas where wages were low and employment precarious. The workers in these areas could not afford to give up their work and go to doctors ; and in consequence doctors, being unable to make a living, found it impossible to set up practices in those areas. But since the Insurance Act made provision both for supplying medical treatment in the shape of medical benefit and also for the financial relief of the sick person afforded by the weekly cash payments of sickness benefit, the workers have been enabled to seek medical advice, and have thus created a new demand for doctoring. Doctors have in this way been encouraged to settle in areas where, owing to the absence of other doctors resulting from the condi- tions prevalent before the days of National Health Insurance, they would be likely to experience a minimum of competition. 13. The feature of sickness benefit which particularly illustrates this co-operation between the cash payments of sickness benefit and the curative treatment provided under the Act is the applica- tion of that benefit, as a first charge, to the relief and mainten- ance of the dependants of an insured person during a period while that insured person is receiving treatment by way of sanatorium benefit as an inmate of a sanatorium. It appears that it would frequently, perhaps in the majority of cases, be impossible for an insured person to avail himself of sanatorium treatment were it not for the provision of this support for his dependants. 14. It is remarkable to what an extent this aspect of the value of sickness benefit, in its co-operation with medical and sanatorium benefits, is emphasised by insured persons themselves recording their own impressions to the Commissions' Inspectors, Society officials, and others. 15. The operation of maternity benefit also is gradually re- vealing many facts of great interest in connection with the general question of the relation between economic conditions and Public Health. Of other effects of maternity benefit it is as yet too early to speak. Experience limited to some 18 months is inadequate to measure accurately the effect which maternity benefit may have in improving the national physique, in Introduction. 7 raising the general standard of health among working women, and in reducing the rate of infantile mortality. But already maternity benefit has thrown great light on the nature of the problem presented for solution, and has revealed many things on which there has hitherto been only the scantiest know- ledge. 16. It has, for example, been made clear that the expectation of unavoidable expense in connection with the actual confinement compelled working women to work up to the last possible moment before confinement occurred, in order that there might be money in hand to meet those inevitable expenses. Expectant mothers were thus in most cases under the necessity of running every kind of risk, because they could not afford to cease work ; and this consciousness of the necessity of continuing work seems to have led many women to ignore dangerous symptoms during the period of pregnancy, in an optimistic belief that it would not really hurt them to continue work which in any case they could not afford to drop. But the assurance of receiving the maternity benefit of SOs. at the time of confinement, by enabling women to dispense with the necessity of collecting a special reserve of money for the confinement expenses, encourages them to seek, and makes it possible for them to obey, medical advice during pregnancy ; and thus it provides a remedy not only against poverty but partially also against the evils of ignorance. It must be remembered that, where a woman ceases work through the occurrence of dangerous symptoms and com- plications in the course of her pregnancy, sickness benefit may be available for her, if she is herself insured. This provision, of course, co-operates with the expectation of maternity benefit; maternity benefit dispensing with the necessity of collecting a reserve for confinement expenses, and sickness benefit com- pensating to some extent for the actual loss of wages, the current income required to meet normal expenses. 17. This aspect of maternity benefit comes to light when one considers the great interest which its institution seems to have evoked in the country at large as to the whole question of the pro- vision made, or to be made, under the State's direction, to deal with questions of maternity. And insured persons themselves, particularly women, when expressing appreciation of maternity benefit, seldom fail to emphasise the relief which it affords from insecurity, with its attendant strain, before and at the time of confinement. (B2o4— Gp. 5) A 4 Introduction. The National Insurance Act, 1913. 18. There has during the past year been a definitely constructive element, as well as the directive element out- lined in paragraphs 1 to 4 above, in the work which the , Commissions have had to perform. This constructive element has been provided by the bringing into operation of the amending Act of the summer of 1913, cited as the National Insurance Act, 1913. 19. The experience of some 18 months had suggested to the Departments responsible for the administration of Part I. of the Act of 1911 certain points on which fresh legislation was desirable. In particular, it was found that certain minor provisions of the principal Act involved administrative difficulties and expense dis- proportionate to their intrinsic importance; and, further, that much of this difficulty and expense fell unavoidably on the volun- tary bodies, such as Approved Societies and Insurance Commit- tees, concerned in the administration of National Health Insur- ance. The Act of 1913 accordingly contains many provisions designed to secure for these bodies administrative simplification and economy. 20. Departmental experience had also suggested the possibility of improving, by means of legislation, the position of the insured person without incurring great additional expense. For example, it was found possible to achieve a general levelling up of rates of benefit for all employed contributors entering into insurance before the 13th October, 1913 ; and this levelling up not only directly benefited a considerable number of insured persons, but also effected an administrative simplification to the advantage of the Approved Societies, with a consequential expectation of economy on the administration account. 2X., The sources, however, which led to the building up of the Act of 1913 were by no means purely Departmental. As soon as it was announced publicly that the Government intended to intro- duce amending legislation, many Approved Societies and represen- tative voluntary bodies devoting themselves to social work inter- ested themselves in the question. Representations from the widest sources were received both departmentally and otherwise, the results of which became apparent during the passage of the Bill, and to a very large degree extended its scope. The Act of 1913 is thus, in a peculiar degree, representative of experience of all types. Every possible facility was given to the considera- tion of proposed amendments, and the Minister in charge of the Bill, at the close of its third reading, expressed his satisfaction that " everyone had given something to the fashioning of the Bill/' Introduction. ^ 22. The Bill was introduced into the House of Commons on the 24th June, 1913; referred to a Standing Committee on the 15th July ; reported by the Standing Committee on the 5th and 6th August ; passed by the House of Commons on the 7th August ; passed by the House of Lords on the 13th August ; and received the Royal Assent on the 15th August. 23. Detailed consideration of amendments effected by the 1913 Act will be found elsewhere in this Eeport. It may, how- ever, be convenient here to set out a brief summary of the most important provisions. References are given to later paragraphs of this Report in which details as to these provisions will be found ; and most of the Sections not included in this introductory summary are discussed under their appropriate heading in the later parts of the Eeport. 24. It should be noted that Section 43 (3) of the 1913 Act provides that it shall come into operation on the 1st September, 1913, or on such later date or dates as the Joint Committee may by Order appoint, subject to the 13th October, 1913, being the latest possible date for the coming into operation of any provision altering the rates of sickness or disablement benefits, and the 15th January, 1914, for any other provision. The dates on which, by Order of the Joint Committee made under this Section, the various Sections came into force are noted where necessary under each Section. In Appendix I, page 476, is a statement of the date of coming into operation of every Section which came into force otherwise than on 1st September, 1913. Medical and Sanatorium Benefits. 25. Perhaps the most important Section of the 1913 Act deahng with medical and sanatorium benefits is Section 9, which requires the Commissioners to make Regulations providing exempt persons with medical and sanatorium benefits. The Commissioners are precluded by the Statute from making the payment of more than 26 contributions a prior condition to the receipt of such benefits. The State grant of two-ninths is payable in respect of such bene- fits. (See paragraphs 494, 1032, 1580 below.) It may be noted that a different scheme of benefits, also carrying the State grant, is under the Statute made applicable to Ireland, in that there is in Ireland no medical benefit. (See paragraph 1311 below.) Section 9 came into operation on the 12th January, 1914. 26. Further important provisions relating to medical benefit are contained in Section 1 of the 1913 Act. Subsection (1) regu- larises the special Exchequer grant-in-aid of medical benefit, and contains a general provision in regard to the application of any further grant that may be made for the purposes of National 10 Introduction. Health Insurance. It thus carries out the promise made by the Prime Minister when the estimate for the grant-in-aid was before the House of Commons. Subsection (2) of the same Section extends the grant to members of Societies who are not insured by reason of age or of permanent disablement. Sickness and Disablement Benefits. 27. In connection with sickness and disablement benefits, the provisions of widest effect in the amending Act are those dealing with the subject of arrears. The 1911 Act, while permitting an insured person who had fallen into arrears to redeem such arrears by paying contributions on his own behalf, left it to the dis- cretion of his Society to determine whether the employer's portion of such arrears was to be excused , or whether it would require from the member himself, as a condition of restitution to full benefit, the full amount of the contribution payable by employer and em- ployed conjointly. Section 7 of the 1913 Act excuses universally the employer's portion of contributions in arrear where the employed person pays up his own proportion. Low-paid workers are given the advantage of the differential scale set out in the Second Schedule to the Act of 1911, and are thus enabled to redeem their arrears by the weekly payment of a reduced sum, which, in the extreme case of workers earning normally not more than Is. 6d. a working day, amounts only to a lei. a week. Under subsection (2) of Section 7 the risk that a particular Society's funds may be unduly depleted through the universal excusing of the employer's portion is met by providing that any loss of this kind in excess of the average allowed for in the actuarial calculations shall be defrayed out of the Sinking Fund, a possible excessive call on the Sinking Fund being in its turn defrayed by moneys provided by Parliament. 28. A further important provision in regard to arrears* is con- ta^ed in Sec 'on 8, Prolonged consideration had led to the con- ciasion that t scheme of arrears penalties contained in the 1911 Act involved berious difficulties of practice; "^ particular it pre- cluded any extension of the period of currency of , contribution cards beyond the term of three months orginally fixed. The adoption of a half-yearly card was being pressed for by Societies on grounds of administrative convenience, and Parliamen de- cided that this demand should, if possible, be met. Parliamen.t therefore repealed -the Sections of the 1911 Act dealing with arrears and substituted a provision in the most general terms * For the sake of convenience, the arrears Sections of the 1913 Act are discussed under aickness and disablement benefits, in that it is these benefits that are principally affected by arrears. It will, however, be understood that heavy arrear b may also affect the other benefits provided under the Acts. Introduction. 11 under which the Commissioners were instructed to frame a scheme, subject to the requirement that the value of the loss occasioned by the failure to pay the contributions which are in arrear must be approximately compensated by the reduc- tion, postponement, or suspension of benefits imposed as a penalty for the arrears. A full discussion of the Regulations made by the Joint Committee with regard to arrears will be found in para- graphs 112 to 130 below. 29. An increase in the rate of sickness benefit for certain insured persons of advanced years is secured by Section 3 of the 1913 Act. The effect of this Section is to level up the benefits of all employed contributors entering into insurance before the 13th October, 1913. (See paragraph 180 below.) The reduced rates of benefit made applicable under the 1911 Act to first-year entrants aged 50 or upwards at the date of entry thus disappear as a result of the Section. 30. The position of persons who became insured as employed contributors at 65 years of age or over was similarly improved. Under Section 49 of the 1911 Act persons of this class, though insured, were only entitled to such benefits as their Approved Society (or, in the case of deposit contributors, their Insurance Committee) might determine. The Commissioners had, indeed, framed model schemes of benefits (see paragraph 248 of the Report for 1912-13) adapted to meet the special conditions of this class, which provided a full actuarial return for the value of the contri- butions paid, having regard to the relatively brief period during which contributions would be payable in respect of them and to the heavy sickness liability incidental to their age, and Approved Societies had in all cases adopted one or other of these schemes. By Section 3 (2) of the 1913 Act, however, persons of the age of 65 or upwards at date of entry into insurance as employed contribu- tors were placed in the position of ordinary employed contributors with full title to benefits on the ordinary terms, except that their right to medical and sanatorium benefits did not accrue until the 14th January, 1914, and that the right to medical benefit after the age of 70 was made conditional on the payment of 27 weeks' contributions before the attainment of that age. The Section came into force on the 13th October, 1913. 31. Section 12 of the Act of 1913 removes certain provisions of the 1911 Act which had imposed administrative difficulties on Societies, or were liable to impose hardship, in certain eases, on insured persons : — (a) Section 12 (1) removes the requirement of Section 8 (5) of the Act of 1911 that at least 50 contributions must have been paid between the end of- one illness and the com- mencement of another in order thaj; the second should not, for the purpose of calculating the rate and duration of sickness benefit, 12 Iniroduction. be regarded as a continuation of the first. Ttie provision of Section 8 (5) of the 1911 Act that 12 months must elapse between the two ilhiesses remains in force ; but the additional requirement that 50 contributions must have been paid was very difficult to put into practice under a scheme of collection involving the use of stamps and cards. In the interests of Approved Societies, there- fore, as well as of the insured person himself, the latter require- ment is removed by the amending Act. Date of coming into operation, 13th October, 1913. (6) Under Section 11 of the 1911 Act, where an insured person was receiving compensation for a disease or disablement of a weekly value less than the weekly rate of sickness benefit to which he was ordinarily entitled, sickness benefit was only payable to the extent of the difference between his full weekly rate of sickness benefit and the weekly value of the compensation which he was receiving. This involved the possibility of some hardship, in that, if the insured person fell ill again within 12 months, the second illness would be treated as a continuation of the first, and sickness benefit would be deemed to have been paid for the whole period of the first ill- ness, although the amount actually received in sickness benefit would be equivalent to a much smaller number of weeks. Section 12 (2) removes this difi&culty by providing that the mem- ber is to be treated as having received sickness benefit not for the full number of weeks of actual sickness but only for a period proportionate to the sum which he actually received as sickness benefit from the Society in respect of the first illness. Date of coming into operation, 13th October, 1913. Maternity Benefit. 32. Sections 14 and 20 of the Act of 1913 have effected im- portant changes in the administration of maternity benefit. The Sections are considered in detail in the following paragraphs : — Section 14 (1) : The 1911 Act had provided that maternity benefit, in cases where the husband was an insured person, was in law the husband's benefit. The husband was required to make proper provision for his wife, subject to a legal penalty. The 1913 Act provides that the maternity benefit, whether it is paid in respect of the husband's or of the wife's insurance, is in every case to be the mother's benefit. (See paragraphs 232, 910 below.) Date of coming into operation, 12th January, 1914. Section 14 (2) : This subsection secures that a married woman employed contributor whose husband is also insured is not to be worse off, as regards the maternity benefit due on her confinement, than she would be if he were not insured, as might, under the Introduction. 13 principal Act, have happened if the husband had, e.g., paid an insufficient number of contributions. (See paragraphs 238, 910 below.) Date of coming into operation, 13th October, 1913. Section 14 (3) : The 1911 Act provided that a married woman employed contributor, while not entitled to more than one maternity benefit, was to be entitled to sickness benefit for the period of four weeks after her confinement, subject to the ordinary rules as to proof of incapacity governing the administration of sick- ness benefit ; apart from married women employed contributors, women were not generally entitled to sickness benefit during the period of four weeks following their confinement. The 1913 Act has substituted for this exception in favour of the married woman employed contributor the payment in her case of a special additional maternity benefit of 305. Besides the ordinary conditions as to waiting periods, etc., a special condition attaches to the receipt of this second maternity benefit, that the re- cipient must refrain from remunerative work during the period of four weeks after her confinement. (See paragraphs 234, 912 below.) Date of coming into operation, 12th January, 1914. Section 14 (4) : The provision of Section 18 (1) of the Act of 1911, that the fee of a doctor called in to a confinement by a midwife in accordance with the rules under the Midwives Act was recoverable as part of the maternity benefit, had been found in certain cases to detract seriously from the value of the benefit, owing to the fact that Societies were sometimes com- pelled to defer the payment of full maternity benefit until it had become clear that they would not be called upon to meet an additional liability in paying the doctor's fee. This pro- vision, accordingly, under Section 14 (4) of the 1913 Act, ceasea to have effect. (See pararaph 240 below.) Date of coming into operation, 1st September, 1913. Section 20 (1) : Under this- subsection, an insured womart who, having been a British subject before marriage, has ceased to be a British subject through marrying an alien, is to be regarded as a British subject for the purposes of the Acts. Aliens under the Act receive less favourable benefits than British subjects, and it was felt to be a hardship that a woman of British nationality should suffer a reduction of benefits by reason of her marriage. Date of coming into operation, 13th October, 1913. Section 20 (2) : Under this subsection, the maternity benefit payable in respect of an alien husband is, in every case in which his wife was before marriage a British subject, to be increased by two-sevenths. This increase brings the maternity benefit payable in such a case to the 305. ordinarily payable in the case of British subjects. The two-sevenths increase is pro- vided from the Exchequer. Date of coming into operation, 12th January, 1914. 14 Introdiiciion. Miscellaneous. 33. The coarse of administration had suggested that, in the application of the provisions of the Act to persons casually or intermittently employed, greater elasticity than was possible within the limits of the principal Act was desirable. Section 19 of the 1913 Act empowers the Commissioners to make Special Orders adapting the provisions of the principal Act to the insurance of persons casually or intermit- tently employed. Under the Section, the Orders may alter che amount of the employed rate of contribution, and the appor- tionment of the contribution between employer and employed, as well as the manner of collection of the contributions ; but any such Order is subject to the statutory condition that the employer's contribution must not exceed 6d. nor the employee's contribution id. (or in the case of a woman, Sd.) a week, nor, if the Order makes the contributions payable day by day, must the employee's contribution for any day exceed Id. A discussion of the administrative developments of this Section will be found in paragraphs 578 to 580 below. 34. Section 2 of the 1913 Act extends in two respects the time for taking advantage of the Acts : — (a) The 1911 Act provided that any person who, not having previously been insured, became an employed contributor after the 14th July, 1913, should receive not the full benefits but re- duced benefits appropriate to his age at the date of entry into insurance. Section 2 (1) of the 1913 Act extends the date from the 14th July to the 13th October, 1913. (See paragraph 179 below.) (h) The Act of 1911 provided that voluntary contributors entering into insurance before the 15th January, 1913, should, while receiving full benefits, pay a lower contribution than those becoming voluntary contributors on or after the 15th January, 1913. Section 2 (2) of the 1913 Act extends the period for taking advantage of this lower contribution to the 12th October, 1913. (See paragraph 179 below.) It may be added that, under Section 4 of the 1913 Act, persons of the age of 60 or up- wards, on ceasing to be entitled to continue in insurance as employed contributors, are entitled to become voluntary contri- butors at the employed rate of contribution even though they do not possess the ordinary qualification of a voluntary contri- butor in being engaged in some regular occupation. (See para- graph 268 below.) 35. Section 5 of the 1913 Act enables a person who would ordinarily be Hable to compulsory insurance to obtain a certifi- cate of exemption on the ground that he is ordinarily dependent Introduction. 15 for his livelihood on his earnings derived from an occupation out- side the scope of compulsory insurance. {See paragraphs 491, 687, 1309.) This Section came into operation on the 1st Sep- tember, 1913. 36. Administrative experience had shown that the drafting ^ of Section 45 (4) of the 1911 Act had somewhat unfairly excluded ^ pertain Societies from participating in the advantages of that '^'Section. Section 21 of the 1913 Act extends the scope of Section 45 (4) of the Act of 1911 to Societies which, while not having actually become approved or established an approved separate section, have amalgamated with an Approved Society, or established a new Society for the purposes of the Act, or taken some such similar step. (See paragraph 252 below.) Date of: coming into operation, 13th October, 1913. 37. Societies approved for, or having members resident in more than one part of, the United Kingdom, had represented that the provisions of Sections 80 to 83 of the 1911 Act, dealing with international Societies, involved them in undue complexity of administration. Section 16 of the 1913 Act contains a number of provisions designed to remove these difficulties, while at the same time protecting the wishes of members resident in the several parts of the United Kingdom. For a full discussion of: Section 16, see paragraphs 60 to 72, and also paragraph 770,. below. The Section came into operation on the 13th October,. 1913. 38. In view of the fact that registered Friendly Societies have for many years been exempt from Stamp Duty upon certain documents used in the business of such Societies,. Section 37 of the 1913 Act exempts Approved Societies also from the Stamp Duty on similar documents. The documents are scheduled in the Second Schedule to the Act, and this Schedule is very comprehensive and includes nearly every document com- monly used. Insurance Committees are similarly exempted, and this exemption means a considerable saving on their adminis- tration account^ in that their agreements with doctors accepting service under the panel are freed from a Stamp Duty which would otherwise have cost 105. in each case. 39. Section 28 of the 1913 Act empowers the Commis- sioners to make Eegulations with regard to the amalgamation and dissolution of Approved Societies ; the withdrawal of ap- proval from a Society in cases where, while no technical offence can be proved under Section 29 of the 1911 Act, its affairs are so seriously mal-administered that it appears inexpedient in the interests of the members that it should remain approved ; the crediting or variation and cancellation of reserve values (a pro- vision actuarially necessary in view of the alteration in various rates of benefit) ; the application to the Navy and Army Insurance Fund of certain provisions of the Acts relating to Approved Socie- ties; the time and method of payment of the sums payable to 16. Introduction. Insurance Committees and the appointment of legal representa- tives, for the purposes of the Acts, of persons of unsound mind. 40. Section 40 of the 1913 Act extends the power of the Commissioners to make Orders under Section 78 of the 1911 Act to the 31st December, 1914. But for this Section, Section 78 of the 1911 Act would have expired on the 1st January, 1914, and consequent difficulties in bringing into operation the 1913 Act might have arisen. Section 40 also enables Orders or Special Orders made under the Acts to be revoked, varied or amended by an Order or Special Order made in like manner as the original Order. It was anticipated that this power would be necessary in effecting the necessary transitions from the 1911 Act to the 1913 Act. n:,- M^i ^ki iqei k. ,di baa eooiJimmcO sofl^iifanl JiT 11. 01^ iioi.to68 .Oh H-^frokgimmoD 1 imi od'3 lo •TeffpeHfTor bae ~~~~~ n,' .Rj^j.'' ' NATIONAL HEALTH INSURANCE JOINI -qa COMMITTEE. dmema B£ I.— GENERAL, 41. The Kegulation-making power and other functions of the Joint Committee under Treasury Regulations continue to be of great importance ; but the actual burden of detailed work falling upon the Committee has tended considerably to diminish. 42. During the past year the constitution of the Joint Commit- tee has been altered through the resignation of Sir John Brad- bury, K.C.B., upon his appointment as Joint Permanent Secre- tary to the Treasury, and by the appointment in his stead of Mr. H. N. Bunbury, C.IB., as Financial Member of the Joint Com- mittee. Further, Mrs. Creighton was compelled to tender to the Treasury her resignation from the Joint Committee, in consequence of other work. The Joint Committee desire to take this opportunity of placing on record their high appreciation of the services rendered by Mrs. Creighton, and their regret that the wide experience of public affairs and social questions which she brought to the deliberations of the Joint Committee are no longer available. 43. It may be noted that the Joint Committee has been in- corporated, under the name of the National Health Insurance Joint Committee , by Treasury Eegulations made under Section 29 of the Act of 1913. Scope of the Joint Committee's Work. 44. The diminution in the actual burden of detailed work falling on the Joint Committee is traceable to two main causes. In the first place, the Treasury Eegulations made under Section 83 of the Act of 1911 impose on the Joint Committee the duty of making a number of the Eegulations required under different Sections of that Act to be made on particular questions. The progress of time has, of course, brought it about that the majority of these Eegulations have now been made, and, as each set of Eegulations is made, the direct duties of the Joint Committee in connection with them, except so far as amending 18 Joint Committee. Regulations may from time to time be required, tend to cease ; for the actual administration of the Eegulations so made lies rather in the hands of the National Commissions and their staff than of the Joint Committee itself. It is true that the Act of 1913 involved the making of certain new Eegulations, some of which are assigned to the Joint Committee under Eegulations of the Treasury ; but the general principle still holds good that the gradual completion of all the various Eegulations required to be made tends to diminish the detailed work falling to the Joint Committee. Secondly, the Joint Committee was in the early days concerned to a large extent with the establishment of general principles which could be applied in the administration of matters on which uniformity of administrative action in the four countries was manifestly desirable. The number of new questions arising under this head becomes gradually smaller, and the building-up of a code of general principles of necessity diminishes the actual number of detailed references to the Joint Committee. 45. The majority of the questions which have fallen directly under the cognisance and consideration of the Joint Committee during the past year are discussed elsewhere in this Eeport. A short reference may, however, be conveniently made here to some of the more important questions of this kind. ' 46. The passing of the Act of 1913 imposed upon the Joint Committee (under Section 43 (3) of the Act) the duty of issuing an Order prescribing the dates on which various Sections, in so far as their date of commencement is not laid down in the Statute itself, should come into operation. (See Appendix I to this Eeport, page 476.) 47. The settlement of two questions of outstanding import- ance was vested in the Joint Committee by the Treasury Eegula- tions made on the passing of the 1913 Act. These questions re- late respectively to (1) the system on which benefits of insured persons are to be reduced on account of arrears, and (2) the special provisions to facilitate the operations of Societies having members in more than one part of the United Kingdom. The latter question is fully dealt with in paragraphs 60 to 72 below, and the former in the Section which follows, devoted to actuarial questions. The Treasury Eegulations also vest in the Joint Com- mittee the power of making Special Orders under the provisions of the Act of 1913 dealing with employments under local authori- ties (Section 6), with casual and intermittent employment (Section 19), and with the apportionment of the contributions between employer and employed where the persons employed by a particular group of employers are in general remunerated at a rate which can be regarded as a normal rate for the class of employment in question (Section 25). The Joint Committee have also been required to exercise powers relating to various matters affecting the machinery of Approved Societies, including Medical Research. 19 provision for amalgamations, transfers, dissolutions, crediting of reserve values and other matters ; and also, acting jointly with the several bodies of Commissioners, to draw up schemes for giving benefits to exempt persons and for distributing grants to Insur- ance Committees in aid of their expenditure. These matters are discussed in detail elsewhere in the Eeport. 48. During the autumn of 1913 the revision of the Medical Benefit Eegulations came up for the consideration of the Joint Committee, partly in connection with amendments due to pro- visions in the 1913 Act, and partly in connection with certain points on which modification of the Eegulations had been shown by experience to be desirable. The amendments are explained elsewhere in this Eeport. 49. In addition, the Joint Committee had under considera- tion a question of great importance, which is dealt with in the following paragraphs : — Medical Eeseaech. 50. Section 16 (2) (h) of the Act of 1911 provides that there shall be available the sum of Id. for each insured person, payable out of moneys provided by Parliament. The Act lays down that this money may be retained by the Commissioners for pur- poses of research; but that, if it is not so retained, it is payable to Insurance Committees in aid of sanatorium benefit. The four Commissions have passed resolutions retaining the Id.^ and a sum of about £55,000 in respect of the year 1914 is thus devoted to research work. It may be noted that the Departmental Com- mittee on Tuberculosis expressed in its Final Eeport the view that * ' the whole of the moneys made available could usefully be spent on research." The amount available under Section 16 (2) )*may be expected slightly to increase in each year, in accord- ance with the natural growth of the population. 51. The application of moneys so retained for purposes of research is, under the Act, to be determined by Eegulations. The Treasury Eegulations assigned to the Joint Committee the duty of making these Eesearch Eegulations ; and the Joint Com- mittee made provisional Medical Eesearch Eegulations on the 20th August, 1913, the substantive Eegulations being made on the 21st March, 1914. These Eegulations of the Joint Com- mittee are the document providing for the administration of the medical research money. 52. The basis of the system established by these Eegula- tions is to be found in the recommendations made in the Final Eeport of the Departmental Committee on Tuberculosis. The Departmental Committee expressed the opinion that a Min- ister or a Government Department could not make the best possible use of the research money without having 20 Joint Committee. the advantage of the advice of a number of different per- sons, and obtaining the assistance of experts in the carrying out of the work. For these reasons the Committee recom- mended the establishment of tv^o bodies to be concerned with the administration of the money, one, the larger body, to exercise functions of a general advisory character, the other to be more directly concerned with the disbursement of the money, framing a scheme of research work and a budget of expenditure, making periodical reports, generally organising and supervising the re- search work wherever carried on, and performing similar duties of an executive character. 53. The Eegulations of the Joint Committee accordingly set up two bodies, one, consisting of 42 persons, called the " Advisory Council for Research," and one, the smaller executive body, con- sisting of nine persons, called the " Medical Eesearch Com- mittee." The membership of both these bodies is given in Appendix II, page 477 below. 54. The Advisory Council for Research consists of repre- sentatives of the Royal Society, of all Universities of the United Kingdom, of the Royal Colleges of Physicians and Surgeons in England, Scotland, and Ireland, of the King Edward VII. Hos- pital Fund for London, and of the Government Departments concerned in matters of Public Health and cognate matters. In appointing the Advisory Council, invitations were issued, in the case of Universities to the Vice-Chancellors, in the case of the Royal Colleges to the Presidents, and similarly in the case of other bodies, requesting these bodies to appoint represen- -tatives on the Council. In addition, nine other persons were invited to serve in a personal capacity, on the ground that their experience was such as to be likely to assist very materially the deliberations of the Council. The necessity of securing the widest possible representation in constituting the Advisory Council resulted in the appointment of 42 members, as opposed to the maximum of 30 recommended in the Report of the Departmental Committee. 55. The constitution of the Medical Research Committee reflects the recommendation of the Departmental Committee's Report that the majority, but not all, of the members should be scientific experts. The practical necessity of keeping the number of the Medical Research Committee small, so as to facilitate frequent meetings and despatch of business, prevented the Medical Research Committee being based on representative lines, and also required that the members should be most care- fully selected in the light of the qualifications which they could bring to the special nature of the problem to be handled. Ac- cordingly, invitations to serve on the Medical Research Com- mittee were sent personally to those persons who seemed, after the most careful consideration, to be best qualified, and not to the heads of any scientific body or bodies with which the members National and International Societies. 21 might be associated. Members of the Medical Research Com- mittee accordingly serve not in a representative but in a personal capacity. 56. The Regulations, besides setting up these two bodies, defined the relations between them, and also between them and the Ministerial head of the Joint Committee. These relations may be summarised as follows : — 57. The Regulations impose upon the Medical Research Committee the duty of framing schemes for research and of sub- mitting them for the approval of the Chairman of the Joint Committee, which must be obtained before any money can be expended on such schemes. The Chairman of the Joint Com- mittee, before approving such a scheme, is required by the Regulations to consult the Advisory Council for Research, and, after the approval of the Chairman of the Joint Committee has been obtained, the scheme commences to operate and money can be expended thereunder. 58. A preliminary scheme of this nature has already been submitted to the Chairman of the Joint Committee ; the Advisory Council for Research has expressed its concurrence in the scheme, and the approval of the Chairman of the Joint Committee has been given. The work of the Medical Research Committee under this scheme is now in process of development, and will no doubt in due course form the subject of a Report when it is more fully established. At present arrangements are in progress for the ac- quisition of a central laboratory for research purposes, for the engagement of staff both scientific and administrative, and for the development of special lines of research in different parts of the United Kingdom. 59. It may be added that advice has been obtained to the effect that the application of the Research Fund is not limited to research in tuberculosis, but that the money may be expended on research into any disease to which insured persons are subject. National and International Societies. 60. Section 16 of the Act of 1913 is designed to meet certain difficulties of administration and accounting with which Societies having members resident in more than one part of the United Kingdom were faced. Where a Society had members in more than one country, Section 83 of the Act of 1911 required that the members in each country should be treated as if they formed a separate Society for the purpose of transfer and of valuation, including the incidents of valuation, the disposal of surpluses and the meeting of deficiences. It followed that entirely separate 22 Joint Committee. funds and separate accounts had to be kept for each of the countries in which an international Society operated. If a member of a Society approved for, e.g., England and Scotland, left the former country to live in Scotland, a transfer value had to be passed from the English to the Scottish fund of the Society, the case being in fact treated as if the member had passed to an entirely separate Society. The funds of the Society in the two countries were subject to separate valuation, and if the membership in either country fell below 5,000 those mem- bers would have to be grouped for valuation purposes with other Societies in that country in order to make up the 6,000 valuation unit. 61. It was represented that these requirements involved an excessive amount of book-keeping at all times, and might involve difficulties on valuation, particularly in the case of Societies ap- proved for more than one country which had only a small mem- bership in any country other than that in which their principal business was carried on. There was also no satisfactory pro- vision for the not uncommon case of members changing their residence to a country for which their Society was not approved. Section 16 (1) of the Act of 1913. — Valuation and Transfers in the case of international Societies. 62. Section 16 (1) of the 1913 Act provides that, subject to the right of members in any country to claim separate valuation, a Society shall have one valuation for all its members, in whatever country they may be resident. The effect of this is to relieve such Societies from passing transfer values when members move from one country to another, and it has enabled other arrangements to be made which materially simplify the accounting and financial work of these Societies. Thus, such a Society will no longer be required to register a transfer when a member moves from one country to another; and, while it will issue to its members in each country the contribution cards appropriate to their country of residence, it will make one return of all its cards to the Commission for the country in which its head office is situate, instead of sending separate returns of contributions to the several Commissions. The Society will, however, still have a separate current account with the Commission of each country in which it operates, and its accounting system must be so arranged as to enable it to prepare returns of expenditure on benefits in each such country. The Section also removes, by abolishing the necessity for separate valuation, the difficulty arising from the membership of an international Society being less than 5,000. 63. The right which, as stated above, the members resi- dent in any country have to claim separate valuation is secured to them by the proviso to Section 16 (1). Under this proviso the arrangements obtaining under the principal Natiofial and International Societies. 23 Act in regard to separate national valuation are to be allowed to continue where the members of an inter- national Society resident in a country other than that in which the registered office of the Society is situate satisfy the Joint Committee that they desire to continue to be treated as if they formed a separate Society. Eepresentations to this effect had, under the proviso, to be made to the Joint Committee within six months of the passing of the Act, i.e., by the 14th February, 1914. By the date appointed, representations were received in respect of the members of nine Societies in Wales and of thirteen Societies in Scotland. 64. It is the duty of the Joint Committee to satisfy them- selves by inquiries that the representations they receive ex- press the desire of the members, and, where they consider that the wishes of members cannot otherwise be properly ascer- tained, to cause a poll of the members to be taken for the purpose. For this purpose, a circular letter has been addressed to each of the local Branches in Scotland and Wales of the Societies with Branches concerned requesting that (where this had not already been done) the question of separate valuation might be put before their members, and information as to their attitude towards the proposal furnished. Section 16 (2) of the Act of 1913. 65. Subsection (2) of Section 16 defines the position as regards national Societies, i.e., Societies approved for one country only, who may have members resident in a country for which the Society is not approved. It is laid down that such a Society is not required to obtain approval for a country for the sole reason that some of its members move into that country. Such mem- bers are treated as if still resident in the country in which they formerly resided. Section 16 (3) of the Act of 1913.— International Societies relinquishing Approval for one or more Countries. 66. This subsection provides that a Society may relinquish approval for any country of the United Kingdom other than that in which its registered office is situate if (a) it has no mem- bers resident in that country, or (h) any of its members resident in that country were resident at the time of their admission to the Society in a country for which the Society will remain approved. The subsection thus affords to certain Societies an opportunity for simplifying their administrative and accounting arrangements by reducing the number of Commissions with which they require to be in communication. Such a Society would be one which originally obtained international approval not with a view to 24 Joint Committee. recruiting members in general outside its own area, but in order to be in a position to admit to membership and to retain for State insurance purposes persons who had been associated with the Society by membership on its private side. 67. Applications which fulfil the conditions laid down by the subsection have been received from four Societies desirous of relinquishing approval for England, two for Scotland, five for Ireland, and seven for Wales, and permission has been given accordingly. Other applications are now under consideration. : Section 16 (4) of the Act of 1913. — Branches. 68. Subsection (4) of Section 16 enables registered Branches of international Societies having members resident in more than one country to simplify under certain conditions their administrative and accounting procedure. Under the principal Act any Branch of an international Society was qualified, if it so desired, to recruit members for any country for which the Society as a whole was approved ; but a Branch which availed itself of its powers in this regard was obliged to keep entirely separate accounts and separate funds for members in each country for which it recruited members ; and the members of the same Branch if resident in different countries had to be treated entirely separately for valuation purposes. 69. Under subsection (4) a Branch of an international Society will henceforth be able to treat all its members in what- ever country they are now, or may become, resident, as if they were resident in the country in which the registered office of the Branch is situate, i.e., the Branch will have only one fund for valuation purposes and will deal exclusively with one Commis- sion in respect of all its members, provided that for the future it restricts admission to persons resident in the country in which the registered office of the Branch is situate. The position therefore of a Branch of an international Society will, as regards members who move to another part of the United Kingdom, ordinarily be the same as that which obtains in the case of national Societies in similar circumstances. (See paragraph 65 above.) 70. The subsection, however, makes provision for the case of Branches (such as Branches in border towns) which desire to continue to recruit members in more than one country. Any Branch so desiring is required to apply to the Joint Committee. If its application is granted, the effect will be that the Branch will have to keep its accounts in such a way as to show separately its benefit expenditure in each country in which it carries on business, and the Head Office of the Society will have accounts and dealings with the Commission of each such country. The whole membership of the Branch will, however, be valued to- gether, except so far as arrangements for separate national valua- tions of all members of the Society may have been made (see Advisory Committee. 2a paragraph 63 above) for any country in which the Branch thus coti^ tinues to recruit members. In that case the effect will be that the position of the Branch as regards separate accounts and separate valuation will remain as under the arrangements provided by the principal Act. 71. Applications from 59 Branches of Societies for permission to recruit members in a country other than that of their registered office have been received by the Joint Committee. .,.^. 72. The full effect of Section 16 in its various applications, and in its relation to Section 40 of the 1911 Act providing under certain conditions for the grouping into one valuation unit of Branches in one geographical area, was explained in two Circulars (A.S. 109 and 110) issued in November, 1913, to all Societies affected. Of these, Circular A.S. 109 was designed to supply the information which would be needed by Affiliated Orders, Cir- cular A.S. 110 being intended for the assistance of centralised Societies. The Continuance in Insueance of Emigrants. 73. Section 32 (1) of the Act of 1911 provides for assistance being given under certain conditions to an insured person who emigrates and joins a foreign or colonial Branch of an Approved Society. If the Branch he joins has given an undertaking, satisfactory to the Joint Committee, to grant corresponding privi- leges in the case of any of their own members coming to this country, it is to receive the emigrant's " transfer value " (i.e., the sum which would have been transferred if he had changed from one Approved Society to another in the United Kingdom). As the transfer value includes the man's reserve value, and therefore usually amounts to a considerable sum, an arrangement of this character should enable him to enter insurance in the new country on substantially more favourable terms. At the same time, the arrangements for corresponding payments by the Branch abroad, which is an essential condition under the Act, are correspond- ingly difficult. A circular and memorandum have been issued to Societies with Branches explaining the way in which foreign and colonial Branches can take advantage of the scheme, but some time may be expected to elapse before they complete the neces- sary arrangements. Advisory Committee to the Joint Committee. 74. A number of meetings of the Advisory Committees to the Joint Committee and to the several Commissions either as a whole, or (where the matter for consideration was not of interest to the whole) in sections, have been held to consider such ques- 26 Joint Committee. tions as the amendment of the Medical Benefit Kegulations, the Eegulations relating to Arrears (which were twice discussed), questions relating to notice of illness and to medical certification for sickness benefit, and proposals for the assistance of employed contributors in arrear with contributions through unemployment, and for a system of referee-consultants, outlined in the Chancellor of the Exchequer's Financial Statement on 4th May, 1914. On each of these occasions the Advisory Committees to the English, Scottish, and Welsh Commissions, and also the Advisory Com- mittee to the Irish Commission, except on questions relating to medical benefit and medical certification of sickness, met jointly with the Advisory Committee to the Joint Committee. 75. Sectional meetings of the Medical and Pharmaceutical members of the Joint, English, and Welsh Advisory Committees have also been held to consider the amendment of the Medical Benefit Regulations and draft Kegulations relating to the con- stitution of Panel and Pharmaceutical Committees. A meeting of the representatives of insured persons on all the Advisory Com- mittees was also held to consider draft Eegulations relating to the amalgamation of and transfer of engagements of Approved Societies, the dissolution of Societies, and the withdrawal of approval from Societies. 76. The Joint Committee have derived much assistance from such criticisms and advice as have been offered by the Advisory Committee, and are particularly indebted to them for the very full and helpful discussions which took place on the sabjects of Arrears and of Medical Certification of Sickness. Other Committees assisting the Joint Committee. 77. In addition to the help given by the Advisory Com- mittee, the Joint Committee have derived considerable assistance from other Committees appointed to advise on special matters. 78. Actuarial Advisonj Committee. — The Actuarial Advisory Committee, which has of course been working since the inception of the Act, has continued its fruitful labours, and allusions to them are made in the portion of this Chapter devoted to actuarial questions. 79. Investments Advisory Committee. — In October, 1913, the Joint Committee appointed an Advisory Committee ' ' to advise the Joint Committee and the several Commissions as to the securities which should be approved by them under Section 56 (2) of the National Insurance Act, 1911, for the in- vestment of funds paid over to Approved Societies for investment or retained by the Commissioners for investment on their be- other Committees. 27 half." This Investments Advisory Committee was composed as follows : — The Eight Hon. Sir George H. Mm-ray, G.C.B., P.O., formerly Secretary to the Treasury (Chairman). Lord St. Davids. The Eight Hon. Jonathan Hogg, P.C, formerly Governor of the Bank of Ireland. Sir Henry Johnson, formerly President of the Law Society. Eobert Martin-Holland, Esq., C.B., Director of Martin's Bank, Limited. W. G. Turpin, Esq., C.B., Secretary and Comptroller-General to the National Debt Commissioners. James Allan Cook, Esq. , General Manager of the Scottish Union and National Insurance Company. Henry A. Daniell, Esq., of Messrs. Mullens, Marshall and Co., Brokers to the National Debt Commissioners. E. Eoger Owen, Esq., General Manager of the Commercial Union Assurance Company, Limited. Edward Eae, Esq., Chairman of the Committee of Provincial Stock Exchanges. 80. Postal Payment of Benefits. — During the past year an Inter- Departmental Committee has been appointed to consider the question of the Postal Payment of Benefits. The Committee was appointed by Treasury Minute, dated 18th June, 191S. and was composed as follows : — Sir T. L. Heath, K.C.B., Assistant Secretary, Treasury (Chairman) . Sir J. S. Bradbury, K.C.B., Member of the National Health Insurance Joint Committee. Sir C. Harris, K.C.B., Assistant Financial Secretary, War Office. Sir H. P. Harvey, K.C.M.G., C.B., Chief Auditor, National Insurance Audit Department. Sir C. A. King, C.B., Comptroller and Accountant-General of the Post Office. H. N. Bunbury, Esq., C.B., Accountant and Comptroller- General, National Health Insurance Commission (England). W. G. Gates, Esq., Assistant Secretary to the Post Office. In view of the appointment of Sir Thomas Heath and Sir John Bradbury to be Permanent Secretaries of the Treasury, the Com- mittee was reconstituted by Treasury Minute dated 26th Sep- tember, 1913, with Sir T. H. Elliott, K.C.B., Deputy Master of the Mint, as Chairman, Sir Thomas Heath and Sir John Brad- bury retiring from the Committee. The Committee reported* in favour of a special form of Postal Order being made available for the use of Approved Societies desiring to pay benefits by post, and the administrative steps to give effect to this recommendation are now receiving attention. ♦ Cd. 7245. 28 Joint Committee. 81. The work of other Committees to which the Joint Com- mittee is indebted is referred to elsewhere in this Eeport. Among these Committees may be mentioned the Departmental Com- mittee on Employment under the Crown and the Navy and Army Fund Advisory Committee. The work of the Departmental Committee on Claims for Sickness Benefit is referred to in para- graph 213 below, where it is more properly dealt with, in that the Committee is by its terms of reference confined to England. Charles F. G. Mastrkman, Chairman of the National Health Insurance Joint Committee. U. W. Harris, Clerk to the CGmmiliee. June, 1914. 29 il.— ACTUARIAL. 82. The duties devolving upon the Actuarial Staff of the Joint Committee during the past twelve months have been of a varied character, and have included the completion of the finan- cial machinery required to be set up by the Act of 1911, the various investigations called for in connection with the Bill of 1913, and the preparation of Regulations by which effect is to be given to the directions of Parliament as embodied in the resulting Act. The following paragraphs will, it is hoped, describe sufficiently the general scope of the work for which the staff has been respon- sible. Tables of Transfer Values. 83. The great majority of the persons insured under the Acts are members of Approved Societies. While the membership of a person is in the nature of a permanent connection between him and his Society, the Act contemplates the possibility of transfer of membership from one Society to another, and pro- vides that, when such a transfer takes place, the sum repre- senting the liability of the first Society shall, in normal circumstances, be paid over to the second Society. The trans- action thus amounts, so far as the first Society is concerned, to the termination of the contract at the option of the member and to the payment of the sum corresponding in principle with the surrender value which is a familiar feature in life assurance transactions. Friendly Societies have not been accustomed to the payment of transfer values except to a very limited extent in connection with transfers between Branches, in the case of some of the Affiliated Orders, and in proceeding to the prepara- tion of the necessary tables the subject had therefore to be approached without any such guidance as to the operation of the system as previous experience might have suggested. 84. The basis of the tables of transfer values was fully con- sidered by the Actuarial Advisory Committee,* and their Report is published as Appendix V.t In that Report particular atten- tion is drawn to the differences which arise between the condi- tions under which reserve values and transfer values have respec- tively to be considered, and indicate that although in principle " reserve value " and " transfer value " are identical quantities, there is in practice an important distinction which, as a matter of equity between Societies, must be carefully observed. 85. In fixing the basis upon which reserve values were to be calculated consideration was given to the fact that, owing to the special conditions prevailing when the Act came into operation, the right of the Societies to decline the membership of persons ♦ See paragraph 77, Report of 1912-13. t See page 488. 30 Joint Committee. whose health was unsatisfactory would not as a rule be exercised effectively. The ordinary table of sickness rates, as " loaded " to meet the special conditions of the Act,+ was considered to provide sufficiently for this feature so far as sickness benefit was concerned ; but in respect of disablement benefit it was deemed necessary to make further provision in respect of the first few years after that benefit came into operation. § In dealing with transfer values on the other hand it was considered that the usual canons of prudent administration would prevail in relation to the accept- ance of members. It was realised that a Society to which a person applies for admission by transfer is in a position to protect itself against loss, by a health scrutiny, and it was con- sidered, therefore, that it ought to be assumed that persons who transferred would be in ordinarily good health. The rates of sickness and disablement adopted in the calculation of the transfer values were accordingly such as would apply in these circumstances. Some exception to the general rule was, how- ever, contemplated in respect of transfers taking place within the first year of the Act, since the conditions governing transfers during that period were seen to be closely allied to those under which persons were admitted into insurance. The special modi- fications made in respect of this transitional period, which are described in the Keport of the Actuarial Advisory Committee upon the subject of transfer value, were such as to approximate transfer value to reserve value during the first three months of insurance and to pass by stages to the permanent transfer value basis, which is reached at the end of the first twelve months. 86. Tables of transfer values based upon the principles here enunciated have been prepared and have been embodied in Eegulations. These tables apply to transfers taking effect during the first two years of the Act. Tables applicable to later periods will be published from time to time as required. In addition to the ordinary tables applicable to employed contributors — divided into three sections, " men," " married women," and ** spinsters and widows ' ' respectively — who entered into insurance before 13th October, 1913, and who are entitled to full benefits, further tables are required for employed contributors who enter after that date, and who are normally entitled to reduced benefits if the age at entry exceeds 17. In the case of a person who, owing to the date of entry into insurance, would normally be entitled to reduced benefits but who has qualified for full benefits by pay- ing the necessary capital sum, or by satisfying his Society that he has been engaged since the age of 17 in the completion of his education, the transfer value is found by adding to the ordinary transfer value a sum representing the value of the additional sick- ness benefit to which he is entitled ; and the Eegulations in- 1 See paragraph 154, page 59. § Cf. the provision actually made, as explained on pages 554, 559-60 of the Report of 1912-13, with the theoretical values as shown on page 592 of the same Keport. Actuarial: Tables of Transfer Values. 31 elude the necessary subsidiary table. The transfer value of a married woman who , on or after marriage , was suspended from the ordinary benefits depends upon her status at the date of transfer. On her suspension a prescribed sum was paid to the Married Women's Suspense Account to enable her to re-enter insurance after the death of her husband for the benefits to which she was entitled before her suspension. If, therefore, she became a special voluntary contributor on her suspension or has ended her suspension by becoming employed in her husband's lifetime, her transfer value as a married woman must only relate to her insur- ance for the future period during which both wife and husband will be living ; and the Tables provide accordingly. 87. Owing to the fact that the rate of contributions payable by voluntary contributors depends upon the age at entry — except in the case of contributors who entered at ages under 45 during the first 65 weeks of the Act, and who were allowed the privilege of payment of contributions at the employed rate — the transfer values applicable to this class differ from those applicable to em- ployed contributors, and special tables have accordingly been framed. Crediting of Eeserve Values. 88. The contributions payable by employed contributors are estimated to be sufficient to support the benefits of persons who enter into insurance at the age of 16, the saving accumulated from the contributions in the early years of membership being sufficient, in these cases, to meet the excess of liability in the later years when the current contributions are no longer equal to the strain of the claims for benefit. In the case of persons who enter into insurance at ages 17 and upwards the contribu- tions paid are not of themselves sufficient to support the benefits, the aggregate difference in respect of the fourteen million persons who have become insured representing a present capital sum of about ninety million pounds. To meet this liability, the Act provides that two-ninths (one-fourth in the case of a woman) of the benefits shall be met from moneys provided by Parliament. The contributions, which are estimated to be sufficient at the age of 16, but at that age only, to provide the whole of the benefits thus become liable to meet seven-ninths (or three-fourths) of the benefits in respect of persons of all ages. Taking the whole in- sured population together, and reserving the special question of the rate of sickness among women, the contributions may be understood to be somewhat more than sufficient to meet the part of the benefits for which the Societies are thus made responsible. 89. It would not, however, be enough to leave the matter there. The conditions as to age distribution and (in the case of women) marriage status differ very widely as between one Society and another, and failure to provide means of correcting these in- 32 Joint Committee . equalities would leave some Societies with insufficient resources while conferring superabundant means upon other Societies. The Act accordingly provides machinery by which the inequali- ties may be remedied and the contribution income appor- tioned among the Societies in strict relation to their needs so far as these are dependent on the two factors just named. This machinery is that of "reserve values." In the first instance a defined proportion of the contributions (two-ninths in the case of men, one-fourth in the case of women) payable in respect of each member is retained by the Commis- sioners and a Sinking Fund is thus raised. As the Socie- ties are responsible for seven-ninths (or three-fourths) of the benefits, they receive a net contribution income which is sufficient to meet their liabilities in respect of ejnployed con- tributors who enter into insurance at the age of 16, but insuffi- cient in respect of all other such contributors. The capital sum required at each age (with the future contributions receivable by the Society) to support the proportion of the benefits for which the Society is liable is then ascertained, and this sum, called the "reserve, value," is credited to every Society in respect of each of its members (employed contributors) admitted at that age. These capital sums are, at the outset, book credits only, but carry interest at the rate of 3 per cent, per annum. This interest and the gradual redemption of the capital sum itself are provided out of the Sinking Fund raised as above explained. It is estimated that the whole operation of redemp- tion will be completed in 20 years, at the end of which period the income of the Sinking Fund will be released and will become available for the extension of benefits. 90. The general effect is, therefore, that while the State pays a part of the benefits of all persons, the younger entrants into Societies , and their employers , contribute during the currency of the Sinking Fund towards the other part of the benefits of the older entrants, the transaction being so arranged that, with the aid of the State grant, the youngest entrants will obtain, apart from the ultimate extension of benefits, the full equivalent of the contributions paid by themselves and their employers, while those who enter at higher ages will obtain more, and at advanced ages very much more, than the contributions paid by them and on their behalf would purchase. Claims hy Approved Societies for Reserve Values. 91. It is evident from this brief general statement that the credits of reserve values are of very great importance to Societies, and that each Society should regard itself as closely interested in the matter, affecting, as it does, the redistribution, according to age, of between four and five million pounds a year which have been collected from, practically, all insured persons, at a uniform rate, without distinction on any ground save that of sex. Actuarial: Crediting of Reserve Values. 33 92. The supervision and control of the reserve value credits was undertaken by the Actuarial Branch, and the following para- graphs describe the successive stages of the work, which is now in full operation. -^d-^iiv- 93. To establish its title to the reserve value in respect of, any member, a Society must show : — (1) that the person in fact became a member; (2) that the statements as to age, class, and date of entry are correct; (3) that the member is a British subject or is entitled to be treated as such under the terms of Section 46 of the principal Act or of Section 20 or 21 of the Act of 1913 ; (4) that in the case of a married woman (a) she was, in fact, married at the time of entry ; and (b) she was then an employed person. 94. Particulars on most of these points are obtained from the membership registers of the Societies, and it follows that before any Society can proceed to prepare its claims the membership register must be written up and verified. This initial requirement has caused some delay, owing to the difficulty which many Societies have experienced in the compilation of their registers from more or less defective forms of application for membership. Checking Claims for Reserve Values. 95. The checking of the registers was undertaken by the National Insurance Audit Department, the forms of application for membership being examined and compared with the entries in the membership registers. Entries in the register in respect of persons who had surrendered no contribution cards to the Society were in general eliminated, on the ground of want of evidence of effective membership. Before admitting as British subjects for the purpose of the Act persons in respect of whom the facts available raised the presumption of alien nationality, due inquiries were made, and, where necessary, appropriate declarations were required. 96. The examination did not extend in the case of very large Societies to every individual entry in the membership registers. In these cases a test examination was made of a substantial pro- portion of the entries, and if this test indicated that the cases of error were relatively few and the errors inconsiderable, the test was accepted as satisfactory proof of the general accuracy of the registers as a whole. 97. While such a test examination is sufficient to establish the general reliability of the registers, it does not ensure that claims for reserve values will not be made in respect of persona who have not surrendered contribution cards. To guard against (B254-Gp. 5) B 34 Joint Committee. any such claims, Societies were instructed to take from the contribution registers the names and register numbers of the members in respect of whom they claimed, and to resort to the membership registers for the other particulars required. It was then arranged, as a departmental process, that the claim for a re- serve value in respect of each person who entered into insurance in the first quarter should be compared with the first quarter's contribution card of that person and a special scrutiny be made of the claims for reserve values in respect of persons stated to have entered into insurance after 13th October, 1912, at ages over 17. This procedure serves the further purposes of confirm- ing the date of entry, which determines the age next birthday at entry (and, therefore, the amount of the reserve value), and of preventing the crediting of reserve values in respect of persons for whom claims have been made elsewhere and have been ad- mitted. This last is a point of some importance in connection with transfers during the first quarter, when many persons who were in fact already recorded as members of particular Societies were accepted as original members of other Societies which should have treated them as transferees. 98. To have insisted on proof of age in the case of every insured person would have thrown a very onerous task upon Societies. It was decided, therefore, in the first instance and by way of experiment, to verify a substantial number of cas^s drawn from all Societies, in order to ascertain whether the state- ments as to age made by insured persons might be accepted as correct on the whole. This test was conducted by the Eegistrar- General on nearly one hundred thousand cases selected at random by the Auditors, and took the form of a search of the Birth Registers. A very substantial proportion of the cases has been traced, and the information given as to date of birth proved, as a rule, either to be accurate or to be not seriously in error. More- over, such errors as have been found have tended to balance one another, and it seems probable that when this investigation (which is still proceeding) has been completed the results will, at any rate in most cases, establish the substantial accuracy of the dates of birth given by insured persons to their Societies. 99. In view of the dependence of the claims for reserve values upon the accuracy of the ' entries in the membership register, as explained in paragraph 94 above, it was deemed advisable to delay the invitation to Societies to claim their reserve values until sufficient time had elapsed to enable them to complete their organisation and to get their registers into a satisfactory condition. In July, 1913, a circular was sent to all Societies inquiring if their registers were in a sufficiently forward state to warrant the preparation of their claims. On receipt of a reply in the affirmative and on corrobora- tion by the Auditor concerned, a general circular containing full instructions was forwarded to the Society, together with a form Actuarial: Crediting of Reserve Values. ,85 for intimating to the Commissioners the approximate number of reserve values v^hich the Society proposed to claim in respect of each of its various classes of members. Central Records. 100. In order that materials may be readily available for valua- tion, for the tabulation of statistics, and for other purposes of public importance in connection with the operations of Approved Societies, it is proposed that a central record shall be kept of the membership of each Society. It is intended to compile this record from the reserve value claims, supplemented by corres- ponding returns in respect of persons, e.g., entrants at the age of 16, or aliens, for v^hom no reserve values can be claimed. Socie- ties were accordingly called upon in the general circular of instruc- tions to furnish information in respect of all members entering into insurauce prior to 13th January, 1913, whether reserve values were claimable or not. The entrants during this period include the great majority of persons in respect of whom reserve values will be credited. 101. Cards specially designed to enable the necessary informa- tion to be given with the minimum of trouble have been sent to Societies on application being made in the required form. In the case of married women, particulars as to date and place of mar- riage, maiden name, and name of employer are required in order that the Commissioners may be enabled to ascertain in each case whether the credit of the large reserve value special to a married woman is justified. The cards when written are compared with the registers by the Auditors before being despatched to the Commissioners concerned. Errors in transcription or otherwise are thus eliminated and avoidable correspondence at a later stage is obviated. 102. Much preliminary work had to be done before the claims for reserve values could be examined. An organisation capable of dealing with about fourteen million cases had to be set up. For the purpose of the identification described above, the first quarter's contribution cards of each Society and Branch had to be sorted into numerical order, and cards which had been returned by the wrong Society (as sometimes happens) had to be trans- ferred to the Society to which they properly belonged. Dupli- cate numbers appeared on the cards of some Societies, and in these cases enquiries had to be made, involving a large amount of correspondence. The system of numbering adopted by some Societies was also found to be unsatisfactory and likely to cause considerable trouble in the future not only to the Departments, but also to the Societies concerned, and arrangements had to be made in such cases for a modification of the system. 103. The examination of the claims already received from Societies is proceeding, but the "cards at present received (B254— Gp. 5) B 2 36 Joint Committee. are only a small proportion of the total number, and many Societies have not yet applied for the cards they will require. In some cases the delay is explained by the incom- plete state of the registers, but in other cases the importance of reserve value credits appears to be insufficiently appreciated, especially v^here officials are comparatively uninformed as to the actuarial basis of insurance. A further communication has been sent to those Societies v^hich at the date of issue had not yet responded to the invitation to them to prepare their claims, and it is proposed, at an early date, to apply further pressure in cases of continued neglect. The Basis of Valuation. 104. The x\ct of 1911 requires that the assets and liabilities of every Approved Society shall be valued at triennial or other intervals upon a prescribed basis. Regulations defining the basis of valuation have accordingly been prepared, and have been sub- mitted to the Actuarial Advisory Committee, by whom they are now being considered. It is anticipated that the deliberations of the Committee will be completed at an early date, and that the Regulations, which deal with every necessary point afi'ecting the measurement of Societies' risks, and include provisions control- ling the valuation of the varied classes of securities in which Societies are empowered to invest the funds handed over to them under the Act, will be published in due course. Employment undek the Ceown. 105. In connection with the investigations of the Interdepart- mental Committee appointed by the Treasury to consider the con- ditions of employment under the Crown as affected by the Acts, the services of the Actuarial Branch were required in estimating the value of the allowances made under the then existing arrangements to various classes of employees. In calculating the value of these sick pay privileges , the liability had to be estimated for quite different periods from those in respect of which sickness benefit is usually payable by Friendly Societies, and recourse was had to the special tables which had been prepared in con- nection with the grant of exception certificates before the Act came into operation and which were embodied, with an account of their preparation, in Appendix VI. to the Report for 1912-13. The Committee recommended in their Report* that the value of the sick pay privileges should be determined accord- ing to the rules which they appended to the Report, and which had been drawn up after consultation with the Chief Actuary. * Cd. 7176. '^ ' Actuarial: Work in connection with the Act of 1913. 37 Actuarial Work in connection with the National Insurance Act, 1913. 106. The proposals of the National Insurance Act Amend- ment Bill as presented to Parliament included provisions for the extension and increase of the benefits granted under the Act of 1911. These provisions affected the finances of the Act, and the Actuarial Branch was instructed to prepare estimates showing the extent to which the State charge would be altered, and what additional reserve values would be required. An Actuarial Ke- port giving details on these matters was published as a White Paper* shortly after the Bill was introduced. Estimates were also made in respect of various proposals which were submitted to the Government on behalf of certain Approved Societies and other interested bodies, and the consideration of which involved questions of finance. 107. The proposals of the Bill in relation to benefits and contributions included the following items : — (a) A contribution towards the cost of providing medical treatment for aged and disabled members of certain Friendly Societies and similar bodies, who had not become insured under the Act. The charge on the State was estimated at d630,000 (in respect of 240,000 persons), for the first year, decreasing by ^2,000 annually thereafter. (6) Increase of the benefits of persons who had entered into insurance at ages between 50 and 65. The financial effect of this concession was (i.) to increase the State charge by an estimated amount of about d9100,000 in the year 1915 and by lesser sums in future years, and (ii.) to increase the reserve values by about ^62,500,000, thus prolonging the operation of the Sinking Fund by about 10 months. (c) The insurance for ordinary benefits of persons who were between 65 and 70 at entry into insurance. Under the Act of 1911 no reserve values were credited in respect of these persons , and the benefits which Societies could safely allow were limited by the contribution oi Id. a week (or Qid. in the case of women) supplemented by a State Grant of 2(Z. for each weekly contribution paid. The estimated cost to the State of the new proposals was, in the year 1915, £60,000, this being the maximum charge. The reserve values required w^ere estimated at ^6827 ,000. id) The discharge of arrears by payment of the worker's por- tion only of the joint contribution of his employer and himself. The cost of this concession, in cases where tne contribution income of the Society concerned wa& not already sufficient to meet it, was to be defrayed, up to a * Cd. 6898. (B254— Gp. 5) B 3 ,38 Joint Committee. maximum of dG100,000 a year, from the income of the Sinking Pund for the redemption of reserve values, any liability in excess of this amount being borne by the Exchequer. The charge upon the Sinking Fund was estimated to extend the period of the redemption opera- tions by about six months, and the contingent liability of the State was conjectured to represent a probable maximum charge of ^20,000 a year. (e) Provision for extension of medical and sanatorium bene- fits to persons holding certificates exempting them from liability to become insured. Contributions are payable by the employers of such persons and the resulting sums were made available by the Act of 1913 for the provision of the benefits named, as though the persons concerned were members of Approved Societies. An additional charge upon the Exchequer followed in accordance with the financial scheme of the Act of 1911. This charge was estimated at ^619,000 a year. 108. The estimated total increased charge on the State in respect of these amendments was nearly iG230,000 in the first year of the full operation of the proposals, while the redemption period of the reserve values was estimated to be extended by one year and a half. 109. Various points affecting finance arose during the pro- gress of the Bill through Committee, and a further Actuarial Eeport* was issued on the completion of the Committee stage. The amendments referred to were as follows : — (a) The minimum number of contributions to be paid to entitle persons who entered into insurance between ages 65-70 to medical benefit after attaining the age of 70 was reduced from 50 to 27. (h) A second maternity benefit in lieu of sickness benefit for the four weeks following confinement was provided in the case of an employed married woman. (c) Provision was made for payment of the full amount of the ordinary maternity benefit to an employed married woman whose husband is employed but who for one reason or another is excluded for the time being from maternity benefit, or is only entitled to reduced benefit. (d) An insured woman who was before marriage a British subject but who had married an alien was directed to be treated for the purpose of benefits as though she had not lost her British nationality. (e) The maternity benefit payable in respect of the insurance of an alien man was increased by two-sevenths in cases where the wife was before marriage a British subject. [Begulations under the Section provide that in no case may the benefit so increased exceed the ordinary amount of 305.] * Cd. 6984. Actuarial: Arrears. , §9. (/) It was directed that reserve values should be credited to Societies in respect of persons resident in Ireland as though such persons resided in Great Britain. The object of this amendment was to facilitate adjustments in the case of change of residence. Medical benefit is not provided, under the Act, in Ireland and in conse- quence the reserve values were smaller than those granted in respect of persons resident in Great Britain, the difference representing substantially the liability in respect of medical benefit after the age of 70. The effect of the amendment was to increase the reserve values by the estimated sum of £196,000. This provision does not, however, of necessity increase the term of the Sinking Fund, since on a person resident in Ireland attaining the age of 70 the sum set free in respect of provision for medical benefit after that age is to be car- ried to a separate account and can be applied, either wholly or in part, to the redemption of reserve values. The amendment amounted, in fact, to little more than an accounting arrangement by which was overcome an awkward technical difficulty arising on transfers of resi- dence between Ireland and other parts of the United Kingdom. ' 110. The financial effect of these aniendments was small, the State charge being increased by about £3,000 in 1915, and by smaller amounts in later years. ' 111. After the Bill became law, the revision of the various tables (reserve values, etc.), affected by its provisions was taken in hand, and the amended tables have been issued from time to time as completed. / Arrears. 112. The Act of 1913 rescinded the provisions of the Act of 1911 under which the benefits of persons in arrears were reduced and in some cases postponed or suspended, and directed the Com- missioners to make and embody in Regulations a scheme for dealing with the subject. Draft Regulations have accordingly been prepared and published. 113. After a few months working of the Act of 1911 the Com- missioners were very strongly pressed by Approved Societies to introduce a half-yearly contribution card instead of the quarterly contribution card originally adopted. It was evident that if the currency of the contribution card were extended to six months, the work of the Societies would be materially lightened, and the oost of administration to the Societies substantially reduced. The Commissioners were therefore anxious to meet the desire of the Societies, but until the passing of the Act of 1913 were unable to move in that direction by reason of the difficulty that would (B254— Gp. 5) b4 40 Joint Committee. have been created in administering the provisions of the Act relating to arrears. 114. Section 10 (2) of the Act provided that the sickness benefit of members in arrears should be reduced proportionately to the amount of arrears in accordance v^ith the table in the Fifth Schedule to the Act. This table was based upon the average amount of arrears of the insured person, and in order to ascertain that average v^^ith theoretical precision it would have been necessary in the case of every claim for benefit to make a calculation based upon the duration of membership and the total amount of arrears at the date when the claim was made. It was proposed to prescribe a method of calculation which would have simplified the process to some extent by taking a quarter-year, corresponding with the contribution period, as the unit of -time in calculating the average ; but it was recognised that 'Oven this moderate concession to administrative convenience in- volved some departure from the strict average which the Act appeared to contemplate. If, however, the contribution cards had a currency of six months, it would have been impossible to apply the proposed modified system without a further and much more serious departure from accuracy than that involved in adopt- ing a quarter of a year of membership as the unit of time for ascertaining the average. In these circumstances it was found impossible to relieve the situation by Eegulations. On the other hand, the calculation of the exact average of arrears, the use of which would have made it unnecessary to consider the term of the contribution card, and would have left the Com- missioners free to adopt a half-yearly card, would not only have been very laborious, but would have been almost impossible to work owing to the difiiculty and inconvenience to the insured persons and their employers arising through the necessity of sur- rendering the contribution card to the Society on each claim for benefit. The Commissioners, after consulting the representatives of many Approved Societies, were satisfied, for these reasons, that any attempt to calculate the exact average would have been im- practicable, and so long as the provisions of the Statute remained unaltered they were accordingly compelled to retain the quarterly contribution card. 115. When the Amendment Bill went into Committee it was found that Approved Societies were very keenly desirous of having a simplified scheme for arrears, under which they would be relieved of the complicated processes inseparable from the calculation of any average. The Government were willing to accept an amendment which would have made it possible to adopt a half-yearly contribution card, while retaining the principle of average arrears. Both, however, in the Committee and in the House of Commons generally the feeling was very pronounced that a radical change in the arrears scheme was desirable, and that the Commissioners should be charged with the responsibility of investigating the many points of difficulty with which the ques- tion was surrounded, and of preparing a scheme which should be Actuarial: Arrears. 41 reasonably simple of operation while at the same time affording due protection to the financial interests of Approved Societies. In the result Section 8 of the Act of 1913 was adopted by Parlia- ment. This Section provides that insured persons who are in arrears shall be liable to such reduction, postponement, or sus- pension of benefits as may be prescribed, so however that any such reduction, postponement, or suspension of benefit shall be approximately equivalent to the value of the loss occasioned by the failure to pay the contributions in arrear. The Section fm-ther requu-es the Eegulations to prescribe the time within which, and the conditions under which, arrears may be paid up. The new Scheme of Arrears. 116. Parliament having thus imposed upon the Commissioners the duty of preparing a new scheme, the matter was at once taken in hand, and the details of a scheme were elaborated. A memor- andum explaining the scheme was submitted to the Advisory. Committee on the 28th October, 1913, and the scheme was, after much discussion, accepted in principle. The Committee urged, however, that it would be desirable (if it were possible) so to vary the incidence of the penalties that the burden should fall less heavily than the scheme pro- posed upon the persons who suffered the longest periods of sickness, even though this necessitated some increase of the penalties in other cases. The scheme was accordingly recon- sidered, and a draft of Regulations, together with an explanatory memorandum of the scheme as amended, was submitted to a second meeting of the Advisory Committee on 20th January, 1914. The Regulations received the unanimous support of the meeting, and have been published as Draft Regulations with the intent that they shall come into operation on 6th July, 1914. 117. The provisions of the scheme so far as they relate to em- ployed contributors are as follows : — (a) Each person will be allowed three weeks of arrears in each year without penalty, and if in any year his arrears are less than three the difference will be carried forward (as reserve contributions) from year to year until a year is reached in which a period of unemployment absorbs them. To give effect to the special conditions of the first year of the Act during which no arrears were deemed to accrue in the case of employed contributors, each person who entered into insurance on 15th July, 1912, will also be credited in 1914 with three additional reserve contributions, while persons who entered in the first year, but at a later date than 15th July, 1912, will receive a proportionate extra credit. In no case will arrears incurred up to 13th July, 1913, be brought for- ward against these credits. * A Memorandum [Cd. 7431] explaining the scheme has been laid befor^ Parliament. ' ,. 42 Joint Committee. (6) If a person is in arrears at the end of any year, running from July to July, after absorbing the above allowance of reserve contributions, he will be allowed three months in which to pay such arrears if he thinks fit. His arrears will be cancelled in full if, before the end of that time, he pays off his own portion of the arrears, the employer's portion being excused under the provisions of Section 7 of the Act of 1913. (c) If at the end of three months his arrears are not so dis- charged he will become subject to a reduction of benefit for the first six weeks of any sickness for which he may claim benefit during a period of 12 months, beginning in the following November. Where the length of his claim exceeds six wrecks the full benefit will be payable (unless the arrears exceed 20) for the remainder of that illness, and for any further illnesses in the 12 months. (d) The reduction of sickness or disablement benefit during the first six weeks will be Id. a week for a man and 6 to be varied, as actuarial considerations are sometimes found to require. To remedy these omissions provision was made in the Act of 1913 empowering the Commissioners to make Eegulations upon the subject, and these Eegulations will, it is expected, be pubHshed shortly. The general principle adopted in preparing the Eegulations has been to secure to Societies reserve values in all cases where the funds arising from the con- tributions are not sufficient to support the liabilities, and to cancel reserve values which have ceased to be required and the retention of which would confer a profit upon the particular Societies holding them, at the cost of the general body of insured persons. 139. The Eegulations will accordingly provide for the can- celling of outstanding reserve values in cases where persons have 52 Joint Committee. gone out of insurance on passing the income limit, or other- wise ; while other provisions will direct the crediting of the appro- priate amounts of new reserve values on any such persons again becoming insured. 140. Further, the Kegulations will provide for the cancellation of outstanding reserve values in cases where persons, for reasons which the Society has not ascertained, have ceased for a defined period to surrender contribution cards, and for the reinstatement of such values where it is subsequently discovered that the cir- cumstances justify that course, for instance, where a person has continued to be an employed contributor although he has failed to comply with the Eegulations as to surrender of his card, or where a person has died and his Society has only become ac- quainted with the fact some time afterwards. 141. Provision will be made for the variation of reserve values in cases where a woman who was unmarried at the date of entry into insurance became a deposit contributor, subsequently mar- ried, and after marriage, became a member of a Society. In such a case the provisions of the Act of 1911 , under which the Society would receive the outstanding part of the spinster's re- serve value which would have been credited had the woman become a member when she entered insurance, would fail to afford the Society proper financial protection, and the Eegulations will enable the Commissioners to credit the larger reserve value which the needs of the case require. 142. Provision will also be made in these Eegulations for the case of a person who transfers from a Society to deposit in- surance. The sum directed to be paid to the deposit account of the contributor in these cases is the transfer value, less any out- standing reserve value, the latter being cancelled. The inten- tion of the Act is, clearly, to provide that the sum transferred from the member's Society shall on the average represent the savings from his own contributions during the time he has been a member of the Society. Since, however, the transfer value represents the liability of a Society in respect of a person who satisfies a higher standard of health than that reflected in the reserve value, the deduction from the transfer value of the out- standing part of the reserve value brings out, as the value of the contributions for the period of membership, a somewhat smaller sum than the equities of the case require. The Eegulations will accordingly provide for the reduction of the part of the reserve value which is to be cancelled to such a sum as will give effect to the intention of the Act. 143. Another article of the Eegulations will provide for the case of the alien who becomes a British subject and thereby becomes entitled to the ordinary benefits of the Act. In such a case no reserve value was originally credited, but some reserve against its liability to him has, in general, been accumulated by the Society out of the alien's contributions. The Eegulations will authorise Actuarial: Deposit Contributors. 53 the Commissioners to credit such a reserve value as will adequately protect the Society, having regard to the increase of its liabilities in which the naturalisation of the alien has resulted. 144. Further provisions of these Eegulations will authorise the variation of reserve values in cases where mistakes as to age or other points affecting the original credit have come to light. Deposit Contributoes. Special Investigation. 145. The provisions of the Act of 1911 relating to deposit contributors come to an end on the 1st January, 1915, and with a view to preparing material for determining the future condi- tions applicable to this class of insured persons, an investigation has been made into the experience of established deposit contri- butors during the first six quarters of insurance. Accounts of about 25,000 deposit contributors in London and of about 60,000 in England outside London were selected at random from the whole body, and abstracts were prepared containing a record of all receipts and payments up to the end of the sixth quarter of insurance. Men and women, British subjects and aliens, and entrants in each of the first five quarters, were represented in approximately the same proportions as in the whole body of deposit contributors in England. The records as to aliens were sufficiently numerous to be worthy of a separate analysis. In the case of deposit contributors in Scotland, Ireland, and Wales, the whole of the established accounts, and not a sample, were similarly analysed. 146. The term " established," used with reference to a de- posit contributor, means that the person concerned has regularly entered into the deposit class by filling up the official appli- cation form. In addition to those- deposit contributors who have taken formal steps to establish their status, there are also certain " unestablished " cases, e.g., persons who do not reply to official communications or take any action other than handing in their cards at the Post Office. It is understood that the number of these cases is constantly diminishing, largely in con- sequence of the continued activity of Approved Societies in en- rolling members. Examination of Statistics. 147. The details of this investigation are shown by the various tables contained in Appendix VI. The more important of the conclusions to be drawn from these tables are as follows : — (a) The deposit contributors are persons of all ages, and about 50 per cent: of the men and 60 per cent, of the 54 Joint Committee. women are under the age of 35. Had this class con- sisted chiefly of persons who, on grounds of health, had been unable to obtain admission to Approved Societies ^ it would have been expected that a preponderating number of them would have been of the middle and higher ages. Such, however, is not the fact. There is ^ it is true, a certain tendency in this direction, the pro- portion of deposit contributors at ages over 50 being nearly 25 per cent., against a normal proportion of 15 per cent, in the case of men and about 20 per cent, against 10 per cent, in the case of women. This, how- ever, seems to be the whole extent of a difference which, had original expectations been realised, would have been much more strongly pronounced. (b) The number of alien deposit contributors is very large in proportion to the total number of deposit contributors whose accounts have been examined, and suggests that about 30 per cent, of all the aliens who are not entitled under Section 45 of the Act of 1911 to be treated as British subjects have become deposit contributors. Again, the age distribution of alien deposit contributors is quite abnormal. About 50 per cent, of them are aged between 20 and 30, this being about twice the proportion that obtains among deposit contributors generally. From these figures it seems evident that a considerable number of aliens who are resident only temporarily in the United Kingdom, having become insurable, have taken advan- tage of deposit insurance with a view to regaining possession of the balances accumulated from their personal contributions when they return to their own countries. The abnormally large number of alien deposit contributors' accounts, which have already been closed on emigration, confirms this conclusion. (c) The payment of contributions by deposit contributors has been extremely regular. In the case of persons who entered into insurance on 15th July, 1912, and returned contribution cards in respect of the whole period up to 11th January, 1914, 50 per cent, of the men in the London area and 47 per cent, of the men outside of the London area paid contributions uninterruptedly at the rate of 52 a year; while 17 per cent, in the London area and 23 J per cent, outside it paid at the rate of between 48 and 51 contributions a year. In the case of women the figures are still more remarkable. In the London area 64 per cent, and outside the London area 71 per cent, paid at the rate of 52 a year ; and 16 per cent, in the London area and 13 per cent, outside it paid at the rate of 48 to 51 a year. These -figures point to great regularity of eniployment, and as the minority of cases in which contributions were less regularly paid must in- Actuarial: Deposit Contributors. 55 elude some persons who are engaged in insurable em- ployment during a portion of the year only, and who have not considered it worth their while to become members of Approved Societies and to pay the full rate of contributions themselves for the remaining part of the year, it must be concluded that the established deposit class is composed only to a very small extent of the unfortunate class at the bottom of the industrial scale whose employment is occasional and precarious. Whether such persons are to be found in greater degree among the unestablished deposit contributors referred to above is, of course, another question. (d) As a further result of the regularity of contribution pay- ments it is found that of the deposit contributors who returned contribution cards for the sixth quarter, a num- ber, representing well over 90 per cent., had accumulated balances on 12th January, 1914, of sufficiently large amount to enable them to go into Approved Societies without suffering any penalty on account of depleted credits. Under Section 43 of the Act of 1911, if a deposit contributor becomes a member of an Approved Society it is necessary to examine his account and to ascertain whether the sum standing to his credit is equal to the "value of his contributions," i.e., the average amount which would have been accumulated out of the contribu- tions paid in respect of him had he been a member of the Society from the date at which he entered into insur- ance. Upon the transfer of such a contributor the Society receives a reserve value in respect of him, and the value of the contributions represents the additional sum which it should receive in order to accept him on the ordinary terms without loss. If, therefore, there is a balance in his account in excess of the value of the contributions, the excess is retained by the Deposit Contributors Fund. If, on the other hand, there is a deficiency in his account the loss is borne by the in- sured person individually. He is placed in arrears to the amount of the deficiency, and his benefits are reduced accordingly. Six to ten per cent, only of the entire number of deposit contributors who have returned con- tribution cards for the sixth quarter would, apparently, be affected by this penal provision. ie) The claims for benefit have been singularly few. It is impossible, of course, to measure the total sickness ex- perience of the deposit contributor class, because with the exhaustion of a deposit contributor's balance his right to benefit terminates for the time being ; and in the earliest months of benefit, when the l^alance to the credit of any deposit contributor was necessarily small, a protracted illness would speedily exhaust the account, 56 Joint Committee. and the record of the sickness would terminate after the first two or three weeks of claim. On the other hand, some useful conclusions may possibly be deduced from a comparison of the number of persons who have made sickness claims with the number of persons who might have been expected to do so, and the data having been scheduled with reference to age these expectations have accordingly been calculated. It is found that the actual number of claimants has been, as a rule, between 25 and 30 per cent, only of that expected. Still more singular is the fact that the claims for maternity benefit have been only about 25 per cent, of the expectation in the London area, and only about 30 per cent, else- where than in London. The sickness experience, taken for what it may be worth, appears to indi- cate that the majority of the deposit contributors are far from being representative of the class of under- average lives to whom it was supposed that the doors of the Approved Societies would be shut, while the very low proportion of claims for maternity benefit ap- pears to indicate the presence among the group of a large proportion of unmarried persons of the particular classes to whom any scheme of insurance would fail to make effective appeal. It might, indeed, be thought from this feature of the experience that the group includes an abnormally large proportion of unmarried persons who expect to attain to an income of d6160 a year and consequently to go out of insurable employment ; but the very general distribution of the deposit contributors over all ages between 16 and 70, and the de- scription of the occupations of deposit contributors given in Appendix XV. of the Eeport for 1912-13, appear to negative this limitation. (/) The various facts which have been collected as to the ages and occupations of deposit contributors would lead to the conclusion that the class is not to be distinguished, from the point of view of earnings, from the general body of insured per- sons. The only means by which any direct investigation could be made on this point was that of tracing out the number of cases in which the deposit contributors' con- tributions had been supplemented by the Parliamentary grant of Id. a week provided under the Act of 1911 in cases where the rate of remuneration does not exceed 2s. a working day. It was found that in England about three per cent, of the men and eight per cent, of the women had benefited by this provision, this percentage being somewhat higher than was expected in the case of men, but very much lower than was looked for in the case of women. It is. Actuarial: Deposit Contributors. 57. of course, quite uncertain whether the small percentage of beneficiaries under this head in respect of women is attributable to ignorance of the provisions of the Act, but it is at least probable that some part of it is so due. About 60 per cent, of all the men and about 50 per cent, of all the women who obtained the " Parliamentary Id.'* received it in respect of a portion only of the time during which they were in insurable employment, this propor- tion being, on the average, about one-half of the time for which this sub-group was so employed. Possibly this feature is to some extent explained by the ignorance of the provisions of the Act to which reference has just been made, and it may be the case that since information on this subject has been more widely disseminated, insured persons are more promptly and more completely assert- ing the rights conferred upon them by the Statute, both against their employers and against the Exchequer. It is however probable, also, that there is a good deal of change of employment among the persons who are re- munerated at very low rates and that earnings vary accordingly, thus carrying at one period the right to the " Parliamentary Id.,'' while at other periods the whole contribution must be paid by the employed person and his employer. The figures are given for what they may be worth, but are not put forward as conclusive. 148. It is impossible to discover, where few contributions have been paid, whether lack of employment, intermittency of " em- ployment ' ' within the meaning of the Act , or ill-health is the cause. For example, in certain areas in Scotland the ratio of deposit contributors to members of Approved Societies is found to be abnormally high, and it appears that large numbers of persons who work on their own account for the greater part of the yeai have definitely chosen deposit insurance as affording the most convenient means of disposing of the relatively few contributions they expect to make in respect of periods of employment. The circumstances of these persons are essentially different from those of persons whose irregularity of contribution is due either to ill-health or to genuine unemployment. It is possible that many persons engaged in seasonal trades may take advantage of the provisions of the Act of 1913, which enable them to claim exemption on the ground that they are ordinarily and mainly dependent on earnings derived from occupations which are not " employment " within the meaning of the Act, and if this should prove to be the case the class of deposit contributors will be reduced by the removal of many persons for whom no effective insurance provision could be made under any compulsory scheme. 149. The figures for Scotland, Ireland, and Wales are closely confirmative of those obtained in respect of England ; and on the whole, therefore, there is no difficulty in reaching the conclusion that the great majority of deposit contributors, taken as a body, 58 Joint Committee. are at least equal to the insured population generally in health, regularity of employment, and other conditions which constitute eligibility for membership of an Approved Society. The Financial Position of Appkoved Societies. Information at present available. 150. Shortly after the payment of benefits began (in January, 1913) it became apparent that the experience of many Societies in respect of claims for sickness and maternity benefit, especially the former, was tending to diverge very considerably from the general average ' ' expectation ' ' of the tables used in the financial basis of the Act. It was difficult at the outset to draw definite conclusions from this feature. The composition of particular Societies in regard to the important element of age was quite un- known , and in the case of women no information was forthcoming as to the relative numbers of married and unmarried members, and as to the degree in which claims for sickness benefit after confine- ment (for which due provision was made by the special reserve values of married women) were influencing the expenditure. Again, sickness benefit became operative in the middle of the winter months, and at a time therefore when all experience showed — as indeed would be expected — that sickness was at its maximum. On the other hand, the right to sickness benefit enured only after 26 weeks had elapsed from the date of entry into insurance and 26 contributions had been paid, and it was quite uncertain in the early months of 1913 what adjustment ought to be applied to the number of contributing persons in order to obtain the effective number in respect of which the Societies became ' ' at risk ' ' of sickness claims immediately when the payment of benefits began. 151. Of these factors in the problem, perhaps that of age is normally the most important in its relation to sickness claims. But if the claims for sickness and maternity benefits are taken together and regard be had only to the combined cost of the two benefits, the element of age is of less importance in the case of men than in the case of women, because the increase in sickness claims as age advances is largely neutralised, in the case of men, by the corresponding fall in the claims for maternity benefit, whereas in the case of women this counterbalancing factor is insignificant owing to the small proportion of insured women who are married. A further consideration, tending at the outset to reduce the importance of the age factor, existed in the reduction of sickness benefit in the case of persons who entered into insurance at ages over 50, but since October, 1913, this reduction has, in virtue of the Act of 1913, ceased to operate, and age has its full effect upon the sickness claims. 152. On the whole, the passage of time and the completion of a full year's experience has, to some extent, relieved the difficulties Actuarial: The Financial Position of Approved Societies. 59 of gauging the situation from the actuarial point of view. Ma- terials for anything approaching an exhaustive inquiry are still lacking, and must continue to be lacking until the Societies have claimed their reserve values and particulars as to age and other conditions have become available ; and further until the Act has been sufficiently long in operation to permit of the accumulation of a substantial body of facts bearing upon the subject to be judged. But from such materials as are now available certain broad conclusions emerge, and these, as stated below, are suffici- ently important to require early consideration with a view to adopting such remedial action, where necessary, as will safeguard the interests of the insured persons in the Approved Societies affected. 153. These conclusions are as follows : — (1) The sickness claims of men, taken as a whole, have been within the actuarial provision. (2) The sickness claims of women, taken as a whole, have been materially in excess of that provision. (3) Great variations have arisen between the sickness claims made upon individual Societies. While in many cases the claims have exceeded the estimates, there are many other cases in which the cost of the benefits has been so far within the estimates as to lead to the expectation that a large number of Societies and branches will be found upon the first valuation to be in possession of surpluses. (4) The sickness claims of both men and women have been, in the case of many Societies, above the standard which should normally prevail, and may be expected to obtain when Societies have become experienced in the admin- istration of sickness benefit under National Health In- surance conditions. <5) The claims for maternity benefit have also varied con- siderably as between different Societies. The Actuarial Basis of Sickness Benefit. 154. It will be coHvenient here to refer briefly to the provision made for sickness benefit in the actuarial estimates, as to which full information will be found in the Reports of the Actuarial Advisory Committee, pages 554-5 and 559-60 of the previous Report. The basis of that provision is the experience of the Manchester Unity of Oddfellows in the period 1893-97, and it appears, still, to be supposed in many quarters that, because the Manchester Unity Table was employed, the provision for sickness is that indicated by the Manchester Unity Table and nothing more. But it should be realised that whereas the composition of every 1,000 lives in the Manchester Unity membership was roughly 785 subject to normal conditions to 215 subject to extra 60 Joint Committee. risk of various kinds and degrees, the corresponding proportions in the whole industrial population of men were found to be 466 and 534, and that the Manchester Unity sickness rate (adjusted to exclude incapacity which created a title to compensation for accident or industrial disease) was loaded to provide for the extra liability resulting from this difference of distribution as between light and heavy risks. Further, the Actuarial Advisory Committee were impressed by the considerations which dictated the expectation of a normally heavier sickness rate among a compulsorily insured population, including some of the very poorest of the people, than had in the past obtained on the general average among a body of voluntarily insured persons, the great majority of whom were fully occupied and a significant pro- portion of whom were not wage-earners. The contribution fixed by the Statute having contained a margin over the original estimates framed in connection with the Bill, the Committee were enabled to give substantial effect, in measuring the sickness risk, to the conclusions to which their deliberations led them ; and an addition of about 13 per cent., being the full amount which the contribution allowed, was accordingly made to the standard rates as already "loaded" for the definite differences in risk above explained. The eventual result was to add about 25 per cent, to the normal Manchester Unity standard of sickness. 155. In view of the considerable provision thus made for sick- ness benefits, it is almost a matter of course that in respect of men the experience of the first year, when taken as a whole, should show a small saving upon the actuarial estimates. It would appear from statements that have been made that the rate of sickness among the older Friendly Societies has risen considerably since the Act came into operation, and that material excess over the provision made for the sickness claims in the voluntary contributions and reserves of the Societies is being experienced. On the Act side, however, the claims on the majority of these Societies appear on the whole to be within the actuarial provision. 156. No reliable information as to the sickness prevalent among women existed before the Act came into operation. The returns of expenditure on benefits for the first year of the Act, when analysed and tabulated, will supply the first collection of useful data as to the sickness risks of women ; and even this experience will have to be adjusted to secure the elimination of figures representing unjustifiable claims before it can be regarded as statistically valuable. The rate of sickness provided for in the case of women was, in these circumstances, practically the same as in the case of men. If it be admitted that, other things being equal, women are subject to a greater amount of sickness than men, it must be borne in mind that occupational conditions do not increase the average rate of sickness among all insured women to the same extent as in the case of insured men ; and Actuarial: The Financial Position of Approved Societies. 61 that in the common rate of sickness employed for the purposes of the Act the natural excess in the case of women may be deemed to be represented by the occupational excess provided for in the case of men. If due weight be given to this consideration as well as to the fact that the real extent of sickness among women was unknown, it will be agreed, doubtless, that difficulty would have been experienced in coming to the conclusion in 1911 that women ought to pay for sickness insurance at a relatively higher rate than was required of men. Future Provision. (i.) Sickness among Married Women. 157. So much being said in support of the considerations which dictated the original rates of contribution, it seems evident that some revision of the finance of the Act in respect of women will be necessary. A substantial part of the excess of claims which has been revealed is due to the claims of women (almost entirely, of course, married women), in respect of the period of pregnancy. Many of these claims, doubtless, have been on the border line of justification. Nearly all of them represent demands which were unknown to the relatively few Friendly Societies of women which existed before the Act, and which, if not explicitly precluded by the rules, would still in general have been repudiated by those Societies as inconsistent with insurance against sickness. (ii.) Sickness among Women generally. 158. Apart from this difficulty, there are indications that, despite the relatively high rate of sickness provided for, the con- tributions are insufficient in the case of women generally. A remedy for this insufficiency could be found in a moderate alteration of the statutory apportionment of the con- tributions of women between the Societies and the Sinking Fund. (iii.) Risks special to particular Societies. 159. The variations which have arisen between the sickness claims made upon individual Societies call for careful considera- tion. It is well known that in many cases the rate of sickness is affected by occupations or by the conditions incidental to particular occupations. On the first of these points, for example, the rate of sickness among chemical workers is much heavier than among agricultural labourers, and on the second point, the miner or the railway worker whose occupation demands a high degree of physical efficiency is frequently pre- vented from going to work by an ailment that would inconvenience but would not incapacitate a clerk or other indoor worker. Cer- tain Approved Societies are composed largely of persons engaged 62 Joint Committee. in particular industries or in allied groups of industries in which the conditions are very similar and in which the rates of sickness are influenced materially by one or other of these factors : and these Societies for the most part exhibit relatively heavy rates of sickness. Again, there are other Societies composed largely of unskilled workers, poorly paid and frequently under-employed, among whom presumably an insufficiency of food and other un- favourable conditions are pre-disposing causes of the compara- tively high rate of sickness which the claims tend to reveal. With all such classes, the uniform rate of contribution which, in the case of men, appears to be sufficient on the general average will tend to be too low, and the adoption of corrective measures will be necessary. 160. A practicable course would be to apply a small propor- tion of the contributions retained by the Commissioners for the redemption of reserve values, with any grant which Parliament might be disposed to make, to the establishment of an Equalisa- tion Fund from which, under strictly defined conditions, grants might be made to Societies in deficiency through excess of risks. 161. The variations in the strain of the claims for maternity benefit fall into the same category of matters requiring the estab- lishment of an Equalisation Fund. These variations, though pro- nounced in some cases, are not greater than was anticipated in the Report of the Actuarial Advisory Committee, wherein the Joint Committee was advised against the re-insurance of this risk ,* partly on the ground that where the cost of maternity benefit was heaviest the cost of sickness benefit would also tend to produce a financial disturbance and one much exceeding that due to the high birth-rate. Excess of claims for maternity benefit is most apparent (as was expected) among Societies of miners, but there are also indications of excess in other cases, which indicate that certain large Societies have either obtained their membership to a disproportionate extent from the poorer sections of the industrial population (among which a high birth- rate is generally believed to prevail) or have adopted methods of recruitment, such as door-to-door application (which means in great measure the canvassing of married women), which have brought to them an abnormally high proportion of married men. Other Causes of Excessive Claims. 162. The excess of sickness claims referred to in the fourth of the general conclusions set out in paragraph 153 points to the necessity for increased vigilance on the part of the Societies and the certifying doctors alike. Many new Societies have yet to dis- cover the most efficient methods of supervision of sick members, and the first year of benefits must be regarded as an experimental period affording but an imperfect indication of the probable strain * See Appendix IV, page 563 of the Eeport for 1912-13. Actuarial: The Financial Position of Approved Societies. 63 upon the funds after a normal and efficient system of administra- tion has been attained. Certain Societies which have been accus- tomed to the payment of sickness benefits under more or less loose conditions, and without accumulation of funds upon an actuarial basis will doubtless be led to alter systems of management which insufficiently check the claims, and are inconsistent with the administration of funds compulsorily levied under Statute and supplemented by drafts upon the National Exchequer. Certain other Societies should more definitely separate the conduct of the State business from that of the private business, and thus alter methods of procedure which appear to lend some degree of support to the suggestion, which has been rather frequently made, that a generous administration of the one is dictated by consideration for the prosperity of the other. Many Societies are faced by the pressing question of over-insurance. As was explained at length in the last Report, the policy gener- ally adopted by the Friendly Societies in the preparation of their schemes under Section 72 of the Act has resulted in the duplica- tion of sickness insurance by the great majority of their members. It should have been foreseen from past experience of high sick- ness benefits that increase of insurances would be immediately followed by an increase of claims, not only tending to disturb the financial basis of compulsory insurance but also reacting severely upon the voluntary funds of the Societies. The Act afforded the Societies the opportunity of deciding whether existing benefits should be reduced (and deficiency in many cases thereby at once extinguished) , or whether existing benefits should be continued regardless of the benefits provided under the Act. The Societies have decided, for the most part, to allow each member to make his own choice, and the great majority of the members, in select- ing additional insurance regardless alike of the burden of extra contributions, of a reasonable relation between insurance and wages, and of the actuarial condition of the voluntary funds, have created, for many of the Societies, a situation to which they must seriously apply themselves. 163. As regards the certifying doctors on whom in great measure the Societies are bound to rely, it is impossible to doubt that there has been, in many quarters, too little recognition of the high degree of confidence which Parlia- ment reposed in the medical profession when it decided to with- draw the administration of medical benefit from the Approved Societies and thereby largely to place in the hands of the pro- fession the well-being of the Societies, whose expenditure on sickness benefit is no less dependent on sound certification than on efficient administrative supervision. There is no doubt that great improvement in certification is both necessary and practicable. 164. Above all, Societies must impress the fact upon their members that their permanent interests in respect of National 64 Joint Committee. Health Insurance are bound up with the prosperity of their Societies. When the payment of benefits began there appears to have been a rather general impression that the funds available for benefits were inexhaustible. That belief was held perhaps more strongly by those who had never been insured than by those to whom insurance was no new thing, but even among the latter many appeared to think that in all circumstances the maintenance of the normal benefits was certain : and this without regard to the losses which might result from defective supervision of claims. Among officials of Societies at least the true position is, it is believed, beginning to be appreciated. General understanding, it is hoped, will follow, and will assist Societies in the administra- tion of a class of risks, the cost of which throughout the history of Friendly Societies has always had a moral as well as a mathe- matical aspect. A. W. Watson, Chief Actuary to the National Health Insurance Joint Committee. Jane, 1914. 65 PAET III. NATIONAL HEALTH INSURANCE COMMISSION (ENGLAND). INTRODUCTORY. 165. The constitution of the National Health Insurance Commission (England) has changed during the past year, owing to the resignation of Sir John Bradbury, K.C.B., on his appoint- ment to be Joint Permanent Secretary to the Treasury. Mr. H. N. Bunbury, C.B., has, by Ti;easury warrant, been appointed a member of the Commission. Advisory Committee. 166. Diu:ing the period under review Mr. W. M. Lawson resigned from the Advisory Committee appointed by the English Commission, owing to the severance of his connection with Approved Society work ; Miss Constance Smith also resigned on account of her acceptance of a post under the Home Office. Mr. Arthur Henderson, M.P., has been appointed a member of the Advisory Committee. 167. In addition to the meetings held in conjunction with the Advisory Committee to the Joint Committee (see paragraph 75 above), the English Advisory Committee has met either as a whole or in sections where the matter for discussion was not of general interest to consider various important questions, including the draft Regulations for the appointment of representatives of insured persons on the permanently constituted Insurance Com- mittees, or proposals for prescribing the places at which meetings of Approved Societies should be held. (B254— Gp. 5) 66 England. APPROVED SOCIETIES. 168. This Chapter of the Eeport deals mainly with the general assistance given by the Commission to Approved Societies through the issue of circulars giving information as to the requirements of the National Insurance Acts and advice as to the administrative arrangements necessary to meet them. It must, however, be borne in mind that it is only one of several methods by which the Commission assist Approved Societies. In the first place, the Commission continues to receive daily a large correspondence, by means of which many difficulties experienced by particular Societies are satisfactorily dealt with. Further, the Outdoor Staff of the Commission receive many communications orally and in writing from officials of Approved Societies and insured persons. The Commission thus receive early informa- tion of any administrative difficulties or defects as they present themselves both to those who administer the benefits and those who receive them, and are enabled to obtain a general view of the Acts in operation. Organisation. Approval of New Societies. 169. Fifty-four Societies have been approved by the Joint Committee and the English Commission since the first week in October, 1912, and further applications for approval are received from time to time. The total number of Societies approved by the Joint Committee and the English Commission, excluding Branches, is now 1,858; 170. Before approval is granted evidence is required that the new Society will commence operations with an assured member- ship of at least 200 insured persons. A new Society is usually intended to meet the particular circumstances of special classes of insured persons, and a Society of this kind is likely to attain a substantial membership within a reasonable time. Examples of Societies recently approved to which this observation applies are the National Advertising Society, the Hunt Servants' Health In- surance Friendly Society, and the Scouts' Approved Society in- stituted in connection with the Boy Scouts' Association. Membership of Approved Societies. 171. Statistics of the number of insured persons who are members of Approved Societies, and of the distribution of the members among the various classes of insured persons, will be found in Appendix VII, page 498 below. The statis- tical information given in these Appendices is necessarily limited to the earlier quarters for the reason that the figures have to be ascertained from the Societies' quarterly returns of contri- butions, and these returns are not made up till some considerable Approved Societies: Organisation. 67 time after the end of each quarter, in order that the trouble arising from the late surrender of cards by members may be reduced to a minimum. From a comparison with the numbers of deposit contributors at the same date, it appears that at the 13th April, 1913, about 97'1 per cent, of the insured population were members of Approved Societies, and 2 '9 per cent, were deposit contributors. Exactly the same percentages were obtained (97 '1 and 2 '9) in both cases when the figures for men and women were examined separately. The ratio of men to women among members of Approved Societies was 2 '237 to 1, and among deposit contributors 2 "242 to 1. It is not uninteresting to note that the ratio of men to women was slightly higher among deposit contributors than among members of Approved Societies. 172. The following summary table of the membership in Eng- land of Approved Societies of various types as at the 13th April, 1913, is for convenience printed below : — 1 ] Men. Women. Total. Societies formed by — Friendly Societies with Branches ... 1,877,051 Centralised Friendly Societies ...' 1,816,266 Trade Unions 948,885 Industrial Assurance Companies ...' 2,162,396 Collecting Societies ' 396,105 Employers' Provident Funds and Works Societies 78,665 510,888 652,379 205,599 1,597,000 267,554 20,432 2,387,939 2,468,645 1,154,484 3,759,396 663,659 99,097 Totals 7,279,368 3,253,852 10,533,220 Amendment of Rules. 173. The Commission have in the course of the year had con- siderable correspondence with Societies in regard to amendments of their rules, which require the consent of the Commission before they become operative. 174. As was anticipated, a large number of Societies found, as the result of experience in administering the Act, that some modi- fications were required in their rules as originally made for that purpose. In the majority of cases dealt with the amendments have been concerned mainly with matters of detail relating to the constitution and government of the Society or to the administra- tion of benefits. In considering such amendments, the Commission have sometimes been compelled to point out that the proposed alteration would be inconsistent with an express provision of the statutes, or would be open to other material objection; but apart from these reservations, the fullest recognition has been given to the important principle of giving Societies the fullest possible share of discretion, and each Society decides for itself as to the form of rules which will enable it most efiSciently to conduct its affairs. (B254— Gp 5) c 2 68 England. 175. It is not unimportant to observe that the Commission's, functions with regard to amendments are limited to consent and the withholding of consent ; their consent does not imply that the amendment is such as they would have themselves suggested^ but only that it is not such as they feel bound to object to. Amendments of rules, e.g., which affect only the administration of benefits on the private side, with which the Commission have no concern, are passed automatically and without scrutiny by the Commission. It is interesting to note, as an illustration of the historical development of Approved Societies, that their association with National Health Insurance has not destroyed the astonishing variety of Societies' rules for the conduct of business, on the private side. Particularly is this the case with old Socie- ties, w^hose private side rules go back perhaps a hundred years. Fortunately the duties of the Commission do not extend either to the interpretation or the enforcement of rules prohibiting the *' buying or tossing for nuts, or receiving nuts under any condi- tions," or providing " That no member shall contribute more to the box in particular than he can earn in general." 176. The alterations effected by the National Insurance Act, 1913, necessitated considerable amendments in the rules of Approved Societies, not only because these rules were, as was explained in the last Eeport, designed to be in a large measure declaratory of the provisions of the Act of 1911^ but because the provisions of the amending Act involve certain modifications of the administrative procedure of Societies, for which sanction was necessary in their rules. In view of the un- necessary difficulties and expense which would in many cases have been involved in securing a regular adoption of the necessary amendments by, e.g., a general meeting of the Society, Section 17 of the 1913 Act provided that if the Executive Body of a Society applied and proved that the amendments could not otherwise be made without delay, the Commission might give authority for the amendments to come into force immediately and to remain in force pending the next ordinary meeting of the rule-making authority appointed under the rules. 177. The Commission decided to issue model rules em- bodying the amendments and additions which would be required in the rules of Societies as a result of the Act of 1913. They considered that it would be an advantage to issue these model rules in such a form as would save Societies the expense of reprinting the necessary amendments on their own behalf. The model amendments were therefore prepared in the form of a leaflet, adapted for insertion without altera- tion in the rules of any Society which might adopt them. An explanatory circular, enclosing copies of the model amendments, and informing Societies of the facilities for amend- ment provided by Section 17 of the Act of 1913, was issued to all Approved Societies. Societies were informed at the same time that further copies of the model amendments could be procured Approved Societies: Organisation. 69 at moderate prices through the ordinary sources supplying Govern- ment pubUcations. The large majority of Approved Societies adopted the model amendments without further alteration, and as a whole the procedure described has proved very successful, and has undoubtedly resulted in a considerable saving of expense to Approved Societies. Adaptation of Machinery to the Requirements of the Act of 1913. 178. The various steps which have been taken by the Com- mission to assist Societies in adapting their machinery to the changes effected by the Act of 1913 are more conveniently dis- cussed under the paragraphs dealing with the various questions as they arise. It may here be noted, however, that early in September, 1913, very shortly after the 1913 Act became law, a circular (A.S. 103) was issued to all Societies, containing a statement of the provisions of the 1913 Act which would affect the work falling to the share of Approved Societies, and informing them of the dates on which, under the Order made by the Joint Committee (see paragraph 24 above), the various Sections would come into operation. The circular also indicated certain general changes of administrative procedure which appeared to be necessary as a result of the Act. 179. Special circulars were also issued to Societies on certain points arising out of the provisions of the Act of 1913 to which it was desired to draw further attention. These may be briefly noticed. Section 2 of the Act of 1913 extended the time for entry into insurance at the flat rate of contribution with title to the ordinai*y rate of sickness benefit from the 15th July to 13th October, 1913. This necessitated a revision of the Table (BB) which had been previously issued,* showing (a) the additional rate of weekly contributions and (h) the lump sum which a person entering in- surance on or after 13th October, 1913, at 17 years of age or over might pay in order to avoid the reduction of sickness benefit under Section 9 (4) of the principal Act. The additional weekly rates of contribution range from Jd. per week for persons between the ages of 18 and 25 at entry into insurance to lOd. for men {9d. for w^omen) between 62 and 65 ; while the lump sum payable ranges from 175. 6d. for men under 19 to a maximum of £4 19s. for men 36 and under 40 years of age, and from 10^. 6d. in the case of single women (19.9. in the case of married women) under 19, to £2 Is. in the case of single women 44 years of age and under 49, and £2 10s. Gd. in the case of married women 36 and under 43 years af age, the lump sum payable decreasing after these ages in proportion to the decrease in the expectation of life. It was impressed on Societies that insured persons must be given in- formation as to their choice between the acceptance of reduced * Circular A.S. 98. (B254— Gp. 5) c 3 70 England. benefit in return for the lower rate of contribution, and the pay- ment of the additional weekly contribution or lump sum in order to secure full benefit. 180. The Eegulations made under Section 3 (3) of the Act of 1913 for the purpose of effecting the transition to the increased rates of benefit provided by that Section were issued in October, 1913. Under the Section , which became operative on the 13th October, an insured person over 50 years of age acquired the right to sickness benefit at the full rate as from that date. The Eegula- tions dealt with such incidental matters as the provision that any sickness benefit received before the 13th October, 1913, at the lower rates must be reckoned towards the whole period of 26 weeks to which, for the purpose of any specific disease or disablement, sickness benefit extended. Payments, on the other hand, in the nature of periodical allowances to persons who entered insur- ance at 65 years of age or over and to whom Section 49 of the principal Act had applied, were not reckoned towards the period of 26 weeks allow^ed for sickness benefit. Persons belonging to this latter class, however, who under the scheme of benefits adopted by their Society w^ere entitled to periodical allowances or payments in the nature of sickness benefit for six months after attaining the age of 70, were declared to be entitled to continue to receive such payments from the date of their attaining the age of 70 until llth January, 1914 ; and persons who had been allowed medical treatment by their Societies continued to receive that benefit until the same date , when the administration of the benefit was taken over by the Insurance Committees. The Work of Associations. 181. The voluntary Associations which, as was explained in paragraphs 175-183 of the previous Report, came into existence as the result of the activities of voluntary committees formed in various areas for the purpose of advising and assisting small Societies in obtaining approval, have continued to carry on this work of assisting the Societies with which they are connected in the administration of National Health Insurance. It was considered desirable by many promoters of such Associations that, after approval had been obtained, some machinery should be provided which could help the associated Societies in any points of difficulty, and which would also secure that any laxity of administration by a Society comprised in a group which proposed to associate in due time for valuation purposes could be discovered and checked at the earliest possible date. In addition to the Associations which came originally into existence with a view to assisting smaller Societies in obtaining approval, some other Associations have been subsequently constituted by groups of Societies which contemplate associating together for valuation purposes, these Associations being formed primarily with the object of checking in the early stages any laxity of administration. Approved Societies: Organisation. 71 182. For the most part these Associations confine their activi- ties to watching the sickness experience of their component Societies. For this purpose the Societies agree to make periodical retm*ns to the Association of their benefit expenditure, and hold occasional meetings of secretaries or other representatives of the Societies. In a few cases, however, where a large contribution is made by the Societies to defray the administration expenses of the Association, Societies obtain regular assistance on any points of difficulty in administration, and also in keeping their registers and accounts, particularly as regards the keeping of the ledgers. In this way Associations are able to afford facilities to their con- stituent Societies for obtaining skilled assistance in a branch of work which might cause considerable trouble and difficulty to officials of small Societies possessing little knowledge of the prin- ciples of book-keeping. 183. The small Societies comprising these Associations, which, as Societies with less than 5,000 members, will require to associate themselves or to be grouped with other Socie- ties for the purposes of valuation, will doubtless use the Associa- tions for the purpose of pooling surpluses and deficiences under Section 39 of the 1911 Act, when the Regulations defining the conditions under which such Associations must work are issued in due course. 184. The number of voluntary Associations of Approved Socie- ties as to which the Commission at present have any information is 22. Of these eight are Associations of rural Societies, and the remainder consist of seitii-rural or urban Societies. The rural Associations are in each case identical with the Associations which in 1912 moved the village Societies of their district to common action in obtaining approval ; and are thus continuing their activities, though in a sphere largely different from that in which they began. Disputes and Appeals. 185. As was explained in the Eeport for 1912-13 (paragraphs 259 to 261) the procedure laid down by the Act of 1911 for the settlement of all cases of dispute arising between an insured per- son and the Approved Society of which he is a member involves (a) a reference to the tribunal, or series of tribunals, what- ever they may be, provided by the rules of the Society for the determination of such disputes, and (6) an appeal from the decision of that tribunal to the Com- mission. 186. A portion of the correspondence with which the Com- mission have to deal arises, as might be expected, from com- plaints by insured persons regarding the action of Societies or their officials. In the great majority of these cases it is apparent that the origin of the complaint is the ignorance or misappre- hension of the insured person as to the provisions of the Acts or (B254— Gp. 5) c 4 72 England. of his Society's rules. In such cases, as well as in those where a misuftderstanding of the case has occurred on the part of an official of the Society, the matter is usually settled without diffi- culty by correspondence. Where, however, the case is one in which a question of the interpretation of the rules is in dispute, or there is any serious conflict as to the propriety of the Society's action, the Commission have to point out that, consistently with the procedure laid down in Section 67 of the 1911 Act and the Begulations made under that Section, they are not in a position to entertain an appeal until the matter in dispute has first been submitted to the tribunal or tribunals provided by the rules of the Society. 187. The procedure of appeal provided by the rules of the Societies of the many different types working the Act is neces- sarily far from uniform. While probably a majority provide for the appointment annually or otherwise of one or more indepen- dent arbitrators to whom all disputes can be referred, many Societies with branches provide that disputes between a member and his branch are referred, in the first instance, to one or more bodies of superior authority to the local branch {e.g., the com- mittee of the district) before appeal can be made to the Com- mission. 188. The Regulations governing the procedure on the final appeal to the Commission, which were issued in the course of the year, provide for the conditions in accordance with which an appeal may be made. Application for leave to appeal is neces- sary, except in certain specified cases of greater importance, such as the suspension of a member from benefit for a period exceeding twelve weeks, or the withholding of benefit to an amount exceed- ing £2. 189. While appeals and applications for leave to appeal to the Commission are increasing, it is not, for the reasons stated in paragraphs 261 and 262 of the previous Report, anticipated that for the present the number will be great. 190. Hitherto all appeals from the Society tribunals have been heard and determined either by the Commission as a whole or by three Commissioners appointed as referees under the terms of Section 67 of the 1911 Act. Particulars of all such cases are in course of publication, but it may be convenient to print here a brief summary of earlier cases. 191. In one case, an insured person applied to an Ap- proved Society for membership on a form containing the question : ' ' Are you in a good state of health ? " to which he replied, " Yes," and the question, " Give any particulars of any illnesses within the past three years," to which he replied, " None." The Society subsequently discovered that in 1892 the man suffered a rupture and had worn a truss ever since, and he was expelled in accordance with a rule of the Society which em- powered the Committee of Management to terminate the mem- bership of any member who was guilty of any wilful mis- Approved Societies: Organisation. 73 statement or omission in his application for membership. The arbitrator appointed under the Society's rule for the decision of disputes found that the member was not in a good state of health at the time he sent in the application form, and that he was guilty of a wilful and material misstatement or omission in his application. From this award the member appealed to the Com- mission, who appointed three of their number as referees in the matter. The referees found that the misstatements or omis- sions were made bona fide and in the honest belief that he was in a good state of health and had not suffered from any illness within the last three years. It was held that the general rule of law that any material misstatement, even if innocent, is sufficient to entitle the assurer to avoid the contract, was excluded by tha express provision as to the ground for expulsion contained in the- rule above referred to, and that on the evidence the misstatements: or omissions were not wilful, and that the man had not ceased to be a member of the Society. 192. In a second case, an appellant Society imposed a penalty of suspension from benefits on the respondent because, while in receipt of sickness benefit, she was found outside her dwelling engaged in carrying coal from the road to the coal-house. The Society alleged that the member had been guilty of a breach of one of their rules — " No member shall follow any occupation while in receipt of sickness, disablement, or other similar bene- fit." The arbitrator decided in the member's favour, and the Society appealed from his decision to the Commission. The Com- mission dismissed the appeal on the ground that, even assuming the facts alleged by the Society to be true, the respondent could not be held to be guilty of a breach of the rule referred to above, 193. In another case, a member of an Approved Society was expelled on the ground that, in her application for membership, she made wilful and material misstatements or omissions as to the state of her health. The form of application asked no ques- tions as to health, but the woman was expelled, and sickness benefit was withheld. No evidence was offered by the Society. It was held that the w^oman was improperly expelled and con- tinued to be a member of the Society, and, the Society con- senting, that she- was entitled to £5 in settlement of her claim for sickness benefit. 194. A member appealed in a dispute which had arisen between himself and his Society as to whether he was or was not incapable of work within the meaning of the Act, and so entitled to sickness benefit. The award of the arbitrators had been to the effect that the member was capable of doing light work. The question at issue on the appeal was entirely one of fact, and procedure was by way of re-hearing. The medical evidence adduced by the parties conflicted, but the referees appointed to hear the appeal were more impressed by the medical evidence adduced on behalf of the appellant, the member's panel doctor, who had been in constant attendance on him for 74 England. -a considerable period and had periodically examined him, and also a second doctor who had examined the appellant as a con- sultant in conjunction with the panel doctor, testifying strongly that he was incapable of any work at all. The referees accord- ingly gave their award in favour of the appellant. 195. A further case turned on the provision of the Act pre- venting the payment of sickness benefit concurrently with damages recovered at common law in respect of the injury causing the incapacity. The member of the Society concerned, who was the appellant, claimed from the Society the sum of £ld, being 26 weeks' sickness benefit at 10s. a week. The Society had paid ;^8 only, withholding £5 on the ground that an equivalent amount had been recovered as damages by the appellant. The arbitra- tors appointed under the rules of the Society had awarded in favour of the Society. From this award the appellant appealed to the Commission, who appointed three of their number to act as referees. The material facts were that the appellant had been knocked down and injured by a motor omnibus and immediately thereafter taken to the hospital. Inquiries were made, but the information obtained was not sufficient to prove negligence on the part of the Omnibus Company. Some time afterwards the appellant called on the Company, who, after expressing regret •at the accident, handed him £5 as a gift — as they said — entirely out of sympathy. On behalf of the Society it was contended that the sum of £5 was in fact damages received or recovered at common law. The appellant contended that the sum was an ex gratia payment, that he could not obtain any evidence to estab- lish negligence on the part of the Company's servants, and that he had no grounds for making any claim against the Company. No evidence was adduced before the referees to the effect either that the Company had admitted liability, or had been under liability, and they awarded accordingly that the sum of £5 was wrongly deducted by the Society from the amount due to the appellant as sickness benefit. 196. A member of an Approved Society had been suspended from benefit for nine weeks and five days, on the ground (1) that she had been guilty of conduct likely to retard her recovery, and (2) that while in receipt of sickness benefit she had been out of doors later than was permitted by the rules of the Society for members in receipt of benefit. In this case it appeared that the arbitrator appointed under the Society's rules had given an award against the member on written documents which were purely ex parte, and, further, were full of hearsay evidence: no opportunity appeared to have been given to the member to appear at the arbitration. The member appealed from this " travesty of an award," and the case was heard by three Commissioners as referees. A great deal of evi- dence was given, and eventually the referees gave their award Approved Societies: Organisation. 75 in favour of the appellant. The referees also animadvierted on the Society's conduct of the case. 197. Another case was that of a member who appealed from the decision of his Society to refuse him sickness benefit while he was an inmate of a hospital. The case was governed by the provisions of Section 12 of the Act of 1911, the amending provisions of the 1913 Act in this regard having not then come into force. A member of an Approved Society without depen- dants contended that sickness benefit was due to him in vh-tue of the words of the Section that the money due in respect of the period while he was an inmate might be expended by the Society *' otherwise for his benefit." The arbitrators appointed under the Society's rules awarded that the member had no claim upon the Society under these words. The member appealed, and on, the suggestion of the Commission both the appellant and the respondents consented to dispense with a hearing. The referees, having satisfied themselves that there was no- allegation by the appellant that the Society acted unreasonably or without due consideration of the circumstances of the case in deciding to make no payment in respect of the period while he was an inmate of the hospital, dismissed the appeal. 198. A member appealed against a decision of his Society fining him 10^. on the ground that he had started work before declaring off sickness benefit. The referees appointed to hear the appeal concluded that the question whether the appellant was intending to impose on the funds of the Society was one of fact and pre-eminently one which those in the locality were well qualified to decide. The referees had no reason io suppose that they would themselves have come to a different con- clusion, and considered that in any event, the officials, in the first place, and then the Committee, had before them all material facts, and had the opportunity of seeing the appellant and judging of his bona fides. The referees, therefore, dismissed the appeal. 199. In a further case, a member of a Society appealed from the decision of the general delegates' meeting of his Society, the tribunal appointed by the rules of the Society to decide disputes. The appellant claimed 10 weeks' sickness benefit, from the 11th June to the 21st August, 1913, and the Society declined to recognise his claim on the ground that they were not satisfied as to his incapacity for work. The referees appointed to hear the appeal had before them evidence showing that the appellant violated one of the rules of his Society in leaving the place where he resided while in receipt of sickness benefit without the consent of the local committee. It also appeared that the member had not produced weekly medical certificates of con- tinued incapacity for work, and the Society alleged, and the appel- lant admitted, that they had informed the appellant's mother that weekly medical certificates would be required. The referees, having regard to all the circumstances of the case, concluded 76 England. that there were not sufficient grounds for interfering with the decision of the general delegates' meeting, and accordingly dis- missed the appeal. Special Arrangements for assisting particular Societies. 200. One of the most important activities of the year has been the establishment by the Commission of arrangements by which Societies, in whose organisation any special weakness has been revealed, are given special advice and assistance to enable them to secure the more efficient working of their administrative machinery. 201. As any weakness of administrative machinery results in a too lavish expenditure of the Society's money in meeting claims for benefit, particularly sickness benefit, the question of the par- ticular steps taken to assist Societies which exhibit any such weak- ness is necessarily relate^d to the allegations, which have been and are being made , that many Approved Societies will find them- selves in serious deficiency at the date of the first valuation. These allegations have, of course, an actuarial aspect, which is discussed in paragraphs 150-164 of this Keport. At the same time, however, it will be apparent that the prevention of undue ex- penditure resulting from imperfect methods of organisation on the part of the Society is not an actuarial but an administrative question. Accordingly hope is entertained that the institution of administrative reforms by the Societies, with such assistance as the Commission can give them through this special machinery, will result in very considerable saving on the benefit expendi- ture, and do much to avert threatened deficiencies in cases where deficiencies may now seem to be in prospect. It must be remem- bered that a number of Approved Societies had no previous experience of the administration of sickness benefits, and that the officials of the Societies have in many cases only a very slight personal knowledge of the members. 202. There are several ways in which any weaknesses in a Society are revealed to the Commission. A Society may requisi- tion issues by the Commission from the Society's funds which are in excess of actuarial expectation in respect of benefits, or in excess of the amount allowed for administration ; complaints may be made by members of delay in the receipt of benefits or failure to obtain them when due ; or the report of the Auditor may reveal that the payments made are improperly vouched for, or that illegal payments are being made, or that the books are not being kept in the prescribed manner. Upon information so obtained the Commission inquire into the position of the Society and its administrative methods by correspondence, by personal visits and by interviews with the officials, or take such other action as the circumstances require. Approved Societies: Organisation. 77 203. It . has been found possible in many cases where the affairs of the Society have been specially investigated to suggest the introduction of reforms, which have led to considerable improvement in the administration of the Society. In some cases, for instance, careful analysis of a Society's records, and detailed investigation of its administrative methods, have afforded indications that unjustifiable claims have been admitted through a practice on the Society's part of paying benefit for pro- longed periods without obtaining medical ' ' renewal ' ' certificates of incapacity- for work, even when the nature of the disease clearly renders the renewal certificate desirable. In others, again, an analysis of records, administrative machinery, and local industrial circumstances has pointed clearly to the necessity of a closer system of sick ' visiting than had hitherto prevailed in the particular Society. But the different administrative questions which can arise and re- forms which can be suggested vary almost infinitely, and the method of investigation is necessarily dependent upon the nature of the difficulty. In some cases the remedy is ob.vious, in others a great variety of factors are operating to the detriment of the Society, and a comprehensive inquiry into every detail of the administrative machinery must be undertaken before any reform or reconstruction can be suggested. 204. Societies have usually welcomed this special inves- tigation, realising that the inquiry has been conducted in the interest of the members of the Society, and have co-operated in placing at the service of the Commission's officers all the avail- able information that was necessary to enable the position to be ascertained. Deficiencies on Administration Account. 205. The amount which a Society was permitted to carry from its contribution account to meet expenditure on administra- tion was limited to 2^. 9d. a member for the half-year ending 12th January, 1913, and to 3^. 5d. a member for the year ending 11th January, 1914. It was recognised, however, that much special expenditure was necessarily incurred in connection with the early stages of the administration of the Act which would not be of a recurring nature, and consequently upon the application of the Society or Branch consent has been given under the Eegula- tions to carry forward the deficiency on the administration account for the period ending 12th January, 1913, to the account for the following year in every case where it appeared that the Society or Branch was able to make good the deficiency by savings on its administration account for the year ending 11th January, 1914. 206. In some cases it would appear that administration ex- 78 England. penses for the earlier quarters have been artificially inflated by excessive liabilities undertaken by the Societies, before they be- came approved, in engaging professional services unnecessarily. Approved Societies and Branches of Approved Societies ceasing to transact Business under the Acts. 207. The practical administration of the National Insurance Acts has shown that the same tendency tov^ards amalgamation and consolidation which is seen in other spheres of co-operative effort has been reflected in some measure in the experience of Approved Societies. A number of Societies which sought and obtained ap- proval appear to have anticipated a membership in excess of the number actually secured, and realised at an early stage in their history as Approved Societies that the interests of the members could best be served by linking up with another Society. Most of the Societies which have ceased to administer the iVct have taken that step-in consequence of smallness of membership. In other cases, difliculty has been experienced in finding suitable officers to carry on the administration of the State insurance business of the Society, and some Approved Societies have trans- ferred their engagements in regard to State insurance in conse- quence of the amalgamation of the Societies on their private sides. 208. Most of the Societies which have ceased to administer the Act have arranged for the collective transfer of their State engagements to another Society, but in a few cases such an arrangement w^as not practicable, and the members have there- fore transferred individually to other Societies. A resolution to cease to administer the Act has been passed by the Society in every case, and all the members have been provided for in other Societies. Similar action has also been taken, for similar reasons, by Branches, which have in many cases proved to have too few members to administer the Act as separate units. 209. The following figures show the actual number of Societies and Branches in England which have ceased to administer the Acts : — As regards Societies, after about 23 months' experience of the Act, out of the 2,208 Societies (having over 12,000 Branches) in England, which have been approved, a certain number^ only 16 of which had a membership of over 250 members, have for one or other of the reasons explained above found it desirable to combine with other Societies to work the Act, instead of continuing their original separate organisation. In only five cases has any such arrangement been made by a Society with a membership of a thousand or over. One of these, a Society with a membership of about 19,000, combined with another with a membership of about 100,000 for reasons of mutual convenience, and not because either was unable in any way to administer the x\ct effici- Approved Societies: Organisation. 79 ently. In the second case, a Trade Union with about 6,000 mem- bers amalgamated with another Trade Union because they desired amalgamation on the private side for reasons unconnected with the Act. In the third case, a Society with about 1,300 members preferred to join a large Affiliated Order, while retaining to some extent its individual character, by forming a separate Bi'anch of that Order. In the fourth case, a federation of village clubs with about 1,200 members transferred for administrative convenience to a County Friendly Society. In the fifth case, a Trade Union of 1,300 members transferred engagements to a Union with 14,000 members for similar reasons. With regard to smaller Societies, 312 Societies, of which only 11 had a membership exceeding 250, have transferred their engagements to other Societies, the latter Societies undertaking in every case to be responsible for the whole of their members, except any who voluntarily preferred to join another Society. There are, in addition to the foregoing 317 cases, 33 Societies (in only one of which the membership exceeded 100) which ceased to administer the Act without such an arrangement as described above being made. In these cases members have transferred individually to other Societies, but in all cases arrange- ments have been made enabling every member to find another Society to accept him to membership, and therewith to accept liability for benefit at the full rate, so that in no case was it necessary for a single member to become a deposit contributor. As regards Branches, 722 of the 12,000 Branches have been reported to the Commission as having ceased to administer the Act as separate organisations. In all these cases the mem- bers have remained within the Society to which the Branch belonged, except in the few instances where they preferred to join other Societies. Regulatio7is as to Amalgamation, Transfer of Engagements, and Dissolution. 210. Regulations under Section 28 and the First Schedule of the National Insurance Act, 1913, have now been published in draft providing for the manner in which the amalgamation and transfer of engagements of Societies and Branches may be car- ried out, and also for the manner in which a Society may be dissolved. The Regulations embody the following main prin- ciples : — (1) Amalgamation. Where the method of amalgamation is not determined by the existing constitution of the Society, the Regulations require a three-fourths majority of the members voting at meetings called by each Society on the question. Where the method of amalgamation is already provided for under the existing constitution the Regulations do not affect the 80 England. method except that they require that the consent of the Com- mission be obtained before the amalgamation is completed ; such consent is conditional upon the Commission being satisfied that the proposal represents the wishes of the members on the State side. (2) Transfer of Engagements. The Society proposing to transfer its engagements can only do so under authority received from a three-fourths majority of the members voting at a meeting on the subject. The Eegula- tions do not require a similar special authority from the members of the Society accepting the transfer, a resolution duly passed by the Committee of Management, under authority included in the rules of the Society, being sufficient. The principle underlying these two different procedures is that members should themselves have the right to vote whenever the proposal is one that seriously affects them. In some cases, e.g., where two or more small Societies are amalgamated, it is clearly desirable that members of each Society should be able to express their opinion as to the fate of their Society. In other cases, for instance, where a small Society of some few hundred members proposes to transfer its engagements to a large Society of some hundreds of thousands, it is clearly desirable that the members of the small Society should all have an opportunity of voting, but any similar provision as regards the larger Society would be unnecessary and impracticable. The Kegulations provide that the Commission shall have power to determine which procedure shall be applied in any particular case according to the actual circumstances of that case. (3) Dissolution. The Act of 1913 also authorised the Commission to make Regulations prescribing the manner and conditions upon which the dissolution of Approved Societies might be effected and pro- viding for any necessary valuations and financial adjustments. The future benefits of a member of a dissolved Society must, of course, depend upon the financial condition of the Society at the time of dissolution. The main problems which the Commission had to solve in connection with the Regulations as to the dissolution of Approved Societies were : — (1) How to deal with all the members of the Society between the dissolution and the time at which their proper rate of benefit can be determined ; and (2) How to provide permanently for those members who, through invalidity, are unable to obtain admission to another Society. Regulations have been made accordingly. They are based on the following scheme : — (a) Provision is first made to see that proper authority is taken from the members for the dissolution of the Approved Societies: Sickness Benefit. 81 Society, and for winding up its affairs at the proper time and in the proper way. (h) A Dissolved Societies Fund is set up to which all the assets of a dissolved Society are transferred, and from which the members of that Society draw their benefits until the future arrangements described below are complete. (c) This Fund is to be administered by the Commission, who are to receive all claims for benefits and exercise all necessary supervision and pay the claims. All mem- bers will begin with the same rate of benefit as that to which they were entitled before their Society dissolved. (d) Meanwhile, the accounts of the Society will be com- pleted under the supervision of the Commission, and a valuation will be made. As soon as this is completed, the future rate of benefit is to be determined in accord- ance with the result disclosed at the valuation. Every member will be informed of this future rate of benefit, and told that he must attempt to join another Society by a specified date, and that on his so joining another Society the necessary reserve to give him that rate of benefit will be credited to the Society. If, therefore, his health is such that he can join another Society, he will pass out of the Dissolved Societies Fund altogether. (e) If, however, his health is such that he cannot obtain admission to another Society, he will continue a per- manent member of the Dissolved Societies Fund and draw his benefits from that Fund, the rate being the same as that to which he would have been entitled if he had been able to join another Society. The necessary arrangements to administer the Fund in this way have been made. Sickness Benefit. Rate of Expenditure. • 211. The exact financial position of Approved Societies will be ascertained by valuations which the Act normally contemplates will take place at triennial intervals. Without valuation the effect in a particular Society of, e.g., the age factor, upon its financial position cannot be ascertained ; and without '^his know- ledge the financial position itself must remain uncertain. The rate at which money is issued to an Approved Society from the credit of that Society in the National Health Insurance Fund does not necessarily indicate even what is the Society's rate of ex- penditure ; and it is not reliable as a criterion whether the 82 England. Society's expenditure is, or is not, within the actuarial provision, until the necessary particulars, e.g., as to age distribution, are available, from which the expected cost of benefits can be calcu- lated. It is also clear that excessive expenditure by a particular Society may not be due solely to excessive sickness : a system of administration exhibiting defective control and supervision over claims for benefit and over members in receipt of benefit may also involve a Society in over-expenditure. In examining the position of a Society, therefore, it is important to ascertain whether the system of administration is properly adapted to its purpose of securing that benefit shall be paid in cases where it is due, and in those cases only. 212. Accordingly, the first question which presents itself for investigation is that of the adequacy to its purpose of the admin- istrative machinery. Paragraphs 200 to 204 above have indicated that the Commission have established a regular system for the assistance of those Societies whose administration appeared to present defects, or whose circumstances were beset by special administrative difficulties; and, as stated above, these special investigations have resulted in many cases in the recommendation and adoption of administrative reforms, which, it is hoped, should substantially reduce the expenditure on sickness benefit in un- justifiable cases. 213. Further, the whole question of the alleged excessive ex- penditure in its administrative aspect has been the subject of general investigation by the Departmental Committee on Sickness Benefit Claims, of which Sir Claud Schuster is Chairman. The Committee by its terms of reference is "to inquire into and report upon the alleged excessive claims upon and allowances by Approved Societies in England in respect of sickness benefit, ^nd any special circumstances which may cause any such claims or allowances." The Committee was appointed on 22nd August, 1913, and its membership was as follows : — Sir Claud Schuster (Insurance Commission). Walter Davies, Esq. (National Secretary of the Order of the Sons of Temperance ; Chairman, Manchester Insurance Committee) . Adam Fulton, Esq., M.B. Miss M. H. Frances Ivens, M.B. Miss Mary Mac Arthur (Secretary of the Women's Trade Union League). William Mosses, Esq. (Secretary of the Federation of Engineering and Shipbuilding Trades of the United King- dom ; Secretary of the United Pattern Makers' Association (Approved Society)). *James Pearse, Esq., M.D., M.B. (Medical Officer of Health, Trowbridge Urban District Council). * In February, 1914, T. M. Carter, Esq., M.D., M.K.C.S., was appointed a imember, in place of Dr. Pearse, resigned. Approved Societies: Sickness Benefit. 83 Lauriston Elgie Shaw, Esq., M.D., M.B., F.E.C.P., M.E.C.S. A. C. Thompson, Esq. (President of the National Conference of Industrial Assurance Approved Societies). A. H. Warren, Esq., J. P. (President of the National Confer- ence of Friendly Societies). A. W. Watson, Esq. (Chief Actuary, National Health Insur- ance Joint Committee). J. S. Whitaker, Esq., M.E.C.S. (Deputy Chaurman, Insur- ance Commission). Miss Mona Wilson (Insurance Commission). Walter P. Wright, Esq. (Grand Master Independent Order of Oddfellows (Manchester Unity) ). Incapacity for Work. 214. Sickness benefit is defined in the National Insurance Acts, 1911 to 1913, as periodical payments while rendered incap- able of work by specific disease or bodily or mental disablement, commencing on the fourth day of such incapacity, and continuing for a period of not more than 26 weeks. 215. It will be seen that the definition requires as a condition of sickness benefit that the insured person should be rendered incapable of work by specific disease or bodily or mental disablement. Clearly the terms of this condition are elastic in character ; they require to be interpreted reasonably and with discretion, in accordance with the spirit and intention of the Act, and preclude the possi- bility of applying any precise code of administrative rules as a test of whether a particular insured person is or is not entitled to sickness benefit. Indeed, it would apparently be an impos- sible matter to draw up any such code which would include all the cases designed by Parliament to fall within the scope of sickness benefit, and to exclude all those cases which Parliament intended to be excluded. 216. Under a definition which requires a discretionary inter- pretation, there is of course always a possibility of a difference of opinion arising between the Society and an individual member as to whether his condition fulfils the requirements of the definition ; and a considerable proportion of the disputes which arise between Societies and members appear to be in connection with a difference of opinion of this kind. In particular, the extent to which the performance of household duties by a woman may be compatible with the receipt on her part of sickness benefit has been attended by this sort of difficulty. On the whole, however, it would appear that Societies have applied the test of incapacity for work to individual cases in a reasonable and equitable spirit. 217. Societies have found a special difficulty in deciding whether the conditions of the Act for the receipt of sickness 84 England. benefit are satisfied in cases of varying degrees of incapacity for work caused by, or occurring during, pregnancy. As indicated in paragraph 157 above, their difficulty has been increased by their reaUsation that payments for long periods during pregnancy v^ere bound to impose a heavy charge on their funds, and by their consequent fear that such payments would result in defici- encies. In these circumstances Societies have doubtless been, in many cases, guided as to their decisions by their previous prac- tice in such cases in the administration of their private insurance. Systems of Administration. 218. No comprehensive account of the systems on which sick- ness benefit is administered by the different Societies is possible, as these systems differ so widely with the type of the Society. Most of the Approved Societies have a history extending to days long before the commencement of National Health In- surance ; and this history has resulted in the establishment of a well-tried machinery, which has, of course, been utilised by the Society for the administration of sickness benefit under the Acts. Of the new Societies which came into existence as a result of the Act, the majority were formed to cater for special classes of insured persons, and, as in the case of the rural Socie- ties and Associations, to meet a special object. The special character of these Societies is reflected in their system of adminis- tration, which is in some cases novel and different from any machinery hitherto in existence. 219. It must be remembered that Approved Societies are deal- ing primarily with their own money, and that they are therefore responsible in the first instance for deciding as to the system which will result in the most equitable, efficient, and economical administration of benefits. Issue and Use of Uniform Medical Certificates. 220. During the first few months of the administration of sickness benefit it became apparent from communications received from Approved Societies, from doctors on the panels, and from insured persons, that certain difficulties were arising in regard to the supply of medical certificates in connection with claims for sickness benefit, and the form in which such certificates should be given. Under the old Friendly Society system of direct arrangement between a Society and a doctor the latter would naturally become readily familiar with the form of certificate in use by the Society for whose members he had arranged to pro- vide medical treatment. But the position was inevitably very different under the system of medical benefit instituted under the Approved Societies: Sichness Benefit. 85 National Insurance Acts where a doctor has patients on his Hst belonging to various types of Society with varying methods of administering benefits. 221. This difficulty led to representation from Societies that their members were sometimes unable to obtain from their doctors the proper completion of the forms of certificates which had been prepared for the use of those members in connection with claims for sickness benefit ; and that their members were only able to obtain certificates in a form which failed to fulfil their particular Society's requirements. It was represented on the other hand by doctors that considerable trouble and difficulty was caused by their being asked to deal with forms of certificate of the most varied kinds and shapes, while insured persons com- plained that the difficulties thus caused led to trouble and delay in the settlement of their claims for benefit. 222. After careful consideration and consultation with the representatives of the medical profession on the Advisory Com- mittee, and of Approved Societies of all types of organisation, the Commission were able to propose an arrangement which has been generally accepted by the parties concerned. This arrange- ment is based on the following principles : — (a) the use of one uniform initial certificate, accepted by any Society, which the insured person sends to his Society at the beginning of his illness ; (b) in the case of forms for continuing and final certificates a uniform wording of the actual certificate to which the doctor appends his signature. 223. Adequate supplies of the uniform initial certificate are famished in book form to doctors on the panels and to all institu- tions approved under Section 15 (4) of the 1911 Act. A doctor is thus able to furnish an initial certificate to an insured person directly he sees him, and is satisfied that he is incapable of work, without any of the delay which would inevitably arise if the insured person had first to obtain a form of certificate from his Society. In the case of continuing and final certificates, on the other hand, it was arranged that Societies should continue to supply the necessary forms to their sick members, to be pro- duced to the doctor for signature as required. They have agreed to print a common form of words for the doctor's actual signature, but each Society has arranged, according to its own discretion, for the insertion on the forms of any additional matter which it may desire (e.g., notes of calls made by the Society's sick visitors). Uniformity in the matter of the con- tinuing and final certificates has thus extended only to the actual form of wording to which the doctor's signature is required: while the availability of the proper form of continuing or final certificate for the doctor's signature has depended on the form being in the possession of the sick memher at the times when the doctor sees him. 86 England. 224. The experience of the last year has shown that the uni- formity in the initial certificates secured by the above arrange- ments was convenient to both doctors and Societies. Indeed, it now appears that the extension of the principle of uniformity, both to continuing and final certificates and to the forms which insured persons sign when declaring on the funds, would be of great advantage, and the Commission have been carefully con- sidering with the Advisory Committees revised arrangements to secure this. Medical Referees. 225. Apart from the appointment of sick visitors, whose services have been of the greatest importance in checking claims for sickness benefit, some Societies have also required their mem- bers in doubtful cases to be medically examined by an independent practitioner. ^ 226. The means to be adopted generally to check improper claims upon the Societies constitute one of the subjects sub- mitted for the consideration of the Departmental Committee whose work is referred to in paragraph 213 above. Pending the Eeport of this Committee, however, it was represented to the Commission that a certain number of Societies desired to make provisional arrangements for the use of medical referees at once ; and that it was desirable that Societies should be encouraged to take temporary action of this kind, both by having their attention called to their powers under their rules and also by a special addition to the administration allowance. A circular was therefore issued to Approved Societies by the Commission in August, 1913, pointing out that it was competent for them under their rules to make arrange- ments to secure the services of medical I'eferees as part of their work of administering sickness benefit. Such arrangements, it was pointed out, could be made by the Societies themselves with individual doctors ; or alternatively the services of referees might be obtained under a general scheme wdthin a given district by applying to the Insurance Committee of the area with a view to the Committee completing the arrangements. The Committee would in that case merely be acting as agents, and not only the actual payments to the doctors but also any admin- istrative expenses would have to be defrayed by the Societies. It was pointed out that any arrangement adopted should be provisional in character, pending the recommendations of the Departmental Committee. 227. With regard to the cost entailed by the employ- ment of referees, it was represented to the Commission that the amount available under the Administration Expenses Regulations was in some cases insufficient to permit of expendi- ture on referees, and the Commission decided to amend Approved Societies: Sickness Benefit. 87 these Kegulations to the following effect : If a Society incurred expenditure during the period of six months ending 31st March, 1914, in connection with the employment and payment of medical referees, and if a deficiency in the administration ac- count due to such expenditure during that period was shown when the account was made up for the year ending 11th January, 1914, or in the account of the following year in respect of expenditure in the period between 11th January and 31st March, 1914, an additional amount might be carried to the account. This additional amount would, however, not be more than was required to meet such part of the deficiency for each year as was due to the expenditure on the referees in the period stated (1st October, 1913, to 31st March, 1914), and the sum of the addi- tional amounts so carried to the account for the two years could in no case exceed a penny a member. Special Arrangements hy Insurance Committees. 228. In two Insurance Committee areas, Bristol and London, special arrangements have been in operation, whereby the ser- vices of a referee have been available to Approved Societies. In Bristol the practitioners in the area made it a condition of accept- ing service under the Act that a medical adviser should be appointed. It was felt by the doctors in the area that they could not undertake to give a thoroughly efficient service except with the assistance of such a medical adviser ; and they therefore pressed for the appointment of an adviser for the whole area in order to avoid the confusion which it was anticipated would arise if each Society in the area were left free to appoint their own referee. The Insurance Committee accordingly "met the wishes of the doctors by appointing, on the 12th February last year, a local practitioner as medical adviser to the Committee. His duty as medical adviser was to advise solely on the question of the capacity of any insured person referred to him either by a panel practitioner or by an Approved Society. During the first nine months the whole of the cost involved in the appointment was borne by the Insurance Committee out of its Administration Fund ; but thereafter Societies were required to pay a fee of 5s. in respect of each case referred and examined, and 2s. 6d. in respect of each case in which the insured person, on being referred, failed to present himself for examination. More recently the panel practitioners of the area have agreed provisionally, and without prejudice to any future arrangements, to contribute towards the cost involved in the appointment. 229. The results of the experiment made in Bristol in the appointment of a medical adviser are of considerable interest. Out of the first 1,000 cases referred, covering the period from February, 1913, to April, 1914, 309 cases were sent by doctors, and 691 by Societies. Four hundred and twenty-nine men were 88 England. referred, and 571 women. In the case of the men, 39-6 per cent, were pronounced fit for work ; 33-7 per cent, unfit ; 18-5 per cent, did not appear for examination ; 4'4: per cent, had already returned to work, and 3 "8 per cent, were compensation cases receiving pay from their employers. Of the women, 40*6 per cent, were pronounced fit for work ; 32-9 per cent, unfit ; 22*7 per cent, did not present themselves for examination ; 3-8 per cent, had already returned to work. 230. In the area of the London Insurance Committee medical referees have also been appointed during a part of the time under review. In August, 1913, the Commission sanctioned, as a tem- porary measure of urgency, a scheme submitted by the London Insurance Committee for placing the services of medical referees at the disposal of Approved Societies. The scheme involved the payment to the referee of a fee of Is. 6d. in respect of each exam- ination, one-third of this sum being payable by the Society referring the case. On the 25th September the Insurance Com- mittee appointed six part-time medical referees for the purpose, their function being to advise as to the fitness for work of the persons referred to them. Of the first 375 cases which actually proceeded to examination before the end of October, there were 87 men, of whom 33 were declared capable, and 288 women, of whom 175 were declared capable. Maternity Benefit. 231. The changes effected by the National Insurance Act, 1913, in the administration of maternity benefit are so far- reaching that it is necessary to discuss them at some length. 232. The "Mother's Benefit.''— Bj Section 14 of the Act of 1913 Parliament has made maternity benefit in every case the woman's benefit, while providing that, if she authorises her hus- band to receive the money, her husband's receipt shall be a sufficient discharge to the Society. This has, of course, necessi- tated changes in the administrative arrangements of Societies, and the Commission have endeavoured to assist them in making these by the issue of model forms. The new arrangements did not come into force, however, till the 12th January this year, and it would be premature to attempt to make any general statement as to the actual differences in the distribution or application of the benefit. It is, of course, still more difficult to estimate how far the statutory recognition of the benefit as the mother's has affected the way in which it is generally regarded by the public, and how far this may in turn indirectly affect the use to which the benefit is put. 233. An illustration of the variety of problems which can arise in dealing with some eleven million insured persons is afforded by the fact that the Commission were asked to advise on Approved Societies: Maternity Benefit. 89 the administration of the benefit in the case of a confinement (which, of course, counted as one confinement) resulting m the birth of twins, one of whom was born on the 11th January and the other on the 13th— i.e., one the day before, and the other the day after, the day on which the new provisions as to maternity benefit came into force. 234. Double Maternity Benefit.— The 1913 Act contains a second important provision with regard to the form of benefit for a married woman employed contributor during the four weeks following confinement. Under the 1911 Act married women em- ployed contributors, unlike other insured women, were entitled to sickness benefit for the four weeks after confinement, subject to the provisions of the Act and the requirements of the Society's rules as to proof of incapacity within the meaning of Section 8 (1) (c), and as to behaviour during sickness. Although in claims for benefit of this kind proof of incapacity for work was required as for any other case of incapacity, yet the mention in Section 8 (6) of the 1911 Act of a definite period of four weeks had a tendency to establish that period, both in the minds of insured persons and in some cases of Societies, as the normal recognised period for such payments ; and sickness benefit came to be expected on the one hand and paid on the other for that period without production of the weekly medical certificate which is ordinarily required to support a claim for sickness benefit. The practice varied, however, and difficulties were often caused where an insured woman who had been attended by a midwife only was called upon to produce a certificate signed by a medical practitioner as evidence of incapacity. Section 14 (3) of the 1913 Act met these difficulties by giving the married woman employed contributor a right to a second maternity bene- fit, ordinarily of 305. , in lieu of the sickness benefit of Is. 6d. a week for the four weeks of incapacity after confinement. 235. This second maternity benefit, like the original sickness benefit for which it is substituted, is payable by the wife's Society, and in respect of her insurance. The benefit thus conferred as a maternity benefit is subject to the incidents and conditions of the original maternity benefit, and may be administered by the wife's Society either as a lump sum or in instalments or in kind. It differs from the original sickness benefit for w^hich it is substituted both in the fact that production of evidence of incapacity for work is not required, and in the fact that the benefit is a fixed sum, not subject to the reduction which w^as attached to the original sickness benefit in cases w^here the incapacity after confinement lasted for less than four weeks. Women in receipt of this second maternity benefit are required, under penalty of a fine, to abstain from remunerative work for four weeks after confinement. 236. The 1913 Act required every Approved Society to make rules to the satisfaction of the Commission pro- viding for this abstention from work. The Commission 90 England. warned Societies by circular of the necessity of amending their rules in this sense before the 12th January, 1914 (the day on which second maternity benefit commenced), and framed a model rule to assist them. 237. In addition, a circular (A.S. 117) explaining the effect of the provisions of the 1913 Act as to the first maternity benefit and the second maternity benefit was issued to Societies ; and such advice as was possible was given with regard to the adminis- trative changes required in order to give effect to these provisions. In particular, revised model forms of application both for the first and for the second maternity benefit were issued by the Commission, in response to numerous requests. (Circular A.S. 125.) 238. The 1913 Act, in addition to these two important amend- ments, removed certain anomalies on points of detail which were inherent in the maternity benefit provisions of the Act of 1911. In the first place, the enactment that wiierever the husband was an insured person the maternity benefit was pay- able in respect of his insurance involved, when taken by itself, the possibility of a woman who was herself insured being in certain circumstances worse off at the time of her confinement from the fact that her husband was an insured person than she would have been if her husband had not been an insured person. This might happen for instance in cases where the confinement occurred before the husband had completed the qualifying num- ber of contributions, or where he was a deposit contributor and the sum standing to his credit at the time of the confinement was less than 305. The Act of 1913 provides that in these circum- stances the reduction in the amount of benefit paid in respect of the husband's insurance, due to the particular defect in his insurance, shall be made good to the wife, if she is herself an insured person, by her Society. The result is that insured wives cannot be worse off in the matter of maternity benefit as a result of defects in the insurance of their husbands. Societies were advised as to the special procedure to adopt in order to deal with these extra claims. 239. A minor amendment may be noticed, which, however, has probably facilitated to a considerable degree the administration ..of maternity benefit. Under Section 35 of the 1913 Act a person who is required for the purposes of the National Insurance Acts to produce a certificate of marriage is enabled to obtain such certificate at a reduced fee of Is. on presenting a requisition (in a form approved by the Local Government Board) to the Eegistrar or other person having the custody of the marriage register. This privilege is an extension of Section 114 of the 1911 Act, which provides similar facilities wdth regard to birth certificates. A circular (A.S. 107) was issued explaining the way to apply for these cheap certificates ; and the necessary administrative arrange- ments were made for their supply, forms of application being sup- plied by the Eegistrar-General to all clergy of the Established Approved Societies: Special Problems. 91 Church and other persons having for the time being the custody of marriage registers. 240. Finally, the administration of maternity benefit has been facilitated by the statutory removal of the provision of the 1911 Act that the fee of a doctor called in by a midwife to a confine- ment should be recoverable as part of maternity benefit. 241. It has been pointed out already that maternity benefit may be administered either in cash or kind at the discretion of the Approved Society administering the benefit in the interests of the mother and child. The evidence before the Commission shows that in the great majority of cases benefit is administered in cash. It is probable that administration in cash commends itself to the insured persons who are the recipients of the benefit ; and it is to be remembered that administration in kind presents certain difficulties which can hardly be overcome except by the institution of a somewhat elaborate organisation. Administra- tion in kind means in most cases the provision of the services of a midwife or doctor, and since the Act of 1911 declares in express terms that every mother receiving maternity benefit is to have free choice of midwife or doctor, this would ordinarily necessitate the institution by the Society of something resembling a panel of doctors and midwives from w^hom each woman could select the person by whom she is to be treated. Special Problems. Compensation undee the Woekmen's Compensation Act, 1906. 242. As a result of the arrangement made by the Commission with practically all the principal Insurance Companies and Mutual Indemnity Societies (see paragraphs 241 and 242 of the previous Eeport) a very large number of notifications have been received as to cases in which insured persons are receiving compensation under the Workmen's Compensation Act, 1906. These notifica- tions state the nature and date of the accident for which com- pensation is being paid (or the date of suspension from work in the case of an industrial disease), the amount of the weekly pay- ment or lump sum, and the estimated duration of incapacity. Societies have been advised that these notifications are pre- served by the Commission, and that they may communicate with the Commission with a view to ascertaining whether a member is receiving any payment by way of compensation. 243. In the great majority of cases compensation takes the form of weekly payments, and in a certain number of such cases an agreement is arrived at for the redemption of such payments by the payment of a lump sum in commutation of further liability. Such an agreement is, however, unenforceable under the provisions of the Workmen's Compensation Act, 1906, unless a memorandum thereof is recorded by the Eegistrar of the County 92 England, Court, who, if he considers the agreement open to objection, e.g., on the ground that the compensation agreed upon is inadequate, may refer the matter to the Judge. Persons interested in the agreement are, by the Eules of Court made under the provisions of the Act, entitled to appear in Court and be heard, and by the ConsoHdated Workmen's Compensation Act Eules, an insured person's Approved Society had been constituted an interested party. By an important judgment recently delivered in the Court of Appeal in the case of Bonney v. Hoyle, it has, however, been decided that an Approved Society is not an interested party in proceedings on an application to register a memorandum of an agreement for the payment of compensation, in the sense that it has any locus standi to be heard and to object to the registra- tion of a memorandum on the ground of inadequacy of the amount of compensation, and to be awarded the costs of such an appearance. 244. The bearing of this judgment on the position of Societies in regard to cases of compensation is receiving the attention of the Commission. At the same time Approved Societies retain their rights under Section 11 (2) of the National Insurance Act, 1911, to take proceedings in the name of , and on behalf of, any member who appears to be entitled to compensation and unreasonably refuses or neglects to take proceedings to enforce his claim ; and they are also able to lay information before the Kegistrar as to the grounds on which they consider that a memorandum as to an agreement in any particular case should not be recorded, without themselves being represented in any proceedings in the County Court. Subscriptions by Approved Societies to Hospitals, Dispensaries, Nursing Associations, &c. 245. Section 21 of the National Insurance Act, 1911, enables an Approved Society to grant such subscriptions or donations as it thinks fit to hospitals, dispensaries, and other charitable institu- tions, or for the support of district nurses; and to appoint nurses for the purpose of visiting and nursing insured persons. 246. As a number of inquiries as to the powers of Societies under this Section had been addressed to the Commission, a cir- cular on the subject (Circular A.S. 106) was issued in October, 1913. This circular pointed out that no special fund or actu- ariarmargin was provided from which expenditure for the pur- poses of Section 21 could be defrayed, and that any such expenditure must therefore be met by a Society from its ordinary benefit funds. That being so, it was for every Society to decide for itself whether judicious expenditure for the purpose of enabling its members to obtain skilled nursing or other special treatment during illness might be expected to have the effect of promoting the recovery of sick members and reducing thereby the amount of their claims on the Society's funds. It was Approved Societies: Special Problems. 93 added that pending further experience of the administration of sickness benefit a Society might consider the desirabihty of refraining from expenditure under this Section beyond the amount of any savings actually realised by carrying to its admin- istration account less than the maximum amount available under the Regulations . It was also pointed out that expenditure on nurses appointed for the purpose of visiting and nursing insured members could not be treated as benefit expenditure unless these persons were appointed for actual sick nursing duties, the payment of persons who acted merely as visitors on behalf of the Society and whose duties were of an administrative character being properly chargeable to a Society's administration account. 247. Up to the present only a small number of Societies have incurred any expenditure under Section 21, the general tendency of Societies being, as it would appear, to reserve consideration of the question in order to obtain further experience of the inci- dence of their ordinary benefit expenditure before deciding to make any commitments of the kind sanctioned by the Section. Ageeements between Approved Societies and Hospitals of WHICH Members of the Society are Inmates. 248. Under Section 12 of the National Insurance Act, 1911, sickness or disablement benefit cannot be paid to an insured per- son while he is an inmate of any hospital, asylum, convalescent home, or infirmary, supported by charity or out of public funds; but the sum otherwise due in respect of such benefit may be dis- posed of in various ways provided for in that Section. In certain circumstances the money may be paid to the institution, towards the cost of the insured person's maintenance if the institution is one supported by charity or voluntary subscription, provided that an agreement for the purpose has been made between the per- son's Approved Society and the authorities of the institution. 249. Eepresentations received by the Commission, both from Approved Societies and hospital authorities, indicated that the provisions of the Section were not fully understood, and the Commission accordingly issued a circular (A.S. 94) on the matter. It was pointed out that the Section did not apply to an institution which was wholly or mainly supported by the sub- scriptions or fees of the persons entitled to make and in fact making use of it, or when it was on a co-operative basis. For the assistance of Societies desiring to make an agreement with the hospital in cases where the Section applies, the circular con- tained also a model form of agreement for the use of Societies, adaptable to the circumstances of each case. The Commission have also made it clear to both hospital authorities and Societies that such agreements must be made before the member enters the institution or during his stay therein, and that in the absence of an agreement so concluded no claim for payment can be enter- tained by a Society after the member has quitted the institution. 94 England. 250. The ameDdment of Section 12 of the 1911 Act effected by Section 15 of the Act of 1913 has not necessitated the revision of the model form of agreement between the hospital and the Approved Society. The effect of Section 15 is to secure that the balance of any sum which would have been due to the member as sickness benefit had he not been an inmate of the hospital, and which is not expended in payments to the member's dependants or payments under agreement to the hospital or otherwise as authorised by Section 12 of the 1911 Act, must be paid in a lump sum or in instalments to the member himself on his leaving the hospital, instead of remaining in the funds of the Society, as was the case under Section 12 of the original Act. The Insurance of Married Women. 251. Societies have found a special difficulty in administering the intricate alternative schemes of insurance provided, under Section 44 of the Act of 1911, for married women. In order to reduce to a minimum the risk of women failing, through inade- quate knowledge of their position, to exercise the options pro- vided in the Statute, the Commission has supplemented the earlier advice and assistance given to Societies in connection with Section 44 by a comprehensive circular (A.S. 127) with model forms, dealing wdth the provisions of the Section and their practical application. Aliens. 252. The Act of 1913 included several provisions affecting the insurance of aliens. Under the Act of 1911 an alien who had on the 4th May, 1911, been resident in the United Kingdom for five years or upwards, and who was on that date a member of a Society which had become approved, or had formed an approved section, was entitled to be treated as a British subject. In view of the con- siderable number of Societies which combined with other Socie- ties to work the Act instead of becoming themselves separately approved. Parliament in the Act of 1913 extended the above privilege to members of Societies which amalgamated with, or transferred their engagements to, an Approved Society, or proved to the satisfaction of the Commission that they had organised, either alone or with other Societies, an Approved Society for the benefit of their members. Further, an insured woman who was a British subject before her marriage became entitled, under the Act of 1913, to be treated for the purposes of National Health Insurance as a British subject, notwithstanding the fact that she might marry an alien and thereby lose her British nationality. 253. The necessary revised forms of declaration to enable effect to be given to these provisions have been prepared and supplied to Societies (Form A.S. 74). The forms include (i.) a Approved Societies: Special Problems. 95 statement to be filled up by a responsible person who is ac- quainted with the apphcant ; (ii.) a declaration by the applicant himself; and (iii.) a certificate, where necessary, from the secre- tary of the Society of which the applicant was a member on the 4th May, 1911. The form, when completed, is retained by the Approved Society of which the applicant is a member for the purposes of the Acl^s, and furnishes a complete record for pro- duction to the Auditor when required. 254. The Act of 1913 also provided that the maternity benefit payable in respect of the insurance of an alien member whose wife before marriage was a British subject is to be increased, subject to Eegulations made by the Commission, by two- sevenths, the increase to be met by moneys provided by Parliament. The Eegulations and the model table of benefits for aliens provide for a maternity benefit in these cases at the uniform rate of 305., the charges against the Society's funds and the State grant being £1 Ss. M. and 6s. Sd. respectively. Transfers of Insured Persons between Societies. 255. Section 31 of the Act of 1911 provides that if an insured person transfers from one Society to another he shall carry with him to the new Society his transfer value, i.e., the sum required to enable that Society to give him the same benefits as before in return for the ordinary contributions, whatever his age at transfer. He does not, however, carry his transfer value in this way if the first Society proves that he left voluntarily without their consent, and that that consent was not unreasonably with- held. The number of transfers effected during the first year and a half of the Act's operation {i.e., up to the 11th January, 1914), as shown by the transfer notes in the hands of the Com- mission, was approximately 60,000. 256. The main administrative problems which the Commis- sion and the Societies had to solve were to secure, first, that in transferences there should be no interval between cessation and commencement of membership in the first and second Societies respectively, during which there might be a dispute as, to liability for benefit; and second, that any dispute as to a member's right to carry his transfer value should receive prompt and just settle- ment. 257. With regard to the first, the Commission have suggested a system under which any Society which is willing to accept an applicant for transfer from another Society should only accept him conditionally upon the first Society consenting to his transfer, or upon the Commission deciding that, notwithstanding refusal to consent, the transfer value is to be passed. Until this ques- tion is settled the man remains a member of the first Society and is entitled to draw benefits from it, and at the same time the second Society avoids the risk of becoming liable for the 96 Erigland, benefits of a member in respect of whom it will receive no reserve or transfer value. 258. The system of quarterly transfers which was instituted when contribution cards were current for a quarter has been continued, in spite of the introduction of a half-yearly card, in order to save the insured person from having too long to wait before effecting his transfer. Certain alterations were, how- ever, necessary as a result of the half-yearly card in the account- ing methods of dealing with transfers. In informing Societies of these changes the Commission took the opportunity of dealing at the same time with the second problem referred to above. Under the National Insurance Acts, as has already been stated, a member has a prima facie right to transfer to another Society if he has a genuine desire so to do, although in any particular case the first Society is entitled to advance reasons why the transfer should Bot be allowed ; and a transfer value will not be passed if the Commission consider that the Society has proved that the refusal to consent was reasonable. The burden of proof is, therefore, intended to rest upon the Society refusing to consent and not upon the member desiring to transfer. It be- came evident that if no Society could accept a transferring member against his first Society's will unless his case had been tried, first by the tribunal or series of tribunals set up under the rules of that Society and afterwards on appeal by the Commission, the burden of proof would in fact be reversed. At the same time the Commission recognised that the Act in any case imposed upon them the administrative duty of deciding, in case of trans- fers, whether the transfer value was to be passed, and therefore of determining whether, if the Society had refused consent, such refusal was proved to be not unreasonable. 259. They therefore intimated their willingness to determine, on the application of a Society which had provisionally signified its readiness to admit a member of another Society wishing to transfer, whether in the event of a transfer of membership taking place the transfer value would pass ; the decision thus being given without requiring the member to appeal first to his Society and then to the Commission. 260. Societies were informed of this procedure in December, 1913, and •847 decisions have since been given with regard to transfers taking effect at 12th April, 1914. In 782 cases it was decided that the transfer value should pass, the Society not having proved that consent was reasonably withheld, and in 65 cases it was held that the Society had proved that consent was reason- ably withheld, and no transfer value accordingly was passed. Persons ceasing to be Insured. 261. Societies have been confronted with a problem of some difficulty in determining on what conditions persons who have entered insurance as employed contributors, but whose status subsequently changes, cease to be insured. Approved Societies: Special Problems. 97 •262. The case of the insured person whose normal occupation is that of employment within the meaning of the Acts, but who ceases to contribute through unemployment, is specifically dealt with by paragraph 4 of Section 79 of the 1911 Act, which pro- vides that he shall be deemed to continue to be an employed con- tributor for a period of twelve months, or beyond that period if his Society is satisfied that the continuance of his unemployment is due to inability to obtain work and not to a change in his normal occupation. During that period he is entitled to draw benefits and may redeem any arrears which accrue by paying off his own share of the unpaid contributions. 263. This provision applies only to persons whose normal occupation remains employment, and not to a man who definitely and permanently goes out of employment, e.g., by voluntarily giving up employment in order to manage a business of his own ; and a serious charge would, of course, have been imposed on Societies if such persons had been entitled to draw benefits for a year without any corresponding liability to pay contributions, or any likelihood of contributions ever again being received in respect of them. 264. A special difficulty arises, however, in the case of those who leave employment in circumstances which make it difificult or impossible to know at the time whether they have perman- ently left employment, or whether employment should still bo considered their normal occupation. They may, for instance, accept some form of employment in which they are not compul- sorily insurable, but within a few months return to employment, within the meaning of the Acts. 265. In order to assist Societies in dealing with this problem, in the treatment of which it was apparent that considerable room for misunderstanding existed, Circular A.S. 118 was issued in December, 1913. This circular drew the attention of Societies- to the provisions of the fourth paragraph of Section 79. In dealing with the specially difficult case of a contributor who ceases |o be employed within the meaning of the Act on account of a definite change in his status which may or may not be of a permanent character, the circular advised Societies that the mem- ber should be treated provisionally as having gone out of in- surance. If before the end of twelve months he returned to insured employment, his insurance was to be regarded as being continuous. If he did not return to employment within that time, his lapse from insurance would be made absolute unless the Society at the end of the year decided that his non-employment was then due to inability to obtain work and not to a change in his occupation. 266. Under this arrangement a member would not be entitled to any benefit during the period of his provisional lapse from in- surance, but in the event of his insurance subsequently proving to be continuous as explained in the last paragraph, his claim to benefit would be subject to reconsideration. The following (B254— Gp. 5) D 98 England. examples were given of a definite change of status to which this procedure should be applied : — (a) A person leaving the United Kingdom with no definite intention of returning within one year. (h) A person employed otherwise than by way of manual labour whose rate of remuneration is raised definitely above ^6160 a year. (c) A person who enters upon an excepted employment (Part II. of the First Schedule to the Act of 1911). (d) A person who enters upon some other occupation, appar- ently of a permanent character, which is not employ- ment within the meaning of the Acts. 267. Advantage was also taken of the issue of this circular to draw the attention of Societies to the essential difference between the position of persons who cease to be employed within the meaning of the Acts because of some change in their economic status and persons who cease to be employed owing to illness. It was pointed out that, in the latter case, no question of ceasing to be insured could arise unless and until the insured person was again in a fit state to work. 268. It has also been pointed out to Societies that the fact of re- tirement on a pension, e.g., from the service of a railway company, on reaching a certain age does not necessarily cause a man to relin- quish the status of an employed contributor, and that if he is seek- ing some other form of employment he is entitled, during a period of temporary unemployment following his retirement, to avail him- self of the provision of Section 79 and to continue to be treated as an employed contributor. Any practical difficulties in dealing with cases of this kind have however been lessened by the pro- visions of Section 4 of the Act of 1913, which has substantially improved the position of contributors in the class by enabling any person 60 years of age or over who can show that he has ceased to be insurable as an employed contributor to continue in insurance as a voluntary contributor paying contributions ot the employed rate. » 99 THE COLLECTION OF CONTRIBUTIONS, THE RECEIPT AND ISSUE OF FUNDS, AND INVESTMENTS. Collection of Contributions. General. 269. The system adopted for the collection of cdhtributions described in last year's Eeport has continued to work with the minimum of friction and inconvenience to employers, to Approved Societies, and to the insured persons themselves. .With the passing of the initial period of the working of the system and thcv experience gained, it has been found possible to introduce certain modifications and improvements, the most important of which are described in the ensuing paragraphs. 270. The Eegulations which have been issued from time to time affecting the collection of contributions and the duties of employers generally have been consolidated, and the machinery for payment and collection is now set forth in concise and con- venient form in the National Health Insurance (Collection of Contributions) Consolidated Eegulations, 1914, which were issued by the Joint Committee and the Commission acting jointly and came into force on the 12th January last. Introduction of Six-Monthly Contribution Card, 271. The most important change provided for by the new Eegulations is the issue of a six-monthly instead of a quarterly card. For the first eighteen months of the operation of the collection arrangements the shorter period of currency was of great value in enabling Societies to keep in close touch with their members and in securing the early correction of errors and of omissions to pay contributions. Apart from these advantages, however, a system which involved a short period of Currency was unavoidable in view of the system of aver- age arrears provided for in the Act of 1911, which it was only practicable to work by averaging over completed periods of cur- rency and ignoring arrears in the current contribution period. To ignore the arrears of each current contribution period, if the period was so long as six months, would have been open to serious objection. This difficulty was removed by the introduction under the 1913 Act of the arrears scheme described in paragraphs 116 and 117 of this Eeport, and the way was thus cleared for pro- viding a card with a longer period of currency than three months. 272. The obvious advantages of a six-monthly, as compared with a quarterly card, are (a) a very great saving of labour to Approved Societies in con- nection with the issue of cards and in the accounting operations on their surrender ; and (B254— Gp. o) D 2 100 England. (b) a consequent substantial saving in postage and the admin- istration expenses of Societies generally. The issue of the six-monthly card was accordingly decided upon after it had been ascertained that the large majority of representative types of Societies v^ere in favour of the proposal. The issue of the nev^ card is also advantageous to employers who keep the cards during their currency. In preparing the new card every effort was made to retain as closely as possible the form oi the original card, and in the result a card was pro- duced of the same size as the old card and having the space for the name and address of the contributor in the same position. Employers who had provided themselves with cabinets for storing the cards of their employees were thus in no way inconvenienced by the change. 273. Opportunity has been taken, following the alterations in the arrangements for collection, to issue a revised edition of the general pamphlet (Pamphlet A) for the information of employers, and their attention is drawn to this pamphlet on the contribution cards themselves. Various memoranda of interest to employers have been issued from time to time, and a list of these is given at the end of the pamphlet. Distributioji and Surrender of Cards. 274. The new Regulations definitely lay upon every Approved Society the duty of issuing to each member of the Society the appropriate card. The duty laid upon the insured person of producing a card to his employer before the payment of wages remains, but he is only required to make application for a card at a Post Office if he does not receive one in due time from his Society, or (if he is a deposit contributor) from the Commission. The Commission regard it of the utmost importance that the in- sured person should keep in touch with his Society, and it is obviously necessary, if confusion and trouble are to be avoided when the cards are surrendered, that, the card which the insured person holds should be issued by the Society, so that it may bear his appropriate number in the Society. At the commencement of the operation of the Act it was recog- nised that, in order to obviate the use of large numbers of emergency cards, employers should be enabled to get ordinary contribution cards for issue to employees who for any reason had failed to get cards themselves ; and small supplies of ordinary cards were issued on application to employers for that purpose. These arrangements were purely temporary, and are no longer in operation. 275. The only other alteration of general interest in the Regulations is the relaxation of the requirement that every con- tributor should sign his card before surrendering it. As Societies are now allowed to number the card before issue, the signature is no longer generally required as a means of identification ; and Collection of Contrihutions. .",•:' ', I X^l in view of the cost and general inconvenience to Societies in having to return large numbers of cards for signature, v^ith the attendant risk of loss, the Regulations provide that the contri- butor is compelled to sign his card only when so required by the Society or the Commission. 276. The arrangements in connection with the contribution cards of exempt persons have been brought substantially into line with the arrangements relating to contribution cards generally. The Commission now issue direct to each exempt person a card bearing his certificate number, for presentation to his employer for stamping in the ordinary way ; and it has been found possible to relieve the employer of the trouble of signing the exemption book. Payment of Contrihutions at the end of the Period of Currency of the Cards. 277. The arrangements outlined in the previous Eeport (paragraphs 800-307) for the payment of contributions in bulk at the end of contribution periods have been con- tinued during the past year. After the first quarter the number of employers who had adopted the arrange- ment fell from 1,243 to 1,073, the decrease being partly due to the fact that the figures for the first quarter included certain local authorities and statutory companies who adopted this method of covering their liability in respect of contributions, pending the issue 6i certificates of exception from liability to com- pulsory insurance in respect of certain of their employees. There has since been a further slight decrease in the number of em- ployers adopting the arrangement, and at present the number of such employers is 1,009, and the number of employed persons included within the arrangement is 812,236. 278. Owing to the extension of the period of currency of the contribution cards from three to six months the scheme has been modified to provide for the stamping of the cards at the end of each half-year. In order to meet the special circumstances of the first half-yearly period, which consists of twenty-five weeks only, stamps representing twelve contributions at Id., 6d., and 4Jd. respectively will be issued in addition to stamps representing ten and thirteen contributions. Employers are given the option of making the necessary deposit for the half-year in one sum in advance, or by quarterly or weekly payments. In certain special cases monthly or fortnightly payments are accepted. Refunds of Contrihutions paid erroneously. 279. In a considerable number of cases contributions have been paid erroneously in respect of persons not required or entitled to be insured, and applications have been received by the Com- mission for the repayment of the value of these contributions. (B254— Gp. 5) D 3 102 England. The Acts do not provide for such repayment, and in so far as the contributions have been paid under a mistake of law there is no obligation to refund them. But many errors are due to mistakes of fact, or of law and fact combined, and on grounds of equity it is the practice of the Commission to allow a refund of contributions paid in error when a claim is made and is sup- ported by adequate evidence. 280. Claims are received from employers, from insured per- sons, or through the medium of Approved Societies. As a rule, to ensure the bona fides and accuracy of the claim, applicants are asked to submit a formal application on a form which is examined and certified by an Officer of Customs and Excise, who furnishes the Commission with any requisite details. When necessary, cases are investigated by the Outdoor Staff. 281. In spite of the instructions given to Societies as to the conditions of insurance and the widespread information conveyed to the public by leaflets and lecturers before the Act of 1911 came into operation, a number of persons entered insurance who were not eligible to do so, or before they became eligible. A wide- spread impression prevailed that any working man or woman could join the scheme at the start as a voluntary contributor at the rate of Id. or 6d. respectively, whatever his or her age. Not a few officials of Approved Societies shared this mistaken idea, and many persons over 45 years of age working at their own businesses consequently began to contribute at these minimum rates, the error generally being disclosed by the examination of the auditors in the third quarter. Many married women also became volun- tary contributors in error. Another frequent mistake was that made by persons who were out of employment at the commence- ment of the Act and stamped their own cards before becoming employed. 282. Another very large group of refund cases is that of per- sons in respect of whom contributions were paid before the age of 16 or after the age of 70. These are due either to ignorance (and in a few cases misstatement) of his real age by tEe contri- butor or to inadvertence by the employer. 283. A fairly large number of other persons who were excepted (being, e.g., in a subsidiary employment or remunerated at a rate exceeding i6160 a year) under Part II. of the First Schedule to the Act of 1911 became insured in error, generally through the em- ployer not understanding their position or wishing to be on the safe side. 284. While endeavouring to meet the reasonable claims of employers and insured persons, the Commission have also had to consider the effect of refunds on the finances of Approved Societies. In the great majority of instances in which persons ineligible for insurance were admitted to membership under the Act the mistake on the part of the Societies was made in good faith ; they were pressed with applications for membership which, if primd facie in order, they had no reason to refuse. Having once Collection of Contributions. 103 accepted the member, they became subject to expenses and Habilities in respect of him, and a refund of the whole amount of the contributions would have imposed on them a serious loss. 285. The Commission accordingly devised a scheme of adjustment which has been accepted by all Societies, whereby the latter retain a part of the contributions surrendered to them. The effect of the adjustments is to allow the Society to retain such portion of the contributions credited to it in respect of the first 26 weeks during which the contributor was treated as an insured person as will meet the charges for that period, and to give credit to the Society for the gross contributions on all cards surrendered to it, without deduction on account of reserve values, in respect of the period subsequent to the first 26 weeks. The balance of the contributions for the first 26 weeks is refunded to the employer for division between him and the contributor, or to the contributor where they have been wholly paid by him. It is a condition of the scheme that the Society should waive its right to recover benefit if any has been given. This arrangement secures to the Society the actuarial value on the average of the liability incurred ; while the contribu- tor has for the period in question been covered by an insurance to which he was not entitled, and if he happens t6 have received benefit, he is not required to restore it. The necessity of holding up claims pending the prepara- tion of this scheme and its acceptance by Societies inevitably delayed the refunds to which it applies. Since last October, however, the work of investigating, approving, and paying, has been steadily in progress, and the great bulk of the outstanding cases is now disposed of. 286. In addition to the claims based on non-insurability referred to in the foregoing paragraphs, refunds are claimed on various other grounds, e.g., the antedating of certificates of excep- tion or exemption, the payment of contributions at excess rates or for excess periods, the duplication of cards for the same period, and the payment of contributions by means of postage or unem- ployment insurance stamps. 287. The number of claims has been sufficiently large to impose a serious burden on the staff of the Department, but as the provisions of the Acts become better understood, there is every reason to hope that these erroneous payments will substantially diminish. New Insurance Books. 288. The first insurance books for members of Approved Societies covered the period from 15th July, 1912, to 12th October, 1913 (i.e., the first five quarters). In ordinary circumstances new insurance books would have been issued in the summer ot 1913, but the Bill of that year was then under discussion and (B254— Gp. 5) D 4 104 England. contained clauses which materially affected the form of the new books. It was therefore necessary to defer the issue of the new books, and to make a simple adaptation of the old books to provide for an additional quarter. The necessary instructions were ac- cordingly issued to Societies, and the new insurance books date from the end of the sixth quarter; not of the fifth. 289. The new insurance book covers the period from 12th January, 1914, to 31st December, 1916, and provides a record of contributions and arrears paid, and of sickness, disablement, and maternity benefits received. It contains an explanation of the way in which arrears are calculated and of the effect of arrears on benefits, and shows exactly how the arrears recorded at the end of each year as outstanding against the member have been arrived at. In addition to the statement of account and record of benefits, the book contains general information as to benefits and as to the collection and payment of contributions and of arrears. 290. In view of the special conditions governing the collection of contributions and the payment of arrears for persons serving on foreign-going and foreign-trading ships, a special insurance book for such contributors has now been brought into use. Condition of Quarterly Returns. 291. The stamped contribution cards at the expiration of their period of currency are handed in by the insured persons to the Approved Societies of which they are members. The Societies have then to establish their claim to credit, representing the net value of the contributions paid, in their account with the Com- mission. This they do by means of the quarterly (henceforward half-yearly) returns of contributions, which^ are sent in together with the stamped cards themselves. 292. The detailed instructions given to Societies in connection with the examination of the first quarter's returns have resulted in an appreciable improvement in the returns for later quarters. Much of this educative work had of necessity to be done by cor- respondence, but in many cases Society secretaries were able to visit the offices of the Commission, and difficulties which would otherwise have entailed a lengthy correspondence were elucidated speedily and without difficulty. These discussions also afforded ah opportunity of investigating the systems which Societies had adopted, and in many cases suggestions were made which have produced satisfactory results. 293. The work of the Examining Branch of the Commission is, however, by no means at an end when agreement has been reached between the return and the stamped cards, and the advice of credit has been issued to the Society. The registers of Approved Societies have been subjected to an exhaustive scrutiny by the Audit Department, and in the course of the investigation many errors have been discovered. Persons have been admitted Receipt and Issue oj Funds. 105 as members who prove to be uninsurable, while others, though properly insurable, have been wrongly classified. Errors dis- covered by the Auditors are notified to the Examining Branch, and the necessary adjustment is then made in the amount credited to the Society. 294. Audit Eeports affecting approximately 5,000 returns for the first quarter have been received, and these have involved a vast amount of work for the Examining Branch. But errors of this nature when once corrected do not recur, and when the initial scrutiny of the registers has been completed the volume of this particular class of work will be relatively small. Receipt and Issue of Funds. Security to he given hy Approved Societies. 295. Many of the Societies which at first elected to take advantage of the proviso to Section 26 of the Act of 1911, under which no security is required from any Society proving that the only funds coming into its hands under Part I. of the Act are required for reimbursing payments already made, have within the year under review found practical inconvenience in the system of paying State benefits in the f^rst instance out of funds obtained from outside sources. They have consequently given security, and are now able to obtain issues of funds in advance to meet current expenditure. The number of Societies which have given security in the various ways open to them, and of those which give no security and continue to finance themselves in the first instance, is given in Appendix X, page 502. 296. A Statement of the losses arising out of malversation or misappropriation by officers of Approved Societies reported, and the number of claims under investigation on 11th January, 1914, is given in Appendix XI, page 502. At that date no pay- ment out of the Fund to make good losses had been made. 297. The approximate amounts standing to the credit of the Central Guarantee Funds established by the Joint Committee and the English Commission on 11th January, 1914, were, respec- tively, ^14,174 and £6,027. Issue of Funds to Approved Societies. 298. Issues of funds to Approved Societies in respect of cur- rent expenditure on benefits and administration are made wherever possible by direct payment to a banking account opened by the Society with a Bank or Trustee Savings Bank. Under the provisions of the Acts requiring the separation of State and private funds it is necessary where banking accounts are kept by Societies that separate accounts should be opened for State fund moneys. These separate banking accounts can be operated on only by those officers of the Society who are authorised by the 106 England. rules of the Society to receive the sums issued by the Com- mission in respect of current expenditure, and with very few exceptions two signatures at least are necessary for the with- drawal of any money from the account. 299. In the case of those smaller Societies which have not considered it necessary to open a separate banking account for State insurance purposes, the sums issued by the Commission for current expenses are paid by money order drawn in favour of two officers of the Society, certified to the Commission as being authorised under the rules of the Society to receive such sums. 300. Some misapprehension has been found to exist as to the provisions governing the amounts which may be issued to Ap- proved Societies from the National Health Insurance Fund. To prevent loss of interest to Societies these provisions require the investment, under specified conditions, of all sums not required to meet current expenditure. Issues of funds in advance are therefore restricted to the amounts estimated to be actually required for benefits and administration over a period of a month. A form of application to the Commission for funds has been devised which should obviate any further misunderstanding on the point. 301. In the case of Societies with Branches, funds issued in advance are, generally speaking, paid by the Commission to the Head Office of the Society, or (in certain cases where the rules of the Society permit) to the District Office under which the Branches are grouped, for distribution to the Branches. It has been found that in some instances the distribution has been made pro rata on the Branch membership without reference to the actual requirements of the Branches, and, as a result, that some Branches have had surplus funds in hand while others have run short of cash to meet expenditure properly incurred under the Acts. Eepresentations have been made to the Societies concerned, and it is believed that the arrangements now made by those Societies will prevent the unnecessary accumulation of State funds in the hands of any Branch, and at the same time ensure that each Branch has funds in hand to meet current expenditure. Accounts of the National Health Insurance Fund. 302. Abstracts of cash receipts and issues out of the National Health Insurance Fund (England) will be found in Appendix XII, page 503 below. Investments. Temporary Investments of Balances. 303. Since the commencement of the Act, moneys in the hands of the Commission not required to meet current liabilities of Societies and Insurance Committees have, in accordance with Investments. 107 Section 54 (3) of the Act, been handed over, as they accrued, to the National Debt Commissioners for temporal^ investment pending ascertainment of the amount available for investment by or on behalf of Societies. The interest earned by the National Debt Commissioners on such part of those sums as represents the credits of Approved Societies V7ill in due course be apportioned and credited to the Societies. The amount temporarily invested v^ith the National Debt Commissioners on 11th January, 1914, amounted to dG10,457,601. About one-half of this amount consists of the sums deducted from con- tributions since the commencement of the operation of the Act to provide for interest on and liquidation of reserve values. The aggregate sums so deducted will ultimately be credited to Societies in proportions varying according to the amount of reserve values standing to the credit of each Society, but this can only be done when the reserve values due to be credited to each Society have been ascertained. The remainder of the amount consists mainly of receipts from sales of health insurance stamps in respect of which credits to Societies or to the Deposit Contributors and other Funds can- not be established until the contribution cards have been surren- dered to the Commission, and of sums reserved to meet payments to Insurance Committees during the following year. Permanent Investments. 304. Beside the temporary investment of balances, the Com- mission are required by Section 54 (3) of the 1911 Act to ascertain periodically what sums standing to the credit of Societies, of the Deposit Contributors Fund, and of the Navy and Army Insur- ance Fund are available for permanent investment. 305. During the period under review, the allocation of moneys for permanent investment has been commenced. Early in August, 1913, a circular was dispatched to all Approved Societies explaining the action to be taken by them to give effect to the system of investment provided by Sections 54 and 56 of the Act in respect of moneys available for permanent investment. 306. This system is as follows : Of the amount avail- able for permanent investment by or on behalf of a Society, three-sevenths (or so far as the sum is attribut- able to women, one-half) is transferred to an account called the Commissioners' Investment Account. These amounts remain to the credit of the Society with the Commission and form part of its assets, bearing interest at a rate fixed periodically (the rate has been fixed at 3 J per cent, per annum for the time being). As the credits of each Society in the Investment Account retain their original value. Societies are not concerned with the selection of the investments, the entire responsibility for which rests with the Government. The moneys in this account are in- vested on behalf of the Government by the National Debt Com- 108 England. missioners in securities which are, for the time being, authorised as investments for Savings Bank Funds ; a Eeturn showing the securities in which National Health Insurance Fund moneys are invested is presented annually to Parliament and published.* 307. The remaining proportion available for permanent invest- ment by the Society itself may be dealt with as the Society may select in one of the three ways provided by Section 56 of the Act, namely : — By transfer to the credit of the Society in the Commis- sioners' Investment Account ; or By investment in the names of the trustees of the Society in any of the securities authorised by Section 56 (2) of the National Insurance Act, 1911 ; or By investment in the names of the Commissioners at the request and on behalf of the Society in such of the securities authorised in the above-mentioned sub-section as the Society may direct. On the 11th January decisions as to their choice between these three courses had been received from 1,121 Societies divided as follows : — A. B. C. 308. Method No. of Societies. Membership. Selected. Men. Women. Total. A B C 885 180 56 1,289,026 4,000,188 379,109 305,835 2,187,107 149,435 1,594,861 6,187,295 528,544 Totals 1,121 5,668,323 2,642,377 8,310,700 309. The First Method (Method A) meets the needs of Socie- ties which are unwilling for any reason to undertake dealing in investments, and, as will be seen from the above Table, has been largely adopted by the smaller Societies. In this connection it is important to remember that amounts transferred to the Com- missioners' Investment Account retain their original value, whilst under the second or third methods Societies gain or lose by the fluctuation in the value of investments. 310. The Second Method (Method B) has in general been adopted by the larger Societies only, which have at command considerable financial knowledge and experience. The Eegula- tions provide that in these cases a special banking account in the names of at least three trustees must be opened for the reception of moneys for investment, the account to be operated on by the joint signatures of all the trustees. All moneys issued by the * The Eeturn for 1913 has been published as H.C. 140—1914. Investments. 109 Commission to the Society for investment are paid into that account and must be invested in the joint names of all the trustees. The securities in which these moneys may be invested are authorised by Section 56 (2) of the National Insurance Act, 1911, namely : — (a) Trustees' securities ; (6) Stock, mortgages, or other securities of a local authority ; or (c) Other securities approved by the Insurance Com- missioners. The question of the authorisation of investments is being con- sidered by an Advisory Committee. 311. The Third Method (Method G) differs from the preceding one only as regards procedure and convenience. The securities are selected by the Society concerned, the range of investments per- mitted being the same as under Method B. The securities are purchased and held by the Commission on behalf of the Societies, the position occupied by the Commission in these cases being virtually that of a custodian trustee. By this means the trustees and the Society can be relieved of the responsibility and trouble connected with the safe custody and purchase of the securities selected. Further, Societies which transact other business be- sides that of insurance business under the Acts can by this method more conveniently separate their investments under the National Insurance Acts from those held by the trustees in respect of other business. 312. In October, 1913, Societies were informed of the amounts which were then available for permanent investment. Further amounts were notified in December, 1913. A Statement showing the disposal of these moneys is appended : — £ Total amount available for investment 3,240,538 £ Amount required to be transferred to Com- missioners' Investment Account ... ... 1,. 381, 791 Amount available to be dealt £ with by Societies : — Retained in Investment Ac- count at request of Societies 260,708 Paid over to trustees of So- cieties for investment ... 870,519 Invested by Commission in securities selected by So- cieties 34,856 Awaiting decision of Societies 692,664 1,858,747 £3,240,538 £3,240,538 110 England. INSURANCE COMMITTEES. Constitution, Powers, and Duties of Insurance Committees, &c. Constitution of Insurance Committees on a Permanent Basis, 313. When returns had been received from all Insurance Committees of the number of insured persons in their areas and of their distribution between the various Societies, the necessary Eegulations were made by the Commission on 3rd May, 1913, providing for the appointment of representatives of in- sured persons to succeed those appointed provisionally by the Orders referred to in paragraph 367 of the previous Eeport. In determining the total membership of the Committees the Com- mission adhered to the numbers fixed at the time of their first constitution, with the exception that the membership of Com- mittees with an original membership of 50 was increased to 60, and that of Committees with an original membership of 70 to 80. 314. The terms of the Act preclude the possibility of a local election of the representatives of insured persons either by the individual members of each Society or by the insured persons in the area, and further confer the power of making the appoint- ments on the Society as a whole, and not on any of its Branches, whether registered or unregistered. The Eegulations, therefore, provided for the appointment and election of representatives by the Societies having members resident in each area, on the basis of the number of such members. 316. It was found necessary for the purpose of the election to draw a distinction between the direct representation of individual Societies and the representation to be accorded to the numerous other Societies whose membership in the area did not entitle them to individual representation. With a view to determining which Societies in any Committee area were entitled to direct representation, an electoral ** unit " for that area was arrived at by dividing the total number of insured persons resident in the area by the number of representatives of insured persons to be placed on the Committee. The result was the unit required. In the case of County areas the unit varied from 29,765 (London), 13,115 (Lancashire), and 11,346 (West Eiding) to 231 (Eutland), 556 (Soke of Peterborough), and 622 (Huntingdon); and in the case of the County Borough areas from 8,050 (Bir- mingham), 7,056 (Manchester), and 6,448 (Liverpool) to 253 (Canterbury), 520 (Chester), and 596 (Blackpool). 316. In the case of direct appointments representation was apportioned on the following principle. Where any Society had a number of members resident in any area equal to or greater Insurance Committees: Constitution, Powers, and Duties. Ill than the unit, the Society was entitled to appoint one member. Where the number was equal to two complete units, the Society was entitled to appoint two members, and so on. Fractions of a unit were disregarded. 317. After deducting the number of direct appointments, the remaining seats were filled by an election in which only Societies having members in the area but not entitled to a direct appoint- ment took part, this election being conducted on the principle of the single transferable vote. Each Society taking part was in- vited to nominate as candidates one man and one woman, or a man or a woman only. 318. Since it appeared desirable, in view of the large number of women who are insured persons, that women should be in- cluded among the members elected to represent insured persons as well as among the members otherwise appointed, a special pro- vision was made in the Eegulations that at least two vacancies should be reserved for the women candidates who received the largest number of votes. 319. The inclusion of a provision of this nature in the rules for the conduct of an election on the principle of proportional representation had not previously been attempted, and the Com- mission are indebted to Mr. Humphreys, Secretary of the Pro- portional Representation Society, for suggestions of special rules embodying this provision. They are also indebted to Mr. Hum- phreys for his assistance and advice in the preparation of the Eegulations as a whole, and in the general conduct of the elections. 320. Special provisions were adopted to secure to deposit contributors their due representation. The Eegulations pro- vided for the appointment on each Insurance Committee of at least one representative of deposit contributors, and, in areas where the number of deposit contributors was equal to two ** units," of two representatives. The only areas in which the deposit contributors were found to be entitled to two representa- tives were the Counties of London and Middlesex. In the absence of any association of deposit contributors the selection of the deposit contributors' representative or representatives was left to the members of the existing Committee appointed by the Commission, the local authority, and the medical profession. Having regard to the fact that the Insurance Committees have to administer maternity benefit in the case of deposit contributors, the Commission urged the desirability of appointing women, and the Eegulations provided that in cases where two representatives of deposit contributors had to be appointed one should be a woman. 321. The elections of the Committees for all the areas, with the exception of that for the Isles of Scilly, which is constituted under separate Eegulations, were conducted simultaneously at the offices of the Commission. In spite of the unfamiliarity of the great majority of the Approved Societies, over 2,000 iA 112 - England, number, participating in the election, with the method of pro- portional representation, Uttle difficulty was experienced, and the number of votes spoilt by errors of marking was so small as to be entirely negligible. The actual counting of the votes for the whole 120 elections occupied less than a week. The results were declared, and the Committees were declared duly constituted on 14th July. Formation of New Insurance Committees. 322. The Insurance Committees of four County Boroughs constituted during the past year have also been set up. Com- mittees were formed for the three new County Boroughs of Barnsley, Dewsbury, and Wallasey, on their constitution, but in the case of representatives of insured persons, in- cluding deposit contributors, the appointments were pro- visional and were terminable on 31st December, 1913, at the latest. When information as to the number of insured persons in these areas and their distribution among the various Approved Societies was available, the representatives of insured persons were appointed and elected in the manner described above, and the Committees were declared constituted on 31st December. In the case of the Insurance Committee for Carlisle, which became a County Borough on 1st April, 1914, it was possible to hold the election for the representatives of in- sured persons before that date, and the Committee was con- stituted on 12th April, the commencement of the quarter for the administration of medical benefit. Travelling Expenses, Subsistence Allowances , and Compensation for Loss of Remunerative Time. 323. The Act of 1911, except in so far as it authorised the Commission to sanction, in the case of County Insurance Commit- tees, the repayment to members of travelling expenses, made no provision for the expenses incurred by members of Committees in respect of subsistence and loss of remunerative time. The Commission sanctioned the repayment of travelling expenses, under this statutory authorisation, in the case of nearly all the County Insurance Committees. 324. The Act of 1913, however, in addition to extending to County Boroughs the provision above referred to, enacts that, besides any allowance for travelling expenses which may be paid, an Insurance Committee may pay to the members of the Com- mittee subsistence allowance and compensation for loss of re- munerative time, in accordance with a scheme prepared by the Committee and approved by the Commission, and that there shall be paid out of moneys provided by Parliament towards the expenses of an Insurance Committee under such scheme such sum (if any) as the Commission, with the consent of the Treasury, may determine. The aggregate amount so paid to Jnsurance Committees: Constitution, Powers, and Duties. 113 Insurance Committees in the United Kingdom is limited by the statute to iG30,000 in any year. These provisions do not apply to District Committees. The grants under this Section will be dis- tributed by the Joint Committee, and the four Commissions have arranged to adopt an uniform course of action in regard to the approval of schemes, and have agreed as to the maximum sum which may be distributed in each country. 325. Only actual members of Insurance Committees will be entitled to payments, but meetings both of the full Committees and of Sub-Committees will rank for the purpose. Any allow- ances made to members in respect of journeys undertaken on the business of the Committees will, however, not fall within the scope of the scheme. It has been settled that a scheme providing for an uniform combined payment to each member attending a meeting could not be approved, and that the provision for sub- sistence must be separated from that for loss of time. The sub- sistence allowance must be limited to the sums which a member of a Committee might reasonably be expected to expend on sub- sistence owing to his attendance at meetings, and the payment of compensation for loss of time must be limited to cases in which the member suffers an actual loss of wages. Associations of Insurayice Committees. 326. Under Section 31 (3) of the Act of 1913 an Insurance Committee may pay as general expenses incurred by them in the execution of their duties any sum, not exceeding ten pounds in any one year, as a subscription to the funds of any Association of Insurance Committees whose objects are approved by the Commission, as well as any reasonable expenses of the attendance of representatives, not exceeding in any case four, at meetings of such Associations, on a scale to be approved by the Commis- sion. The objects of the National Association of Insurance Com- mittees have been approved under this Section. District Insurance Committees. 327. At the date of the publication of the previous Eeport, schemes for District Committees, as submitted by County Insur- ance Committees under the Eegulations made by the Commission in accordance with the proviso to Section 59 (4) or the Act of 1911 , had been approved in respect of 23 areas. Since that date six further schemes have been approved, viz., for Devon, Dorset, Northumberland, Surrey, West Sussex, and Worcestershire; and the Commission have in the case of 14 Insurance Committees exercised their power to dispense with the constitution of District Committees on the ground of special circumstances. 328. Except in a few areas the District Committees are now in operation, the range of their duties being, within the limits de- fined in the Eegulations, wider or narrower according to local 114 England. circumstances, e.g., the extent and character of the County area, the density of the insured population within the area, the distri- bution of the insured population, the facilities for access to the central offices of the Insurance Committee, &c. Local Medical Committees. 329. The Local Medical Committees contemplated by the Act of 1911 have been active during the year in most County and County Borough areas. There has been an increase in the number of Local Medical Committees recognised since the issue of the last Keport. At that time 154 Committees had been recog- nised, of which 48 were for County areas, 59 for County Borough areas, and 47 for District Insurance Committee areas. At present 43 Committees for County areas and 68 Committees for County Borough areas are recognised and will hold office until 15th July, 1914, while 102 Committees for districts had been recognised up to the end of December, 1913. 330. The Commission are required by Section 62 of the Act of 1911 to satisfy themselves, before recognising a Local Medical Committee, that the Committee is representative of the duly qualified medical practitioners resident in the area. This duty renders it necessary for the Commission to examine both the personnel of individual Committees and the method of their con- stitution. With a view to facilitating the preparation of schemes for the constitution of Committees to hold office after 15th July, 1914, four model schemes dealing with the matterg which are essential to the representative nature of the Com- mittee have been prepared and issued by the Commission. These model schemes provide both for the cases in which the resident practitioners desire that the personnel of the Local Medical Committee should be the same or substantially the same as that of the Panel Committee, as well as for those in which it is preferred that the Local Medical Committee should be formed independently of the Panel Committee by means of election either by one meeting or by district meetings. 331. The duties and powers of the Local Medical Com- mittees, as revised and extended during the year, give to these bodies, and thus to the medical profession through them, an active voice in the settlement of many important questions affecting the administration of medical benefit and the relation- ships between the medical profession and insured persons. The principal powers and rights secured to the Committees are the following : The Insurance Committee must consult the Local Medical Committee with regard to the following matters ; proposed arrangements and rules for the administration of Insurance Committees: Constitution, Powers, and Duties. 115 medical benefit which it may be proposed to submit to the Com- mission for their approval ; the preparation of the list of prices on the basis of which payment for drugs and prescribed appliances are to be calculated ; any revision either of the conditions of the medical service or of the terms on which the supply of drugs and appliances is undertaken ; ^the fixing, varying, or revocation of any income limit for the purpose of the administration of medical benefit ; questions arising as to whether an operation or oth^r service needed in the course of treatment of an insured person can consistently with the best interests of the patient be properly undertaken by a general practitioner of ordinary professional competence and skill. 332. Amongst the duties imposed on the Local Medical Com- mittee is that of considering any complaint made by a practi- tioner on the panel against any other practitioner on the panel involving any question of the efficiency of the medical service of insured persons. The Local Medical Committee may require the Commission to hold an Inquiry as to whether the continuance of a practitioner on the panel is prejudicial to the service of insured persons in the area. 333. The Local Medical Committee has also a right to nomin- ate one member to the Medical Service Sub-Committee formed for dealing with any disputes arising between persons entitled to obtain treatment from practitioners on the panel and the practi- tioners giving such treatment. Panel Committees. 334. Section 32 of the Act of 1913 authorises the formation under Eegulations made by the Commission of Committees repre- senting the practitioners on the panel, as distinguished from the Local Medical Committees, which are representative of all practitioners in the area served, whether on the panel or not. The Section provides that in any case in which an Insurance Committee are required to ascertain the opinions and wishes of the practitioners on the panel they shall do so through this Panel Committee, and it empowers the Commission to assign other powers and duties to these Committees. 335. In framing the Eegulations governing the formation of Panel Committees, the Commission had regard to the desirability of giving to the medical practitioners on the panel in each area the opportunity of settling, in view of local conditions, the most convenient method of appointing the Committee charged with the duty of acting on their behalf, and of providing, at the same time, a simple general procedure by which a first Committee might be elected for those areas in which no desire was expressed for any special method of appointment. 116 England. 336. The scheme of the Commission provided for Committees, numbering from 20 to 40 (but as a rule from 20 to 32) in the case of Counties, and from 20 to 28 (in a majority of cases 20) in the case of County Boroughs. It was stipulated that in all cases at least three-quarters of the numbers elected should be practitioners on the panel list, while the remainder might be any qualified medical practitioners, whether on the- panel list or not. Pro- vision was also made to meet the case of County areas in which it was desirable that the principle of representation of practi- tioners by districts should be followed. The Eegulations provided that the first Committee might be appointed under a scheme submitted by any 20 practitioners on the panel list or a third of all such practitioners, whichever number was the smaller, and failing the submission of such a scheme, should be elected by the practitioners on the panel list in the manner prescribed by the Eegulations. Where the number of practitioners on the panel was 20 or less they were constituted as the first Panel Committee without any election. It was provided that members should hold office until 15th July, 1914, and that each Committee might, before 31st March, 1914, prepare a scheme for submission to the Commission providing for the appointment of the subsequent Committee. 337. The elections in the 52 areas where no special scheme was submitted were conducted in November, 1913, by a Eeturn- ing Officer appointed by the Commission. In 62 areas (31 Counties and 31 County Boroughs) Panel Committees were appointed under schemes submitted by the local practitioners. It would appear that in a majority of cases the alternative schemes submitted were intended to secure as far as possible identity of personnel in the composition of the Local Medical and Panel Committees. 338. Under the revised Medical Benefit Eegulations, Panel Committees have a right to examine the accounts of the panel practitioners, and to be consulted by the Insurance Committee in, amongst other matters, any contemplated revision of the terms of service of panel practitioners, the preparation or revision of the Drug Tariff, the fixing, varying, or revocation of any income limit for the purpose of the administration of medical benefit , the amount of the quarterly advances to practitioners, and the^ preparation of the rules relating to the administration of medical benefit. Amongst the duties of the Panel Committees may be mentioned the completion of arrangements with the Insurance Committee for the assignment of insured persons who experience difficulty in obtaining a doctor, the conduct of investigations into alleged excessive or extravagant prescribing, and the election of representatives on the Medical Service Sub -Committee. Panel Committees have the power generally to make representations to the Comrqissioners on any arrangements proposed by the Insur- ance Committee for the administration of medical benefit. Insurance Committees: Constitution, Powers, and Duties. 117 Pharmaceutical Committees. 339. Section 33 of the Act of 1913 provides for the formation of Committees of chemists and other persons supplying drugs, &c., to insured persons, and for giving such Committees a right, subject to Kegulations, to be consulted by Insurance Compaittees on all general questions affecting the supply of drugs and appli- ances to insured persons. 340. The Regulations made by the Commission for the appointment of these Committees required that the Pharmaceu- tical Committee for each County or County Borough should con- sist of a number of persons equal to one-fifth of the number of members of the Insurance Committee for that County or County Borough, not less than two-thirds of the total number of mem- bers appointed being registered pharmacists. The persons entitled to elect the Pharmaceutical Committee were the persons, firms, or bodies corporate who, on the 13th October, 1913, were under agreement with the Insurance Committee to supply drugs, medicines, or appliances; but any person whose name was in- cluded in the register of chemists and druggists at the same date was qualified for election. 341. A normal method of election was prescribed, though option was given to the electors in any area to propose an alternative plan of election where the procedure proposed in the Regulations seemed unsuitable. In no case was any alternative scheme submitted, and the elections were carried out by the Com- mission. The first Committees were appointed to hold office until 15th July, 1914, and any Committee was entitled, before 31st March, 1914, to prepare a scheme, subject to the approval of the Commission, for the appointment by the electors of the subsequent Committee. 342. The powers and duties of the Pharmaceutical Committees are laid down in the revised Medical Benefit Regulations. Among the more important of these are the right of examining chemists' accounts, the right of making representations with regard to any extravagance in prescribing with a view to an in- vestigation by the Panel Committee, and the duty of considering complaints made by any person supplying drugs or appliances against any other such person, involving any question of the efficiency of the service of drugs or appliances to insured persons. 118 England. Administration of Sanatorium Benefit. EVENTS LEADING UP TO THE PKESENT POSITION. 343. The Act places upon Insurance Committees the duty of administering sanatorium benefit, and of arranging for the pro- vision of treatment for suitable cases of tuberculosis occurring among insured persons in their areas. This treatment may be either (a) institutional : (i.) in sanatoria, hospitals, or other residential institu- tions ; (ii.) through dispensaries; (h) domiciliary : in the patient's home. As regards institutional treatment, Insurance Committees are re- quired to make arrangements to the satisfaction of the Commission with persons or local authorities (other than Poor Law Authori- ties*) having the management of sanatoria or other institutions approved by the Local Government Board, and are not empowered themselves to erect or purchase institutions. As regards domi- ciliary treatment. Insurance Committees are required to make arrangements to the satisfaction of the Commission for the pro- vision of such treatment in a manner approved by the Local Government Board. 344. The Insurance Act inaugurated a national campaign against tuberculosis by means of the provision of treatment by In- surance Committees for insured persons, and, in due course, their dependants, as a benefit of National Health Insurance. The finance of sanatorium benefit was framed accordingly. In the first place the Act provided for capital grants (to an amount fixed by the Finance Act, 1911, at ^1,500,000) towards the erection of sanatoria, &c., with a view to stimulating the supply of accom- modation to meet the demand. As regards the actual cost of the provision of treatment. Committees were secured a minimum income out of the National Health Insurance Fund at the rate of Is. dd. per annum per head of the insured population of their respective areas; and in order that additional resources might be available to them to finance the extension of their activities into the sphere of dependants, express provision was made for their income being supplemented, with the consent of the Treasury and the County or County Borough Council for the area, by half-and-half subventions out of the Exchequer and the rates to the amount of any estimated deficit. 345. The original finance of sanatorium benefit involved, therefore, direct grants-in-aid from the Exchequer to Insurance Committees to the extent of one-half of any sums required to supplement their minimum income where the benefit was ex- tended to dependants of insured persons, it being anticipated that * Section 39 of the Act of 1913 provides that for this purpose the Metro- politan Asylums Board shall not be regarded as a Poor Law Authority. Insurance Committees: Sanatorium, Benefit. 119 the Council for the area would be willing to contribute the balance towards the cost of operations embracing so large a part of the general population. Circumstances, however, arose which in some respects tended to modify the original scheme. Great stress was laid by the Eeport of the Departmental Committee on Tuber- culosis on the importance to the success of a national campaign of comprehending all classes of the population without distinction in the scope of the arrangements made for treatment, and on the necessity for the complete co-ordination of all organisations, voluntary or otherwise, interested in the treatment of tuberculosis. The Government decided to guarantee direct to County and County Borough Councils undertaking a general scheme for the treatment of tuberculous persons a proportion of the cost of maintenance by means of a grant-in-aid, now well-known as the Hobhouse grant. This grant was promised towards the cost of comprehensive schemes for the whole area to the extent of half the deficit on the annual cost of the scheme, after taking into consideration the payments by Insurance Committees and any other incidental sources of revenue. Hence the Hobhouse grant is closely analogous to the grants-in-aid originally contemplated, with the important exception that it is made direct to the local authority, and not to the Insurance Committee. 346. The complexion of the original plan was therefore, modified. In lieu of a scheme for insured persons and their de- pendants organised by Insurance Committees and financed out of their income supplemented by contributions from the Exchequer and the rates, the plan came to contemplate a com- prehensive scheme for the whole area, organised by the local authority, and financed partly out of rates and partly by the aid of contributions from Insurance Committees and the Exchequer. Participation in such a comprehensive scheme, therefore, became the new object of those concerned in the administration of sana- torium benefit. THE PKESENT AIM OF INSUKANCE COMMITTEES. Participation in Comprehensive Schemes. 347. The measures adopted by the various Insurance Com- mittees during the year 1913-14 thus relate to a period of transition, and the value of the work they have accomplished must be measured by the magnitude and variety of the difficulties which have had to be overcome, as well as by the tangible results which have been achieved. To the duty imposed on them by the Act of organising immediate measures for effectively secur- ing for insured persons forms of treatment which had hitherto been within the reach of a comparatively small section of the popu- 120 England. lation, was added the task of adapting those measures so as to accord with the institution, actual or potential, of a comprehensive scheme providing treatment not only for insured persons but for all tuberculous persons within the area. To the following account of the progress made in the establishment of comprehen- sive schemes it must be prefaced that the Local Government Board, in their Eeport for 1912-13 (pages xiii. to xxvii. of the third volume) have already placed on record the historical development of this movement, especially, of course, as regards the share taken in the movement by County and County Borough Councils. 348. Where Committees are not yet in a position to negotiate agreements with the Council of their area, owing to the fact that no comprehensive scheme has yet been established in the area, they have adopted arrangements of a provisional character with a view to securing that the best form of treatment practicable in the circumstances may be provided by the aid of such institutions and agencies as are already available. They have, at the same time, kept in view the desirability of making no arrangements which might at a later date present an obstacle to participation in any scheme that may subsequently be formulated by the Council. 349. Where, on the other hand, the County or County Borough Council has formulated a comprehensive scheme, gener- ally in consultation with the Insurance Committee as well as of necessity with the Local Government Board and through them with the Commission, the Insurance Committee have been in a position to frame their arrangements on a permanent, not a provisional, basis. The natural sequel to the approval of a scheme by the Local Government Board is the conclusion of an agreement between the Council and the Insurance Committee, whereby the latter agree to pay over certain sums from their Sanatorium Benefit Fund towards the cost of institu- tional treatment, and the former undertake to provide institu- tional treatment for suitable cases of tuberculosis recommended for sanatorium benefit by the Insurance Committee. These arrangements, whether of a provisional nature only or of a more lasting character, have involved, in the case of most Insur- ance Committees, inquiries, consultations, and negotiations with County and County Borough Councils, and other local authorities and bodies, many of such negotiations necessarily being of a somewhat protracted nature. 350. Up to the 7th May, 1914, considerably over 100 Councils had submitted to the Local Government Board schemes for pro- viding institutional treatment for both insured and uninsured per- sons suffering from tuberculosis. In nearly every case the schemes submitted are of a comprehensive character, providing for accommodation in sanatoria and hospitals, as well as for Insurance Committees : Sanatorium Benefit. 121 treatment at one or more dispensaries; in only a few cases are the schemes at present Kmited to the provision of dispensary treatment. The Nature of a Comprehensive Scheme. 351. Although in details the comprehensive schemes estab- lished in different areas necessarily differ according to local cir- cumstances, the general outlines of such a scheme, as recom- mended by the Departmental Committee on Tuberculosis, and now in full force in many areas, are uniform and may be briefly summarised. A complete scheme of this kind consists of two parts, the " sanatorium unit " and the " dispensary unit." Domiciliary treatment, though closely linked up with the compre- hensive scheme in areas where such a scheme exists, is not an integral part of the scheme, being based on direct agreement betw^een the Insurance Committee and the doctors on the panel. 352. The " sanatorium unit " comprises the various classes of residential institutions. Those institutions which take at present, and probably will in the future continue to take, a predominant place are sanatoria and hospitals, but this unit may also comprise farm colonies and open-air schools. Accommodation in resi- dential institutions would be provided normally to the extent of one bed in a sanatorium and one bed in a hospital for each 5,000 of the population, adopting the basis suggested by the Depart- mental Committee. In some cases the provision does not quite reach, but in other cases it considerably exceeds, this standard. The proportion of hospital beds to sanatorium beds varies in different areas, but there is at present a preponderance of sanatorium beds, to a greater or a smaller extent, in most areas. It must, how^ever, be borne in mind that patients needing observa- tion for the purpose of diagnosis or for determining the form of treatment, and patients for whom a short course of educational treatment is considered desirable, can equally well be provided for in a sanatorium, if close at hand, as in a hospital. 353. The " dispensary unit " consists of the dispensary acting in co-operation with private practitioners of the district served by the dispensary. Through the dispensary provision is made for the diagnosis of cases suspected to be tuberculous, and for advice being given as to the treatment suitable to each case. The dispensary serves also as a centre for actual treatment, dispensary treatment being suitable, in a very large proportion of cases, at one stage or another of the disease. One or more nurses are usually attached to each dispensary, and the services of these nurses may be available for visiting in their own homes dispensary pa- tients who are receiving treatment. In County Boroughs of the normal size one dispensary is sufficient. In Counties, however, the dispensary organisation is necessarily more complex, and it is usual in such, areas to have a suitable number of main dispen- 122 England. saries, branch dispensaries, and, possibly, " visiting stations " also. These latter would be in the outlying districts of the County, and would generally be open only on " market day." Branch dis- pensaries would be open more frequently, as the population served would be greater. The essence of the dispensary unit is not so much the buildings which may serve as local centres, but the presence of the expert medical officer, who acts as Tuberculosis Officer, and the various activities conducted under his direction and supervision. The Tuberculosis Officer provides the element which welds together the whole scheme of treatment, and, in par- ticular, links up the dispensary with domiciliary treatment. 354. The extent to which the success of any scheme depends upon the efficient staffing of the dispensary unit, therefore, can scarcely be over-estimated. Provision is normally made for the appointment of an Administrative Tuberculosis Ofificer, respon- sible for the general administration of the tuberculosis scheme in the area, and of one or more Tuberculosis Officers, administratively subordinate to him. These Tuberculosis Officers are appointed in virtue of their special qualifications and experience in dealing with tuberculosis, and it is usual for one of these Officers in each area to be responsible for the clinical side of the work. The Medical Officer of Health is usually appointed Chief Administra- tive Tuberculosis Officer, and in a few cases he also assumes clinical responsibility, with the assistance, however, in clinical matters, of an Assistant Tuberculosis Officer. In County areas where branch dispensaries and visiting stations exist the Assistant Tuberculosis Officers attend at stated hours. 355. Under a comprehensive scheme, the domiciliary treat- ment of insured persons is linked up with the dispensary organisa- tion of the scheme in two ways. First, the Act requires that all treatment shall be given in a manner approved by the Local Government Board ; and, under the Order made by the Board in July, 1912, practitioners undertaking domiciliary treatment are required to furnish to the Consulting Officer appointed under the scheme reports upon persons receiving domiciliary treatment under their care, at agreed intervals. The Tuberculosis Officer acts as the Consulting Officer, and with him the general practitioner must confer. Secondly, the arrangements made by the Insurance Committee secure the services of one of the Tuberculosis Officers, generally the Officer clinically responsible to the Council, as the Committee's Medical Adviser. Thus, where an in- sured person is granted domiciliary treatment, the Medical Adviser, in his capacity as Consulting Officer, can obtain information enabling him to advise the Committee as to what other form of treatment, if any, may from time to time be most suitable. Indeed, the Tuberculosis Officer keeps in touch with all tuberculous cases applying for or receiving treatment under the scheme. He is thus in a unique position to fulfil the functions of Medical Adviser to the Insurance Committees: Sanatorium, Benefit. 123 Committee by advising them, in the case of insured per- sons, what form of treatment is suitable in the case of a new applicant for sanatorium benefit, and what changes of treatment are found desirable as the case progresses. 356. Under the majority of the schemes submitted for ap- proval, shelters are, or will be, made available. Shelters may be regarded as an adjunct either of dispensary or domiciliary treat- ment, since in many cases a shelter may be advantageously lent to a person attending the dispensary for treatment ; and, similarly, where persons are in receipt of domiciliary treatment a shelter may be a valuable aid to treatment. In either case the shelter is placed close to the house of the patient. 357. Under some comprehensive schemes the services of the nurses attached to the dispensaries are available for visiting in their own homes insured persons in receipt of dispensary treat- ment. Where this is not the case, resort is most generally had for the purposes of domiciliary treatment to the assistance of a local nursing association. The arrangements made to this end by Insurance Committees vary in different cases. Comprehensive Schemes in actual working. 358. Examples of complete schemes, illustrative of the scope which such a scheme may embrace, are afforded by the schemes operative in the three largest provincial towns, Liverpool, Man- chester, and Birmingham. 359. Liverpool. — The scheme formulated by the Corporation of Liverpool is of particular interest as showing what may be effected by co-operation between the public authorities, the medical profession, and voluntary agencies for dealing with tuber- culosis. Before the commencement of the Act, the Corpora- tion of Liverpool had been active in the matter of the treatment and prevention of tuberculosis. In addition to the preventive measures adopted in the city, such, for example, as housing im- provements, control of the milk supply, disinfection of premises occupied by tuberculous persons, etc., certain specific measures for prevention and treatment had been in operation for many years. 360. As it was found that the accommodation for the treat- ment of pulmonary tuberculosis at the voluntary and Poor Law institutions needed supplementing, the Corporation in 1907 opened wards in one of its isolation hospitals to provide accommo- dation for 25 tuberculous patients. The number of beds was subsequently very considerably increased. In 1910 a Tubercu- losis Officer was appointed to give his whole time to tuberculosis work, and to report to the Medical Officer of Health thereon. Dispensary work was carried out at the Central Consumption Hospital. The treatment of tuberculous children was in large measure undertaken by the Liverpool Invalid Children's Associa- tion in connection with three institutions for children. 124 England. 361. For many years past tuberculous persons discharged from institutions have been kept under observation by officers of the Pubhc Health Department , and since the establishment of dis- pensaries in the area, the name and particulars of each patient discharged from the Corporation Sanatoria and other institu- tions have been forwarded to the dispensary in the district in which the patient resides, and arrangements are then made by the Medical Officer in charge for the supervision of the case by himself in conjunction with the patient's own medical attendant, and each case is, so far as possible, carefully followed up. In regard to children discharged from institutions where they have been under treatment for various forms of tuberculosis, the Liver- pool Invalid Children's Association continue their interest, and this Association has acted for many years as an " After Care ' ' Committee in addition to its other activities. 362. The arrangements' already operative before the com- mencement of the Act w^ere such that they readily lent themselves to adaptation and extension as the foundation of a comprehensive scheme on the lines recommended by the Departmental Com- mittee. The essentials were present, and the Corporation, Poor Law Authorities, and voluntary agencies were working together and had enlisted the sympathy of the whole medical profession in the area. 363. The adaptation and enlargement of the scheme com- menced immediately the Act came into operation, with the result that at the present time the existing accommodation in residential institutions belonging to the Corporation amounts to 280 beds, whilst there are available approximately 230 additional beds in neighbouring institutions not owned by the Corporation, though not all of these latter beds are used by Liverpool patients. On the 11th January, 1914, 294 insured patients were in resi- dential institutions under arrangements made by the Insurance Committee. 364. The Chief Tuberculosis Offices continues his work, and an addition of several Tuberculosis Officers has been made to his staff. The Consumption Hospital has now become the central dispensary, two additional dispensaries having been established, one in the northern, the other in the southern part of the city. The spirit of co-operation shown by the public and voluntary agencies in Liverpool is evidenced by the fact that, w^hilst the Con- sumption Hospital does not belong to the Corporation, the Cor- poration have appointed and pay the salaries of the staff at the tuberculosis dispensary portion of the Hospital. 365. Except as regards residential accommodation, the Liver- pool scheme is now in the final form — at any rate for the pre- sent. As regards residential accommodation, one of the Cor- poration's institutions is to be enlarged so as to contain 200 beds for adults, 150 for children, and, as the general scheme has Insurance Committees : Sanatorium. Benefit. 125 received approval, a grant has been promised by the Local Govern- ment Board in respect of the structural alterations necessary for this purpose. 366. Arrangements are made for utilising the v^ork of voluntary hospitals and agencies. Children will be further pro- vided for, since, in addition to the beds to be made available for them in the Corporation institution referred to above, and the accommodation in the existing institutions for children, the In- valid Children's Association contemplates building a sanatorium v^ith 100 beds near Liverpool. The Invalid Children's Associa- tion, although a voluntary agency, has, owing to its close co- operation with the Public Authorities, come to be regarded in Liverpool as a permanent branch of the Public Health Depart- ment. 367. The question of open-air and residential schools is now under consideration by the Education Committee, but apart from any accommodation of this nature that may be rendered available , the Corporation estimates for the annual maintenance of 590 beds for adults and children suffering from all forms of tuberculosis, whereas the recommendations of the Departmental Committee would only involve, at the rate of one sanatorium bed and one hospital bed for each 5,000 of the population, the provision of 300 beds, the population of Liverpool, at the time of the 1911 census, being 746,566 persons. 368. The Insurance Committee have entered into an agree- ment with the Corporation for a period of 30 years for the pro- vision of all forms of institutional treatment required by insured persons. The Committee have also, apart from their agreement with the Corporation, made arrangements for securing the services of nurses in connection with domiciliary treatment, and acces- sories to domiciliary treatment, in the form of special nourish- ment, are provided upon medical recommendation. 369.' Manchester.— The Corporation of Manchester, which had a population of 714,427 persons in 1911, has adopted a scheme involving, on the side of residential treatment, the extension of one of its existing institutions so as to accommodate 300 patients, the purchase of the Abergele Sanatorium with 50 beds from the South Machester Board of Guardians, and the retention of some 60 beds in the Crossley Sanatorium. 370. As regards dispensary treatment, the Corporation decided that one central dispensary, easily accessible from all parts, would better suit local circumstances than the establishment of several dispensaries. As in Liverpool, the central dispensary is to be worked in conjunction with the local Hospital for Consumption, at which tuberculosis dispensary work was carried out before the commencement of the Insurance Act. Some of the physicians on the Hospital Staff now receive salaries from the Corporation , and are available as consultants in respect of the treatment given at 126 England. the dispensary and in the Corporation's institutions. There is in addition a whole-time tuberculosis staff consisting of four or five Tuberculosis Officers working in conjunction with the dispensary. 371. The previously existing offices of the Medical Officer of Health being inadequate, the Corporation has purchased premises adjoining the Hospital for Consumption ; some of the rooms will be used as an extension of the dispensary itself, and the building will also serve as offices for the Tuberculosis Medical Staff, for the nurses, eight in number, of whom, however, only two have as yet been appointed, and for the Public Health Inquiry Officers, seven in number. The nursing work in connection with sanatorium benefit is, at present, carried out by the Manchester and Salford District Nursing Association. The nurses are appointed to attend cases under treatment at home, to make reports thereon, and generally to minister to the needs of the cases they attend. The value of after-care work is recognised, as well as the importance of enlisting the sympathy and co-operation of public, voluntary, and other charitable agencies in this work. 372. The Insurance Committee have entered into an agreement with the Corporation for participation in this comprehensive scheme for a period of 21 years. 373. Birmingham. — In Birmingham an institution, with ac- commodation for 48 patients, was opened in January, 1909, and another, for 57 patients, in October, 1910. Other measures were taken by the Corporation, of which the most important was the establishment of a Municipal Tuberculin Dispensary : the work carried on there has become widely known. A system of visita- tion of cases was carried out by health visitors. 374. When the Insurance Act came into operation the Cor- poration extended the dispensary organisation, and, with respect to accommodation in residential institutions, provided a total of some 400 beds, a number considerably in excess of the standard suggested in the Departmental Committee's Eeport. 375. It is interesting to note, as an example of co-operation between public authorities and voluntary agencies, that the Bir- mingham Hospital Saturday Fund, in connection with the facili- ties afforded through the institution of a comprehensive scheme, has erected a sanatorium of 90 beds at Eomsley Hill. 376. Examples of Councils making generous provision for in- stitutional treatment might be multiplied, but those of the three important cities quoted above will suffice to show the nature of the considerable endeavours which are being made to deal adequately with tuberculosis, as well as to explain the general provision for the treatment of the disease by means of compre- hensive schemes. It is a matter for regret that London itself, with its great resources for the treatment of all forms of disease, cannot be instanced as an example of a great area co-ordinating and concentrating all its appropriate resources, through a com- prehensive scheme, on the combating of tuberculosis. Insurance Committees : Sanatorium Benefit. 127 Progress made in the establishment of Comprehensive Schemes. 377. Before a general scheme is recognised as suitable for grants from the Exchequer, either in aid of the capital expenditure to be incurred upon institutions proposed to be provided under the scheme, or in aid of the maintenance of the scheme when estab- lished, the approval of the Local Government Board, to which Department is entrusted the distribution of the grants available, is required in respect of the plans for erecting new, or adapting existing institutions, and also in respect of the details of the scheme as a whole. 378. Councils, before submitting schemes to the Board, usually confer with representatives of the Insurance Committee upon their proposals, as the value of such co-operation is generally recognised. When a scheme has been approved, it is always contemplated that the Committee will, as soon as the Council are in a position to provide institutional treatment for insured per- sons, make an agreement with the Council, under which such treatment will be undertaken by that body. 379. In virtue of the provisions of Section 64 of the Act, the Commission are consulted in connection with all proposals in- volving the distribution of the State grants in aid of capital or maintenance expenditure, and, as each comprehensive scheme submitted will, if approved, involve either one or both of these grants, all such schemes are considered by the Commission as well as by the Local Government Board. 380. Of the schemes submitted by County Councils and County Borough Councils up to the 7th May, 1914, the schemes of the following 34 County Councils and 56 County Borough Councils have been approved either in general or in detail or in both :— Counties. Cheshire. Cornwall. Cumberland. Derbyshire. Devon . Dorset Durham. Essex. Gloucestershire. Hertfordshire. Isle of Ely (instalment of a complete scheme). Kent. Lancashire. Leicestershire. Lincolnshire, Parts of Holland. Lincolnshire, Parts of Kesteven. Lincolnshire, Parts of Lindsey. Middlesex. Northamptonshire. Northumberland . Nottinghamshire . Shropshire, Somerset. Staffordshire. Suffolk, East. Suffolk, West. Surrey. Sussex, West. Warwickshire. Westmorland. Wiltshire. Worcestershire. Yorkshire, East Riding (partial scheme). Yorkshire, West Riding. 128 England. County Boroughs. Barnsley. Bath (partial scheme). Birkenhead (partial scheme). Birmingham. Blackburn. Blackpool. Bolton. Bootle. Bradford. Brighton. Bristol. Burnley. Burton-on-Trent. Bury. Canterbury. Carlisle. Chester. Coventry. Croydon. Derby. Dudley. Eastbourne. Gloucester. Halifax. Hastings (partial scheme). Ipswich. Kingston-upon-Hull. Leicester. Lincoln. Liverpool. Manchester. Middlesbrough. Newcastle-upon-Tyne. Northampton. Norwich (partial scheme). Plymouth. Portsmouth. Rotherham. St. Helens. Salford. Sheffield. Smethwick. Southampton. Southend-on-Sea. South Shields (partial scheme). Stockport. Stoke-on-Trent. Tynemouth. Wallasey. Walsall (partial scheme). Warrington. West Bromwich (partial scheme). Wigan. Wolverhampton. Worcester. York. 381. In connection with this Hst it may be stated that some of the approved schemes embody arrangements for joint action between County Councils and County Borough Councils. Under Section 64 (3) of the Act, the Local Government Board are empowered to make by Order such provisions as appear necessary or expedient, by the constitution of joint committees, joint boards, or otherwise, for the joint exercise by County Councils and County Borough Councils of their powers in relation to the provision of sanatoria and other institutions for the treatment of tuberculosis, in order to facilitate co-operation amongst such authorities for this purpose. Combination of this kind has, as a rule, been between County and County Borough Councils in near proximity. 382. Up to the 16th March, 1914, the appointment of Tuber- culosis Officers had been notified in respect of the following 38 County areas and 58 County Borough areas, the asterisk de- noting that part of the Officer's time is devoted to other official work : — Bedfordshire. Cumberland Berkshire. Derbyshire. Buckinghamshire. Devon ''Cambridgeshire. Dorset. Cheshire. Durham. Cornwall. Essex. Insurance Committees : Sanatorium Benefit. 129 Counties — continued . Gloucestershire (joint with Gloucester City). Herefordshire. Hertfordshire, Isle of Ely. Kent. Xiancashire (joint with Barrow- in-Furness, Bootle, Bury and Wigan). Leicestershire* ^Lincoln, Parts oi Lindsey. Middlesex. Northamptonshire. Northumberland. Nottinghamshire. Oxfordshire. Shropshire. Somerset (joint with Bath). Staffordshire. Suffolk, East. ♦Suffolk, West. Surrey. Sussex, East. Sussex, West. Westmorland. Wiltshire. Worcestershire. Yorkshire, East Riding Yorkshire, West Riding. County Boroughs. Barrow-in-Furness (joint with Lancashire). Bath (joint with Somerset). Birkenhead. Birmingham. Blackburn. Blackpool. *Bolton. Bootle (joint with Lancashire). Bradford. Brighton. Bristol. Burnley. *Burton-on-Trent . Bury (joint with Lancashire). Croydon. Derby. Dewsbury. Dudley. ^Eastbourne. Gloucester (joint with Gloucester- shire). ^Halifax. Hastings. *Huddersfield. *Ipswich. Kingston-upon-Hull. Leeds. Leicester. ^Lincoln. Liverpool. Manchester. Middlesbrough. Newcastle-upon-Tyne. Northampton. Norwich. Nottingham. Plymouth. Portsmouth. Preston. Reading. Rochdale. Rotherham. St. Helens. Salford. Sheffield. Smethwick. Southampton. Southend-on-Sea. ^'Southport. South Shields. Stoke-on-Trent. Sunderland. Tynemouth. Wakefield. Wallasey. West Ham. Wigan (joint with Lancashire). Wolverhampton. ^Worcester. York. 383. London is prominent among the 11 Counties (out of a total of 48) in which no Tuberculosis Officer for the County has been appointed. It will be noticed that Tuberculosis Officers have been appointed for some areas in respect of which no com- prehensive scheme has yet been approved. Such appointments may be regarded as indicating that the formulation of a scheme, or of an instalment of a scheme, is in contemplation. (B254— Gp. 5) E 13D England. Agreements between Committees and Local Authorities. 384. In connection with the participation of Insurance Committees in comprehensive schemes, the question as to the form of agreement which w^ould be the most suitable as a basis of arrangements between Councils and Com- mittees for this purpose w^as considered by the Local Govern- ment Board and the Commission in consultation, and, in November, 1913, the Commission issued to Insurance Committees the model form of agreement which appears as Appendix XIII, page 504, the same form being issued to Councils by the Local Government Board. 385. The Committee and the Council having made such adaptations of the model agreement as may appear appro- priate in view of local circumstances, the Council submits the draft agreement so resulting to the Local Government Board, and the Committee furnishes a copy to the Com- mission, since any arrangements made by the Committee re- specting the treatment of tuberculosis require the approval of the Commission under Section 16 of the Act. The Commis- sion and the Board consider the draft agreement in consultation, and, if necessary, the Commission suggest to the Insurance Com- mittee any desirable modifications of the draft submitted. 386. Since the model agreement has served as the basis of most of the comprehensive agreements now in force between Councils and Committees, a brief comment upon its terms as affecting Insurance Committees will be desirable. Clauses 1 and 2 (a) relate to the duties of the Tubercu- losis Officer as Medical Adviser to the Committee. The Tuber- culosis Officer not only advises the Committee upon particular cases and supervises any treatment given at the dispensary or ill tlie Council's residential institutions, but acts generally as expert Adviser upon the administration of sanatorium benefit. It will also be remembered that, under the Local Government Board's Order relating to the domiciliary treatment of tubercu- losis, he acts as Consulting Officer in connection with that form of treatment. Clause 2 (6) relates to the provision of dispensaries, the Council undertaking to treat in the dispensaries provided under the scheme such insured persons as the Insurance Committee may nominate for dispensary treatment. Clause 2 {d) of the agreement relates to residential ac- commodation. In this clause the Council undertakes to provide a fixed minimum number of sanatorium and hospital beds which shall be available for the use of insured persons ; the Committee's discretionary power of nominating insured persons to beds in the Council's institutions up to the minim imi numbers so agreed being limited only by the provisos that (1) the Council may refuse to admit any person if the Tuberculosis Officer certifies that the patient would derive greater benefit from some other form of treatment than that provided in the institution concerned, or that the patient's physical condition is such as to render him Insurance Committees : Sanatorium, Benefit. 131 ineligible for admission under the rules of the institution ; and (2) the person under treatment shall observe any regulations made by the Council or by the managers of the institution for the control and management of the institution. Clause 3 of the agreement requires the Committee to consult with its Medical Adviser before making any recom- mendation for benefit which will involve treatment being given in any institution, including dispensaries, provided under the scheme. Though under the agreement the Insurance Committee have no right to demand residential treatment for insured per- sons beyond the numbers specified in the agreement, the Council may, in its discretion, admit further insured persons into their institutions if the Tuberculosis Officer recommends such action. Committees and Councils are normally working together for the treatment of tuberculosis, so that the number of insured persons under treatment in the residential institutions provided under the scheme is determined by the number needing treatment, and is often in excess of the minimum numbers fixed in the agreement. Clause 4 determines the Committee's payment to the Council. Out of the sum of Is. M. per insured person eligible for sanatorium benefit available to the Committee, 6d. is paid to the practitioners on the panel in respect of personal services rendered in connection with domiciliary treatment. Of the remaining 9d. some portion is retained by the Committee to meet its adminis- trative expenses in connection with sanatorium benefit, the cost of drugs and medicines, and of additional nourishment where this is ordered as ancillary to treatment, in connection with domi- ciliary treatment, such travelling expenses as may be allowed to insured persons when going to or from institutions for treatment, and any other incidental expenses. The Committee usually retains for these purposes a sum between 2d. and 1^/. per insured person, so that the figure inserted in Clause 4 is usually either Id. or Sd. or such intermediate sum as local circumstances may render appropriate. 387. The model agreement contains no reference to the de- pendants of insured persons as, under a comprehensive scheme, their treatment as part of the uninsured population will be under- taken by the Council, the Insurance Committee being responsible only in respect of insured persons. 388. Agreements between Insurance Committees and Coun- cils, generally on the lines of the model agreement, have been made in the following areas : — Counties. Cumberlaud. Staffordshire. Dorsetshire. Suffolk, West. Essex. Surrey. Leicestershire. Warwickshire. Middlesex. Westmorland. Shropshire. Yorkshire, East Riding. Somersetshire. Yorkshire, West Riding. (B254— Gp. 5) E 2 132 England. County Boroughs. Birmingham. Liverpool* Blackpool. * Manchester. Burton-upon-Trent. Newcastle. Coventry. Smethwick. Dudley. Wolverhampton. Kingston-upon-HuU. Worcester. Agreements have been made in Cambridgeshire, Lincolnshire Parts of Lindsey, East Sussex, and Bootle, limited at present to dispensary arrangements only. 389. Agreements are for a term varying from a maximum of 60 years to 30 years in some areas, and to 21 years or less in others. In some areas the agreement is only for one year in the first instance, but such a temporary arrangement affords a basis for subsequent agreement for a more prolonged period, a short period being first fixed in order that experience of the working of the agreement may be obtained. 390. These figures do not, of course, mean that comprehensive schemes are only in operation in these particular areas. In many cases comprehensive schemes are operative, but the actual agree- ment, for one reason or another, has not yet been formally completed. PKOVISIONAL AKKANGEMENTS WHEEE NO COM- PKEHENSIVE SCHEME EXISTS. 391. It must be clearly understood that even where no treat- ment is yet available for the general population under schemes prepared by the local authorities involving expenditure out of the rates and appropriation of Exchequer grants, treatment by way of sanatorium benefit is in every area available for insured per- sons. Dispensary treatment is, of course, dependent, in such areas, upon the existence of a dispensary. Even where dispen- saries have not been provided by the Council, a dispensary (or dispensaries) belonging to a voluntary association may be avail- able. In a very large majority of County Boroughs, however, even where no complete scheme exists, Tuberculosis Officers have now been appointed and municipal dispensaries established, which are available to Insurance Committees for the provision of sana- torium benefit. In the County areas, too. Tuberculosis Officers have , for the most part , been appointed , and considerable progress is being made with the establishment of dispensaries. Where no Tuberculosis Officer has been appointed, Committees have, almost without exception, secured the services of the Medical Officer of Health as their Medical Adviser. Insurance Committees : Sanatorium Benefit. 133 392. As regards residential treatment, all Insurance Com- mittees are in a position to make satisfactory arrangements for the treatment of insured persons, apart from the establishment of comprehensive schemes. Arrangements have normally been made to secure beds in institutions belonging to the Council, or, if such accommodation is either non-existent or inadequate for the Com- mittee's purposes, arrangements have been made with privately- owned institutions, of which a large number have been approved by the Local Government Board for the purposes of sanatorium beneht. In all such cases, care has been taken not to reserve beds in such institutions for such a prolonged period that the Com- mittee would not be in a position to make arrangements to secure this form of treatment through the Council, in the event of the Council at any time becoming in a position to undertake a comprehensive scheme. 393. A very large proportion of the County Borough Councils which are not yet in a position to provide institutional treatment- under a comprehensive scheme have, nevertheless, under arrange- ments with the Insurance Committee, adapted existing residen- tial institutions in the borough to meet the needs of insured per- sons. In some cases the accommodation thus provided is re- garded as temporary only ; but in others these existing institutions will take a permanent place in a comprehensive scheme, when fully developed, and serve as tuberculosis hospitals if not also as sanatoria. 394. County, as opposed to County Borough, Insurance Com- mittees are not so fortunately situated as regards existing resi- dential institutions of this nature, so that, where it has not been possible for them to arrange for the use of beds in institutions belonging to County Boroughs situated within the geographical area of the County or in institutions belonging to Joint Hospital Boards, recourse is had to privately-owned sanatoria approved by the Local Government Board, pending the erection of new institutions. 395. As regards domiciliary treatment, the fact that in any par- ticular area, whether County or County Borough, there may not be in existence a comprehensive scheme in no way affects this form of treatment, as Insurance Committees direct the administration of such treatment even where the Council undertakes all the institu- tional treatment of insured persons. Domiciliary treatment does not form a subject of agreements between Councils and Com- mittees, practitioners on the panel having undertaken to give this form of treatment in a manner approved by the Local Government Board in respect of any insured person upon their panel list, in consideration of the payment of a capitation fee of 6d. per annum for each such person, this 6d. being part of the sum of Is. dd. available for all form of sana- torium benefit. It may, however, be noted that where no (B254— Gp. 5) E 3 134 England. Tuberculosis Officer has yet been appointed, the Medical Officer of Health (who, as stated above, is in these circumstances gener- ally the Committee's Medical Adviser as well) will be the Con- sulting Officer under the Local Government Board's Order relating to domiciliary treatment. 396. In addition to the special medical treatment provided in cases of tuberculosis under domiciliary treatment, through the contact maintained between the panel practitioners immediately responsible for the treatment and the Consulting Officer ap- pointed under the Local Government Board's Order above referred to, domiciliary treatment may embrace the provision of a shelter for the patient to sleep in, and the services of a nurse under arrangements made by the Insurance Committee. Further, the majority of Insurance Committees have supplied, as part of domiciliary treatment, accessories in the form of special nourishment, such as eggs, milk, &c. The allowance of such accessories is tnade upon medical recommendation only, strict regard necessarily being had to the fact that it is the duty of an Insurance Committee, in connection with sanatorium benefit, to arrange for the treatment of disease and not to relieve destitution. 397. In a few areas sanatorium benefit has been extended to the dependants of insured persons, but normally the funds of In- surance Committees are not sufficient to bear the additional cost that would be entailed by such extension of the benefit. On -the 11th January, 1914, the end of the first quarter of the sana- torium benefit year 1914-1915, the extension of the benefit to dependants generally (or to special classes of dependants), as a result of resolutions passed by Insurance Committees, was only operative in 16 areas, 38 Committees, who had at one time or another extended the benefit, having revoked the extension before that date. As will be gathered from what has already been said upon the subject of comprehensive schemes, the revo- cation by Committees of this extension of benefit does not neces- jarily indicate that treatment for tuberculosis amongst dependants is no longer available ; on the contrary , it may merely indi- cate that a comprehensive scheme has become operative in the area, rendering treatment available for dependants upon exactly the same footing as other uninsured patients. Eespon- sibility for their treatment having thus been assumed by the Council, the Committee is in a position to revoke such complete or limited extension of the benefit as it may have previously maintained. The Administration of Sanatorium Benefit in the County of London. 398. The special features of local government in London have given rise to some considerable variations in the normal scheme Insurance Committees : Sanatorium Benefit. 135 for the treatment of tuberculosis. While the London County Council is recognised as the authority which should be respon- sible for the general co-ordination of treatment, the Councils of the Metropolitan Boroughs have to some extent taken part in the general scheme, many of them having prepared schemes for the provision of dispensary treatment, while leaving to the County Council the arrangements for the provision of institutional treat- ment and the general co-ordination of the w^ork in London as a whole. 399. Up to March 16th, 1914, Tuberculosis Officers had been appointed in the following 18 Metropolitan Boroughs : — Battersea, Bermondsey, Camberwell, Chelsea, Deptford, Fulham, Greenwich, Hampstead, Kensington, Paddington, Poplar, St. Marylebone, St. Pancras, Shoreditch, Stepney, Wandsworth, Westminster, and Woolwich. Up to that date appointments had not been made in respect of the 11 Metropolitan Boroughs of Bethnal Green, the City, Finsbury, Hackney, Hammer- smith, Holborn, Islington, Lambeth, Lewisham, South wark,. and Stoke Newington. 400. For the purpose of enabling the London Insurance Com- mittee to secure accommodation for insured persons, the London County Council made an arrangement with the Metropolitan Asylums Board by which the Council were able to provide for the Insurance Committee 300 beds at the Downs Sanatorium, near Sutton, and 200 beds at the W'inchmore Hill Sanatorium. Since the Metropolitan Asylums Board is technically a Poor Law Authority it was not possible for the Insurance Committee, under the provisions of Section 16 (1) (a) of the Act of 1911, to make this arrangement direct with the Board, but under the provisions of Section 39 of the Act of 1913 this tech- nical difficulty has been removed, and it is now open to the Metropolitan Asylums Board to enter into agreements with a County or County Borough Council, or, with -the consent of the Council concerned, with any authority (including Insurance Com- mittees) for the provision of sanatorium and hospital accommoda- tion for insured persons. 401. In addition to the accommodation thus obtained through the County Council, the London Insurance Committee has ob- tained beds in other sanatoria, and has made arrangements with Metropolitan Borough Councils having the management of dis- pensaries and with voluntary dispensaries for dispensary treat- ment for insured persons. 402. During the year from the 15th January, 1913, to the 11th January, 1914, inclusive, a total of 4,685 persons in London received benefit (3,377 men, 1 ,308 ' women) . The following table shows the various forms of treatment which these patients (B254— Gp. 5) E 4 136 England. received during the same period — any one patient being liable to be counted more than once if he, or she, received more than one form of treatment : — Form of Treatment. Sanatorium Hospital . . . Dispensary Domiciliary Men. 1,899 597 480 2,353 Women. 753 189 204 903 Total. 2,652 786 684 3,256 NUMBEK OF PEESONS RECEIVING SANATOEIUM BENEFIT. 403. In January, 1914, the Commission, in conjunction with the other Commissions, called for a Eeturn from Insurance Com- mittees as to the administration of sanatorium benefit for the first 18 months' operation of the benefit — from the 15th July, 1912, to the 11th January, 1914. This Eeturn has been laid before Parliament, and appears as Appendix 111, on page 479. The Eeturn shows that, so far as regards English Insur- ance' Committees, 34,416 persons during that period received sanatorium benefit in one form or another. Some of these persons were the dependants of insured persons recom- mended for benefit during periods when the extension of the benefit in various areas, under resolutions passed by the Insur- ance Committees of those areas, was in operation. This figure, however, does not, of course, include those persons to whom treatment has been afforded solely in virtue of the existence of comprehensive schemes, but only such persons as have received treatment under arrangements made by Insurance Committees, whether those arrangements have, in fact, been made with the local authorities or otherwise. The Eeturn, as already stated, relates to a period of 18 months. In view of the fact that future Eeturns will normally relate to yearly periods, a further Statement appears as Appen- dix IV, giving the figures contained in Tables I, II, and III of the Eeturn, adjusted so as to include only those w^hich relate to the period from the 15th January, 1913, to the 11th January, 1914, both dates inclusive, with a view to providing a basis of comparison with similar Eeturns which may be made in future years. Insurance Coin7nittees : Sanatorium Benefit. 137 SUMMAEY OF AERANGEMENTS MADE BY EACH INSURANCE COMMITTEE. 401. The following paragraphs summarise the arrangements in force in each Committee area as at 11th January, 1914, the particulars given being collected from the Return above referred to. The figures of the number of persons who have received benefit are also brought down to the same date. The fact that a number of persons have received sanatorium benefit in more than one form accounts for any discrepancies that may appear from a comparison of the total number stated to have received benefit, and the sum of the numbers stated to have received treatment in its various forms. 1. Administrative Counties. The Bedfordshire Insurance Committee have made regular arrangements with the Alfred Bojd Memorial Sanatorium and the Painswick Sanatorium, whereby there are available for their patients 10 and 2 beds respectively in these Institutions. They have also made it a practice to secure a number of beds for individual patients, where required, in various other Institutions. There are no disp*^nsaries in the Bedfordshire area, but arrangements have been made with the Rural District Nurses Association for the provision of nurses on an attendance basis ; and the arrangements made by the Committee include the use of 7 shelters. 154 persons — the total number of persons recommended for treatment— had received sanatorium benefit in the area. 94 received residential treatment. The Berks Imurance Committee have an agreement with the Maitlancl Sanatorium under which 9 sanatorium beds are available for Insurance Com- mittee patients. Arrangements are also made for securing beds for individual patients in a number of other Institutions. These arrangements are provisional only, a County Council scheme being at present under consideration. As regards dispensary treatment, patients are seen either at the Tuberculosis Officer's Central Office in Eeading, the dispensary being provided bj the Berks County Council, or, more usually visited by the Tuberculosis Officer at home, since it is difficult for patients living in rural districts to attend the dispensary. Arrangements for nursing have been made with the Berks County Nursing Association, the Royal Victoria Nursing Home, and other organisations. 17 shelters, provided by the Berks County Council, are in use. All the 120 insured patients recommended for sanatorium benefit have received treat- ment — 58 residential. The Biicks Inswrance Committee provide residential treatment in the Great Baddow Sanatorium, Essex, and in the Maitland Sanatorium in Oxfordshire,. 7 and 5 beds respectively being available in those institutions for Insurance Committee patients. In addition several non-pulmonary cases have^ been treated in the Royal Sea Bathing Hospital, Margate. There are 2 dis- pensaries available to the Committee, one at High Wycombe and the other at- Thame, in Oxfordshire ; these are provided by the Bucks County Council and the Oxfordshire Association for the Prevent-ion of Consumption respectively. District nurses employed by the various District Nursing Associations in the area visit such cases as are recommended by the Tuberculosis Officer ; and two half-time nurses have been appointed by the County Council. There are also 5 shelters in use, provided by four District Councils. 125 persons received treat- ment out of 126 recommended. Of these, 71 were treated in sanatoria, and 5 received dispensary treatment. In addition 2 dependants of insured persons received benefit. 1'38 England. The CaTnh'idgeshire Insurance Committee have made no genei'al agreement reserving beds in any particular institution, but send individual patients to sanatoria as occasion arises. There is at present no dispensary treatment available, but it is understood that the County Council are arranging for a dispensaiy in the town of Cambridge. For the purposes of nursing, arrangements are in force with the District Nursing Association, and there are 22 shelters hired by the Committee from the County Council. 108 insured persons, out of a total of 113 recommended, received treatment, 25 being treated in sanatoria. In addition 6 dependants of insured persons have received sanatorium benefit in the form of domiciliary treatment. Tn the area of the Cheshire Insurance Committee 45 beds are available for the Committee's patients in four institutions, viz. : — The Painswick Sanatorium, the Cranham Lodge Sanatorium, the Wensleydale Sanatorium, and the Manchester Hospital for Consumption at Bowdon. In addition, individual patients are sometimes sent to other institutions, beds being taken as required. There is at present no dispensary service in the area. As regards nursing, arrangements are made with the Cheshire County Nursing Association and with the Hoylake and West Kirby Nursing Association for the services of district nurses. Two shelters have been hired from the Crewe Borough Council. 281 insured persons out of 315 recommended received treatment, 199 in residential institutions. These included 12 non-pulmonary cases. The Cmmwall Insurance Committee have made ai-rangements whereby they have available eight beds in the Devon and Cornwall Sanatorium for Con- sumptives ; and in addition patients have been sent to other institutions under special arrangements. One dispensary at Penzance is now working ; but it is understood that three others, at Tuckingmill, St. Austell, and Liskeard have been approved by the County Council. Nursing arrangements, pending the completion of the County Council's scheme, have been made with the District Nursing Associations. Six shelters provided by the County Council are already in use, and others, it is understood, are being ordered, 188 insured persons, out of 195 recommended, received treatment, 47 being treated in sanatoria. In addition, 71 dependants of insured persons out of 79 recom- mended were treated during the same period, 6 being treated in sanatoria. The Cumherland Insurance Committee have no definite number, of beds reserved in any sanatorium or hospital, patients being sent to different institutions usually, however, to the Blencathra Sanatorium. There are at present no dispensaries in use, but the Cumberland County Council are now establishing dispensaries in a number of suitable localities. The County Nursing Association is making arrangements with the County Council for nursing tuberculous persons. The Insurance Committee have hired 12 shelters from the County Council. 87 insured persons, out of a total of 94 recommended, received treatment, 51 in sanatoria. In addition, 89 dependants, out of 95 recommended, were granted sanatorium benefit, 23 being treated in sanatoria. The Derbyshire Insurance Committee^ pending the completion of a compre- hensive scheme now under consideration, have not reserved a fixed number of beds in any particular institution, but send persons recommended for in- stitutional treatment to different institutions as occasion arises. A sanatorium however is in course of erection at Chesterfield in which a definite number of beds will be allocated to the use of insured persons. Dispensaries, 7 in number, situated in Chesterfield, Glossop, Ilkeston, Long Eaton, Derby, Burton-on- Trent, and Matlock are provided by the County Council. The nursing arrangements in Derbyshire form a special feature of the proposed Derbyshire scheme, there being a stafi' of 25 health visitors, whose services are arranged for by the County Council in connection with the compulsory notification order and school inspection. There are 78.shelters in use in the county. Up to the 11th January, 1914, 381 persons had been recommended for benefit, all of whom received treatment. 71 were treated in residential institutions, 275 attended dispensaries, and 102 were treated in their own homes. As regards dependants, every dependant of an insured person recommended for treatment has received treatment, the total number being 194. 27 have received sanatorium treatment, 149 dispensary treatment and 37 domiciliary treatment. The Devon Insurance Committee have an agreement with the County Council under which sanatorium beds in two institutions, and hospital beds for Insurance Committees : Sanatorium Benefit. 139 pulmonary cases in the Newton Abbot Hospital, are available to the Com- mittee. Other beds have been obtained as and when required. Dispensaries are established at Exeter and Torquay, and two others are in process of development at Barnstaple and Stonehouse. Nursing arrangements have been made with all associations affiliated to the County Nursing Association. 12 shelters have been provided by the County Council. 255 insured persons have been recommended for treatment, and every case has received treatment. 97 have been treated in residential institutions, 29 through dispensaries, and 129 in their own homes. As regards dependants, the 11 recommended for benefit have all received treatment, 3 in sanatoria. The Dorset Insurance Committee have made arrangements with the Hawthorndene Sanatorium at Bonchurch securing 10 beds for Insurance Committee patients, with 5 other beds if required. In addition, one bed in the Bridport Hospital is reserved for non-pulmonary cases ; other insured persons recommended for institutional treatment have been sent, under special arrangements, to other institutions. There is at present no dispensary treatment in the County. The Dorset County Council however propose, under the comprehensive scheme now formulated, to establish 4 dispensaries. The Dorset County Council have let 22 shelters for the use of the Committee. Up to the 11th January, 1914, 186 insured persons out of 189 recommended for benefit, have received treatment, 75 of these being residential cases. In the Durham area, a comprehensive scheme is now under consideration, pending the completion of which the Insurance Committee have made arrange- ments with 10 institutions, under which over 150 beds are available for Insurance Committee patients. In addition, 6 patients have been sent under special ar- rangements to other institutions. The administration of sanatorium benefit in this area is remarkable, not only for the large number of beds acquired by the Committee, but also for the large number of dispensaries available ; there are 11 dispensaries in the County, at Durham, Darlington, Hartle- pool, Stockton, Bishop Auckland, Stanley, Consett, Swalwell, Sunderland, Jarrow, and Horden. Arrangements have been made with the Durham County Council for the services of health visitors for the recipients of sanatorium benefit. The present number of this staff is 24. There are 12 shelters, provided by the Durham County Council. Up to the 11th January, 632 persons, were treated, 406 in residential institutions and 33 at dispensaries. 309 dependants of insured persons, the total number recommended, have also received treatment, 186 in sanatoria, and 28 through dispensaries. The Essex Insurance Committee have secured, through the County Council, , 115 beds in 12 institutions. They have a large number of dispensaries available,, there being 14 of these in the County. The County Council have arranged for nurses to assist at the dispensaries, and there are 57 shelters in use, provided under agreement by the County Council. 909 persons, the total number recommended, have received treatment, 527 residential, 310 through the dispensaries and 249 in their own homes. In addition 361 dependants of insured persons, also the total numberrecommended, have received benefit, 54 residential and 220 through dispensaries. A comprehensive scheme has been formulated for the County. In Gloucestershire^ 38 beds are available for Insurance Committee patients in the Cranham Lodge Sanatorium. There are 5 dispensaries, at Cheltenham, Cinderford, Gloucester, Stroud, and Warmley. There is a whole-time nurse available, and 17 shelters have been provided. All the arrangements of the Insurance Committee for the provision of institutional treatment are with the Gloucester Joint Committee for Tuberculosis. The number of persons treated, up to 11th January, 1914, was 297, the total number recommended for treatment. There were 135 cases of residental treatment, 61 dispensary cases, and 180~ domiciliary. As regards dependants, all the 96 cases recommended for treat- ment received treatment, 39 in sanatoria, 10 through dispensaries, and 47 in in the form of domiciliary treatment. The Hampshire Insurance Committee have the use of beds in various institu- tions including 5 for non-pulmonary cases at the Royal Sea Bathing Hospital, Margate. Arrangements have been made with the City of Winchester for some cases to be treated at their dispensary. There are no nursing arrangements, but 20 shelters have been obtained by the Committee through the County 140 England. Council. 256 insured persons, the total number recommended, have received sanatorium benefit, 147 in residential institutions, 3 through dispensaries and 227 b}^ way of domiciliary treatment. 20 non-pulmonary cases have been treated. As regards dependants of insured persons, 84, the total number recommended for benefit have received treatment, 15 residential, one dis^ en- sary, and 77 domiciliary. The Herefordshire Insurance Committee have available 10 beds in the Cian- ham Lodge Sanatorium for the treatment of insured persons. Dispensaries in the area, provided by the County Council, are situated at Hereford, Kington, Ledbury, Leominster, Boss and Wigmore. There are sub-stations at Peter- church and Weobley, and another dispensary is shortly to be opened at Brom- yard. Nurses are provided unier arrangements between the County Co ai"il and the County Nursing Association, and there are 12 shelters provided by the County Council, together with 6 more in process of construction. 84 insured persons have received treatment, 38 in sanatoria. The Hertfordshire Insurance Committee have available 23 beds, in four ins'itu- tions and also send individual patients to other institutions under special arrangements. There will be some 13 dispensaries available in the area under the comprehensive scheme formulated for the area by the County Council. Arrangements have been made for nursing, both in connection with dispensary and domicilictry treatment. There are 20 shelters available, of which 13 are at present in use, loaned to the Committee by the Hertfordshire County Council. 289 insured persons out of the 292 reconmiended have received sanatorium benefit ; 158 of these have been residential cases, 18 dispensary cases, and 123 domiciliary cases. The Huntingdonshire Insurance Committee have no beds reserved under agreement, but send jjatients to difierent institutions under ad hoc arrange- ments in each case. There is a dispensary at Huntingdon provided by the Hunts County Council. There are 9 shelters, hired from the Hunts County Council, in use by the Insurance Committee. 46 insured persons, out of 46 recommended, have received benefit, 22 being treated in sanatoria. 33 dependants of insured persons have received treatment, 9 in sanatoria. The Isle of Ely Insurance Committee have no standing agreement with any institutions, but send persons for institutional treatment under special arrangements made for each case. There is no dispensary service, but a nurse is provided through the District Voluntary Nursing Associations, in cases recommended by the Committee. 38 insured persons have been recommended for treatment, of whom 20 have been granted treatment, 19 in sanatoria. Benefit has not been extended to dependants. The Isle of Wight Insurance Committee send insured persons for residential treatment in each case under ad hoc arrangements with different institutions. No dispensary treatment is available in the area. Altogether 76 persons have been recommended for benefit, of whom 66 have received treatment, 42 in sanatoria and 30 by way of domiciliary treatment. One dependant has also been treated. In the Isles of Scilli/ not a single case of tuberculosis has been brought to the notice of the Insurance Committee, and accordingly no arrangements for institutional treatment have been made. The Keiit Insurance Committee have available 52 beds in 5 different insti- tutions, and have, in addition, sent numerous individual patienta to other institutions under ad hoc arrangements. The County has a large number of dispensaries, their total number being 11 ; these are provided by the Kent County Council. The Kent County Council has also made arrangements with the Insurance Committee for the services of 4 whole-time nurses, together with part-time nurses in certain districts. The Committee have hired 40 shelters from the County Council. The Committee have provided treatment for all insured persons recommended therefor, the number of these being 744. 308 of these haA^e received residential treatment, and 85 through dispensaries. The arrangements for sanatorium benefit in Lancashire are remarkable for the complete system of Tuberculosis Officers which is being set up. The system is under the control of a Chief Tuberculosis Otficer there being 2 subordinate Insurance Committees : Sanatorium Benefit. 141 officers for the County and 5 appointed jointly with various County Boroughs in the County. This system of staffing provides a basis for the establishment of a comprehensi p-e dispensary organization throughout the County adapted to the special circumstances of the County with its large number of County Boroughs. The Committee have made the following temporary arrangements pending the institution of a complete general scheme. They have available 151 beds in various sanatoria and hospitals, and in addition have frequently sent individual cases to other sanatoria or hospitals under ad hoc agreements. The Insurance Committee have provided 9 shelters. Up to the 11th January, 1914, 1,104 persons had been recommended for treatment, every one of whom received treatment. 563 of these persons received treat- ment in sanatoria. The Leicestershire Iiuurarice Committee have made arrangements with the County Council for the tise of 38 sanatoria beds. This arrangement is temporary, pending the institution of the permanent scheme formulated for the county. There is a residential dispensary at Hinckley, and a second in course of erection at Coalville. There are also sub-dispensaries at Coalville, Melton Mowbray and Market Harborough. The Leicester County Nursing Association have made an agreement to supply nurses to visit patients receiving domiciliary treatment. Seven shelters have been provided by the Committee, and 13 are on hire from the County Council. 230 persons have been recom- mended for treatment in the area, and 229 have received treatment. 155 of these have received treatment in sanatoria, and 58 through the dispensaries. The Holland (Lincolnshire) Insurance Committee have no standing agree- ment with any institutions but make special arrangements for residential treatment in each case. There are no dispensary facilities in the County, and no arrangements have yet been made for nursing ; 6 shelters are in use, provided by the Holland County Council ; 47 persons have been recommended for treatment and all have received treatment ; 29 of the 47 have been treated in sanatoria. Sanatorium benefit in this area has been extended to dependants, of whom 24 have received treatment, 4 in sanatoria. The Kesteven {Lincolnshire) Insurance Committee have 2 beds available in the Withernsea and the East Riding Sanatorium and 2 in the Maltings Farm Sanatorium. In addition, individual cases are sent to other sanatoria under ad hoc agreements. There is no dispensary treatment in the area, but in connection with domiciliary treatment arrangements are made with various nursing associations for the services of nurses, and 6 shelters have been hired by the Insurance Committee from the County Council. 77 persons, the total number recommended, have received treatment in the area, 21 of them in sanatoria. In addition 23 dependants have been recommended for treatment and received treatment, 4 in sanatoria. The Lindsey {Lincolnshire) Insurance Committee have available 4 beds ia the Ipswich Borough Sanatorium, and in addition have an arrangement with the Dean Head Sanatorium, Horaforth, whereby the Committee, though reserving no fixed number of beds, may send patients as occasion demands. Patients have also been sent to Ventnor and Lincoln. At present no dispensaries are available, but provision for dispensaries is made in the comprehensive scheme now under consideration. In cases where nursing has been required the Committee have made arrangements with the Local Branch of the Lincolnshire Nursing Association. 44 shelters have been provided by the Lindsey County Council. 144 insured persons have been recommended for treatment, of whom 143 have been treated, 76 in sanatoria. 10 dependants, the total number recommended, have received treatment, 1 in a sanatorium. The London Insurant Committee have reserved 300 beds at the Downs Sanatorium, 200 at the Winchmore Hill Sanatorium, and 6 at the Ipswich Sanatorium. The first 2 sanatoria are the property of the Metropolitan Asylums Board, and the Insurance Committee have entered into agreement through the London County Council for the use of the stated number of beds in the institutions. The agreement for the use of the beds at Ipswich is with the Ipswich Borough Council. 50 beds at Downs and 50 at Winchmore Hill are hospital beds for pulmonary cases. In addition many patients are sent by the London In^uretnce Committee to other institutions as and when necessary. Dispensary advice in London is provided by the use of all dispen- 142 E7igland. saries in the County approved by the Local Government Board, 25 in number. These are provided by Borough Councils and other bodies. Arrangements for nursing in individual dispensary cases have been made at the request of the Committee by voluntary associations. The use of shelters is also a matter dealt with by dispensaries, where established. 4,736 insured persons have been recommended for treatment, of whom 4,685 have received treatment. 3,438 were treated in residential institutions ; 684 were treated through dispensaries ; 3,256 received domiciliary treatment. The Middlesex hisurance Committee have secured 92 sanatorium beds, and 30 hospital beds for pulmonary cases in the three institutions, namely, Clare Hall, the Fairlight Sanatorium at Hastings, and the Winchmore Hill Hospital. Many insured persons have also been treated in other institutions. There are three dispensaries at present in use, one at Edmonton, one in Hornsey, and one at Harrow. These are provided by the Middlesex County Council, and others will be ready shortly. The County Council provides a nurse at each dispensary, and shelters are a^so available. 983 persons have been recom- mended for treatment, of whom 887 have received treatment. 615 of these have received treatment in residential institutions, and 11 through dispen- saries. The Nw'folk Insurance Committee have an agreement with the Kelling Sanatorium, under which 19 beds are available for the Committee's use. There is no dispensary service available in the County, nor is any provision made for nurses. The Committee have provided 29 shelters in connection with domiciliary treatment. 144 insured persons have been recommended for treatment, of whom 125 have been treated, 65 in sanatoria, and 92 by way of domiciliary treatment. In addition, 51 dependants of insured persons have been recommended for benefit under the Committee's resolution extending the benefit to dependants, and 49 of these 51 dependants have received treatment, 10 in sanatoria. The Northamptonshire Insurance Committee have available 9 beds in the Northamptonshire Sanatorium at Creaton for the use of Committee patients. In addition, a number of insured persons have been treated under individual agreements in other institutions. There are three dispensaries working in the area, at Ketterin;^, Wellingborough, and Northampton, these three being provided by the County Council. There are three dispensary nurses attached to the Kettering and Wellingborough dispensaries. The County Council has provided shelters. 236 iubured persons have been recommended for treatment, and all have received treatment, 51 in sanatoria and 36 through dispensaries. The Committee have extended sanatorium benefit to dependants, and all the 136 depandants recommended have been treated. 5 of these have been sanatorium cases, 1 a hospital case, and 2 dispensary cases. The Northumberland Insurance Committee have arranged for the use of beds in various sanatoria as occasion has required. There are no dispensary arrangements in the County. Arrangements are in force whereby district nurses attend insured persons receiving domiciliary treatment, and in connection with domiciliary treatment 23 shelters have been provided by the Committee. 157 persons have been recommended for treatment, of whom 152 have received treatment, 49 in sanatoria. In addition the Committee has extended benefit to dependants, of whom 34 have been recommended for treatment and 24 treated, 21 of them in sanatoria. The Nottinghamshire Insurance Committee participate in a comprehen- sive scheme now established, under which 24 beds are reserved for the Committee under the agreement with the Council at Ratcher Hill Sanatorium, Mansfield. As regards dispensary treatment, the agreement makes provision for 4 dispensaries in the county, which,- however, are not yet in operation. Two of the four nurses to be appointed by the County Council under the agreement had been appointed at the 11th January, 1914. No shelters are used. 154 insured persons were recommended for treatment, every one of whom received treatment, 72 in sanatoria. In Oxfordshire no beds are expressly reserved for the Insurance Committee in any institution, but patients are sent under separate agreements / different sanatoria. The majority haA^e been sent to the Maitland Sanatori to Insurance Committees: Sanatorium Benefit. 143 at Peppard Commou. Dispensaries are in existence at Oxford, Chipping Norton, Witney, Banbury, Bicester and Thame. These dispensaries are provided by the Oxfordshire Association for the Prevention of Tuberculosis. The dispensary work of that Association is a feature of the arrangements for sanatorium benefit in the County. There are 2 nurses provided by the Association and 19 shelteis are in use. 115 insured persons have been recom- mended for treatment, of whom 111 have been treated. 23 have received their treatment in sanatoria, 8 in hospitals, as many as 81 through dispensaries, and 51 by way of domiciliary treatment. Benefit has been extended to dependants ; out of 12 applications for treatment 11 have been recommended, and 8 have been treated, 7 in residential institutions. The Rutland Insurance Committee have reserved no beds in any particular institution, but send insured persons to diflferent institutions under ad hoc agreements. There is no dispensary service in the County and no arrangements for nursing have been made. '4 shelters are in use, 2 provided by the Upping- ham Rural District Council. 16 insured persons have been recommended for treatment, and they have all received treatment, 6 in sanatoria and 13 by way of domiciliary treatment. As regards dependants of insured persons, 8 have been recommended for treatment, all of whom have been treated, 2 of them in sanatoria. The Shropshire Insurance Committee have concluded an agreement with the Shropshire Association for the Prevention of Consumption for the use of beds in the King Edward VII. Memorial Sanatorium at Shirlett. No actual number of beds is reserved, but cases are admitted to the sanatorium in accordance with the number of beds available. This arrangement is temporary only, pending the establishment hy the County Council of a com- prehensive scheme. A dispensary in Shrewsbury, provided by the County Council, is now available, and a nurse is attached to the dispensary. 14 shelters have been provided by the Committee. 120 persons have been recommended for sanatorium benefit, of whom 119 have been treated. 66 of these were treated in the sanatorium, and 6 received dispensary treatment. Sanatorium benefit has recently been extended to dependants, and of the 9 recommended for benefit all have received treatment. 2 of these have been sanatorium cases. The Soke of Peterborough Insurance Comm ittee have reserved 1 sanatorium bed at Engel Home, Cheddar. In addition, insured persons have been sent under separate agi^eements to other institutions, such as Fairlight and Maitland. Negotiations are proceeding for the establishment of a dispensary by the County Council. Arrangements have been made with the Florence Saunders Nursing Association and the Northamptonshire Nursing Association under which the Committee secure the services of nurses for those cases recom- mended by the medical adviser. 7 shelters have been hired by the Committee and 2 have been provided by the Peterborough Kural District Council. 41 persons have been recommended for treatment, of whom all have been treated, 16 in sanatoria. Jn addition, 17 dependants have been recommended for and have received benefit, 6 in sanatoria. The Somerset Insurance Committee have no definite arrangements for permanently retaining beds in institutions. They have however experienced no difiiculty in obtaining beds under individual arrangements in different sanatoria as cases were from time to time recommended for residential treatment by the Tuberculosis Ofiicers. There is a large number of dispensaries m the County — 10 in all — and these well distributed. Nursing arrangements have been made with the County Nursing Associations, nurses being supplied in cases recommended by the Tuberculosis Ofiicers. No less than 88 shelters have been provided by the County Council. 421 insured persons have been recommended for benefit, and all have received treat- ment, 153 residential, and 53 dispensary treatment. 24 of the 420 cases have been non-pulmonary. Benefit has been extended to dependants, and 136 dependants, the total number recommended, have received treatment, 34 in sanatoria, and 121 through the dispensaries. 15 of these 136 cases have been non-pulmonary. The Staffordshire Insurance Committee are making arrangements for institutional treatment with the Staffordshire, Wolverhampton, and Dudley 144 England. Joint Committee for Tuberculosis. The Joint Committee will provide a minimum of 45 beds for patients recommended for benefit by the Insurance Committee. The Joint Committee for Tuberculosis has provided 5 dispensaries, 1 for the Northern part of the County at Newcastle, 1 for the central part in Stafford, and 3 ia South Staffordshire at Wolverhampton, Wednesbury, and Dudley. These premises are temporary. Sub-dispensaries, it is understood, are to be established in various centres. No permanent arrangements have yet been made for nursing. There are 70 shelters in use provided by the Joint Committee for Tuberculosis. 533 insured persons have been recommended for treatment in the County, of whom every one has received treatment. 291 have been treated in sanatoria and 5 through dispensaries. Ill dependants of insured persons have received treatment, 36 in sanatoria. In the area of the East Suffolk Insurance Committee there ia an agreement between the Committee and the Ipswich Corporation under which 18 beds are available in the Ipswich Borough Sanatorium for Insurance Committee patients. There is no dispensary service nor any nursing arrangements. There are 8 shelters in use in the area. 125 persons have been recommended for benefit, all of whom have been treated, 55 in sanatoria. 49 dependants of insured persons have been treated, 5 of them in sanatoria. The West Suffolk Insurance Committee^ under the arrangements of a com- prehensive scheme for the County now in operation, have the use of 12 beds in 2 institutions. There is a dispensary provided under the compre- hensive scheme at Bury St. Edmunds. As regards nursing, a whole-time County nurse is employed, and, in addition, the Committee look to local nursing associations, where they exist, for the services of nurses in domiciliary cases. There are 8 sheltei's in use, 4 provided by the County Council and 2 by local sanatoria authorities. 82 insured persons have been recommended for treat- ment, all of whom have secured treatment, 51 in sanatoria and 4 through the dispensary. 67 have received domiciliary treatment. The Surrey Insurance Committee have available upwards of 80 beds in 4 insti- tuiions ; and in addition insured persons are sometimes sent under special arrangements to other institutions. There was on the 14th January, 1914, only one dispensary open, at Barnes, provided by the Barnes Urban District Conncil. There are no nursing arrangements in force. There are 15 shelters in use. 455 insured persons have been recommended for benefit, all of "v^hom have received treatment. Of these 351 have received residential treat- ment, 39 at the dispensary, while 190 have received domiciliary treatment. The Ea&t Sussex Insurance Committee have available 8 beds in 2 sanatoria, and, in addition, send patients to other sanatoria under individual arrange- ments. The East Sussex County Council have provided 3 dispensaries at Hastings, Hove and Lewes. The Sussex County Nursing Association have agreed with the Insurance Committee to provide nurses in all cases where their services are necessary. 5 shelters have been purchased by the Committee, and under the agreement with the County Council shelters are to be provided by the Council for persons receiving dispensary treatment. 156 persons have been recommended for treatment, of whom 148 have received treatment. There have been 78 residential and 123 domiciliary cases. The West Sussex Insurance Committee have available 11 beds in 2 different institutions, besides sending individual patients elsewhere under special arrangements. A scheme for the establishment of dispensaries in the area has been under consideration. The Committee have agreed with the local Nut sing Association to nurse patients receiving home treatment. 1 10 insured persons have been recommended for and received benefit ; 51 have received residential, 82 domiciliary treatment. For a short period benefit was extended to dependants in this area, and 27 dependants, the total number recommended, were treated. The Warwickshire Insurance Committee have 32 beds available in 3 local institutions, and have also sent 7 persons elsewhere under individual arrange- ments. Dispensary treatment is available through the Ladies Care Committee Dispensary at Southam. 29 shelters are in use in the area. 200 insured persons have been recommended for benefit, 187 of whom have received treat- Insurance Oonimittees : Sanatorium Benefit. 145 ment ; 113 weritrict Nursing Associations for the nursing of cases recommended by the Tuberculosis Officer. The Insurance Committee have also rented 10 shelters from the County Council. 199 insured persons have been recommended for treatment, and 198 have been treated. 69 of these have been inmates of sanatoria, 196 have attended the dispensaries, and 173 have received domiciliary treatment. The Worcestershire Insurance Committee secured 12 sanatorium and 14 hospital beds in two institutions as part of the comprehensive scheme in operation in the County. The permanent arrangements under the comj^rehen- sive scheme secure the exclusive use of 20 beds to the Insurance Committee. There are as many as 14 dispensaries in the County provided by the County Council under the comprehensive scheme. At 5 dispensaries the services of nurses attached to the County Nursing Association are utilised. There are 23 shelters in use. 236 insured persons have been recommended for benefit, every one of whom has been treated. 139 persons have received residential treatment, and 47 have attended the dispensaries. The Ea^t Riding of Yorkshire Insurance Committee have 12 beds at the Witherngea Sanatorium for the use of insured persons. There is a central dispensary at Beverley provided by the County Council. There are no nursing arrangements in force, nor are there any shelters available. 66 insured persons have been recommended for treatment, of whom 54 have been treated. 39 of these have been inmates of sanatoria. The North Hiding of Yorkshire Instance Committee have 45 beds available in the Wensleydale Sanatorium. One patient has been treated under special arrangements at the Home Sanatorium, Bournemouth. There is no dispensary treatment available, and no arrangement has been made for nursing or for the provision of shelters. 146 insured persons have been recommended for treat- ment and all have been treated. 118 of these have been inmates of sanatoria. The Wtst Riding of Yorkshire Insurance Committee have 90 sanatorium beds available in sanatoria. " Occasional " beds have been secured in seven other institutions. The administration of sanatorium benefit in this area is remarkable for the extent to which dispensary treatment has been utilised ; no less than 28 dispensaries have been established by the County Council. The County Council also provide the services of nurses in connection with each dispensary. There are 24 shelters in use by the Committee provided by the County Council. Of 874 insured persons recommended for treatment, 868 146 England. have received treatment ; 485 have been treated in sanatoria, no less than 772 through dispensaries, while 170 have received domiciliary treatment. As regards the dependants of insured persons, to whom sanatorium benefit has been extended, 430 have been recommended for treatment, of whom 424 have received treatment. 73 have been inmates of sanatoria and dispensai'y treat- ment has been granted to all. 2. County Boroughs. Bar7isley did not become a County Borough until the 15th April, 1913, so that the Barnsley Insurance Committee has only existed since that date. Between that date and the 11th January, 1914, the Committee received 23 applications for sanatorium benefit. All applicants received treatment, 16 in sanatoria. A comprehensive scheme for the area was already under consideration at the commencement of 1914, and pending its establishment, beds are being secured in the Brierly Gap Sanatorium belonging to the Hemsworth Rural District Council. Nursing in connection with domiciliary treatment is under- taken by the Barnsley and District Nursing Association. The Barrow-i7i-Furness Insurance Committee have arranged with the Town Council for the provision of residential accommodation for tuberculous j)atients. The Town Council have beds in the Meathop Sanatorium, and the Insurance Committee regularly reserve 6 of these, and may, if occasion demands, take more. A tuberculosis officer has been appointed, jointly for the County Borough and for the neighbouring parts of Lancashire. 34 insured patients have been recommended for treatment, and 33 have been treated, 27 in sanatoria. The Bath Insurance Committee have made arrangements for obtaining beds, as and when required, either at the Winsley Sanatorium, near Bath, or at the Cranham Lodge Sanatorium. The Bath City Council is participating in the comprehensive tuberculosis scheme of the Somerset County Council, under which a dispensary is provided at Charles Street, Bath. Nurses from the Bath District Nursing Home attend patients in receipt of domiciliary treatment. 49 insured persons have been recommended for, and 40 have received, treatment, 22 in sanatoria. Sanatoiium benefit has been extended to the dependants of insured persons, of whom 6 have received treatment, 2 in residential institutions. The Birkenhead Insurance Committee have made arrangements for reserving four beds at Meathop Sanatorium and a similar number at Blencathra Sanatorium. Further beds, as required, have been obtained from the Liverpoo . Sanatorium, Frodsham. Insured persons nominated for dispensary treatment receive this form of treatment at the Corporation's Dispensary, and the services of nurses attached to the Queen Victoria Nurses Association have been made available for insured persons receiving treatment in their own homes. 113 cases have been recommended for and have received treatment, 59 in resi- dential institutions, and 30 through the dispensary. The Birmingham Insurance Committee obtain all institutional treatment required for insured persons through the Birmingham Corporation with whom they have an agreement on a permanent basis. Reference is made to Birming- ham's comprehensive scheme in paragraphs 373 to 375 above. 1,991 recom- mendations have been made, and 1,815 persons have been treated, 1,359 in sanatoria, 995 through the dispensaries, and 328 by way of domiciliary treatment. The Blackhwrn Insurance Committee have secured beds through the Blackburn Corporation, beds being regularly available at Meathop Sana- torium, and in the sanatorium wards of the Blackburn Fever Hospital. The Corporation lias provided a dispensary organisation of which the Insurance Committee avail themselves for insured persons. 154 persons have been recommended, of whom 147 have received treatment. There have been 121 residential, 32 dispensary, and 25 domiciliary cases. The Blackpool Insurance Committee have entered into an agreement with the Blackpool Corporation for the provision of all institutional treatment of insured persons. A comprehensive scheme for the treatment of tubercu- losis is operative in the area, beds being provided in the Municipal Hospital Insurance Committees: Sanatorium. Benefit. 147 and dispensary treatment at the Public Health Offices. A Tuberculosis Officer serves the County Borough and the neighbouring parts of Lancashire jointly. 62 insured persons have been recommended and 61 have been granted treat- ment, 39 in residential institutions and 24 through the dispensary. The Bolton hisurance Committee had 8 beds reserved for the Com- mittee's use in the Meathop Sanatorium, in which institution further beds have been obtained from time to time for individual cases as occasion demanded, 10 beds were also reserved in the Wilkinson Sanatorium, Bolton, and an additional 10 in the Bolton Borough Hospital. A dispensary organisation has its centre in the Public Health Office, and a tuberculosis nurse is available for dispensary and visiting work. 168 of the 183 insured persons recommended for benefit, have received treatment, 143 residential, and 33 through the dis- pensary. In Bootle the Insurance Committee have hitherto arranged to obtain beds as necessity required in preference to reserving a fixed number for a period in advance. Beds have in this way been obtained in the Liverpool Sanatorium, Delamere Forest, and in the two local institutions, the Linacre Hospital belonging to the Corporation and the Bootle Borough Hospital. A tuber- culosis officer has been appointed to serve the County Borough and the adjoining area of Lancashire, and the Bootle Corporation have established a municipal dispensary. The Corporation have established a dispensary in Irlam Road, and have appointed a tuberculosis nurse, 133 cases have been recommended for benefit and 132 treated, 56 residentially and 60 through the dispensary. The Bournemouth Inmirance Committee have reserved a number of beds in the Royal National Sanatorium, Bournemouth, having a call upon 25 beds in that institution. Beds have occasionally been obtained for individual patients in the Firs Home, Bournemouth, Of the 90 cases recommended, 88 have received treatment, 56 in residential institutions. The B)xidford Insurance Committee have availed themselves of the provision made by the Bradford Corporation for the treatment of tuberculosis under which 50 beds are available for Committee pa ti en's in the Bierley Hall Hospital, which is equally suitable for the treatment of " sanatorium " and " hospital " cases. A municipal dispensary is at work in Howard Street. The services of nurses are available in connection with the dispensary organisation. All the insured persons recommended for treatment, 256 in number, have been given treatment. 171 have been to residential institutions, and 174 have attended the dispensary. Benefit has been extended to dependants, and 41, the total number recommended, have received treatment, 30 in residential institutions. The Brighton Insurance Committee have arranged for all institutional treatment with the local authority, the Brighton Corporation having estab- lished a dispensary at the Town Hall and a Borough Sanatorium. Arrange- ments have been made by the Committee with the Queen's Nurses Association for the Brighton area to attend insured persons in receipt of domiciliary treat- ment. The Insurance Committee have, on the average, had some 20 insured persons under treatment in the Borough Sanatorium at any one time. 155 insured persons have been recommended for, and 145 have received, treat- ment, 114 residential and 54 dispensary. The Bristol hisurance Committee have made arrangements, through the Cor- poration, for securing 22 beds in the Winsley Sanatorium, near Bath, and 2 in the Corporation's institution at Ham Green, near Bristol. Additional beds have been obtained occasionally at the Maitland Sanatorium, Peppard Common, and at the Royal National Sanatorium, Bournemouth. A dispensary has been opened at Redcliffe Parade West, and arrangements for a second are in hand. Nursing services are available in connection with the dispensary organisation. The Bristol Corporation has undertaken a comprehensive scheme for dealing with tuberculosis in the County Borough, and an agreement between the Gonmiittee and the Corporation of a permanent nature is contemplated. 410 insured persons have been recommended for benefit and 377 have received treatment. 220 have been in sanatoria, and 150 have attended the dispensary. As regards dependants, to whom benefit has been extended, 36 recommenda- tions have been made and 29 cases treated. 148 England, The Burnley Insurance Committee have made use of the municipal dispensary by arrangement with the Corporation, The Committee have secured the residential accommodation they have required through the Corporation who have, in addition to other provision, reserved beds at Meathop Sanatorium and in the Felix House Sanatorium. The majority of the persons who have completed a period of residential treatment on the recommendation of the Committee received the treatment in the Crown Point Hospital, near Burnley, belonging to the Corporation. If necessary, a nurse employed by the Corporation visits patients weekly. The Burnley Corporation has undertaken a com- prehensive scheme, and the Insurance Committee are contemplating entering into an agreement with them for a period of years, at an early date, for the provision of institutional treatment. 108 insured persons have been re- commended for treatment. Benefit has been given in 102 cases, 49 residential and 33 dispensary. The Burton-u-pon-Trent Insurance Committee make use of the Corporation's institutions by aiTangement with that body. These institutions are the dispensary and the Outwoods Sanatorium. 46 of the 47 cases recommended have been treated, 37 in sanatoria and 23 through the dispensary. Benefit has been extended to dependants, of whom 16 have received treatment. The Bury Insurance Committee have obtained practically all their residential accommodation through the Bury and District Joint Hospital Board, patients receiving treatment at the Board's two institutions,the Aitken and the Ain«worth Sanatoria. No dispensary was available during the period referred to, but the Bury Corporation has now formulated a comprehensive scheme for dealing with tuberculosis in the area. There were no nursing arrangements and no shelters The total number of insured persons recommended, 96, have received treat- ment, 84 in residential institutions and 66 in their own homes. The Canterbury Insurance Committee have reserved 1 bed in the Benenden Sanatorium and further beds are obtained as and when the necessity for them arises. 16 insured persons have been recommended for treatment and 15 have been treated, 7 in sanatoria. Benefit has been granted in one case to a dependant of an insured person. The Chester Insurance Co^nmittee have 2 hospital beds in the Chester Isolation Hospital, by an agreement with the City Council, Other patients have been sent, under individual arrangements, to various other institutions. There is a dispensary in operation in the area, situated in Queen Street, an institution managed by the Chester Association for the Prevention and Cure of Consump- tion, Arrangements have been made by the dispensary authorities with the CTiester and District Nursing Association, whereby insured j persons are visited under the direction of the medical adviser to the Committee, No shelters are at present in use. 27 of the 30 insured persons recommended for benefit have received treatment, 12 residentially and 11 through the dispensary. The Coventry Insurance Committee have available 15 sanatorium beds, under arrangements made through the Coventry City Council, in the Winsley Sana- torium near Bath, the Royal National Hospital for Consumption at Ventnor, and the Bramcote Sanatorium near Nuneaton. There is no dispensary in operation. 5 shelters are available and insured persons are nursed by the district nursing association. 225 insured persons, the total number recom- mended, have received benefit, 58 in residential institutions and 202 by way of domiciliary treatment. The Croydon Insurance Committee have 6 sanatorium beds reserved in the Benenden Sanatorium and hospital beds in the Croydon Fever Hospital. A dispens iry has been established by the Borough Council in Katharine Sti eet. A health visitor has been specially appointed to the Public Health Staff for duties arising under the tuberculosis scheme adopted by the Borough Council. 165 insured persons have been recommended for treatment, all of whom have been treated, 110 residentially and 77 through the dispensary. Five dependants recommended for benefit have received treatment. Insurance Committees: Sanatorium, Benefit. 149 The Berb^ Irisurance Coimnittee have no standing arrangement for the reservation of any particular number of beds. Individual patients are sent to various institutions under ad hoc arrangements. The Corporation hus provided a dispensary in Ford Street, at which Insurance Committee patients can be treate 1. The Corporation provide the services of health visitors. A comprehensive scheme is under consideration. 137 persons have been reco u- mended for treatment, and 131 treated, 129 residentially, 58 through the dispensary and 13 by way of domiciliary treatment. Benefit has not baen extended to dependants. The Devonport Insurance Committee have reserved three sanatorium beds at the Didworthy Sanatorium. Arrangements have been made for utilising the King Edward VII Dispensary in Plymouth. The dispensary provides the services of nurses as part of the agreement with the Insurance Committee. No shelters are in use. 56 insured persons have been recommended for treat- ment, and 49 treated. 22 have been treated in sanatoria, 2 through the dispensary, and 27 by w^ay of domiciliary treatment. The Deicsbury Insurance Committee have 2 beds reserved in the Morton Banks Sanatorium, Keighley, and in addition have sent patients to other institutions under individual arrangements. A dispensary has been established by the West Riding County Council in Halifax Road, and there are 2 nurses attached to the dispensary who attend the dispensary patients. Between the 1st April, 1913 (the date on which the Insurance Committee for the new County Borough was constituted), and the 11th January, 1914, 31 insured persons were recommended for treatment, of whom 30 received treatmei^t, 14 in sanatoria, and 13 through the dispensary. 5 dependants of insured persons were recommended, of whom one was treated in a sanatorium. The Dudley Lisurance Committee have not reserved any beds under a general arrangement but send insured persons to different institutions under ad hoc agreements. General arrangements for institution of treatment are being made with the Staffordshire, Wolverhampton, and Dudley Joint Com- mittee for Tuberculosis. No nursing arrangements are at present in force, but a health visitor is to be appointed, and arrangements are being made with existing nursing associations. No shelters are used. 43 insured persons have been recommended for treatment, all of whom have received treatment, 27 in sanatoria. Benefit has been extended to dependants, and all the 5 recommended for treatment have received treatment, 4 in sanatoria. The Eastbourne Insurance Committee had at one time a standing arrangement wdth the East Anglian Sanatorium for the reservation of bed?, which arrangement has now come to an end. Patients are now sent under individual agreements to different institutions as cases arise. A dispensary in in operation situated in the Town Hall, provided by the Town Council. There are no nursing arrangements, and no shelters. 66 insured persons have been recommended for treatment, and 65 have been treated, 27 in sanatoria and 4 at the dispensary. There have been 35 domiciliary cases. Benefit has been ex- tended to dependants ; 18 dependants have been recommended for benefit, all of whom have received treatment. The Exeter Insurance Committee have secured 12 sanatorium beds under a standing agreement in the Exeter Sanatorium, at Pinhoe, 2^ miles from the city. This agreement is made with the Exeter City Council. 34 insured persons, the total number recommended, have received sanatorium benefit, 11 being treated in sanatoria, and 22 having received domiciliary treatment. Benefit has been extended to dependants, 23 out of the 24 dependants recommended having received treatue it, 7 in sanatoria. The Gateshead Insurance Committee have reserved 1 1 sanatorium beds and 3 hospital beds for pulmonary cases in 4 different institutions. Arranfr*^m«nty for nursing are in force with the local nursing association. Up to the 14th January 79 insured persons, the total number recommended, had received, sanatorium benefit ; 38 in sanatoria. Benefit has not been extended tijo dependants. 15C Enqland. The Gloucester Insurance Committee have made arrangements reserving 5 beds at Cranham Lodge Sanatorium. Arrangements have been made for dispensary treatment with the Gloucestershire Joint Committee for Tuberculosis, a dis- pensary being provided at Barton Street, Gloucester. The nurse specially appointed for tuberculosis work attends at the dispensary and visits the cases. The Gloucestershire Joint Committee has provided 3 shelters. All the persons recommended for treatment, 64 in number, have received benefit ; 27 have been treated in sanatoria, 26 through the dispensary, while tl have received domiciliary treatment. As regards dependants, 7 have been recommended for treatment, and 4 have been treated, one of the 4 in a sanatorium and 2 through the dispensary. The Great Yarmouth Insurance (7omm?J^^ee have an agreement with the Kelling Sanatorium for the reservation of 6 sanatorium beds. There is no dispensary, nor have any arrangements been made for nursing or the provision of shelters All the 65 insured persons recommended for treatment have been granted treatment, 25 in sanatoria. Benedt has not been extended to dependants. The Grimsby Insurance Committee have 5 beds reserved in the Ockley Sana- torium, Surrey, together with 3 beds in the Hull and East Riding Con- valescent Home, Withernsea. No dispensary treatment is available. 5 shelters are in use, provided by the Grimsby Corporation. 67 insured persons have been recommended for treatment, of whom 62 have been treated, 36 in sanatoria. The Halifax Insurance Committee have reserved 12 hospital beds for pulmonary cases through an agreement with the Borough Council. Persons nominated for residential treatment are sent as occasion requires to different institutions, the majority having been sent to Wensleydale. A dispensary has been established at Clare Road, Halifax, by the Borough Council. 106 insured persons, the total number recommended, received benefit ; 78 have been treated in residential institutions, and 16 have attended the dispensary. As regards dependants, of the 8 recommended for benefit all were treated — 5 in residential institutions, 3 at the dispensary, and one in his own home. The Hastings Insurance Committee have reserved 4 sanatorium beds, 2 from the Hastings Corporation in the Hastings Borough Sanatorium, and 2 in the Eversfield Chest Hospital at St. Leonards-on-Sea. Cases also are sometimes sent to other institutions. A dispensary has been opened at the East Sussex Hospital, Hastings, by the Borough Council and the East Sussex County Council acting jointly. There are no nursing arrangements and no shelters. 40 insured persons have been recommended for benefit, and 39 have received treatment, 23 being treated in sanatoria and 36 by way of domiciliary treatment. The Huddersfield Insurance Committee have a standing agreement with the Huddersfield Borough Council, whereby beds in the Council's institution are available for the use of Committee patients. There is a dispensary in Ramsden Street, Huddersfield, established by the Borough Council. There are no nursing arrangements. The Borough Council has provided one shelter. 102 insured persons have been recommended for treatment, of whom 92 have been treated. 91 have been treated residentially, 43 have attended the dispensary, and there have been 56 domiciliary cases. The Ipswich Insurance Committee have an agreement with the Ipswich Borough Council for the reservation of beds in the Ipswich Sanatorium, and the Borough Isolation Hospital. Such number of the 65 sanatorium beds available in the first institution as may be required are used for Committee patients. A permanent scheme is now under consideration. A dispensary has been established by the Borough Council, and a nurse is attached to the dispensary. 4 shelters have been provided by the King Edward VII Memorial Fund and handed over to the Council. All the insured persons recommended for benefit have been treated ; 78 residentially and 9 through the dispensary, while there have been 5 domiciliary cases. Insurance Committees: Sanatorium Benefit. 151 The Kingston-on-Hidl Insurance Committee have 31 sanatorium beds, the majority of these being secured by agreement with the Hull Corporation at the City Hospital, and the remainder in the Withernsea Home. Occasional patients have been sent to other institutions. There are 2 dispensaries in the Borough, provided by the Hull Corporation. The Hull Corporation employs 2 nurses in connection with the compre- hensive scheme, whose services are thus available for insured persons. 2 shelters have been provided. 270 insured persons have been recom- mended for treatment, all of whom have been treated ; 173 of these have b en treated residentially, and 171 have attended the dispensaries. Nearly every patient recommended for benefit has also received domiciliary treatment either before or after receiving institutional treatment. Benefit was, prior to the in- ception of the comprehensive scheme in the Borough, extended to dependants, and the 12 dependants recommended for benefit all received treatment. The Leeds Iifisuratice Ccrmmittee have reserved beds under agr-eement with the Leeds City Council at the Killinbeck Hospital, and further beds have been obtained by agreement with the Leeds Association for the Prevention and Cure of Tuberculosis at Armley Hospital and at the Gateforth Sanatorium, Selby. Dispensary treatment is provided at the Central Tuberculosis Dispen- sary, New Briggate, and at the Branch Dispensary in Gt. George Street. The Central Dispensary has been established by the City Council, and the Branch by the Leeds Association. All nursing arrangements are made by the Tuber- culosis Officer and provided by the Leeds City Council and by the Association. There are no shelters. 756 insured persons have been recommended for benefit of whom 742 have received treatment. 586 have been treated in residential institutions, 401 have attended the dispensary, and 11 have been given domiciliary treatment. The Leicester Insurance Committee have reserved sanatorium bed?, under agreement with the Corporation, in the Groby Koad Sanatorium. Dispensary treatment is provided at the Borough Dispensary in St. Nicholas Street, established by the Town Council. The Committee have arranged with the Leicester District Nursing Association for nursing. There are 6 shelters in use. 597 insured persons have been recommended for benefit, every one of whom has been treated. 317 have been inmates of sanatoria, and 250 have attended the dispensary. The lAncoln Insurance Committee have an agreement with the Lincoln Corporation reserving beds in the City Hospital for Committee patients. There is a dispensary in Bank Street, provided by the Lincoln Corporation. 60 insured persons have been recommended for treatment, and all of these have been treated, 43 residentially. As an after-care measure dispensary treatment has been accorded to all the insured persons able to attend after they have received residential treatment. There have been 17 domiciliary cases. 2 dependants of insured persons have received treatment, one of whom has been sent to a sanatorium. Keference has already been made {see paragraphs 358 to 368 above) to the general arrangements for the treatment of tuberculosis in Liverpool. Arrangements have been made with the Liverpool Queen Victoria Nursing Association for nursing tuberculous patients. 1,080 insured persons have been recommended for treatment, and 1,078 of these have been treated, 586 as inmates of residential institutions. 123 have attended dispensaries, and 618 have received domiciliary treatment. Sanatorium benefit has been extended to dependants, of whom 575 have been recommended for benefit. Of these 515 have received treatment, 443 residentially and 27 through the dispensaries, while 86 have received domiciliary treatment. The arrangements for dealing with tuberculosis in Manchester' are also referred to in paragraphs 369 to 372. The Committee have entered into an agree- ment with the Manchester Corporation for the provision of institutional treatment for a period of 21 years. Up to the 11th January, 1914 under arrangements made by the Committee, 942 insured persons had been recom- mended for benefit, of whom 935 have received treatment. There have been 733 residential, 351 dispensary, and 624 domiciliary cases. 152 England. The Middlesbrough Insurance Committee have reserved no beds perma- nently, but send insured persons to various institutions under individual arrangements. The majority have been sent to the Deanhead Sanatorium or to Wensleydale. A dispensary has been established and arrangements have been made with the local nursing association for the visitation of patients in their own homes. 86 insured peisoiis have been recommended for treatment, of whom 82 have been treated. 56 have been sent to sanatoria, and 58 have attended the dispensary. 13 dependants of insured persons have also been treated, 8 in sanatoria. The Newcastle-upon-Tyne Insurance Cortmiittee^ under the comprehensive scheme in force in Newcastle, obtain beds at Barrasford Sanatorium through the City Council who also provide hospital accommodation as part of the scheme. The dispensary is working in temporary premises in the Town Hall Buildings, being provided by the City Council. 2 visiting nurses are also provided under the scheme. The scheme makes provision for the use of 6 shelters. 253 insured persons have been recommended for treatment, 252 of whom have been treated. 123 have received residential treatment, 8 have attended the dispensary, and there have been 227 domiciliary cases. 58 depen- dants were recommended for benefit and all received treatment, 25 in sanatoria. The Northampton Insurance Committee have made provisional arrangements pending the institution of a comprehensive scheme now under consideration for securing the treatment of patients in the Northamptonshire Sanatorium at Creaton, the Northampton Corporation Consumptive Hospital and other institutions. There is no dispensary service at present. 163 insured persons have been recommended for benefit and all have received treatment, 57 resi- dential. 7 dependants have also been treated. The Norwich Insurance Committee have 10 sanatorium beds reserved at Kelling, and additional beds, if required, are from time to time en- gaged by the Committee in the same institution. A dispensary is now being established by the City Council. Negotiations for nursing are in progress with the Norwich District Nursing Association. The Insurance Committee have provided 4 shelters. 202 insured persons have been recommended for benefit of whom 189 have been treated. 82 have been sent to sanatoria. 12 dependants have also been treated, 7 in sanatoria. The Nottingham Insurance Committee^ while having no specific number of beds reserved in any institutions, have made most of their arrangements for providing insured persons with residential treatment with the Nottingham Town Council, whereby patients are sent to the Bagthorpe Sanatorium. Individual patients are also sent to other institutions, such as Ventnor, Midhurst, and Bournemouth. The City Council has established a dispensary at North Church Street, Nottingham. There are no nursing arrangements and no shelters. 303 insured persons have been recommended for benefit, of whom 301 have been treated. 219 have been sent to residential institution-'. 23 dependants of insured persons have also been treated, all in sanatoria. The Oldham Insurance Committee have no definite agreement as to reservation of beds, but obtain from the Corporation such residential accommodation as is required for insured persons. There is a dispensary in Mill Strf^et established by the Corporation. 264 insured persons have been recommended for benefit, all of whom have been treated, 178 in residential institutions, and 11 through the dispensary. Two dependants of insured persons have been granted domiciliary treatment. The Oxford Insurance Committee have reserved 2 beds in the Maitland Sanatorium at Peppard Common, and patients have also been sent to various other institutions. Dispensary treatment is given by the Oxfordshire Associa- tion for the Prevention of Consumption. 26 insured persons have received benefit, 20 in the form of residential treatment. The Plymouth Insurance Committee have made no arrangements for the reservation of beds in particular institutions, pending the completion of a comprehensive scheme, but secure beds as and when they are required. The King Edward VII Memorial Dispensary, in Frankfort Street, has been Insurance Committees: Sanatorium Benefit. 153 established by public subscription in memory of His late Majesty, and by arrangement therewith the Committee have secured dispensary service fur patients recommended by them for dispensary treatment. The dispensary pro- Tide nurses, and the services of health visitors appointed by the Council are also available. There are no shelters in use. 154 insured persons have been recom- mended for benefit, of whom 153 have been treated, 46 residentially and 26 through the di-spensary, while there have been 125 domiciliary cases. Benefit has been extended to dependants, of whom 33 have been recommended, and 27 treated. The Portsmouth hisurance Committee have reserved 19 sanatorium beds through agreement with the Town Council, at Lang-.tone Hospital. Patients have also been sent to other institutions under individual arrangements. There is a central dispensary available provided by the Town Council. There are three whole-time tuberculosis nurses and three health visitors, who are part-time tuberculosis nurses, in the employment of the Town Council. The Committee have the use, as required, of 6 shelters belonging to the Town Council. 300 insured persons have been recommended for sanatorium benefit, every one of whom has been treated. 126 have been treated in residential institutions and 275 have been treated at the dispensary. 10 dependants have received treat- ment, 3 in sanatoria. The Preston Insurance Committee have reserved 6 sanatorium beds at Bowdon Sanatorium, and 2 at Felix House Sanatorium in Durham. Premises have been taken by the Town Council in North Road, Preston, for the purpose of establishing a dispensary. There are no nursing arrangements and no shelters. 81 insured persons have been recommended for treatment, and all have been treated ; 32 have been sent to sanatoria. Benefit has not been extended to dependants. The Reading Insurance Committee have 12 sanatorium beds, available at the Ventnor Sanatorium and in addition send individual patients to other institu- tions where necessary. The Town Council propose opening a dispensary in London Street, and the Committee have hired 12 shelters from the Town Council. 117 insured persons have been recommended for benefit, all of whom have received treatment, 67 in residential institutions. The Rochdale Insurance Committee have an agreement with the Bury and District Joint Hospital Board under which the Board accommodate all patients sent to them by the Committee. Generally about 12 beds are occupied by Committee patients. The Rochdale Corporation has established a dispensary in Yorkshire Street. 116 insured persons have been recommended for benefit and 100 have received treatment, which in 34 cases was residential. The Rotherham Insurance Comm.ittee have entered into an agreement with the Rotherham Corporation under which 15 beds in the Corporation Sanatorium in Badsley Moor Lane are reserved for Committee patients. A dispens ^ry has been established by the Corporation in the offices of the Public Health Officer, Frederick Street. 74 insured persons have been recommended for benefit, and 70 have been treated. 38 of these have been treated in sanatoria, and 36 through the dispensary. Benefit has been extended to dependants, of whom 22 have been recommended. 20 have been granted treatment, 5 in sanatoria and 9 through the dispensary. The 8t. Helens Insurance Committee obtain all the beds required for patients recommended for benefit under arrangements made with the Town Council. A dispensary is in operation at Claughton Street, provided by the Corporation. 76 insured persons have received benefit, out of 77 recommended. There have been 59 residential cases and 33 patients have attended the dispensary. 2 dependants also have received residential treatment. The Salford Insurance Committee have entered into an agreement with the Corporation whereby not less than 23 sanatorium and hospital beds are reserved for Committee patients. There is a dispensary in Regent Road, maintained by the Corporation. 417 insured persons have been recommended for benefit, of whom 395 have been treated, 206 in residential institutions. 215 persons have attended the dispensary, and there have been 240 domiciliary cases. 154 England. The Shefield Insurance Committee have entered into agreement with the Corporation for the provision of all institutional treatment required for insured persons. The Corporation dispensary is situated in Horley Street. There are no nursing arrangements and no shelters. 613 insured persons have been recommended for benefit, every one of whom has received treatment. 522 have been sent to sanatoria or hospitals. 286 have attended the dis- pensary. Prior to the establishment of a comprehensive scheme, sanatorium benefit was extended to dependants ; and during this period of some six months 62 dependants, the total number recommended, received sanatorium benefit. 23 of these received residential treatment, and 54 attended the dispensary. The Sniethwick Insurance Committee participate in the comprehensive scheme of the Town Council. In addition to accommodation in residential institutions, the Town Council have provided a dispensary, and one nurse has been appointed by the Council for visiting purposes in connection with the dispensary. The Town Council have purchased 5 shelters, and will make these available for insured persons as and when recommended by the Tuberculosis Officer. 77 insured persons have received treatment, 49 in sanatoria. 7 dependants were ti'eated at the dispensary. The Southampton Insurance Committee have an agreement under which sanatorium beds are available for Committee patients in the Borough Sana- torium. The Town Council has provided a dispensary in East Park Terrace. Nurses have been provided under special arrangements with the local authority. There are no shelters used. 166 insured persons have been recommended for benefit, and all have been treated. 123 have been sent to sanatoria, and 96 have attended the dispensary. The Southport Insurance Committee have 2 beds reserved for Committee patients at Meathop Sanatorium, Westmorland and patients are sent to other institutions where necessary A dispensary has been established by the Borough Council in Post Office Avenue. The services of a nurse engaged by the Borough Council are available for insured persons. 1 70 insured persons, the total number recommended, have received benefit, 22 in sanatoria and 66 through the dispensary. The South Shields Insurance Committee have an agreement with the Town Council whereby 5 sanatorium beds in two different institutions are available for Insurance Committee patients. The Council has provided a dispensary in the Medical Officer's Department at the Municipal buildings. There is a whole- tinie nurse on the dispensary staff, who assists at the dispensary and visits the homes of patients in receipt of dispensary treatment. There are no shelters in use. 116 insured persons have been recommended for benefit, all of whom have received treatment. 29 have been sent to sanatoria, and 20 treated through the dispensary. Under the Committee's resolution extending benefit to the dependants of insured persons, 48 dependants have received treatment. The Stockport Insurance Committee have reserved 10 beds in the Man- chester Hospital for Consumption, Bowdon. There is no dispensary treat- nient in the area. Nursing arrangements have been made with the Stockport Sick Poor Nursing Association. 116 insured persons have been recommended for benefit, all of whom have been treated, 60 residentially. The Stoke-on-Trent Insurance Committee have acquired 19 beds under separate agreements with different institutions. The Corporation has established a dispensary in Albert Terrace, Shelton. In connection with the dispensary there is a staff of nurse health visitors employed by the Corporation. The Cor- poration has provided one shelter. 288 insured persons have been recommended for benefit, of whom 286 have received treatment, 129 in residential institu- tions. 137 have received dispensary treatment, and 168 domiciliary treatment. 5 dependants out of the 6 recommended have received dispensary treatment. The Sunderland Insurance Committee have an agreement securing to it 13 beds in two institutions. Individual patients have also been sent to other institu- tions under ad hoc arrangements. No dispensary is yet established. Arrange- ments have been made with the Sunderland District Nursing Association tor the provision of the services of a nurse if required. 136 insured persons have received treatment, being the total number recommended ; 73 have been sent to sanatoria. 10 dependants have received treatment, 3 in sanatoria. Insurance Committees: Sanatorium Benefit. 155 The Tynemouth Insurance Committee are in negotiation with the Borough Council with a view to the formulation of an agreement for the provision of institutional treatment for insured persons in connection with the compre- hensive scheme formulated bj the Council. The dispensary has been established. The Council has engaged one whole-time nurse for tuberculosis work. 61 insured persons have been recommended for treatment, who have all been treated. 26 have received residential treatment. 44 have attended the dispensary, and 37 have received domiciliary treatment. The Wallasey Insurance Committee^ in connection with the comprehensive scheme for the area, are arranging with the Corporation for the provision of sanatorium and hospital beds for Committee patients as required. There is a temporary dispensary at Mill Lane Sanatorium. The permanent building is in course of erection. The number of insured persons recommended for benefit during the last three-quarters of the year 1913 (the Insurance Committee for the newly constituted County Borough not having commenced its duties till after the close of the first quarter) was 28. The total number recommended for benefit received treatment ; 17 in residential institutions and 9 through the dispensary The Walsall Iiuurance Committee pending the establishment of a compre- hensive scheme have no specific number of beds reserved in any institution, but send patients to different residential institutions under ad hoc agreements. Negotiations for the establishment of a dispensary and for nursing are in progress. 147 insured persons have been recommended for benefit, all of whom have been treated, 95 being sent to sanatoria. 16 dependants have been treated, 4 in sanatoria and 12 by way of domiciliary treatment. The Warrington Insurance Co^mmittee have entered into provisional arrange- ments with the Corporation, whereby patients recommended by the Com- mittee are sent to the Sankey Sanatorium ; under this arrangement no definite number of beds is reserved to the Committee. The provision of dispensary treatment is now under consideration. There are no nursing arrangements and no shelters. 79 insured persons have been recommended for treatment and 76 have been treated, 50 in residential institutions. The West Bromwich Insurance Committee have 6 sanatorium beds avail- able at the Mount Sanatorium, Bromsgrov^e. In addition, individual patients have been sent under special arrangements to other residential institutions. The Insurance Committee have arrangements with the District Nursing Association for the nursing and visiting of persons receiving domiciliary treat- ment. 73 insured persons have been .recommended for benefit, and 71 treated. Of these, 33 have been treated in sanatoria. The West Ham Insurance Committee have 47 beds reserved in the Dagenham temporary sanatorium by agreement with the West Ham Corporation. Patients have also been sent from time to time to other sanatoria and hospitals. Dispensary treatment is given at the Essex Royal Memorial Dispensary, 116, Leytonstone Road, Stratford, by agreement with the King Edward VII Association for the Prevention of Consumption in Essex. The dispensary service includes the attendance of nurses upon dispensary cases. One shelter is available in the area. 281 insured persons have been recom- mended for benefit, of whom 266 have been treated, 169 in residential institu- tions, 13 at the dispensary, and 215 by way of domiciliary treatment. Sanatorium benefit has been extended to dependants, and 19 dependants have been treated, 5 in sanatoria and 9 through the dispensary. The West Hartlepool Insurance Committee have an agreement with the local Association for the Prevention and Cure of Consumption under which 6 sanatorium beds are regularly available for Committee patients. There is no dispensary, but a nurse has been engaged for whole-time service by arrangement with the Medical Adviser to the Committee. All the insured persons recommended for treatment, 83 in number, have been treated. 23 have gone to sanatoria. Benefit has not been extended to dependants. The Wigan Insurance Committee have an arrangement with the Wigan Corporation whereby 3 sanatorium and 3 hospital beds are available at the Bowdon Sanatorium. There is a dispensary in Rodney Street. The services of nurses engaged by the Wigan Corporation under their com- 156 England. Erehensive scheme are available for nursing insured persons. No shelters ave hitherto been required. 81 insured persons have been recommended for benefit, of whom 71 have been treated, 63 in residential institutions. The Wolverhampton Insurance Committee are entering into an arrangement with the Staffordshire, Wolverhampton and Dudley Joint Committee for Tuberculosis, under which beds are provided for the Committee's patients. There is a dispensary in Ked Lion Street provided by the Joint Committee. Negotiations for nursing services are pending. 99 insured persons have been recommended for benefit and all have been treated. 58 have been inmates of sanatoria and 5 have attended the dispensary, while there have been 40 domiciliary cases. The Worcester Insurance Committee have entered into agreament with the City Council which has established a comprehensive scheme in the area. Under this agreement 6 sanatorium and 9 hospital beds are reserved for Committee patients, the number of hospital beds ultimately to be increased to 12 ; the municipal dispensary is also made available for the use of insured persons. A tuberculosis nurse has been appointed. 2 shelters are in use. The total number of insured persons recommended for treatment, 71, have received treatment, 55 residential and 3 dispensary treatment. The Yorlc Insurance Committee have an agreement with the York Corporation whereby 6 sanatorium beds are retained for insured patients in the Open Air Wards at Yearsley Bridge. Two further sanatorium beds are also reserved at Withernsea under an agreement witli the trustees of the Convahscent Home there. A dispensary has been established by the Corporation at 11, Cast legate. Nursing arrangements have been made by the Corporation dispensary which provide the services of one nurse, and one visitor for after-care. 8 shelters are available for use if required. Ill }.ersons have been recommende 1 for benefit, all of whom have been treated, 66 in residential institutions, while there have been 54 dispensary and 21 domiciliary cases. Administration of Medical Benefit. ' 405. The history of medical benefit since the pubUcation of the last Eeport is a record of continuous improvement in the relations between the medical profession and the authorities administering the Acts, and of steady progress and co-operation, on the part of all concerned, in the work of perfecting the administrative fabric, not only by means of the elimination of defects revealed by experience or unavoidably due to the circumstances attending the inception of the benefit, but also by means of the extension and adaptation of the machinery so as to secure a mere complete enforcement of the rights and duties already established. Special Arrangements for Change of Eesidence and Modifications in Procedure. Temporary Residents. 406. The difficulties which arose in the early part of 1913 in connection with the temporary removals of insured persons were dealt with by the adoption of a system usually styled the ' * green voucher system," from the voucher with which temporary resi J Insurance Committees: Medical Benefit. 157 dents were provided for presentation to doctors on the panel in the area of their temporary residence. This document was, how- ever, merely the outward symbol of a special method of financial adjustment between the funds of the two Committees concerned in the removal, termed, for convenience, the " case-value '* system. The object of this system was to provide, at the expense of the home area's funds, remuneration for the doctors attending the temporary residents at a rate equivalent to the average remuneration payable in respect of the treatment of insured per- sons. This system, which came into operation at the end of the first quarter of 1913, was at the outset imperfectly understood by the medical profession, and attracted a certain amount of hostility both from individual practitioners, and, in some in- stances, from organised sections of ' the profession. Efforts were, however, made, by means of conferences and otherwise, to induce a better understanding in the matter, with the result that by the early summer the co-operation of the medical profession had, generally speaking, been secured, while very little later opposition was withdrawn in the few outstanding cases of or- ganised resistance. These special arrangements proved them- selves of real convenience to the insured population, and were largely made use of. Notwithstanding the delays and hindrances occasioned by the attitude of the medical profession, and the difficulties, inherent in any new scheme, of familiarising individual insured persons with the facilities offered, over 17,000 vouchers were issued during the last nine months of the medical year closing in January, 1914, of which nearly 10,000 were actually used to obtain treatment. The system is now a recog- nised and established feature of the current medical benefit machinery, though it has been found possible in connection with the medical card system (see paragraph 439) to incorporate the objects of the green voucher in the new medical card, and thus to dispense with the necessity for a separate voucher. (See Appendix XV, page 508.) The Special " Travellers " Arrangements. 407. The acceptance by the medical profession of the methods and principles of these temporary resident arrangements enabled the Commission to give effect to the scheme, which had been for some time previous in contemplation, for affording special facilities to persons frequently moving from place to plaoe in the course of their employment. Very considerable difficulty had previously been experienced by persons in this class in deriving full advantage from the normal arrangements for the administration of medical benefit; and the special scheme for insured persons of this "traveller" class was designed to meet these difficulties by providing each "traveller" with a special (yellow) voucher entitling him to obtain, as a temporary resi- dent, medical and sanatorium benefits in any area in Great 158 England. Britain and sanatorium benefit in any area in Ireland. 'J^hese arrangements were put into operation in the course of Septem- ber, 1913; and though, notwithstanding the efforts of the Com- mission to bring them to the knowledge of the persons interested, they were not immediately utilised to the full extent expected, they are now becoming better known and more widely appreci- ated. Nearly 4,000 insured persons are already in possession of yellow vouchers, and the number of applications for them shows no signs of diminishing. 408. The occupations chiefly represented are : Theatrical pro- fession (including actors, actresses, showmen, wardrobe and pro- perty masters), nurses, commercial travellers, engineers, electri- cians, erectors, plumbers, boatmen, bargemen, persons engaged in the coasting trade , domestic servants , and railwaymen ; while there are also comprised : chauffeurs, evangelists, carpenters, joiners, bricklayers, plasterers, advertisement inspectors, navvies, Post Office telegraph and telephone employees, supply teachers and governesses, asphalte and wood block layers, exhibition assistants, steam-roller drivers and flagmen, stocktakers, Trade Union or- ganisers and Society agents, fishw^orkers, canteen employees, Marconi operators, landscape gardeners, railway bookstall atten- dants, well-sinkers, molecatchers, fellmongers, as well as many others, including some insured persons "of no definite occupa- tion." Approved •Institutions. 409. In June, 1913, representations were made to the Com- mission on behalf of the Friendly Societies' Medical Alliance, the body representing the majority of institutions approved for the purposes of medical benefit under Section 15 (4) of the 1911 Act, that the ordinary arrangements which obtained on the re- moval, whether permanent or temporary, of insured persons who had chosen to receive their medical treatment from doctors on the panel (and which under the existing Eegulations were restricted to those persons) should be made available to insured mem- bers of approved institutions. It was further represented that the requirements of the Regulations as to the calculation of the Insurance Committee's contributions, viz., on the basis of the average expenditure of institutions on both insured and non- insured members, was in practice inequitable, and that the basie of contribution should be the actual expenditure upon insured persons without reference to or inquiry into the expenditure or accounts of the institutions in so far as they related merely to the treatment of the non-insured. 410. As a result of conferences between the Commission and representatives of the Friendly Societies' Medical Alliance, it was found that the restriction as to removals (which had previously been inserted in the Regulations owing to the apprehension of difficulties in connection with financial adjustments) could, as a Insurance Committees: Medical Benefit. 159 result of experience, be abolished; and in the Medical Benefit Amendment Regulations of the 18th September, 1913, provisions were accordingly included extending the normal arrangements as to removal, whether temporary or permanent, to insured members of approved institutions. It was also provided that the contributions of the Insurance Com- mittee should be calculated by reference to the ex- penditure of the institution upon the medical attendance and treatment of its insured members, and made upon a certified statement of such expenditure. A form of certificate for the purpose was prepared by the Commission, and copies were fur- nished to Insurance Committees. 411. The provisions of the Medical Benefit Amendment Eegulations have now been substantially embodied in the National Health Insurance (Medical Benefit) Regulations (England), 1913. Medical Benefit in relation to the Act op 1913. 412. The position as regards medical benefit was not greatly affected by the provisions of the 1913 Act. The provisions of the Act as to Panel and Pharmaceutical Committees have, how- ever, a somewhat important bearing upon the development of medical benefit and its administration. These bodies are dealt with in greater detail in another section of this Chapter (see paragraphs 334 to 342 above). In relation to medical benefit, however, their importance lies in the fact that prior to their establishment there had been no statutory or otherwise recog- nised bodies, expressly representing the doctors or chemists on the panel, with whom Insurance Committees could satisfactorily conduct collective negotiations. The Local Medical Committee were representative of all the doctors resident in the area, whether on the panel or not; and they were, of course, entitled to be consulted upon general questions affecting the ad- ministration in the area. But the need was felt for the exist- ence of statutory bodies which, as expressly representative of the doctors and chemists contracting with the Committee, could act on their behalf in the matter of their contracts and bind their constituents, within certain limits, as to the terms of the bar- gain, and the manner in which it was to be carried out. Further, their co-operation with the Insurance Committee in the dis- charge of administrative duties incidental to the medical service was facilitated by the privilege extended to them by the 1913 Act of obtaining, upon their joint request and by general con- sent, an allotment out of the medical benefit funds of the Insur- ance Committee of sums not exceeding in all Id. in respect of each insured person in the area entitled to receive treatment from a doctor on the panel, for the purpose of defraying their expenses of administration. 160 England. Eevision of Medical Benefit Eegulations. 413. Early in the autumn, the Commission took in hand the task of a general revision of the Medical Benefit Pvegulations, partly to secure their proper adaptation to the requirements of the 1913 Act, partly with the object of remedying such defects and omissions as experience had brought to light in the course of the year's working, and partly with a view to a re-arrangement and simplification of the actual text. 414. The administrative arrangements above referred to in connection with temporary residents were, with a view to the avoidance of any further doubts as to their validity, expressly embodied in the Eegulations themselves, and minor amendments of detail w^ere effected in matters of procedure and financial machinery. Alterations of perhaps greater importance were made in respect of the allocation of insured persons, the calcula- tion of doctors' credits, and the procedure in dealing with com- plaints. Allocation and Doctors' Credits. 415. Experience had shown that it was difficult, or even im- possible, for Insurance Committees to bring their register of insured persons up to date with sufficient accuracy to enable it to be utilised for the purpose of an exhaustive personal alloca- tion to doctors of the insured persons who had failed to make a choice of doctor. While the substantial objects of the register were attained, the actual personnel of the insured population in any particular area proved to be of so shifting a character that, having regard to the delay necessarily involved in the notifica- tion of removals, it was felt to be doubtful whether the register could at any particular date represent the personnel of the in- sured population of the area with sufficient accuracy to enable an exhaustive personal allocation as on that date to be success- fully carried out. These circumstances came to the knowledge of the Commission early in the year, when a circular was addressed to Insurance Committees, suggesting steps by means of which Committees might, without inconvenience or inequity, postpone the contemplated allocation ; but as further experience only confirmed the view that such an allocation could not be use- fully performed, the Eegulations were revised so as to relieve Committees of the obligation to attempt to allocate, and consequential provisions were inserted requiring arrangements to be made by the Insurance Committees with the Panel Com- mittees to secure facilities for the personal assignment to doctors of individual insured persons, as occasion might require. 416. It followed from the abolition of the system of ex- haustive personal allocation that an equivalent provision was necessary to secure a distribution of the available funds among doctors on the panel in accordance with the risk which they r Insurance Committees: Medical Benefit. 161 respectively assumed. Further, a change was made in the method of calculating doctors' quarterly credits by substituting the number on the doctor's list at the beginning of the quarter as the basis of his credit in lieu of, as previously, the mean of the numbers on his list at the beginning and end of the quarter, with the object of expediting advances and simplifying the necessary calculations. The doctors' accounts for 1913 are now being settled {see paragraphs 444 to 451 below). Procedure in dealing with Complaints. 417. The range of matters which stand automatically referred to the Medical Service Sub-Committee was enlarged to include all complaints by Approved Societies as to the certificates given to their members for sickness benefit by doctors on the panel. Two new Sub-Committees were created, viz., a Phar- maceutical Service Sub-Committee, to deal with disputes between insured persons and chemists on the panel, and a Joint Services Sub-Committee, to deal with disputes which, on in- vestigation in the first instance by either the Medical Service Sub-Committee or the Pharmaceutical Service Sub-Committee, appeared, in the opinion of the Sub-Committee, to involve ques- tions affecting both services. 418. The powers of the Insurance Committee in dealing with complaints upon the report of the Medical Service Sub- Committee were in some respects enlarged. The power of the Committee to remove insured persons from the list of a practi- tioner was, in certain special circumstances, extended, subject to the practitioner's right of appeal to the Commission ; and pro- vision was made that, where any expenses had been reasonably and necessarily incurred by an insured person entitled to obtain treatment from a doctor on the panel owing to a breach by the doctor of his agreement, the Committee should be empowered to recover such expenses from the doctor, and to repay them to the insured person. On the other hand, doctors on the panel were afforded a general right of appeal to the Commission against any decision of the Insurance Committee on a question investigated by the Medical Service Sub-Committee or otherwise arising. Revision of Doctors* Agreements. 419. The revised Eegulations were published in draft during the first week in November. Insurance Committees had in the meantime been warned that the revision would in certain respects vary the terms and conditions of the existing contracts with practitioners; and they had, therefore, previously given notice to those practitioners of the Committee's intention to vary the conditions of the contracts and to offer revised contracts for their acceptance. Model agreements were issued simultaneously with the Draft Regulations, incorporating the provisions of the (B254— Gp. 5) F 162 England. Eegulations. These were adopted, with minor local modifica- tions, by all Insurance Committees, and discussion and negotia- tions immediately took place upon them between those Com- mittees and the representatives of the medical profession during the last two months of the year. 420. With one exception the provisions of the new Agree- ments were accepted by the medical profession without demur. The model agreements issued by the Commission and adopted by Insurance Committees imposed a condition, however, which was felt to be necessary in view of the reported existence of certain abuses; viz., that the doctor entering into agreement with the Committee should not accept any remuneration other- wise than from the Committee in respect of the treatment afforded under his agreement to the insured persons on his list. Objections were raised in many cases to this condition, the scope and object of which was in some instances misinterpreted ; but these objections were ultimately waived and the agreements re- executed on the new terms and conditions in all areas. Chemists' Agreements and the Drug Tariff. 421. A similar revision took place of the agreements entered into between Insurance Committees and chemists for the supply of medicines and prescribed appliances. Proposals were con^ currently made by the registered pharmacists in each area for the modification of the Drug Tariff previously adopted. These pro- posals, which were put forward on uniform lines throughout the country, were discussed by the doctors on the panel and ulti- mately agreed to, the net result of the modifications as a whole being in the general direction of an upward tendency in prices. Applications under Section 15 (3) of the Act of 1911. 422. In December, 1913, before the draft Medical Benefit Regulations had been made substantive, representations were received from the General Medical Council with regard to certain incidents of the procedure established for giving effect to the provisions of Section 15 (3) of the Act of 1911 as applied to the case of persons desirous of making their own arrangements for receiving treatment not from registered practitioners but from persons who are not qualified, i.e., not registered under the Medical Acts. 423. The Act had left it open to every Insurance Com- mittee, in the exercise of their discretion, to grant leave to an insured person to make arrangements for treatment by an un- registered person, and the position in this respect was made clear in the course of the passage of the Bill through the House of Commons. But it was anticipated that the great majority of applications for what are now known as ' ' own arrangements ' ' would be received from persons desirous of being treated by doctors who were registered practitioners though not on the panel, as has in fact been the case, and the Regulations opera- Insurance Committees: Medical Benefit. 163 tive in 1913 did not accordingly deal under expressly separate provisions with arrangements for the two classes referred to. 424. It came to the knowledge of the Commission, however, that applications had, in fact, been received by some Insurance Committees from persons desirous of being treated by unregis- tered persons, and that some difficulty had been experienced in connection with these applications owing to the absence of a specific separate procedure for such cases. It was urged upon the Commission by the General Medical Council that confusion might arise if Committees were required to consider under one provision of general application two sets of cases differing so widely in character, and that situations of difficulty would cer- tainly be created by the indiscriminate adoption, in respect of all types of case, of administrative procedure primarily devised with a view to the circumstances of treatment by qualified prac- titioners only. Eor these reasons the General Medical Council requested the Commission to amend the Regulations, when making them substantive, in such a way as would be calculated to prevent the occurrence in practice of difficulties of this kind. The Commission accordingly decided to restate in the revised Regulations the practical effect of those operative for 1913 in the form of distinct and separate provisions, setting out the differences in the conditions to be observed in the two sets of cases, and the different circum- stances in which a contribution to the cost of treatment may be made by an Insurance Committee. These amendments, the objects of which received the full concurrence of the General Medical Council, were duly carried out in the substantive Regu- lations which came into force on the 12th January, 1914. The Commencement of the 1914 Medical Year. 425. The new doctors' and chemists' agreements came into operation simultaneously with the new Regulations on the 12th January, 1914. Special Mileage. 426. A sum of d650,000 was provided in the Supplementary Estimates for National Health Insurance (Special Grants), 1912-13, for payments in respect of mileage to practitioners prac- tising in districts of the United Kingdom in which special diffi- culties of locomotion or special sparsity of population prevail. In accordance with the terms of the estimate, this sum fell to be distributed under a scheme prepared by the National Health In- surance Joint Committee, the amount allocated for the purpose of grants to Insurance Committees in England amounting to £26,000. 427. In considering the further apportionment of this share of the grant among those Committees in England entitled to participate therein it was found that the circumstances of the (B254— Gp. 5) F 2 164 England. areas concerned varied to such an extent as to make it imprac- ticable to apply any uniform system of distribution to the whole country. But it appeared necessary in practice, for the purpose of a preliminary apportionment of the sums available, to arrive •at some common measure of the various circumstances, geo- .-graphical and otherwise, which would justify a grant from the Mileage Fund ; and, as a result of experiment, a standard average formula was devised on the basis of which a preliminary appor- tionment was made among Committees from whom claims upon the grant had been received. The circumstances of every area for which a grant had been claimed were then examined separately, and the amount of each grant, as calculated on the average basis, was adjusted to meet the particular local conditions of which the average w^as the resultant. 428. The actual grants for 1913 (which vary from £2 to £3,000) were thus arrived at with the closest regard to the rela- tive urgency of the needs of the several areas, and in practically all cases after consultation and negotiation with the Insurance Committee and the representatives of the doctors concerned in each instance. It is believed that the apportionment is accepted by the medical profession as doing substantial justice, within the limits of the total sum available, to the relative claims of the areas concerned ; but it has been expressly made experimental , and subject to revision as regards 1914 and subsequent years in the light of experience derived from the actual working of the basis for 1913. 429. For the distribution of the grant among the doctors en- titled to participate, each Committee has, further, been required to submit a scheme. A model has been prepared by the Com- mission and issued for the assistance of Committees in framing their schemes. 430. Applications for a grant from the Fund have been received from, and grants have been made to, 41 Committees. In addi- tion, one or two Committees have announced their intention of making a claim for 1914. Schemes for the distribution of the grants have been received from 30 Committees, and have been approved in the case of 18 Committees. Administeative Machinery. 431. Very onerous tasks have been successfully performed by Insurance Committees in connection with the completion of their registers ; and some important changes have been made in the system upon which those registers are operated and in the general administrative machinery and procedure of which they form part. 432. In addition to the " index register," or register of insured persons as indexed in the order of their Approved Societies, &c., it was necessary for the Committee to keep an account against each doctor of the insured persons on his list for the time being. Insurance Committees: Medical Benefit. 165 This in fact necessitated the compilation of a second register termed the "medical index," of insured persons in the order of the doctors by whom they had been accepted. This laborious task was undertaken by Insurance Committees early in 1913 by means of a careful check against the index register of the names, &c., shown on the doctors' returns of persons accepted by them. Much difficulty was experienced by reason of the fact that the particulars of the insured persons were in a large proportion of cases incorrectly given, either through the error of the insured persons themselves or through inaccurate transcription on the part of doctors. 433. The change of system above referred to, which in itself involved Committees in further initial operations of con- siderable magnitude, requires for its explanation a brief review of the circumstances which called for its adoption. It is, of course, essential to the administration of a benefit to which a section only (however large) of the general popula- tion is entitled, that the authorities administering the benefit should be in a position to recognise and identify those persons who are entitled to claim from them. With this object the index register of insured persons was compiled ; but as the register was not sufficiently accurate at the date of the commencement of medical benefit, a personal voucher in the form of the pink " medical ticket " was issued through the Approved Societies to all insured persons entitled to medical benefit in order to enable them to substantiate their claim thereto. 434. This voucher was, however, intended to be a temporary ex- pedient only. Under the system originally contemplated Approved Societies were required to furnish Insurance Committees with particulars as to the removals, deaths, lapses, and suspensions &c., of their insured members, with the object of enabling each Committee to keep its register in close correspondence, as nearly as might be, with the actual insured population of the area for the time being ; and as it was anticipated that under this system, when in full operation, the Insurance Committee would generally be in possession of information as to the identity and title of the insured persons who made a choice of doctor, &c., in their area, it was considered possible to dispense with any voucher or docu- ment of title on the part of the insured person, and to enable him to make his choice by means of a form (Form Med. 32) obtainable at any Post Office. 435. Experience proved, however, that having regard to the very high percentage of removals among the insured population and to the difficulties encountered by Approved Societies in securing information as to the removals of their members, their f notifications could not be relied upon in this important respect to keep the registers of Committees accurate. It appeared to be necessary, therefore, to modify the basis upon which the register was operated, and a new system was accordingly considered, involving the principle of a personal voucher in the form of what is now known as the " medical card." (B254— Gp. 5) F 3 166 England. The Medical Card System. 436. The medical card is a four-page (buff) card, intended to be issued to the insured person by the Committee for the area in which he resides at the date of issue, and bearing the Committee's name and address. It also bears the insured person's name and address, and if he has already chosen a doctor in that area, the name of that doctor. Full general instructions are given on the card as to the procedure necessary to obtain medical benefit and the rules of conduct to be observed by patients undergoing treatment. It thus serves not only as a voucher by means of which the doctor may recognise the persons for whose treatment he is responsible, but also as a vehicle for conveying to insured persons information as to their rights and duties and as a document of title to the benefit itself. 437. The medical card contains three spaces for utilisation by the holder in connection with a choice of doctor, the first for use if he has not already chosen a doctor, the second for use if he has already chosen a doctor but has removed permanently outside the area of that doctor's practice, and the third for use in the event of his requiring a doctor during temporary residence elsewhere. In the first case the insured person fills up the appropriate space and hands the card to the doctor, who retains it if he accepts the applicant and transmits it to the Committee, who return it to the insured person. When the insured person removes from the area within which the services of the doctor already chosen are available to him, he may make a fresh choice in the area of his new residence by filling up the second space on the card and handing it to the doctor chosen. The doctor takes the card and transmits it to the Insurance Committee, who issue to the insured person a fresh medical card bearing their own name and address. 438. The importance of the medical card as regards the difficulties of registration already alluded to are therefore two- fold. The insured person is always in possession of a document which, should he remove beyond the area of practice of the doctor already chosen, enables him to make a fresh choice. Further, the exercise of this fresh choice necessarily results in the transmission to the new Insurance Committee of the insured person's old medical card ; and as this bears the name and address of the Insurance Committee by whom it was issued, the new Committee are immediately in a position to communicate with the Committee in whose register the person was previously entered, with a view to his transfer from one register to the other. 439. Incidental advantages are secured by the adoption of this system. In particular it has been found possible, while preserving the case-value method of adjustment in connection with temporary residence, to combine with the other functions of the medical card those of the old green voucher by means of the provision of the third space above referred to. The holder Insurance Committees: Medical Benefit. 167 is thus enabled to obtain medical benefit during temporary resi- dence without applying for and securing a separate document of title. 440. The adoption of these principles as affecting the medical profession was discussed and accepted by their representatives on the Advisory Committee at a Conference on the 17th October, 1913. Further, as regards the modification involved respecting the system of registration, the whole matter was fully considered at three conferences, specially convened for the purpose during the month of December, of Chairmen and Clerks of Insurance Com- mittees, at which the principles and details of the scheme were unanimously accepted by those present. 441. Steps were accordingly taken by Committees to put the new arrangements into operation as from the beginning of the 1914 medical year. These involved the preparation and issue of medical cards to the bulk of the insured population, including all those insured persons who had already chosen a doctor ; and special emergency arrangements were made by Committees to deal with this initial issue without delay. As a result of excep- tional efforts the whole issue was practically completed by the end of the first quarter of 1914, while in the case of many Com- mittees the despatch was effected considerably earlier. As was expected, the task of the initial bulk despatch proved to be very heavy ; but , though necessary for the purpose of bringing the system into operation, it will not require to be repeated, the normal working conditions involving a small and regular issue only to keep pace with the current demands. 442. Over ten and a half million cards were despatched on the initial issue. Special arrangements had been made for the return to the Committees of those cards which failed to be de- livered ; and approximately 800,000 cards were thus returned as undelivered owing to various causes. As contemplated by the original scheme, this return was of value to Committees, in enabling them to clear their registers and render them more ac- curate ; and similar advantage is still being derived from the operation of the system in other respects. 443. The elimination of error from the registers is, however, a matter which is still receiving the attention of Insurance Com- mittees and the Commission. The Settlement of Accounts for the 1913 Medical Year. 444. Early in the course of the year 1914 the Commission took into consideration the steps necessary to enable Committees to effect a settlement of accounts for 1913 with the doctors and chemists, approved institutions, and persons making their own arrangements in their respective areas. Advances had, of course, been made during the year to doctors, chemists, and approved institutions ; but these had necessarily been made in most cases on a conservative basis leaving a margin due upon the annual settlement. (B254— Gp. 5) F 4 168 England. 445. The matter was one of some difficulty in view of the fact that the finance of medical benefit practically resolves itself into the distribution, in accordance with the Eegulations, of a sum calculated by reference to the mean insured population during the year in each area. The mean calculation depends, of course, upon the ascertained growth of the insured population ; and , as it was clear that the returns necessary for this purpose would not be forthcoming for some considerable time, it was considered de- sirable, in the interests of the persons pecuniarily concerned, not to postpone the settlement until the final figures were received. The figures of the insured population entitled to medical benefit at the beginning of 1913 were already available ; and as the actuarial estimates showed that the net increase was not suffi- ciently considerable to affect to any great extent the re- muneration payable, it was suggested to Insurance Com- mittees that they should proceed to a settlement on a basis which made no allowance for the net increase in insured population, leaving any small further sums which subsequently became due to them to be applied by way of further final dividends. 446. The Commission accordingly proceeded to calculate debits to Approved Societies and to the accounts of deposit con- tributors on this basis, and to apportion, in accordance with the procedure already adopted, the total sum thus collected, to- gether with the appropriate Exchequer grants, among the several Insurance Committees in proportion to their respec- tive insured population as based upon the mean of the counts of their index registers during the year. Many intricate adjustments and allowances were, however, still necessary. In particular the case-value debits in connection with temporary residents required to be calculated before the net amount avail- able for distribution could be determined in any area, and the contents of the Central Fund and the rate of payment on tem- porary resident fees ascertained. For the purpose of these case- value calculations it was necessary to collect from every doctor on the panel his records of cases treated ; and much delay was unavoidably occasioned by the issue of letters and reminders to those doctors who for one reason or another delayed or neglected to discharge their duties in this connection. 447. Apart, however, from the difficulties which, as indicated above, attended the process of ascertaining the amount avail- able for distribution by each Insurance Committee, there re- mained the apportionment of that sum by each Committee among their respective funds constituted under the Eegulations, viz., Panel Fund, Drug Fund, Drug Suspense Fund, Institutions Fund, and Special Arrangements Fund. As this apportion- ment involved calculations of considerable complexity and ques- tions of interpretation of which Committees had had no previous opportunity of gaining experience, the Commission decided, both for the purpose of expediting the settlement and of giving assist- ance to Committees in accounting operations which were the first of their kind, to undertake the necessary calculations them- Insurance Committees: Medical Benefit. 169 selves. A return was accordingly obtained from all Insurance Committees giving the necessary figures extracted from their books; and upon the basis of these returns the required calcula- tions were made and notified to them for their assistance in the apportionment of their credit. 448. The progress of the settlement brought to light certain misunderstandings and difficulties which might naturally have been expected in connection with the first year's working. Owing in part to the methods of allocation adopted by some Committees and in part to the initial error and inflation in the registers of Committees, which, as explained above in paragraphs 442 and 443, is now in course of correction, expectations were formed by the medical profession in very many areas of receiving payment on the basis of a population much in excess of that actually in existence. Explanations were accordingly necessary in many cases, it being pointed out that, as shown in Appendix XIV to this Keport, the whole of the moneys due from Approved Societies in respect of their members entitled to medical benefit, and from the accounts of deposit contributors entitled to medical benefit, together with the amount due from the Treasury in respect of all those persons, had in fact been apportioned among the several Committees, and that accordingly the credits available for re- muneration represented the agreed amount per head in respect of the whole of the insured population entitled to medical benefit. 449. More serious difficulties arose in connection with the accounts of chemists on the panel. The agreements accepted by the chemists as a body and entered into by individual chemists provided for payment for drugs, etc., supplied in accordance with an agreed tariff so far as the funds allocated for the purpose would permit, provision being made for the discounting of the bills of chemists in any area in which the total bills exceeded the sums available. The tariff itself required to be agreed locally by the Insurance Committee, the doctors and the chemists. As a matter of fact, the tariff propounded by the chemists themselves was universally accepted by Insurance Committees and by the doctors locally interested without, in view of the discounting pro- visions, any close examination on a commercial basis. 450. It was anticipated that, with proper regard to economy in prescribing, the. funds available would be sufficient, notwith- standing the discounting provision, to enable the chemists to be properly remunerated for the drugs supplied; and, in order that economy might be secured, the Eegulations provided for sur- charges being made against the doctors responsible in any case in which it appeared upon a scrutiny that extravagant prescribing had taken place. Towards the end of 1913, and in the earlier part of 1914, however, it appeared probable that in certain areas the chemists' bills for the year would be in excess of the drug funds available ; and the position in this respect was confirmed by the actual figures established in the course of the settlement. It was clear in many cases that the excess was due either in whole or in part to extravagance in prescribing, although doubt- 170 England. less the unequal incidence of sickness as between the several areas tended to exaggerate the eifect of any such extravagance in the less healthy areas. Eecourse was accordingly had to the provisions of the Kegulations for dealing with excessive pre- scribing. Under these provisions the amount of any surcharges is payable into the Drug Fund of the Insurance Committee, and becomes available for the payment of chemists' bills, so that it is unnecessary that any discounting should take place in respect of any excess of chemists' bills over the Committee's funds due to extravagance, where proper advantage has been taken of the Regulations in question. Hence, inasmuch as there may be available to meet the cost of chemists' bills in any area not only the Drug Fund of the Committee but also the amount of any surcharges in respect of extravagant prescribing, it is not possible to ascertain, pending the completion of the necessary scrutiny, what sum will ultimately be forthcoming towards the drug ac- acounts, or to what, if any, extent these accounts will ultimately require to be discounted. The scrutiny is at present proceeding in many areas, while in other areas the adoption of this course is under consideration. 451. A summary of the financial results of the apportionment of medical benefit funds is given in Appendix XIV, pages 506 and 507. Inquiries relating to the Continuance of Practitioners UPON the Panel. 452. Under Section 15 (2) (6) of the Act of 1911, where the Commissioners, after such inquiry as may be prescribed, are satisfied that the continuance of any duly qualified medical practi- tioner in the list of medical practitioners who have agreed to attend and treat insured persons whose medical benefit is admin- istered by the Committee would be prejudicial to the efficiency of the medical service of the insured, they may remove his name from the list. The procedure to be followed in such in- quiries is provided for in Part VI. of the National Health Insur- ance (Medical Benefit) Regulations (England), 1913. Where a representation that the continuance of a practitioner on the panel is prejudicial to the efficiency of the medical service of the in- sured is made by any Insurance Committee, Local Medical Com- mittee, or Panel Committee, the Commission must, and if the representation is made by any other person or body, the Com- mission may, hold an inquiry in the manner prescribed by this part of the Regulations. Where, however, it appears to the Commission that the alleged facts on which any representation is based are or may be subject to investigation by any other tribunal, they may, if they think fit, direct that no further steps should be taken under the Regulations pending the issue of such other investigation. 453. For the purpose of each inquiry an Inquiry Committee is constituted. The Inquiry Committee is composed of a barrister- at-law, or solicitor, in actual practice, and two medical practi- Insurance Committees : Medical Benefit. 171 tioners. At, the conclusion of the inquiry, the Inquiry Com- mittee draw up a report stating the relevant facts established by the evidence and the inferences of fact, which in their opinion may be drawn from such facts. The Commission consider the report of the Inquiry Committee and give their decision. 454. Four inquiries have been held under this part of the Kegulations. The representation in each case was made by the Insurance Committee, and in each case the Commission directed that the name of the practitioner should be removed from the list. In one case, however, they intimated to the Insurance Committee that, having regard to the particular circumstances of the case, there would, in their opinion, be no impropriety in the Insurance Committee acceding to an application by the doctor to be restored to the list in the following year. The substance of the complaints differed in the individual cases. In two of them the complaint was that the doctor attended at his surgery so irregularly that his patients were unable to receive medical treatment. In another case the complaint was that the doctor had failed to give the necessary medical attendance to an insured person, and that he had allowed a third person to sign his name on certificates of incapacity for sickness benefit without having, in fact, examined the persons certified on the days on which the certificates were given. In the fourth case, the substance of the complaint was that the doctor, under an assumed name, supplied drugs (including scheduled poisons) and dispensed his own prescriptions, well knowing his action to be contrary to the Medical Benefit Regulations and to the terms of his own agreement with the Insurance Committee. MEDICAL BENEFIT.— GENERAL REVIEW. 455. Many of the difficulties w^hich beset the admin- istration of medical benefit arise directly out of those features of freedom and elasticity which are most char- acteristic of the system established by the Legislature, and which constitute its peculiar value as reflecting, as regards the insured population on the one hand, the bent of the na- tional temperament, and as regards the medical profession on the other (in accordance with their express desire), the conditions of private practice. In essentials, therefore, the present medical benefit scheme may be described as the embodiment in an ad- ministrative system of a nexus of private and voluntary relations between individuals ; and the special problems presented are fundamentally concerned with the reconciliation of those appar- ently diverse propositions. The provision for many millions of insured persons, wherever they happen to be in Great Britain, of medical treatment by means of access to, and free selection from the ranks of a service in which all qualified medical practi- tioners and pharmacists are free to be enrolled requires a machine not only far-reaching and comprehensive, but elastic and adapt- able, not only complex, by reason of the many intricate personal 172 England. relations involved, but also swift in action and responsive to the sudden emergencies of disease. 456. From this point of view an examination of the system resolves itself into two parts, the one concerned with its effect upon the insured population, the other with its consequences as regards the medical profession and the service afforded by them. 457. As regards the insured population, a necessary conse- quence of the embodiment of these relations into a system is the establishment of a procedure. The requisite procedure must be adaptable to, and keep touch with, the multiplicity of conditions throughout which the insured person's access to benefit is to be preserved ; it must necessarily be of the simplest ; and it must, moreover, be operated, not by any external sanctions, but by the minimum degree of action by the insured person himself in his own immediate self-interest. These canons have been carefully observed, and so far as possible secured, in the actual construction of the administrative machinery ; but the problem which necessarily arises with any system, however simple, is not only to convey to the insured population a sufficient knowledge of the steps necessary to be taken by them and of the facilities and advantages offered, but also to induce them to take those steps and to choose a doctor forthwith without waiting until they are ill. Difficulties naturally result, therefore, from ignorance of the nature of the provision afforded, and from ignorance and inertia with regard to the steps necessary to access. 458. These difficulties can doubtless be completely removed as, with increasing experience, the insured population becomes more completely educated as to the nature and details of the system. It was not to be expected that over ten million persons could in the course of a few months become conversant with even the outlines of the scheme, or that it would be possible to put them, individually, in possession of effective knowledge as to the appropriate steps to be taken in all circumstances. Neverthe- less, so far as information is available, the progress which has been made is very striking. At the end of 1913, the first year of medical benefit, the number of insured persons returned as having chosen, and been placed on the lists of, panel doctors alone in England represented 96 per cent, of the total insured population (excluding that of Manchester and Salford, where this criterion does not apply). In all probability these lists contain some duplication in respect of insured persons who have, upon removal, chosen a doctor in the new area without being immediately removed from the list of the doctor in the area they have left. On the other hand, the figures do not include the insured persons who have selected an approved institution or been allowed to make their own arrangements ; and it may be taken that the figure of 96 per cent, substantially represents the fraction of the insured population who have taken steps to secure the advantages of the benefit. Again, in London, where the administration has been attended by exceptional difficulties, and i Insurance Committees: Medical Benefit, 173 a less successful result might have therefore been expected, the figure returned on the above basis, in respect of panel doctors' lists only, amounts to over 90 per cent, of the insured population. 459. It is not, therefore, the case that, as has been stated, any large proportion of the insured population is without access to benefit on the ground of objections to the nature of the service offered or owing to any inadequacy or failure of the administra- tive machinery. These statements are, it is believed, based upon the fact that the registers of most Committees include a substantial number of insured persons who have not chosen a doctor in the area. But experience has shown that this sectioii of the register includes the bulk of the inflation referred to above in paragraph 448 ; and the fallacy of the assumptions based uporh these data is proved by the result of an investigation recently con- ducted in a district of the metropolitan area with the object of inducing insured persons in their own interests to exercise their right of selection. 460. This investigation, which dealt with about two thousand cases from the section of the register above referred to, taken at random and without any selection, disclosed the circumstances shown in the following Table : — Sample Examination of Cases of Insured Persons shown on Register as NOT having chosen a Doctor. Grounds for apparent inaction. Percentage. 1. Already on Doctor's list, but not returned as such owing to misapprehension or clerical error 2. Removed — («) From the area (6) From the United Kingdom (c) Leaving no trace 3. Neglect... 4. Ignorance of procedure 5. Ceased to be insurable 6. Dead 7. Joined Army or Navy 8. Preferred private doctor 9. Have paid privately for treatment . . . 10. Miscellaneous grounds {e.g., contemplate leaving United Kingdom, insurability in doubt, &c.) ... 31-2 4-6 1-4 27-6 19-6 4-3 3-6 0-5 0-5 3-8 0-6 2-3 100 461. Thus the great majority, amounting to nearly 70 per cent, of the insured persons concerned, proved either to have re- moved from the area (being in all probability on the list of a doctor in another area), to have left the country or otherwise ceased to be entitled to the benefit, or to be already on the list of a doctor in the area though not returned as such owing to some misapprehension or clerical error. Ignorance of procedure was responsible for the failure to choose a doctor in 4 per cent, only of the cases, while sheer neglect accounted for nearly 20 per cent. 174 England. 462. Of the persons in Class 8 who stated that they had pre- ferred a private doctor, some stated that they were giving up a private doctor and intended to choose a panel doctor. Some were accustomed to obtain treatment through an unrecognised medical club or institute, or possessed opportunities of obtaining treatment gratis, while of the others it may be inferred that they include some persons who, if and when they have occasion to require a doctor, may, notwith- standing, have recourse to the panel. Similarly the persons in Class 9 who had paid privately for treatment probably include some persons who had so paid in ignorance of their rights, and who will in future avail themselves of them. But even without the discount which must obviously be made from both classes on these considerations, the percentage of persons who, on account of ignorance, preference, or prejudice, deliberately refuse to avail themselves of their medical benefit is negligible, inas- much as, without any allowances, and assuming the average found in the cases dealt with to be maintained in the rest of the persons represented by the section of the register referred to, the two classes in question only account for 0-27 per cent, and 1-7 per cent, respectively of the insured population of the area. 463. So far, therefore, as the insured population is concerned, there appears to be no reason for dissatisfaction with the present position'br the progress which has already been made as regards the working of the system. Knowledge is rapidly spreading ; and the introduction of the medical card system should, it is believed, effect a great advance by providing insured persons with an almost universally available means of access in nearly all cir- cumstances which are likely to arise. 464. Turning now to the aspect of the system as it concerns the medical profession and the medical service, it is, similarly, in connection with those features which preserve the conditions of private practice that difficulties have been encountered and w^re liable to arise. All qualified practitioners are entitled to be enrolled in the service, and insured persons are entitled to a free choice from among the practitioners so enrolled. As in ordinary course of private practice, the principles of open com- petition are mainly relied upon to secure for the competent man as large and remunerative a practice as he can success- fully undertake, and to preclude his acquisition of a larger number of patients than he can properly attend. The principles of economic supply and demand are in the main relied upon to recruit the ranks of the service in any particular district or area (although it is, of course, the first duty of the Insurance Committee to secure a panel which is amply adequate for the service of the area), and to secure a local distribution of the available practitioners which will enable their services to be utilised with the least amount of waste and overlapping. Further, the relations between doctor and patient are still to a Insurance Committees: Medical Benefit. 175 considerable degree the private relations of private practice, and remain so unless and until either party invokes the authority ad- ministering the benefit to do justice in the matter of a complaint or dispute. 465. Dealing first with the last-mentioned pomt, there appears to be little doubt that the personal relations between panel prac- tioners and their panel patients are, generally speaking, entirely satisfactory. Complaints are comparatively rare in most dis- tricts ; while reports from all parts bear witness to an increasing spirit of mutual understanding. As regards the standard and quality of the treatment given, this naturally varies, as it must inevitably do under a system which, reproducing the free elements of private practice, admits all qualified practitioners, without selection. But, at the lowest estimate of the position,, an enormous number of men and women are now receiving treat- ment for their ailments who previously were accustomed to go without; while, on the other hand, insured persons have been enjoying, at the hands of the more conscientious and competent* doctors, a service of the standard of that accorded to remunerative patients of the well-to-do classes. Signs are not wanting, more- over, that definite tendencies are in operation, originating with the medical profession themselves and fostered by the respon- sible authorities, to raise the standard of the whole of the in- dustrial practice of the country and to enhance the value of the insurance service. 466. As regards the nature and quality of the supply of medi- cines and appliances under the present system, there have been no grounds for dissatisfaction. Questions have been raised in a very few isolated instances as to the quality of the drugs fur- nished ; but no cases have been reported which, upon investiga- tion, have justified any allegations that the drugs supplied in connection with the insurance service were of an inferior standard. ' 467. In the matter of certification, however, where under the present system the nexus of relations reaches its highest degree of complication as between doctor, patient. Insurance Committee, and Approved Society, it cannot be said that at present equally satisfactory results have been attained. In this province the medical benefit system replaced, not the conditions of private practice, but the pre-existing relations of contract practice between the club or lodge and their medical officer. These rela- tions involved a close touch between the Society and the doctor acting as custodian of the Society's funds ; and as the circum- stances attending the early stages of medical benefit were such as to impair in some respects the nature of the understanding between Societies and the medical profession, their mutual con- fidence has had to be restored. Administrative action is, however, being taken to overcome the difficulties which have arisen. Moreover, the spirit of co-operation, as already stated, is growing; and already, in some areas, the medical profession 176 England. and the Approved Societies have of their own motion established a rapprochement with the happiest practical results. 468. The number of doctors on the panels in England (ex- cluding duplicates within each area, but including doctors on more than one panel) amounts to over 16,000, while over 10,000 shops are available for the supply of medicines or appliances, or both, to insured persons. The number of doctors has steadily increased, as will be seen from the following comparative figures : — Strength of panels on 15th January, 1913 ... 13,996 14th April, 1913 ... 15,659 13th October, 1913 ... 15,870 31st May, 1914 ... 16,059 The total increase in strength since the commencement of medical benefit is thus over 2,000. 469. As regards the sufficiency of the number of panel doctors available for the country as a whole, there can be no possible doubt. On the figures given above, and after an allowance is made for the elimination of duplicates, the average number of insured persons per panel doctor is only about 750, a number for which responsibility can, except under abnormal conditions, be accepted by a single doctor with the greatest ease. In pro- ceeding to consider the actual distribution of insured persons among doctors, it must be remembered that this is likely to be governed by two factors, viz., the relative extent of the personal powers and opportunities of doctors of acquiring a practice, and their local distribution and relative availability. 470. As regards the first consideration, it is natural to expect that the forces of competition would result in the existence of lists above and below the average in size ; and properly so , since it is right that competence and thoroughness in attendance should be recognised and rewarded by a large practice and correspond- 'ing remuneration. The early circumstances of medical benefit were, however, such as to disturb for the time being the operation of the competitive forces. In some districts doctors delayed coming on the panel at the outset, with the result that many selections were made before the panels were complete, and no opportunity subsequently arose for a change of doctor until the end of the year. Nevertheless, the actual position as it existed prior to the first opportunity for change was far from unsatis- factory. Taking the figures of 100 Insurance Committees of a representative character, it appeared that at the end of 1913 over 50 per cent, of the panel practitioners had 500 or less insured persons on their lists, 70 per cent, had 750 or less, 80 per cent, had 1,000 or less, 90 per cent, had 1,500 or less, while over 96 per cent, had no more than 2,000. While the number of insured persons for whom a panel practitioner can properly accept responsibility will, of course, vary with his personal competence and the extent of his private practice, lists of the size above-mentioned could not, save in exceptional circumstances, be deemed excessive ; and as regards Insurance Committees: Medical Benefit. 177 the isolated instances in which doctors' lists greatly exceed these figures, it is generally the case that the practice is shared with a partner or assistant. There are doubtless cases, however, in which a redistribution of panel patients could be effected with advantage to the patients themselves and the standard of the service afforded. Keforms in this respect are taking place, and will continue to do so, as the insured population become aware, and avail themselves, of their opportunities of changing their doctors ; and the whole question is attracting the careful attention of Insurance Committees and the medical profession locally. 471. In general it may be said that the commencement of medical benefit found a local distribution of practitioners reason- ably adequate to the local distribution of the population and to the varying incidence of sickness. This was, of course, due to the fact that the principles of supply and demand had under the previous conditions of private practice resulted in a local distri- bution most suitable on economic grounds. In some districts, however, particularly in London, notwithstanding the existence of much sickness and disease, the poverty of the population offered no inducements to doctors to practise ; and one of the first results of the commencement of medical benefit was to indicate those districts in which the paucity of resident practi- tioners proved only too clearly the grave conditions which had previously existed and the timeliness and value of the advan- tages which the medical benefit provisions of the Insurance Act afforded. It was surmised that the new economic position would attract practitioners to such districts ; and this expecta- tion, though it is as yet early to expect any complete adjust- ment, has not been falsified. In one of the London boroughs in which these serious conditions previously existed, four new practi- tioners have started in panel practice ; in another borough , eight , and in another, nine new practitioners have started in panel practice ; while in a district comprising several small boroughs where a marked shortage previously existed , at least five . new practitioners have joined the panel ; the total amounting to a net addition of 26 to the ranks of the medical profession in these districts in London alone. 472. A general review of medical benefit would not be complete without a reference to the manner in which In- surance Committees have discharged their functions. The constitution of Insurance Committees, containing, as they do, a majority of insured persons' representatives whose interests, as individuals, are identical with those of the insured population, and who on behalf of their constituent Approved Societies have the strongest motives for encouraging the suppres- sion of sickness and disease, has fully justified the objects with which it was devised. Further, the presence on these Commit- tees of representatives of doctors, chemists, nurses, and mid- wives has rendered them peculiarly suitable for undertaking the 178 England. task of administration with expert knowledge and with full acquaintance and sympathy with local conditions, while the Council representation has enabled the Committee to profit by the experience of persons versed in public life, and has afforded a most valuable link between the Committee and the local authority. ' Insurance Ci)mmittees have successfully discharged many onerous duties of administration and negotiation, and their enthusiasm and interest in the problems with which they have to deal is uncommon in the history of similar local bodies. In particular, it is worthy of record that although the provisions of Section 63 of the 1911 Act regarding excessive sickness are as yet not wholly available, at least one instance has come to notice in which, through the activity of the Insurance Committee and the general operation of the Insurance Act, attention has been drawn to the existence of grave insani- tary conditions, and steps taken to put the public health law into operation. The Insurance of Deposit Contributors. 473. The administration of the insurance of deposit contri- butors, in spite of the many inherent difficulties to which refer- ence was made in the previous Keport, has been carried on with successful regularity. 474. The difficulty experienced in keeping in touch with deposit contributors, owing to the frequency with which they change their addresses without either correcting the entries in their contribution cards or notifying the Com- mission, was to a large extent met by a change in the arrangements for issuing and surrendering cards at the Post Office. The Commission now issue the cards direct to the contributors, enclosing with every card an envelope ad- dressed to the Commission, and suitably marked for purposes of identification. At the end of the period of currency of the card^ the contributors post them direct to the Commission in these envelopes. Contributors who do not receive cards from the Commission can obtain them by filling up forms of applica- tion at the Post Office, but stamped cards are no longer surren- dered at Post Offices, and contributors tendering cards for surrender at Post Offices are handed addressed envelopes in which to post the cards to the Commission. 475. Owing in some cases to contributors having moved from the addresses shown on their surrendered cards before com- munications from the Commission could reach them, in some cases to neglect on the contributor's part to deal with com- munications received, and in some cases no doubt to the inability of contributors to understand the questions asked, there has always been difficulty in obtaining the declarations which are required before the class of insurance can be determined and accounts opened in the Deposit Contributors Fund. A very Insurance Committees: Deposit Contributors. 179 simple form of declaration has, therefore, been printed on the flap of the new envelopes issued by Postmasters for the return of cards, with the result that declarations are now obtained in a much higher percentage of cases than was formerly the case when separate declaration forms were issued, and, as the declara- tions are received by the Commission with the cards, difficulties of identification due to changes of address are largely avoided. 476. The arrangements made by Insurance Committees for the administration of the benefits of deposit contributors, described in paragraph 678 of the previous Eeport, have worked satisfactorily,, and continue in operation. Transfer of Deposit Contributors to Approved Societies. 477. The most notable, and at the same time the most satisfactory, feature of the work has been the very large number of transfers of deposit contributors to Approved Societies. Special efforts have been made to make clear the advantages of joining Societies, and in certain selected areas personal inves- tigation has been made by the Outdoor Staff of the Commission into the causes that have led insured persons to become deposit contributors. An account of these investigations has already b'een published in a Parliamentary paper, Cd. 7034. Cases of refusal by Societies to accept applications were remarkably rare. 478. Reference was made in the previous Report to cases in which contributors had joined Societies after an account in the Deposit Contributors Fund had been opened, and to the Order under Section 78 of the Act that was made to place such contributors as nearly as possible in the position in which they would have been if they had joined Societies on entry into insurance. In addi- tion, however, to the transfers of persons who had been estab- lished as deposit contributors, the Commission had to deal with a large number of cases where contributors had joined Societies after the prescribed time of three months and 14 days from entry into insurance, but had taken no steps to furnish the Com- mission with the information as to age, nationality, and occupa- tion which is required before accounts in the Deposit Contribu- tors Fund could be opened for them. Their earlier cards had been surrendered at Post Offices, and had been transmitted to the Commission. Societies were frequently in doubt as to their liability to provide benefit for such members until the transfers had been completed. In the ordinary course it would have been necessary to obtain from each contributor a declaration as to age, nationality, and occupation, and from these particulars to open an account in the Deposit Contributors Fund, which would immediately be closed by the transfer to the Society. As, owing to the provisions of the Order referred to above, no finan- cial effect was involved in passing the contributors in these cases through the Deposit Contributors Fund, a further Order was made providing that the contributors should for all purposes 180 England. be deemed to have been members of the Societies from the date of their entry into insurance. 479. One hundred and thirty thousand cases of contributors who joined Societies before 15th July, 1913, were dealt with under these two Orders. It was found, however, that deposit contributors, who were from the start eligible for membership of Societies, were joining Societies in large numbers after that date, and in order to place these contributors in the same position as those who had joined Societies in the first year, a further Order was made continuing the provisions of the previous Orders until 27th April, 1914. By this means an additional 60,000 transfers have been dealt with. 480. The following Statement shows the number of applica- tions for transfer from the Deposit Contributors Fund to Ap- proved Societies : — (i.) Applications relating to " established " contri- butors 103,000 (ii.) Applications relating to " unestablished " con- tributors 88,000 (iii.) Applications relating to contributors who joined Societies within the prescribed period, duplicate applications, &c. ... ... ... ... ... 19,000 210,000 Benefits of Deposit Contributors during 1914. 481. The previous Eeport detailed the practical difficulties found to arise in administering Section 42 (e) of the Act of 1911, and the measures taken to meet them in the year 1913. The Order authorising these measures expired on the 31st December, 1913, and, as the circumstances which led to its issue still remained, it was necessary to make similar special arrangements in respect of the year 1914. . This was done by means of a further Order under Section 78 of the 1911 Act and Section 40 of the 1913 Act. 482. The provisions of this Order were substantially the same as for the previous year, but to secure as far as possible that every contributor remained in benefit for the year 1914, the Commission took power under the Order to reserve in the ac- count of each deposit contributor the sum required to meet the charge on account of medical and sanatorium benefits and the Insurance Committee's administration expenses up to 31st December, 1914, before making payments on account of benefits in the last quarter of the year 1913. 483. Any benefit so withheld was paid after the end of the quarter in any case in which further contributions to replace the amount reserved were paid, and also in any case in which the contributor did not remain in insurance after the end of the year. It may be remarked that the necessity of reserving any benefit in this way arose in comparatively few cases. Insurance Committees: Deposit Contributors. 181 Statistics. 484. In all, 454,000 contributors who entered into insurance between 15th July, 1912, and 11th January, 1914, have been established as deposit contributors, that is, have filled up the official declaration form and have furnished the information neces- sary to have accounts opened in the Deposit Contributors Fund. Of these, only 195,994 paid contributions as deposit contributors during the sixth quarter ended 11th January, 1914. 485. In addition to the established contributors, there are those persons who surrender their contribution cards to the Com- mission, but do not reply to communications sent to them and take no steps to establish their status. During the six quarters to 11th January, 1914, contribution cards were received from 234,000 unestablished contributors, but of these only 42,000 sur- rendered cards for more than one quarter, and only 15,000, in- cluding 7,000 new entrants into insurance, paid contributions as deposit contributors for the sixth quarter ended 11th January, 1914. It would appear, therefore, that practically the whole of the unestablished class is made up either of contributors who were employed only for a short time during the 18 months under review, and whose normal occupation is not employment under the Act, or of those contributors who passed out of insurance soon after entry. 486. Owing to the difficulty of obtaining any information from contributors who cease to pay contributions, it is not possible to state the exact number of established and unestablished deposit contributors who were still in insurance as deposit contributors on 11th January, 1914, but it can be assumed that the number was very little in excess of the number of contributors who paid contributions for the quarter ended 11th January, 1914. 487. Particulars of the number of cards surrendered each quarter by deposit contributors, and statistics relating to claims for benefit and payments on death and emigration are shown in Appendices XVI to XVIII on pages 510 to 512 below. An exhaustive inquiry into a large number of deposit contributors' accounts has been undertaken, the results of w^hich are pre- sented in Appendix VI, page 491, and discussed in paragraphs 145 to 148 above. 182 England. QUESTIONS RESPECTING LIABILITY TO INSURANCE AND PARTICULAR CLASSES OF INSURED PERSONS. Exempt Persons. Additional Qualification for Exemption. 488. It was explained in paragraph 686 of the previous Keport that any person employed within the meaning of the Act of 1911 is entitled to a certificate of exemption under Section 2 if he proves that he is either (a) in receipt of a pension or income of the annual value of £26 or upwards not dependent on his personal exer- tions, or (b) ordinarily and mainly dependent for his livelihood upon some other person. Such a certificate exempts an indi- vidual employee who would otherwise be insurable from liability to compulsory insurance : the employer pays his own share of the appropriate weekly contribution in respect of an exempt person, but the exempt person himself does not contribute. 489. The Act of 1913 has provided a third ground on which a certificate of exemption may be claimed. Section 5 of this Act gives an employed person the right to a certificate on proof that he is not dependent on the wages or emoluments of his insurable employment, but is ordinarily and mainly dependent for his liveli- hood on the earnings derived from an occupation which is not employment within the meaning of the Act. 490. Occupations for the purposes of this Section may be divided into two categories : (1) employments which would have been insurable had they not been excepted under Part II. of the First Schedule to the Act of 1911 ; (2) other occupations which are adopted as a means of liveli- hood but ^re not insurable employments. Established Civil Servants, Municipal or Poor Law employees or policemen whose employment is covered by a certificate of exception ; elementary school teachers whose service is recorded under the Elementary School Teachers (Superannuation) Act, 1898 ; and all persons who are employed otherwise than by way of manual labour at a rate exceeding £160 a year for whole-time service fall under the first category. Under the second category fall those business and professional persons who, whatever their income, are not insurable because their occupation is not em- ployment within the meaning of Part I. of the Act of 1911. 491. This Section has only been operative since the 1st September, 1913, and the number of certificates granted under this head is comparatively small up to the present time, but it is Exempt Persons. 183 probable that when the terms of the Section become better known and understood a considerable number of persons will take advantage of it. 'Number of Exempt Persons. 492. When the 1911 Act came into force in July, 1912, many persons applied for exemption under the erroneous impression that, although they did not happen to be employed, or in many cases did not even contemplate employment, it was necessary for them, provided they satisfied the conditions laid down in Section 2 of the Act, to obtain certificates. All certificates issued during the first year of the operation of the Act expired on the 13th July, 1913, and during the year a careful examination was made of the records of exempt persons, in order to ascertain how many of them were likely to apply for renewal of their certificates. A circular letter was issued to those persons whose certificates the Commission were not prepared to renew in the absence of further definite information as to their title to exemption, setting forth the advantages which were to be gained by entering into insur- ance during the first year of the Act. Out of the 95,000 exemption certificates granted during the first year, about 30,000 were surrendered at the end of that period for the reasons indi- cated above. There are at the present time about 65,000 exempt persons, and of these nearly two-fifths are exempted on the ground of dependence. Of this latter class, about 40 per cent, are apprentices or young persons dependent upon parents or guardians, who will in most cases subsequently enter into insur- ance. Provision of Benefits for Exempt Persons under Section 9 of the Act of 1913. 493. Section 4, subsection (4) of the Act of 1911 gives the Commission power to make Regulations for the purpose of giving benefits to the holders of exemption certificates, and provides that the contributions paid by employers in respect of exempt persons may be used in whole or in part for the benefit of those exempt persons who subsequently become employed contributors. It was, however, found impracticable to formulate at the outset a satisfactory scheme of benefits for this class in the absence of information as to the numbers of exempt persons who might be expected subsequently to enter insurance. 494. After an analysis of the figures for the first year, the Commission were able to advise Parliament, in con- nection with the preparation of a scheme for providing exempt persons with benefits, that the sums available in the Exempt Persons Fund were sufficient to provide medical and sanatorium benefits for those exempt persons who were in fairly regular employment. Accordingly, Section 9 of the Act of 1913 enacts that the Eegulations which the Commission were em- powered to make under Section 4 (4) of the principal Act shall 184 England. provide for applying the contributions paid in respect of exempt persons towards the provision of medical benefit and sanatorium benefit for them as though they were members of Approved Societies. This is subject to the proviso that — (a) the conditions so imposed shall not require payment of upwards of 26 weekly contributions before the person becomes entitled to such benefits ; (6) where the total income from all sources of any such person exceeds one hundred and sixty pounds a year, he shall be required to make his own arrangements for receiving medical attendance and treatment, and sub- section (3) of Section 15 of the principal Act shall apply accordingly. 495. The provision of medical and sanatorium benefits thus becomes a first charge on the Fund, and it is proposed to review the financial position in this connection at the end of each year. Scheme for Medical and Sanatorium Benefits. — How Administered. 496. The scheme by which medical and sanatorium benefits are available for exempt persons came into operation on the 12th January, 1914. The Eegulations provide that any person who was the holder of a certificate of exemption on that date and in respect of whom not less than 13 contributions had been paid by the em- ployer before the 13th October, 1913, shall be entitled to bene- fit as from the 12th January, 1914. As regards those exempt persons who had not 13 contributions to their credit previous to the 13th October, the Begulations provide that, as soon as 20 contributions have been paid in respect of them, they shall be entitled to apply to the Commission to be allowed to enter into benefit ; and after the expiration of six weeks from the date of receipt of this application they will, in the ordinary course, have qualified for entry into benefit. Those persons who, though eligible, fail to apply, will become entitled to benefit from the beginning of the benefit period following the contribution period in which the twentieth contribution is paid. The ordinary benefit period covers the first and last six months of the financial year respectively, but in the first year of the operation of the amending Act the benefit period runs from the 14th January to the 30th September. 497. Exempt persons who have once established their title to benefit are to continue in benefit so long as the number of contributions paid in respect of them in any contribution period is not less than 13. A contribution period lasts for six months, at the end of which time all cards are examined, and, if in the course of this examination it is found that the contributions on any particular card are less than 13, provision is made in the Eegulations to carry forward from the preceding contribu- tion period, and if necessary from the penultimate period, Exempt Persons. 185 any balance of contributions in excess of 13, in order that the exempt person may not be deprived of his title to benefit. Any balance of contributions used for this purpose cannot be used again to make up any deficiency in any subsequent contribution period. Where an exempt person has become suspended from benefit, he does not again become entitled to benefit until 13 contributions have again been paid on his account. 498. Exempt persons who attained the age of 70 before the 12th January, 1914, are not entitled to receive any benefit, but those who attained the age of 70 after that date continue to be entitled to medical and sanatorium benefits for life, provided that at least 27 contributions were paid in respect of them before attaining that age, subject to suspension for certain periods where a person at the time of attaining the age of 70 is already sus- pended from benefits. 499. It is intended at the end of the first and every subsequent year, after ascertaining the amount standing to the credit of the Exempt Persons Fund and making any necessary provision to meet the contingent liabilities of that Fund, to determine what, if any, proportion shall be paid out of the Fund, in the succeeding year, of the capital sums required under subsection (4) of Section 9 of the Act of 1911, for securing sickness benefit at the full rate for exempt persons who enter into insurance as employed con- tributors in the course of that year. No payment will, however, be made out of the Fund towards the provision of these capital sums in respect of an exempt person who enters into insurance, unless he has paid to the Commission the balance of the capital sum required. Machinery for the Administration of Benefits. 600. Medical and sanatorium benefits for exempt persons are administered through Insurance Committees. As each person obtains a certificate of exemption, a form of declaration is sent to him to fill up, in which are set out the necessary particulars to enable the Commission to arrange for the issue to him of a medical ticket so soon as he is qualified for benefit. Those persons who were exempt on the 12th January, 1914, in respect of whom 13 contributions were paid before the 13th October, 1913, have already been notified that they are entitled to benefit, and medical tickets will have been issued to them by their respective Insurance Committees. Those persons in respect of whom 20 contributions are necessary before they can qualify as applicants for benefit are required, when making application, to forward their contribution card, together with an application to the Commission, when a fresh contribution card will be sent to them for the remainder of the contribution period. On becoming entitled to benefit a notification is sent to the exempt person and to the Insurance Committee, stating the date from which entry into benefit takes effect. A medical ticket giving full particulars as to procedure is then issued by the Insurance Committee to the 186 England. exempt person. When an exempt person sends his contribution card to the Commission at the end of each half-year, he receives an acknowledgment stating the number of contributions paid. This acknowledgment takes the place of an insurance book. When an exempt person ceases to be entitled to benefit, a notification to that effect is sent to the Insurance Committee, who recall the medical ticket from the exempt person. 501. Those exempt persons whose total income from all sources exceeds £160 a year are instructed to give notice to their Insurance Committee that they are required to make their own arrangements for medical attendance and treatment, towards the cost of which they will receive a contribution from the Insur- ance Committee, providing certain conditions are satisfied. Number of Exempt Persons receiving Benefits. 502. Although the number of certificates current at the beginning of the year was over 64,000, the number of exempt persons actually in employment in any given quarter is esti- mated to be between 45,000 and 50,000. On a scrutiny being made of cards received during the sixth quarter, it was found that the average number of contributions paid on each card was 11-9. Between 35,000 and 36,000 exempt persons are now receiving benefits, and the absence of complaints indi- cates that the machinery of administration is working with remarkable smoothness. An examination of the applications for certificates goes to show that the economic and social status of exempt persons does not differ appreciably from that of the insured population generally, and this is con- firmed by the fact that the benefits were claimed by over 99 per cent, of the persons entitled to them under the Regulations. It is true that among the persons who are granted certificates on the ground of dependence are a certain number of young persons on the threshold of a professional career who are in receipt of more or less nominal salaries and are in fact dependent on well- to-do parents. But, as far as can be seen, persons of this class form an inappreciable proportion of the total body of exempt persons, probably less than 1 per cent, of the whole. The fact that less than 200 out of approximately 36,000 persons entitled to the benefits refused to claim them indicates how generally medical and sanatorium benefits are appreciated. Collection of Contributions in respect of Exempt Persons. 503. The provision of benefits having taken a definite form, it was considered desirable to alter the arrangements for the collection of contributions in respect of exempt persons. Pre- vious to the 12th January, 1914, the employer of an exempt person was responsible for the custody of the quarterly exemption card, and was required when paying wages to sign the exemption Exceptions. 187 book issued to the holder of the certificate. Since the 12th January, 1914, the custody of the card, which now runs for six months, has been entrusted to the exempt person, as in the case of the employed contributor, and the employer is no longer required to sign the exemption book, which has been revised and merely takes the form of a copy of the certificate of exemption. Exemption cards are issued direct from the offices of the Com- mission to exempt persons shortly before the commencement of each contribution period, and they are not, as in the case of other contribution cards, to be obtained at Post Offices. Number of Exemption Certificates issued. 504. Details of the number of certificates issued will be found in Appendix XlX, page 513. Exceptions. Exceptions under Paragraphs (h) and (c) of Part II. of the First Schedule to the Act of 1911. 505. Persons engaged in ** excepted " employments are, as regards that employment, altogether outside the scope of the Acts ; neither employer nor employee pay any contributions. In regard to the issue of certificates of exception, there is little to add to the statements contained in paragraphs 703-711 of the Eeport for 1912-13. 506. Section 2 of the Act of 1913 extended the period of entry into insurance with the right to full benefits up to 12th October, 1913. Since that date persons entering insurance for the first time above the age of 17 have been ordinarily liable, under the provisions of Section 9 (4) of the Act of 1911, either to increased contributions or to reduced benefits, unless they pay the capital sum necessary to entitle them to full bene- fits. Many certificates of exception have been granted on terms including an undertaking on the part of the authority to pay any capital sum necessary to entitle an excepted person on leaving the authority's employment to enter insurance with full benefits. In such cases the capital sum is collected from the authority by the Commission on behalf of the Approved Societies concerned. But the number of these claims has proved to be relatively small and indicates that excepted employments are for the most part stable, though allowance must be made for the fact that municipalities and other public and local authorities tend to recruit their staff from one another, with the result that persons pass from one excepted employment to another. 507. The number of certificates of exception issued from 1st 188 England. April, 1913, to 31st May, 1914, and the approximate numbers of persons covered thereby are as follows : — Number of Certificates issued. Approximate Number of • Persons affected. Men. Women. Total. Crown Departments Local and other Public Autho- rities Eailway and other Statutory Companies 2 29 1 3 2,339 1 1 1,546 4 3,885 1 Totals 32 2,343 1,547 3,890 A list of the authorities to whom certificates have been issued from the 1st April, 1913, to 31st May, 1914, is contained in Appendix XX, page 514 below. Exceptions under Paragraph (i) of Part II. of the First Schedule to the Act of 1911. — Employments classed as Subsidiary. 508. A second year's experience of the operation of the Act of 1911 has not suggested the need for any considerable addition to the employments which at the time of the issue of the last Keport had already been excepted, under Part II. (i) of the First Schedule, from the compulsory provisions of the Act on the ground that they are ordinarily undertaken as subsidiary employ- ment only and not as the principal means of livelihood. Since the issue of the Eeport four Special Orders excepting certain em- ployments as subsidiary have been made. 509. The Order of 29th July, 1913, superseded the first Order of the year 1912, and so far as England is concerned differs only from that Order in the addition to the excepted employments of part-time employment as a supernumerary in or about a theatre. This exception is limited to cases in which the person employed as a supernumerary is not otherwise ordinarily engaged in or about the theatre or place of entertainment. 510. The Order of 13th August, 1913, specifies one employment only, viz. ," employment for a period not exceeding one day on each occasion, as an occasional helper to, or substitute for, a weaver regularly employed in a cotton mill, where the employer of the weaver pays no wages or other pecuniary remuneration, in respect of the employment, to the person so employed as helper or sub- stitute." It is a common practice in the Lancashire cotton mills for a weaver who is obliged through sickness or any other cause to absent himself from work for a day to provide a substitute for himself, generally a member of his family, who would not Questions Determined under Section 66 of the 1911 Act. 189 have any other employment within the meaning of the Acts. The substitute works with the impHed consent of the employer, but the wages for the whole week are paid direct to the regular weaver. It was represented that occasional contributions paid in respect of such work would be of no use to the substitutes, and it appeared to the Commission that the employment was one which might be properly excepted as subsidiary. The Order does not extend to persons who are under a running engagement to act as substitute for a weaver at regular intervals, say once a week, although that employment may be only for a day at a time. 511. A similar Order, dated 26th March, 1914, has been made in the case of the woollen and worsted trade. 512. The Order of 10th October, 1913, defines the position of sub-postmasters who are remunerated by scale-payment. By the Order issued on 13th July, 1912, employment in this capacity was excepted where it took place in a shop or other place in which the employed person carries on another business. This basis of exception soon proved to be unsatisfactory, as it had the effect of taking out of insurance a large number of sub- postmasters, who, although complying with the terms of the Order, were in fact mainly dependent for their livelihood upon their Post Office employment and regarded their private business as a subsidiary source of income. The Com- mission therefore decided to amend the Order. Some little difficulty was experienced in devising a satisfactory method of discriminating between sub-postmasters who might reasonably be excepted and those w^ho appeared to have a sound claim to be treated as employed contributors. The solution finally adopted consisted in excepting employment as a sub- postmaster remunerated by scale-payment, and bringing back into insurance any person who is mainly dependent for his livelihood on the earnings derived by him from employment as a sub-postmaster, and who renders on the average not less than 18 hours' personal service in each week in that capacity. Care was taken that this Order should come into operation before October 13th, 1913, in order that those sub -postmasters who were brought into insurance for the first time might not suffer reduc- tion in their rate of benefit owing to their late entry. Questions determined under Section 66 of the Act of 1911. General. 513. Information was given in the last Eeport (paragraphs 736 to 777) as to the nature of the questions determined under Section 66 of the Act of 1911, and the procedure followed in con- nection therewith. Since the issue of that Eeport numerous further applications have been received and dealt with, the majority of which have related to the question whether an em- ployment is employment within the meaning of the National Insurance Acts. As explained in the former Eeport, the ordinary course was for forms of application to be forwarded to the Com- 190 England. mission through the local Officers of Customs and Excise, but more recently the questions have frequently been forwarded through Inspectors who, in the course of survey or otherwise, have found cases of difficulty. Many of the cases submitted have not been such as to require a formal decision in accordance with the Eegulations. Enquiries made through the Outdoor Staff have frequently been sufficient to elucidate the facts in such a way as to enable the Commission to dispose of the case either by direct reference to the provisions of the Acts or Orders made thereunder, or by reference to cases that have already been decided where the circumstances were similar. The number of cases in which formal decisions have been given since the issue of the last Eeport is about 80. Public Hearings. 514. The Commission have arranged for public hearings to take place in regard to certain applications where the facts were difficult to ascertain otherwise, or points of special difficulty were involved. One such hearing took place at the head office of the Commission and related to the employment of lay agents by the Home Mission Committee of the Wesleyan Methodist Church. It had already been decided by the Com- mission that a lay evangelist working in a circuit of the Church under the control of the superintendent was not employed under a contract of service within the meaning of the National Insur- ance Acts, but in view of the special relationship existing between the Home Mission Committee and the lay agents under its charge, the question was raised whether the latter were not em- ployed under a contract of service by the Committee. On con- sideration of the evidence submitted, the Commission decided that the lay agents in question were not employed under a contract of service ; and this decision , against which an appeal was lodged, was upheld by his Honour Judge Woodfall in the Westminster County Court on December 2nd, 1913. Appeals are now pending in two other cases, but although nearly four hundred formal decisions have been given, these three are the only cases in which appeals have been entered. Other questions on which hearings have recently been held at the head office relate to the employment of masters and mates of barges on the Thames, and of officers and engineers on various classes of vessels in the mercantile marine ; these cases are still under consideration. 515. In other cases, hearings have taken place locally before Commissioners or a member of the legal staff of the Commission. Among such local hearings mention may be made of the following : — Wood and coppice cutters in the district of Ulverston.— It was ascertained at the hearing that timber merchants engage men to cut growing coppice wood which they have bought, each man being given a part of the wood to cut and being paid at a Questions Determined under Section 66 of the 1911 Act. 191 piece-rate. The merchant may direct the man what class of wood he shall cut, or in the absence of specific instructions the men cut the wood according to their own judgment and discretion. It also appeared that the wood-cutters have, on occasions, been dismissed for unsatisfactory work. In these circumstances the Commission decided that the employment of the men in question is employment under a contract of service. Wood-cutters in the District of Guildford. — A hearing in this case showed the facts to be similar to those existing at Ulverston, and the Commission have arrived at a similar decision. Stone-hreakers employed hy the Gallington Urban Dis- trict Council. — The evidence obtained at a local hearing was to the effect that the men are engaged for personal service to break heaps of stone to a certain size, being paid at a piece-rate, and the Commission decided that they are employed under a contract of service. (See paragraph 521 below.) Nail-makers in the Bromsgrove District. — The question in this case was whether certain persons who receive iron from nail manufacturers to make up in their own homes into nails, which are then returned to the firms, are employed as outworkers within the meaning of Part I. (c) of the First Schedule to the Act of 1911. The evidence submitted at a local hearing showed that the workers are charged for the iron at a price which would allow the firm a small profit in the event of the iron not being returned, and on returning the nails they receive an increased payment which includes the cost of the iron used. There was no evidence of any intention on the part of the workers to purchase the iron unconditionally, and in practice the nails are invariably brought back to the firm from whom the iron was obtained. On con- sideration of the whole of the evidence, the Commission decided that the persons engaged under these conditions are employed by the firm as outworkers, and are accordingly required to be insured. Question Submitted to the High Court. 516. Under the third proviso to Section 66 (1) of the Act of 1911, the Commission may, if they think fit, submit to the High Court a question whether any class of employment falls within the scope of the Act. In addition to the cases mentioned in para- graphs 746 to 747 of the previous Eeport, the Commission have referred to the Court the question whether certain master tailors, who make up and finish garments for a merchant tailor or whole- sale clothing manufacturer, the work being done at the house or other premises of the master tailors, are employed as out- workers within the meaning of Part I. (c) of the First Schedule to the Act. Mr. Justice Warrington gave a decision on the 30th July, 1913, in which he held that, although the relation of master and servant did not obtain in this case, the relation of employer and employed did obtain by virtue of paragragh (c) of Part I. of the First Schedule. All that was essential for the 192 England. purpose of finding that a man is an outworker was that articles or materials should be given out to him for the purposes of the trade or business of the person whose goods they are and that they were to be made up, cleaned, washed, ornamented, finished, or repaired, or adapted for sale. The employment of the master tailors on the terms submitted to the Court was therefore employ- ment within the meaning of the Act, unless the persons were excluded by a Special Order made by the Commission. 517. Following on the above decision of the High Court, the Commission issued an Order in October, 1913, excluding from the scope of Part I. of the Act of 1911 outworkers of the classes following : — (1) Persons to whom articles or materials are given out, but who are not themselves substantially engaged in thej actual manipulation of those articles or materials. (2) Persons to whom articles or materials are given out, not being articles or materials which it is the trade or business of the person by whom they are given out to manufacture, make up, clean, wash, alter, ornament, finish, or repair, or adapt for sale. 518. The Commission have had under consideration various questions that have arisen in the application of the above Order to particular cases and circumstances, and decisions on. points of doubt will be issued from time to time. In the application of the first exception, the view of the Commission is that the test of whether the outworker is himself substantially engaged in actual manipulation of the articles or materials given out to him is not the relation which his own manual work bears to the whole work done on the materials by himself and his assistants (if any), but the amount of time which he spends in the manipulation of the materials when viewed in relation to the time spent in his business as an outworker. Provided that he is engaged in manipulation to an extent which makes his work of this nature, considered by itself, an employment of appreciable importance in relation to the whole, it appears that the outworker is not excluded. 519. The second exception above quoted expresses in terms the interpretation which had hitherto been placed by the Com- mission upon the words ' ' for the purposes of the trade or busi- ness of the last-mentioned person " in the definition of an out- worker contained in Part I. (c) of the First Schedule. This interpretation is illustrated by decisions of the Commission that are referred to in paragraph 763 of the former Report. The words in question have not received any authoritative interpretation by a Court of Law, and it was thought desirable to provide against any doubt which might arise. 520. The provision by an outworker of materials for use in the process of the work which is given out to him will not ordin- arily affect his position as an outworker. If, however, it can be shown in any case that the main purpose for which an article is given out is the addition of new materials of value rather than Questions Determined under Section 66 of the 1911 Act. 193 the application of labour, so that the article returned is, in substance or in character, essentially a new article differing from that which was given out, the person would probably not be regarded as being employed as an outw^orker. Questions determined otherwise. 521. Among the questions which have recently come before the Commission for formal decision under Section 66 mention may be made of the following : — Sheep-Shear ers. — It was decided by the Commission that a man employed to clip sheep at a price per fleece clipped, being engaged for whole-time service while the work lasted and being subject to a right of control and dismissal by the employer's shepherd at any time, was employed under a contract of service. On the other hand, a case was submitted in which a gang of from six to eight sheep-shearers elect one of their number as fore- man to arrange with various farmers for the shearing of sheep. The foreman notifies each farmer when his gang will visit the farm for performance of the various stages of the work, and when the work is completed payment at an agreed rate per hundred sheep sheared is made by the farmer, the gang dividing the sums equally, except that the foreman receives a small additional sum for his special services. The Commission decided in this case that the employment of the gang of sheep-shearers is not employ- ment under a contract of service within the meaning of the National Insurance Acts. Men employed hy Local Authorities for getting gravel, breaking stones, work on the road, etc. — It had previously been decided in some cases of employment of this nature that the men in question were not employed by the Council under a contract of service. Such men were found to contract for the execution of a certain piece of work, and not to be subject to a right of the Council to control them as to the method of its performance. The Commission have, however, had more recently to consider other cases in which it appeared that the men were engaged tQ work in person at a piece-rate of payment, so long as required by the Council, and were liable to dismissal at the Council's pleasure. Although in practice the work is sometimes not such as needs detailed supervision by the Council's Surveyor, the Commission have held in certain cases that the men are employed by the Council under a contract of service, the previous decision given on a different set of facts not being applicable to cases of this kind. Laundry Receiving Agents. — Questions have been submitted to the Commission relating to the position of women who take in linen from customers to be sent to a laundry. In some cases the work is done on the premises of the receiving agent, who is not under obligation to devote any definite time to the work but merely receives a commission on such articles as are (B254— Gp. 5) G 194 England. sent through her to the laundry. In such circumstances the agent is not employed under a contract of service by the laundry. Cases have been considered, hov^ever, in which the receiving agent v^orks on premises which are rented from the laundry, payment for the agent's services being made by commission on the takings, out of which the employer retains the amount due for rent. Although little or no control is exercised by the employer, the woman is practically required to be in attendance for the whole day, and has to carry out any instructions which may be given to her. The Commission decided that a person employed under these conditions is employed within the meaning of the Acts. Nurses. — The general considerations relating to the liability of nurses to insurance are set out under paragraph 755 of the previous Report The question arose in what circum- stances a trained nurse working on her own account, who, while in attendance on a patient at the home of the latter receives board and lodging, &c., from her employer, is excepted from com- pulsory insurance under Part II. (g) of the First Schedule to the Act of 1911 on the ground that she is remunerated at a rate exceed- ing £160 a year in value. For the purpose of determining the rate of the nurse's remuneration from her employment, account has to be taken of the value to her of the accommodation, &c., which she receives in addition to money payment. The Commission -decided, in a particular case submitted to them, that a trained nurse who is employed at a fee of two guineas 'a week, together with the provision by her employer of board, lodging, and a laundry allowance of two shillings and sixpence a week, in cir- cumstances which were described in the application, is remuner- ated at a rate not exceeding in value £160 a year, and that accordingly, when engaged by an employer under these conditions, ^he is liable to compulsory insurance. Employees of Local and other Public Authorities. 522. In the application of the provisions of the Act of 1911 to persons employed under local and other public authorities a doubt was found to exist as to whether certain classes of officers employed under such authorities were employed under a contract of service so as to render them liable to be insured. This doubt arose primarily from the legal difficulty in regarding persons who are appointed under statutory powers, for the performance of duties which are more or less clearly defined by statute, as having entered into a contract of service with the authority by whom they are appointed. 523. The liability of such persons to insurance was established beyond question by Section 6 of the Act of 1913, which provides as follows : — " There shall be added to Part I. of the First Schedule to the principal Act, which specifies the classes of employment Employees of Public Authorities. 195 which is employment within Part I. of the principal Act, the following paragraph : — (e) Employment under any local or other public authority except such as may be excluded by a Special Order." This Section came into operation on the 1st October, 1913. 524. After consultation with various representative bodies who were invited to express their views on behalf of local authori- ties and their officers, the Joint Committee and the Commission issued a Special Order under the above provision excluding certain classes of persons from the operation of the Section. This Order [the National Health Insurance (Employment under Local and Public Authorities) Exclusion Order, 1913] provides that em- ployment of the following classes under any local or other public authority shall be deemed not to be employment within the mean^ ing of Part I. of the Act of 1911 : — Employment as Chaplain or other minister of religion. Employment as a duly qualified medical practitioner. Employment as a Coroner or Deputy Coroner. Employment as a Public Analyst. Employment as a Public Vaccinator. Employment as Superintendent Registrar or Deputy Super- intendent Registrar, Registrar of Births and Deaths or Deputy Registrar of Births and. Deaths, and Registrar of Marriages or Deputy Registrar of Marriages. Employment under a contract of apprenticeship with-out money payment. Employment as an unpaid officer of any local or other public authority. Employment otherwise than as an officer or servant of a local or other public authority, not being an employment specified in Part I. {a}, (h), (c), or (d) of the First Schedule to the National Insurance Act, 1911. 525. Persons who are employed under any local or public authority and whose employment is not of a class excluded a» above are required to be insured as from 1st October, 1913, subject to the ordinary conditions of exception, e.g., on account of the rate of remuneration in individual cases being over ^160 a year, or on account of the grant of a certificate of exception to a particular authority under Part II. (h) of the First Schedule to the Act of 1911. 526. Where the position of a particular person employed under a local or public authority was in doubt prior to the 1st October, 1913, and contributions were paid prior to that date, such con- tributions are placed to the person's credit as if previously they had been properly paid in respect of him, an Order having been made under Section 78 of the Act of 1911 to provide for tk6 regularisation of such contributions. It may be observed, how- ever, that in the special case of Assistant Overseers and certain Collectors of Poor Rates, the Commission had previously decided I (B254— Gp. 5) a 2 196 England. under Section 66 that there was no contract of service, and accordingly these two classes of officers did not, as such, become insurable as employed contributors until the 1st October, 1913. Questions as to who is the Employer of an Employed Contributor. 527. Under the National Insurance Act, 1911, the Commis- sion had no power to determine as between two or more persons which of them is for the purposes of the Act the employer of an employed contributor. It has now been provided by Section 27 (2) of the National Insurance Act, 1913, that if any question arises on this head the question shall be determined in like manner as a question under Section 66 (1) (a) of the Act of 1911, and tha^ Section shall apply accordingly. The new provision came into force on the 1st September, 1913. Questions as to who is the employer of an employed contributor can therefore now be determined by the Commission in the same way as questions as to whether an employment is employment within the meaning of the Acts, but there is no provision for a direct reference to the High Court on the former class of question, similar to that pro- vided by the Act of 1911 in regard to a class of employment. 528. In order to adapt the procedure arranged under Section 66 to meet the new class of case, Provisional Kegulations were issued in December, 1913, providing for variation in the forms of application to be used in cases submitted on the question who is the employer of an employed contributor. These forms are designed to show the relationship existing between the em- ployed person, his immediate employer, and any other person other than the immediate employer who may be thought to be the employer for the purposes of the National Insurance Acts. When an application is received copies of it are ordinarily sub- mitted to the other parties concerned, in order to obtain their statements. Normally there are two such parties, in addition to the applicant, who are interested in the question. 529. As the questions which arise under this provision will frequently be affected by the Regulations issued under Schedule III. (6) to the Act of 1911 relating to intermediate employers, information is specifically asked for in the forms, in order to show to what extent those Regulations are applicable. 530. The Commission have up to the present received few applications for determination of questions under Section 27 (2) of the Act of 1913. Among the cases submitted mention may be made of applications to determine whether the owner or the master of a barge is the employer of the mate ; a public hearing on a case of this kind took place on March 23rd. De- tailed investigation by the Inspectors is ordinarily required in dealing with such applications, and in cases of special difficulty Questions as to who is the Employer. 197 formal hearings may be necessary in order to ascertain the exact relationship existing between the various parties. It is not yet possible to give any general information as to the result of cases dealt with under this Section. Exemptions under Section 51 of the Act of 1911. 531. The certificates of exemption under Section 51 of the Act of 1911 which were granted to Institutions carried on for charitable or reformatory purposes were drawn to operate until the 31st December, 1914. It was ascertained, however, that in some of the cases in which such certificates were issued there was no necessity for the Institution to have a certificate, owing to the fact that none of the inmates was employed within the meaning of the Acts. In order to determine how far this is the case with other Institutions, the Commission have made further inquiry into the conditions under which the inmates of the homes in respect of which certificates have been granted are engaged during their period of residence. These investigations have so far shown that in numerous other cases the inmates are not em- ployed by the managers of the Institution w^ithin the meaning of the Acts, and that the managers therefore incur no legal liability under the Acts in respect of the inmates, either during their period of residence, or at the time when they leave the Institu- tion. In such cases steps are being taken to cancel the certifi- cates, which there is no need for the managers to hold. 532. When a certificate is to be cancelled the Commission have pointed out to the managers that although they are under no legal liability as regards insurance of the inmates, it would be open to the managers, if they so desired, to undertake to pay such sums as may be necessary, in respect of any inmate leaving the Institution, to secure that the inmate on subsequently entering or resuming insurance under the Acts is not placed at a dis- advantage, as regards the benefits to which he is entitled, on account of his not having been insured while resident in th^. Institution. 533. An amendment of Section 51 of the Act of 1911 was made by Section 24 of the Act of 1913, which varies the words defining the class of persons who are inmates of the Institution to whom the certificate of exemption applies. In the Act of 1911 these inmates were described as *' persons who are inmates of and supported by the Institution." This was amended so as to read " persons who for such (i.e., charitable or reformatory) purposes are inmates of the Institution." No practical difference is introduced by this amendment, but it places beyond doubt the view that was previously held that the certifi- cates do not affect the position of members of the staff of the Institution or of any inmates who may be resident therein other- wise than for charitable or reformatory purposes. (B254— Gp. 5) G 3 198 England. Questions under Section 47 of the Act of 1911. Special Orders under Subsection (1). 534. Under sub-section (1) of Section 47, Special Orders are made specifying classes of employment where, locally or generally, employees receive wages during sickness under a prevalent custom or practice. Since the publication of the Eeport for 1912-13 it has not been found necessary to make any additions to the classes of employment -included in the Special Orders of general applica- tion made under the sub-section. 535. From time to time individual employers have intimated their desire to apply the Section to persons in various classes of employment not included in any Orders, but the information furnished by them and the consequent inquiries have not indicated the prevalence, in the case of any one of these particular classes, of a custom or practice of paying wages during sickness suffici- ently general to justify its inclusion in an Order under sub- section (1). Special Orders under Sub-section (7). 536. Sub-section (7) authorises the making, on the application of the employers and under suitable conditions, of Orders including within the scope of Section 47, either generally or in a particular locality, other classes of employment, notwithstanding that there may be no prevalent custom or practice of paying wages during sickness. Few employers' applications have been received for Special Orders under sub-section (7) , and in three cases only were the Commission able to grant such applications as have been made. By an Order issued on the 14th July, 1913, the pro- visions of the Section were extended to all employees of the Bank of England (not covered by the Orders under sub-section (1) ) who were entitled to not less than one week's notice of the termination of their employment ; and the application of the Section was similarly extended to employees of the Yorkshire Conservative Newspaper Company, Ltd., by an Order issued on the 28th January, 1914. In the latter Order were specified also certain classes of the employees of the Liverpool Victoria Legal Friendly Society. Special Orders relating to Employment under the Crown. 537. Considerable modifications will shortly be effected in the application of Section 47, and of Section 47 as applied by Section 53 (2), to unestablished Civil employees of the Crown, on the basis of the recommendations contained in the Third Eeport* of the Inter-departmental Committee on Employment under the Crown issued in October, 1913. * Cd. 7176. Questions under Section 47 0/ the 1911 Act. 199 It is proposed to bring within the scope of the Sections — (1) all such unestablished persons employed mainly in pro- fessional, clerical, or supervisory duties ; (2) all such unestablished persons receiving board or lodging as part of their remuneration. All other classes compulsorily insurable are to be insured under the ordinary provisions of the Acts, the special provisions of Sections 47 or 53 not being applied to them. 538. The effect of these modifications will be to extend the application of the Sections (among Crown employees) and to create a general uniformity in the treatment of similar classes throughout the Service. ' Employers' Notices. 539. The total number of notices received from employers, stating that they propose to adopt the provisions of the Section, exceeds 3,000. Of these more than 100 have been given by local authorities and institutions under the terms of the Special Order relating to employment by those bodies, and approximately 50 have been submitted under the Order extending the provisions of the Section in the case of employees of co-operative societies. Approximately 50 notices of withdrawal from the provisions of the Section have been received. General. 540. Systematic inspection has brought to the notice of the Commission a number of cases in which employers have taken advantage of Section 47 , but have omitted to submit the requisite notice to the Commission, being unaware of the necessity for so doing. In such cases either the prescribed notice has been obtained or, if the circumstances required it, the em- ployer has made good any underpayment of contributions which has occurred. 541. Inspection has also been instrumental in bringing to light other irregularities in the application of the Section such as its complicated nature renders inevitable at the outset, as for example the error of applying the Section to persons belonging to classes of employment which have not been included in a Special Order, or of discriminating between individual employees engaged in the same class of employment. There has, however, been no indica- tion of any intentional failure on the part of employers to dis- charge the liabilities incurred by the adoption of the Section. The Insurance of Outworkers. The Unit System. 542. The alternative system of payment of contributions in the case of outworkers by reference to units of work, as revised after Mr. Pope's inquiry and explained in paragraphs 912 and 922 (B254-Gp. 5) G 4 200 England. of the Keport for 1912-13, has now been in operation for over 12 months, and except on minor points has been found to require httle further revision. 543. The Commission have freely exercised the discretion se- cured under the Outworkers' Eegulations in allowing employers who have given the system a trial but have found it unsuitable for the conditions of their trade to revert to the ordinary system of payment of contributions on a weekly basis. Many employers also have taken advantage of the new Kegulation which permits them to place some of their outworkers on the unit system, while pay- ing contributions in respect of others on the weekly basis. Inspection and correspondence have proved that far less mis- understanding regarding the system exists, and cases of failure to stamp outworkers' cards or of incorrect stamping owing to mis- apprehensions are diminishing in number. Explanatory Leaflet No. 25, in which the unit system is explained, has been recently revised and brought up to date. 544. The total number of employers of outworkers who have, since the commencement of the Act of 1911, given notice to adopt Method B (the unit system) is at the present time 1,900 ; of these employers, some 120 withdrew their notices before the end of the fourth quarter, and altogether 330 of those who originally applied for the special outworker contribution cards have for various reasons now ceased to use the unit system. The number of employers who are now paying contributions on Method B is 1,570 — a slight increase on the corresponding figure last year. The principal industries in which outworkers who are insured on the unit system are engaged are : — Hosiery manufature. Lace manufacture Tailoring Glove-making General drapery (blouses, under- clothing, &c.) Boot and shoe manufacture ... Shirt-making Chair-caning Paper and cardboard box making Brush-making Carding buttons Chain-making New Units of Work. 545. The following special units of work have been provisionally fixed since the issue of the previous Eeport : — Silk-skeining in Leek and district Chevening and marking for hosiery Carding buttons . with 310 employers 270 240 85 70 70 60 60 50 40 35 24 s. d. 12 6 10 7 6 Insurance of Outworkers. 201 s. d. Carding hooks and eyes 6 Net-making by outworkers in the service of employers • carrying on business as net manufacturers in the county of Dorset 6 Sewing lawn tennis balls 10 6 Shawl fringing in the counties of Yorkshire and Lancashire 12 6 " Normal " Rate of Remuneration. 546. In accordance with the provisions of the Second Schedule to the Act of 1911, where the rate of remuneration does not exceed 25. 6d. per working day in the case of a man or 25. in the case of a woman, the contributions payable by employers and em- ployed persons vary from the ordinary contributions, in accord- ance with the actual rate of remuneration in each week. As it stood the Second Schedule had to be applied to each individual outworker for each week. In practice it is found that where a number of persons are employed at the same piece-rate there is ^considerable variation in the earnings both as between individuals, and from week to week in the case of the same individual. If most of the employees earn on the average about lAs. to 155. there will probably be in every week a number of them — though they may not always be the same individuals — whose rate of remunera- tion for that week will fall below 125. There was necessarily considerable labour required to determine the rate of remunera- tion per working day of each worker in every week; in order that the appropriate stamp might be affixed, and in the case of out- workers in particular such a determination was found to be exceed- ingly difficult to make. Further, it has been alleged that in some cases the differentiation of contribution rates and the increased amount payable by the employer in respect of a slow worker tended to discourage the employment of the less efficient workers. 547. To meet these difficulties, Section 25 of the Act of 1913 provides that where it appears to the Commission that the persons employed by any employer or group of employers in any class of classes of work are in general in receipt of a rate of remunera- tion which, although liable to fluctuation, is normally : (a) not more than l5. 6d. a working day ; or (h) more than l5. 6d. but not more than 25. a working day ; or (c) more than 25. but not more than 25. 6c?. a working day ; the Commission may by a Special Order declare that all the persons employed by that employer or group of employers in that class or those classes of work shall for the purposes of the prin- cipal Act, but subject to any exceptions contained in the Order, be treated as if they w^ere constantly in receipt of the normal rate of remuneration, notwithstanding that those persons or any of them may in any week receive in fact a higher or lower rate of remuneration. 202 England. 548. There are at least three leading classes of case in which it is anticipated that the powers given to the Commission may be exercised with advantage : — (i.) where in a class of employees the average worker's rate of remuneration for a working day falls within a specified limit, though the rate of remuneration of a few exceptionally slow, old, or partially disabled workers falls below such limit, while that of the exceptionally quick workers rises above it ; (ii.) where the rate of remuneration of a class of employees, though normally within one of the specified limits, is, owing to temporary slackness or other causes, below or above such limit in occasional weeks ; (iii.) where through part-time employment or through other causes it is difficult to ascertain precisely the rate of remuneration for a working day, as in the case of the outworker. It will be seen that the primary fact to be ascertained in any case which arises for consideration is the amount of the normal rate of remuneration of the class of employees as a whole. 549. The normal rate of remuneration of a class of employees working on the same piece-rate is not a term which has been exactly defined. In view of the possibility of a considerable number of applications for Special Orders under this section it appeared to the Commission desirable to conduct the inquiries necessary in individual cases on a statistical basis. 550. The following procedure has been provisionally adopted for this purpose. The employer of the class of employees in question is requested with the assistance of an Inspector to fur- nish figures representing the earnings of all the persons, with the exception of learners, employed in that class of work during a certain number of typical weeks selected from different seasons or different months so as to allow for any seasonal fluctuations, together with information as to the length of the full working week. From these figures the rate of remuneration of each worker for each week is calculated on the basis of the recognised work- ing week. The position of the predominant rate of remuneration is then determined for the whole group of results. 551. If it appears to be well within one of the specified limits of the Section, then it is considered that a case has been made out for a Special Order. If, however, this does not give a satis- factory indication of what may reasonably be regarded as the normal rate, the general distribution of rates of remuneration with reference to the specified limits is considered. This pro- cedure is only necessary in cases where no exact figures as to earnings are available without special investigation. In the cases of classes of outworkers however for whom a special unit has been fixed, the unit itself, which has in most cases been deter- mined by very careful inquiry on similar lines, can reasonably be regarded as the normal rate. Insurance of Outworkers. 203 552. Considerable misapprehension has always existed as to the rates of contribution payable in respect of outworkers. Further, even when employers have realised that the rate of con- tribution depends on the individual outworker's rate of remunera- tion for a full working day, it has not always been an easy matter to estimate their rate of remuneration, for outworkers are very seldom employed full time and still more seldom have clear records of the amount of time taken. The work has to take its turn with household and domestic duties. 553. The Commission have therefore taken advantage of the provisions of Section 25 to issue a Special Order, the effec^, of w^hich is that in all cases where a special unit of work has been fixed and such unit of work does not exceed 155., the rate of remuneration for a working day will be deemed to depend on the value of the unit of work, and will be ascertained by dividing the value of the unit of work by six. For example, in the case of the class of work described as " chevening and marking for hosiery," for which a special unit of 10<9. has been fixed, the employer w^ill affix a 5d. stamp for each unit of work done by any of his female outworkers and will be entitled to deduct Id. in each case, even though the particular outworker's rate of remuneration may not exceed Is. 6d. or may exceed 2^. a working day. This Order was issued in draft, and, in the absence of valid objections, has been presented to Parliament. It is thought that its operation will obviate much of the difficulty felt by em- ployers in estimating an outworker's rate of remuneration. 554. A draft Order has also been issued covering various classes of work carried on in factories which are subject to a determination under the Trade Boards Act, 1909. Several applications from individual employers are still under considera- tion. Questions as to who is the Employer of an Outworker or Class of Outworkers. 655. Under Section 26 of the Act of 1913 the Commission may by Special Order provide that as respects any particular out- workers or class of outworkers the person specified in the Order shall be deemed to be the employer. 556. The purpose of this provision was to give the Commission special powers to enable them to treat as employers of outworkers a warehouse or firm which gives out work to middlewomen or contractors to be distributed to the actual outworkers. In law, the middlewomen, who frequently are de facto not much more than distributing agents remunerated by commission, are the employers of the outworkers. 557. It has not so far been found necessary to put these powers into operation, as an increasing number of firms who give 204 England. out work through middle women have agreed to pay the middle - women an additional percentage in order to enable them to meet the cost of the insurance of the actual outworkers. An inter- esting experiment is being tried at Birmingham, whereby this percentage, together with an additional payment deducted with her consent from the middlewoman's remuneration, is to be paid by the firm to the Inspector instead of to the middlewoman, and the stamping of the insurance cards of the middlewoman's out- workers will be undertaken by the Inspector. There is reason to expect that, quite apart from the tendency to eliminate the middlewoman altogether, the difficulties arising in connection with National Health Insurance from her presence in so many outwork trades will gradually disappear, either by similar schemes of co-operation between firm, middlewoman, and outworker, or by the use of the special powers given to the Commission under Section 26 of the Act of 1913. The Insurance of Persons in the Mercantile Marine. Amendments of Section 48 of the Act of 1911. 558. Under Section 48 (1) of the principal Act a seaman is not entitled to sickness benefit for any period during which the owner of the ship is liable under the Merchant Shipping Act, 1894, to defray the expense of the necessary surgical and medical advice and attendance and medicine, and of his maintenance. The period during which the owner is so liable is normally the period from the signing of articles until the date of the seaman's return to a port in the United Kingdom. In the case of the seaman employed on a foreign-going ship this limitation of the right to benefit is counterbalanced by a proportionate reduction of the amount of contributions payable. In the case of seamen em- ployed on home-trade vessels contributions are payable at the full employed rate, and the owner's liability under the Merchant Shipping Acts will not as a rule last more than a few days, being terminated as soon as the seaman is landed at a port in the United Kingdom. The term home-trade ship includes, however, vessels trading between the United Kingdom and the Channel Islands, the Isle of Man, and that part of the coast of Europe which lies between the Kiver Elbe and Brest, and it may happen occa- sionally that a seaman employed on a home-trade ship has to be left behind sick at a foreign port. In such circumstances, though the owner is liable to pay for his medical attendance, &c., and maintenance until his return to the United Kingdom, his right to wages ceases as soon as he is put ashore and discharged from the ship's articles. As already explained, under the principal Act no benefit was payable to or in respect of him whilst the owner's liability referred to above lasted. It was represented that this resulted in hardship, if the man had dependants, and by Mercantile Marine. 205 Section 23 (1) of the Act of 1913 the Society is given a discretion to pay benefit to the dependants for any period of sickness after the owner has ceased to be liable for wages. 559. A minor amendment to Section 48 of the principal Act is the provision whereby the Seamen's National Insurance Society is entitled : — (1) to accept as members seamen who are not insurable as employed contributors but are entitled to be voluntary contributors, and (2) to allow members who leave the sea-service and become or continue to be voluntary contributors to remain members of the Society. Payment of Contributions by Employers in respect of Seamen neither domiciled nor resident in the United Kingdom. 560. Section 48 (3) of the 1911 Act provides that a seaman neither domiciled nor resident in the United Kingdom shall not be deemed to be employed within the meaning of the Act ; and that the employer's part of the contribution, and the employer's only, shall be payable in respect of such a seaman. The contributions thus collected from shipowners amounted for the first year of the operation of the Act to approximately eleven thousand pounds. 561. As was to be expected, a very large number of cases have arisen where it w^as doubtful whether a seaman had a domicile or place of residence in the United Kingdom. The Commission have therefore devised a procedure whereby such questions may be effectively determined. If at the time of the men's discharge any doubt or dispute arises as to the insurability of an alien sea- man, he is required to complete and sign two forms containing a series of questions designed to elicit the information necessary to determine his position. These forms are then transmitted to the Commission by the Officer before whom the discharge takes place, together with any contribution card which may have been stamped by the master of the vessel before the doubt as to insurability arose. The Commission's decision on the particulars before them is then communicated to the seaman, and if necessary repayment is made of the value of any deductions from his wages which may have been made in error. 562. The system adopted for the collection of contributions in respect of foreign-domiciled seamen has hitherto been that described in paragraph 895 on page 214 of last year's Eeport, but it may be mentioned that the Commission are at present in com- munication with the Board of Trade regarding the possibility of devising a new system to reduce the number of returns w^hich it will be necessary to call upon shipowners to render. It is antici- pated that if such a scheme as is contemplated is found to be practicable, it will relieve owners of considerable clerical labour, and will furnish a more effective guarantee of the correct payment of contributions. 206 England. The Insurance of Seamen, Marines, and Soldiers. 563. The system under which seamen, marines, and soldiers are insured was set out in some detail in paragraphs 825 to 865 of the Keport for 1912-13. The contributions made in respect of those of them who elect to be insured during their term of service are such as to secure to them (a) maternity benefit while serving ; (h) a transfer value to enable them to enter civil insurance on discharge without loss by reason of their service. 564. The only benefit which they receive, or pay for, during service is maternity benefit, the balance of contributions paid by or in respect of them being required for liquidating the reserve values credited in respect of them and for building up the neces- sary transfer values. The total contribution is Sd. per week, of which the man pays l^d., and the balance is contributed from Admiralty or Army Funds. Seamen, Marines, and Soldiers in Approved Societies. 565. Out of the 337,000 men who are insured under Section 46 •of the Act of 1911, 50,000 seamen and marines and 150,000 ■soldiers are known to have obtained admission to Approved Societies. Owing to the fact that it takes some time to establish the fact of admission to an Approved Society, and owing to the absence of any form of application for admission during service to benefits out of the Navy and Army Insurance Fund, the exact number of serving men entitled to benefits out of the Navy and Army Insurance Fund can only be ascertained when Societies have claimed all their members. There are about 20,000 ■cases still unsettled, but these are being rapidly cleared up. The figures given above, however, may be accepted as approximately aiccurate as regards the position on the 31st December, 1913. 566. The prescribed time for joining Approved Societies for all men serving at the commencement of the Act, whether abroad or at home, expired finally on the 30th June, 1913. New entrants have in every case six months from the date of entry into service in which to join an Approved Society. This position has, however, been considerably modified by the Act of 1913, Regu- lations under which allow men to transfer to an Approved Society at any time during service. Maternity Benefit (Navy and Army Insurance Fund only). 567. 2,713 claims for maternity benefit have been paid in respect of seamen and marines, and 1,100 in respect of soldiers. These figures do not comprise the claims paid in respect of members of Approved Societies. 568. It ¥^as found that owing to the provision under the Act Seamen, Marines, and Soldiers. 207 of 1911 whereby a discharged seaman, marine, or soldier was given three months in which to join an Approved Society, there was no fund from which the maternity benefit for which he had paid- during service could be defrayed in the event of a con- finement taking place within the three months after discharge, without the man having joined a Society. In order to provide for such cases the Commission made an Order under Section 78 of the Act of 1911 whereby such men were provided during the pre- scribed period with maternity benefit out of the Navy and Army Insurance Fund, their contributions being appropriated to that Fund during the period whilst they remained so entitled. Twenty-five claims were thus dealt with under jthis Order. Discharged Men re-admitted to the Navy and Army Insurance Fund under Section 46 (3) {h) of the Act of 1911. 569. 469 men were re-admitted to the Navy and Army Insur- ance Fund on discharge through inability by reason of the state of their health to obtain admission to an Approved Society, making a total of 568 up to the 31st December, 1913 ; 86 persons have died or withdrawn by transfer to an Approved Society, leaving a. net total at the end of the year of 482 discharged men re-admitted to the Fund. Beyiefits received by re-admitted Members of the Navy and Army- Insurance Fund. 570. The following figures give the statistics as to benefits for re-admitted men up to the 31st December, 1913 : — Number of members who have received sickness benefit 282 Amount of sickness benefit paid ... ... £2,118 Numbers of members who have been in re- ceipt of sanatorium benefit ... ... 106 Amount paid or due for sanatorium benefit £1,345 Number of maternity benefit claims ... 10 Amount paid for maternity benefit ... ... £lb 571. Claims for sickness benefit are dealt with promptly, and members of the Fund have very rarely experienced any difficulty or necessity for special inquiries. Any inquiries which have been received have been due to the member not having under- stood or not having carried out the very full instructions which have been sent to him. A considerable proportion of the mem- 'bers of the Fund have already drawn their full 26 weeks' sickness benefit, and are now qualifying for the receipt of disablement benefit. 572. As regards sanatorium benefit, the arrangements made with the Admiralty and the War Office for the retention of men suffering from tuberculosis for a short period after their dis- charge, pending arrangements for their removal to a civil insti- tution, have been continued during the year. These arrange- 208 England. ments are of great value to tne men, as they obviate the necessity of a more or less long wait while arrangements are being made for their reception in a sanatorium. It is estimated that about 50 members of the Fund have been retained temporarily in Naval and Military Hospitals at the cost of the Fund. Advisory Committee. 573. The Navy and Army Insurance Fund Advisory Com- mittee, established under the Eegulations governing the Fund, held 42 meetings in the course of the year. All applications for admission to benefits were considered by this Committee, as well as points of difficulty arising in connection with particular claims for benefits. ^ Amendments effected by the Act of 1913. 574. The National Insurance Act, 1913, introduced several important alterations in the conditions of insurance set out in Section 46 of the principal Act. These are as follows : — 575. The term " marine " was made to include every war- rant officer of marines except Eoyal Marine gunners, and the term * * soldier ' * was made to exclude the soldier who had not been finally accepted for service. A warrant officer of the marines is not a "marine" or "seaman," although a warrant officer in the Army is a " soldier." A warrant officer of marines is not an "officer" like the naval warrant officer, but is in a similar position to the Army warrant officer. It was, therefore, necessary in order to bring him into insurance that the term " marine " should be amended. About one-third of the persons who are attested as soldiers are rejected on medical grounds shortly after attestation and never become attached to a unit. It was obviously inconvenient that such persons should change i]heir status in insurance, and the law now provides that a person does not come under the provisions of Section 46 of the principal Act until he is finally accepted for service. 576. Under Section 28 and paragraph (e) of the First Schedule, the Commission are given power to make Eegulations for improving the machinery of the Navy and Army Insurance Fund by applying any of the provisions of the National Insurance Acts relating to Approved Societies to the Fund. This was mainly necessary for the purpose of transfers under Section 46 of the principal Act. After the time prescribed for joining an Approved Society had elapsed it was not competent for any man during his service with the colours to transfer to an Approved Society. This restriction operated hardly on the man, as it was often difficult for him on discharge to obtain admission to an Ap- proved Society , especially as after discharge he was usually unem- ployed for a short time, and Societies were, therefore, reluctant to admit him. It was clearly to the man's advantage that he \ Seamen, Marines, and Soldiers. 209 should be allowed to join an Approved Society at any time, and Regulations have now been made which will enable this to take effect. The Regulations also continue the arrangements referred to in paragraph 568 above, under which the maternity benefit of persons who have been insured in the Navy and Army Insurance Fund up to the date of discharge is paid out of that Fund until the time for joining an Approved Society has elapsed or until they join an Approved Society. 577. Under paragraph (g) of the First Schedule the Com- mission are given power to make Regulations under which, in the case of persons entitled to benefit out of the Navy and Army Insurance Fund who are of unsound mind, the Admiralty or Army Council may appoint a person to exercise any right of election which such person is entitled to exercise, and may appoint a person to receive on behalf of such person any sums by way of benefit which would otherwise have been payable to him. In the case of persons of unsound mind discharged from the Army or Navy, it is most rare to find that a Committee has been appointed, or that the value cf the estate warrants the expense incurred in the appointment of a Committee. There is, therefore, nobody who can act on the insane person's behalf. It was necessary that the Lunacy Laws should be modified in this respect in order that a simple procedure might be adopted whereby persons discharged from the service as insane might receive the benefits to which they would ordinarily have been entitled. Regulations have been made accordingly. Casual Labour in the Port of London. 578. Section 19 of the Act of 1913 confers power on the Commission to make Special Orders modifying the principal Act in its application to persons whose employment is of a casual or intermittent character. Such an Order may apply either gener- ally to all persons casually employed, or particularly to a single industry or group of industries. It may set up for the industry to which it applies a system of collection of contributions different from that in general operation. It may vary the amount both of the employer's and the workman's contributions, and may pool the amounts payable by the employers and apportion them among employers, subject to the conditions that the amount pay- able by employers in respect of any workman's insurance in a week may not exceed 6d., and the amount payable by the work- man may not exceed Ad., and that if a system is set up by which the contributions are payable day by day the workman may not be required to pay more than Id. a day. 579. In framing this Section Parliament had in view two difficulties that had arisen in connection with certain classes of ill-organised labour, particularly in the Port of London. The complaint was made that the effect of laying the full burden of 210 England. the employer's share of the insurance on the first employer in the week was that after the first day of the week some employers gave a preference in taking on men to those whose cards were already stamped. Men who failed to get employment on Monday in trades in which there is a chronic surplus of labour found themselves handicapped in competing for work on later days of the week. Eecognising that a stamped card was a considerable assistance in obtaining work, in some cases men paid the whole Id. and affixed stamps themselves. The schemes at Liverpool, Goole, and other ports described in paragraphs 967 to 991 of the last Eeport, which are based on voluntary agreements between the employers and the Trade Unions, are so devised that any difficulty of this kind with the insurance cards is impossible. The second difficulty concerned the large number of men along the Thames side who average less than three or four days' work per week, and on whom the burden of the fourpenny contribu- tions presses unduly. The low-wage Schedule in the Act of 1911 , which allows a reduced contribution from a workman whose rate of remuneration is less than 2^. 6d. a working day, does not help such under-employed men, who, when they happen to be at work, earn more than this per working day. But the lot of a man who earns 6s. or 105. in one or two days' work and gets no more work during the rest of the week is worse than that of the man who earns only 2s. 6d. a day but is employed every day. Section 19 allows the reduction of the workman's contributions if he obtains less than four days' work in a week. 580. As already stated, Parliament, in framing the Section, had chiefly in mind the Port of London, and the Commission have therefore dealt with this case first. Careful inquiries were made as to the conditions of Thames side employment, and conferences took place with representatives of employers and em- ployed. Owing to the complicated conditions of the Port of London and the time occupied in negotiations with the various interests involved, the preparation of an Order occupied some months. The Order has been published in draft during the last few days, and the statutory period during which formal objec- tions may be lodged by any of the parties concerned is now run- ning. The scheme embodied in the Order if brought into opera- tion in its present form will apply to all men employed on engagements which do not entitle them to a week's notice, in the Port of London from Westminster to beyond Gravesend, with the exception of certain specified classes. The most important of these are the lightermen, the carmen, and men employed in ship- repairing and engineering yards. A waterside labourer to whom the scheme applies will be required to deposit his insurance card at one of the special offices to be established by the Commission, and will receive in exchange a numbered tally, which will act both as a cloak-room ticket for the card and as a means of identification. Every employer will be required to make a return once a week of the tally numbers of the men he employs Casual Labour in the Port of London. 211 on, each day of the week. He will also be required to give to each man he employs a voucher for each day of employment. For this voucher he will be entitled to deduct one penny from wages, subject to the condition that when a man has obtained four vouchers in any week (i.e., when he has paid fourpence) no further vouchers need be given to him, and he will be immune from further deduction. A man who gets only one day's work in the week will pay Id., the man who gets two days 2d., three days Sd., and four or more days Ad. The vouchers will be sup- plied to the employers by the Commission, and a charge of one penny will be made for each. The man's share of the contribu- tion will in effect be automatically collected through the employer. The card of each workman, whose tally number appears in any week in any of the returns made by the employers, will be stamped with a Id. stamp at the clearing house. The differ- ence between the total sum required for the men's Id. stamps and the total of the pennies which the men have paid in return for vouchers will be pooled among all employers. The share of the pool to be paid by each employer will be proportional to the total number of separate individuals he has employed in the week. 212 England. THE WORK OF THE OUTDOOR STAFF. Oeganisation. 581. The Outdoor Staff of the Commission is distributed among Divisions and Districts, as follows : — Division. Northern Districts. ''(1) Northumberland Gateshead Headquarters. and Market Street, Newcastle-on-Tyne. (Divisional Headquarters.)* (2) Cumberlana ana West- 18, Bank Street, Carlisle. morland (3) North Durham (4) South Durham and i_ Middlesbrough ''(1) Manchester, Oldham, and Salford (2) Liverpool, Birkenhead, North Western «j Bootle, and Wallasey I (3) North Lancashire I (4) East Lancashire 1^(5) South Lancashire f(l) West Riding (North)... I (2) West Biding (Central) North Eastern j (3) West Riding (South)... (4) North and East Ridings I (excluding Middles- l^ brough) f(.l) Birmingham, Sir.eth- wick & West Bromwich (2) Cheshire (excluding Birkenhead and Wallasey) (3) Staffordshire Western ...-{ Central (4) Worcestershire, Shrop- shire, and Hereford- shire 1^(5) Warwickshire f (1) Leicestershire, Notting- I hamshire, and Rutland (2) Derbyshire •{ (3) Bedfordshire, Hunting- donshire and Northamp- tonshire (4) Buckinghamshire and l^ Hertfordshire (1) Norfolk and Cambridge- shire Eastern ■^ (2) Lincolnshire I (3) Suffolk t_(4) Essex Balliol Chambers, West Sunnyside, Sunderland. Darlington.* 76, Victoria Street, Manchester (Divi- sional Headquarters).* 3, Crosshall Street, Liverpool.* 36, Guildhall Street, Preston.* 20, Richmond Terrace, Blackburn. Midland Bank Chambers, Wigan. 18, Park Lane, Leeds (Divisional Head- quarters).* 34, Byram Arcade, Huddersfield. Tontine Chambers, Haymarket, Shef- field.* Paragon Buildings, Jameson Street, Hull,* and 81, Skeldergate, York. 191, Corporation Street, Birmingham (Divisional Headquarters.)* I*arr'8 Bank Chambers, Crewe. 132, Newport Road, Stafford ; and Gresham Chambers, 14, Lichfield Street, Wolverhampton.* 50, Foregate Street, Worcester.* 23, Market Place, Rugby. 63, London Road, Leicester.* (Divisional Headquarters.) Old Bank Chambers, Irongate, Derbv.* 47, High Street, Bedford.* Brook House, Francis Street, London, W.C. 3, Alexandra Mansions, Prince of Wales Road, Norwich.* (Divisional Headquarters.) St. Edmond's Chambers, Silver Street, Lit coin. 17, Museum Street, Ipswich. Brook House, Francis St.,London,W.C.* The offices at which women inspectors or w^omen assistant inspectors are stationed are marked with asterisks. Outdoor Staff. 213 Division. Metropolitan Dis'rlcts. f (1) London, North (2) „ South (3) „ East (4) „ West ^(5) „ Central f (1) Bristol and Bath Headquarters. •1 Brook House,Francis St., London,W.C.* (2) G-loucestershire and South Western ■{ Somersetsh i re I (3) Wilts and Dorset I (4) Devonshire and Corn- (^ wall f (1) Middlesex and Surrey 3, Woodland Koad, Tyndall's Park, Bristol (Divisional Headquarters).* Ditto. 20, Oatmeal Row, Salisbury. ifotte Street, Plymouth, and 7, Bedford Circus, Exeter.* Brook House, Francis St., London, W.C. (Divisional Headquarters).* (2) Kent 24, Stone Street, Maidstone.* South Eastern •{ (3) Sussex ... ... ... 24, G-loucester Place, Brighton. I (4) Hampshire ... ... 105, Above Bar, Southampton.* I (5) Berkshire and Oxford- The Cedars, London Road, Reading, l^ shire 582. The organisation of the Inspectorate as regards both men and women remains substantially the same as that outlined in paragraphs 1013 to 1015 of the previous Keport. Duties of the Outdoor Staff. 583. The work of the Outdoor Staff falls into two main classes, that of securing compliance with the provisions of the Acts relating to the collection of contributions, and that of acting as local administrative and intelligence officers for the Commis- sion in all branches of administration. Inasmuch, however, as the staff are not directly concerned with the administration of benefits, which is in the hands of Insurance Committees and Approved Societies, their functions in this respect — though hardly less onerous and important — are of a secondary nature. For this reason the following Eeport on the Outdoor Staff is con- cerned principally with the contributory side of the work and does not profess to treat, otherwise than incidentally, of the administration of benefits. This subject is dealt with more appropriately under the relevant headings in the earlier part of this Eeport, in the preparation of which any information derived from the Inspectorate has been available. 584. In last year's Eeport some account was given of the initial difficulties that faced the staff in connection with the bringing into operation of the new conditions affecting practically the whole of the adult population, and of the methods adopted to overcome these difficulties. This task has now been successfully accomplished. Organised resistance to the law is a thing of the past ; isolated resistance is extremely rare. The work of the staff has not diminished, it has rather increased, but its nature has changed considerably. This change has developed more rapidly in industrial than in country districts. In the latter the bulk of the work still lies on the con- tributory side. Farmers find difficulty in understanding the precise application of the low-wage provisions ; they are prone also to stamp cards quarterly, and, for the sake of convenience, 214 England. to make deductions every three weeks, from the wages of labourers paid weekly. Casual agricultural labour has also given consider- able trouble. In industrial districts smooth working has been secured more readily. Wilful evasion or irregularity on the part of employers of substance is now practically non-existent. Em- ployers of a poorer class still present some difficulties, especially employers of outworkers, and there are problems still to be over- come in connection with casual labour. But not only are these difficulties actually less in towns than in the country, owing to the more ready dissipation of ignorance, but they are also easier to deal with on account of their concentration. 585. As however the presence of the local Inspector has be- come more widely known his work has increased rapidly in other directions. Insured persons now not only readily disclose to him the existence of petty evasions and irregularities, but also come to him in increasing numbers to obtain guidance and assistance in securing the payment of benefits to which they consider them- selves entitled. Although inspectors are at all times careful to avoid any interference as between an insured person and his Approved Society in regard to benefits admin- istered by the Society, they are able to do much to remove misunderstandings and difficulties to the. advantage ot both parties. The number of callers at the various offices is increasing rapidly, and the work of dealing with their inquiries and complaints constitutes no small draft on an Inspector's time. Moreover, as the crystallisation of principles admits of greater decentralisation, his share of general administration tends con- stantly to grow. The smaller Approved Societies still rely largely on his assistance, and, although Insurance Committees are in no need of direct advice and assistance, and the manner in which they discharge their duties is the subject of general praise, most of their Clerks continue to keep in close touch with the Com- mission's Inspectors. 586. As regards the division of functions between the men and women staffs, certain trades, principally those in which female labour largely preponderates, are allotted for inspection to the women staff, who are responsible for seeing that contributions are duly paid at the proper rates. Under this arrangement out- workers ordinarily fall to the women inspectorate, and much careful and patient work has been necessary to deal with the prob- lems involved in adapting compulsory insurance to this form of employment, especially in the case of the lace finishing trade in Nottingham and the numerous outwork industries in Birmingham and the surrounding country. Apart from their work on the contributory side, the most important duty of the women staff at present is that of advising insured women concerning whose claim to benefit some difficulty or misunderstanding has arisen. In industrial areas, especially in Lancashire and the Birmingham district, the number of women who thus seek the advice of the inspectorate is very large; the advice, of course, being always Outdoor Staff. 215 given within the limits referred to in paragraph 585 above. The question of the payment of sickness benefit dm-ing pregnancy, the test of incapacity apphcable to women, and the exercise by married women of the options given by Section 44 of the principal Act have proved the most fruitful sources of difficulty, and take up a considerable portion of the time of the women inspectorate. 587. The following paragraphs show briefly the nature of the work that has fallen to the Outdoor Staff (both men and women) in the different Divisions during the year under review. Northern Division {Northumberland, Durham (with Middles- brough), Cumberland, Westmorland). 588. The character of the work in the Northern Division during the last year has shown a marked change. Twelve months ago the greater part of the time and energies of the staff was occupied in investigating complaints against employers, and most of the complaints were of failure to stamp cards. During the past twelve months the attitude of the public towards the Act has undergone a slow but certain change. Active resistance has practically ceased. The employer has given up resistance. The insured person is now no longer indifferent. He has gradually realised the benefits of the Act, and his indifference has given place to a determination to be insured. Complaints of non-pay- ment of contributions, of course, still continue to be made, but on investigation they appear to be due to bona fide ignorance, to differences of opinion as to liability, to quarrels about wages, or to a mistaken idea on the part of the employer that he can use the Act to penalise an employee against whom he has a grievance. 589. Nevertheless, the volume of work has increased at a rapid rate owing to the number of requests for assist- ance (small by comparison with the number of insured persons but formidable when concentrated) that are received from insured persons who for one reason or another find difficulty in securing payment of the benefits that they consider to be due to them. Even in this Division, with its highly organised labour, the ignorance of insured persons is often amazing. For example, there is a widespread belief that all Approved Societies are identical, that all Society officials are officers of the same large State organisation, and that it matters not to what Society a stamped card is handed. Instances have arisen where for four or five quarters in succession cards have been handed in to a different Society each quarter. Further, many insured persons are seriously handicapped by their entire inability to express themselves intelligibly in writing, or to understand a plain, straightforward letter. Little can therefore be done by correspondence, even when the matter in hand is simple. The majority of local officials of Approved Societies are neither careless nor unsympathetic, and they welcome the assistance of the In- spector : and by constant communication with many different Societies an Inspector can gather up good points in administra- tion and carry them round from Society to Society. 216 England. 590. Although pressure of work has now practically stopped all survey work, yet a considerable amount has been accomplished since the publication of the last Eeport. In Northumberland about three-sevenths of the survey still remains to be done. During the past summer 1,279 farms and small holdings were visited, but no irregularities of any moment were discovered. Taking the whole County of Northumberland, 4,200 visits to employers have been made and 25,000 cards inspected. Only 1 per cent, of the employers were guilty of serious irregularities, and 99 per cent, of the employees were found to be properly insured. In Durham survey was continuous until about last July. The County has been fairly well covered with the excep- tion of the extreme Western portion. Nearly 17,000 employers have been visited, and some 320,000 cards examined. The irre- gularities found were mainly of a minor character, and affected 8 per cent, of the employees whose cards were seen. Visits were paid to over 1,000 farms, and irregularities were found in the cases of 10 per cent, of the employers visited. In Cumberland and Westmorland, roughly, 640 employers have been visited and 3,366 cards seen, without discovering any irregularity of moment. 591. Although a general survey of the country is undoubtedly desirable, not only for the purposes of discovering evasions, errors, and omissions, but also for the purposes of thoroughly dissemin- ating information as to the Acts, the postponement or delay of survey is not perhaps of great importance. So long as the insured person himself will act as informant and draw the Inspector's attention, either directly or through his Society, to any irregu- larity, the whole time of the staff can be spent in actually rectify- ing errors, in visiting offending or ignorant employers, in giving them warning or instruction, as the case may require, without needing to inspect cases which are regular in order to discover those that are irregular. 592. The Inspectors keep in close touch with all the Clerks to the Insurance Committees, and with the general business of each Committee. In some instances the Clerks frequently ask for the Inspector's advice. In others his assistance is not sought. As his services have been urgently re- quired in another direction the work that has forced it- self upon him has claimed his time, and less time than formerly has been given to Committee work. This does not mean that the work has been neglected. Every Clerk in the Division knows that an expressed desire on his part will always secure the attendance of the Inspector at a meeting, but when not actually required an Inspector can at present employ his time more usefully than in attending meetings where he is merely an observer. 593. It is probable that in the Northern Division the Insur- ance Act came into operation with less difficulty and trouble than in any other part of the United Kingdom. With a population closely approaching three millions, the greater part of which is Outdoor Staff. 217 crowded into a comparatively narrow strip of land extending only from Blyth to Middlesbrough, mainly occupied in the highly organised trades connected with coal, iron, shipbuilding, etc., with every industry permeated with Trade Unionism, with Friendly Societies and Co-operative Societies already operating and managed by working men, it is obvious that suitable condi- tions existed for the success of the Act. Although inquiries have been made in all parts of the Northern Division, no spot has been discovered where the benefits are not being administered in a very businesslike manner. As has been shown, however, this does not mean that the staff have been entirely free from complaints or have experienced no difficulties. That could hardly be expected with an insured population of 800,000 persons. The very fact that here are found skilled trade unionists, well versed in democratic government, has produced a crop of com- plaints. Such persons very soon learn to what they are entitled, and they will not brook inefficiency in their officials or delay in administration. They know where to complain, and Inspectors very soon hear if anything is wrong. But perhaps no more strik- ing proof of the smooth working of the Act generally could be given than a comparison of the numbers of insured persons with the number of difficulties found in regard to the administration of benefits. Although exact figures are not available, the number must be far less than 1 in 1,000. North-Western Division (Lancashire ^ with Birkenhead and Wallasey). 594. The work dealt with in the North- Western Division during the past 18 months may be divided roughly into two parts. At first there were the ordinary work of survey and the task of clearing up the irregularities that were disclosed; the duty of helping secretaries of Approved Societies to obtain a grasp of their work ; of assisting the Clerks of Insurance Committees ; and of inquiring into special points raised in regard to various classes of employment. As time went on the character of the work underwent a substantial change. While survey inspection con- tinued, the nature of irregularities disclosed gradually became less serious, secretaries of Approved Societies became familiar with their work, and Insurance Committees reached a position where the assistance of Inspectors became unnecessary. On the other hand, the commencement of benefits opened inquiries which have taxed the energies of the staff, and have been the chief feature during the later months of the year. 595. In the early part of the year the Health Insurance Officers were exclusively engaged in survey, and the com- pact nature of the Division enabled this to be brought to an advanced stage. Latterly these Officers have had to take a large share of administrative work, and survey has corre- spondingly fallen off. In addition, the more populous urban districts having been completed, the survey work which has recently been done has been in the thinly populated rural areas 218 England. where much travelling is involved and fewer visits can be accom- plished. To the end of December 121,393 survey visits to employers have been made and 1,215,814 cards inspected. Since the total insured population is 1,885,700, the first complete survey is within measurable distance of being finished. In the course of this survey 56,007 irregularities were discovered. Of these 23,837 were of a trifling nature, and were adjusted at once. The remaining 32,170 required a further visit before adjustment was secured. Many were difficult cases requiring patience and tact, but all obstacles were overcome, and it says much for the manner in which the Officers have done their work that ©nly four prosecutions have been necessary. 596. The nature of the irregularities may be classified as follows in their order of frequency : — 1. Late payment of contributions, i.e., payment after wages are paid. 2. Payment of contributions at the wrong value through mis- calculation of rate of remuneration. 3. Failure to cancel stamps. 4. Omission to pay contributions in respect of casual or part- time employees. 5. Payment of contributions at the rates provided under Section 47 for classes not included in Special Orders under the Section. 6. In the case of outworkers, adoption of the " Unit " system without the requisite permission. 597. The last five classes are entirely due to misapprehension or ignorance, and on being corrected by an Officer are not likely to occur again. The first class is different ; for there are certain employers, chiefly farmers, shopkeepers and small tradesmen, who do not see the necessity of stamping when wages are paid and decline to stamp until the end of the contribution period. 598. It can truthfully be said that of actual resistance there is none. It is a striking commentary on the general feeling that while in the early stages wholesale abuse was in many cases poured out on the Officers, they are now received with invariable courtesy. There can be no doubt that the work of the Officers has been of immense value to employers and employees alike. 599. In close connection with the work of survey is that of special inquiries as to the insurability of certain classes, and a considerable amount of this work has been done in the Division. This need not be enlarged upon further than to mention that special inquiries were made relative to share fishermen, shirt makers, "spec" boatmen, casual labour in coal yards, fustian cutters, "sick" weavers, cop reelers, " hobblers," barrowmen, marine engineers, wood cutters, harvest " binders," &c. Special inquiries were also made by the staff as to the class of deposit contributors, and into the insurance of members of travelling theatrical companies and variety artistes, as well as into the insurance of Irish migratory labourers. In connection with the special investigation regarding Irish migratory labourers, it may Outdoor Staff. 219 be mentioned that while in practically all cases the ordinary farm workers proved to be insured, the position as regards these migratory labourers was found to be unsatisfactory, owing to ignorance on the part of the farmers as to their obligations. In all cases, hundreds in number, adjustments were obtained. 600. In the early part of the year Inspectors fourid the secre- taries of many Approved Societies seriously troubled by the diffi- culties of keeping their registers and books. For some months the Inspectors and Assistant Inspectors spent night after night in the process of educating these secretaries in their work, in some cases even in the elements of simple bookkeeping. The need for this has to a great extent passed away, and the secretaries are now able to get along without much assistance. Still, if the Inspectors have not now to visit the secretaries so regularly, the latter constantly seek their advice when anything unusual arises. During the latter part of the year, after the 1913 Act became operative, many meetings were held throughout the Division which were addressed by the Inspectors and well attended by the Society officials. 601. To some extent during the whole year, and especially during the past four months, every Inspector has had to deal with a number of questions from insured persons regarding the payment of benefits. Many were of a trifling nature, due either to a misunderstanding on the part of the insured person or a clear error on the part of the Society, and were easily adjusted. Oil the other hand, there were many which had to be carefully investigated. This has taken up much of the time of the staff. They have, however, seen something of the other side of the picture. The records of the Manchester Board of Guardians (whose area contains less than half the people of the city) show that during the first six months of the operation of benefits under the Act there were on an average 3,595 persons receiving in- door relief weekly, as compared with 3,887 for the cor- responding period of the previous year. There were 18,488 weekly payments of outdoor relief as compared with 29,677 for the same period of the preceding year, at a cost of ^1,953 as compared with £2,623. As regards the Liverpool dockers, it is stated on credible authority that in 50 per cent, of the cases where sickness benefit has been granted, the home would have been broken up, the furniture sold, and the family engulfed by the workhouse if it were not for the sickness benefit granted by the Act. Generally also, it is said that there is less of what the doctors call " walking sickness " since the Insurance Act has come into force, and the man who should really be in bed instead of struggling with pain and weakness at his daily task is able to give the doctor a fair chance of making a good job of his case. North-E astern Division (Yorkshire, excluding Middlesbrough), 602. The work of the Outdoor Staff in the North-Eastern Division has diffei cd somewhat ' from that carried out prior to 220 England. the date of the last Keport. Until then they had been engaged principally upon a town survey and a limited amount of rural investigation; but between June and November, 1913, they were largely employed in a routine rural survey, and great progress towards its completion has been made, although visits were proportionately fewer owing to the greater distances to be covered, and the average number of employees discovered on each visit was smaller. 603. The total amount of survey accomplished by the staff since appointment is as follows : Visits made to employers, 73,982; cards seen, 894,906; irregularities rectified, 11,238. In order to secure the adjustment of these irregularities two visits were necessary to many of the employers concerned. Taking the number of employees in respect of whom cards have been seen as 894,906, and the total number of insurable persons in the Division as 1,283,000, it will readily be observed how far the survey has progressed generally. During the period, special attention was directed to haymakers, threshers, women field workers, pea-pickers, boarding-house employees, and captains and mates of keels. 604. The rural survey revealed a widespread idea that cards could be stamped quarterly irrespectively of when wages were paid. Adjustments were made und undertakings obtained that the practice should cease. Ke- visits will be made, and stronger measures taken, if necessary, as this particular irregularity, apart altogether from the loss occasioned to the Insurance Fund, fre- quently leads to non-stamping and loss of cards in the case of employees leaving during the quarter. There is also the danger that an impecunious employer who has deducted the employee's share weekly, may find as the quarter proceeds that he cannot meet his liabilities, including stamp-purchase. Several such cases have come to light locally, and in this connection the small employers of Sheffield cause much anxiety to the Inspector. 605. Apart from this, the most common irregularity appears fco arise in connection with the contributions of persons over 21 and earning low wages ; but excessive deductions in this con- nection are now becoming much less frequent. Survey has also been the means of discovering some deliberate evasion. 606. The experience of the months under review demon- strates the continued usefulness of survey work. If the staff were not coming into touch thus with careless and dilatory em- ployers, and those who defer payment of contributions until the end of the quarter, it is certain that a large number of complaints concerning non-payment of contributions would arise ; these , in turn , would in many cases lead to delay in the payment of benefits. There are, of course, still some in respect of whom no contributions are paid, e.g., casual workers in town and country, charwomen, persons receiving small money payments, and part-time workers. It is only possible to be sure of detecting these by routine ineipection, though Miforma- Outdoor Staff. 221 tion of them is received from time to time from the employees. Cases are also brought to light in which farmers and other employers have adopted the provisions of Section 47 without having given notice, and often without being entitled to adopt it in respect of the occupations in question 607. The Staff when on survey often meet with per- sons in trouble ; one considers that short measure of sickness benefit has been paid to him, and he does not know his remedy; another left his card at his last job and has not been able to obtain it ; another had someone else's card given to him when he was working 50 miles away perhaps ; another is "in two Approved Societies " and neither will pay benefit. These matters can generally be set right by the advice and action of the staff. 608. Cases of positive resistance have been very few indeed, but there has been a good deal of attempted evasion on a large scale. A test inspection of pea-pickers in the Goole neighbour- hood showed that a few employers only were taking trouble to comply with the law; insurable pea-pickers, generally speaking, were loth to produce cards to their employers because, they alleged, the employers would not permit them to work if they did. Again, a considerable amount of time was devoted to visit- ing employers who in 1912 were known to have employed Irish migratory labourers. Many cases were also met with on survey. The amount of evasion discovered in respect of them was consider- able. Some of the employers pleaded ignorance and stated that the labourers themselves were also ignorant of their liability to be insured. Others accepted forms of various kinds as evidence of exemption. Others, again, having seen proper exemption books, took them to mean that no contributions what- ever were payable. Evasion on a large scale was encountered in the Selby and Goole areas in connection with the women field- workers, who in various ways perform a large share of the work on farms where much market garden produce is grown. The work is intermittent, although many of the women are employed in a considerable number of weeks in the year. The casual men who assist at threshing operations have presented some difficulty, owing to the fact that sometimes they are engaged by the farmer, and sometimes by the owners of the machine. Special attention has been given to these cases on survey with excellent results. 609. The administration of benefits by Approved Societies has added a new duty to those originally devolving upon the Inspec- torate, namely, not only to render assistance at the request of Society officials, but to deal with inquiries and complaints from insured persons seeking to obtain benefits. Many of these in- quiries are in the nature of disputes between Societies and their members into which an Inspector cannot enter, but a large number are due to mistakes and misunderstandings on the part of either the Society or the member, and can in most cases be amicably adjusted after investigation. This work has taken up 222 England. much of the Inspectors' time, but it is seldom that a bond fide complaint is not found to be susceptible of adjustment by these methods. 610. The thorough way in which the administration of Na- tional Insurance has been woven into the industries and homes of this large area in so short a time since it was initiated is very remarkable. It is true that much still remains to be done in the way of dispelling ignorance and removing: anomalies of admin- istration, but such defects are the exception and not the rule, and, for the overwhelming majority of persons entitled to them, benefits are readily obtainable without trouble or delay. Western Division (Cheshire (excluding Birkenhead and Wal- lasey), Staffordshire, Shropshire, Warwickshire, Worcester- shire, Herefordshire). 611. Survey work in the Western Division is well advanced, 83,358 visits having been paid to employers up to the end of the sixth quarter; 790,112 cards were inspected, and 53,514 irregu- larities disclosed and subsequently rectified. 612. In Cheshire a complete survey has been made of the farms, and extremely friendly relations exist between the agri- cultural community and the Outdoor Staff. In Staffordshire a complete survey has been made in many districts and parishes, but much of the Northern and North-E astern parts of the County remains to be covered. In Warwickshire, particularly the Southern parts of the County, many errors in the payment of contributions have been discovered, including, in almost every case, over-deduction from wages. Special difficulty was experi- enced owing to the absence of wages books. After much labour, friendly adjustment has been secured in all cases, and correct payment is anticipated for the future. In Worcestershire, Here- fordshire, and Salop, the main survey work has been devoted to farms, and has disclosed many petty evasions but very little pronounced resistance. Farmers are often found to be deducting a shilling from wages every third week instead of the prescribed fourpence a week, and explain that the lack of small change renders this necessary. Many farmers stamp quarterly and pay weekly, stating that their remoteness from a post office prevents the full observance of the law. In each case brought to light the proper procedure has been explained with good results. The problem of the Irish migratory labourer has been dealt with much more satisfactorily this year than in 1912, the labourer being found much keener upon securing his "insurance rights." ' 613. The general results of survey show that the vast majority of employers appreciate the advantages of the Acts, the more so as the payment of the various benefits has lightened the anxieties of humane employers interested in the welfare of their work- people. Eecalcitrant employers are fewer than they were, the change being due mainly to the better conception of the value of the Act brought about by the payment of benefits. A number of careless and ignorant small employers continue to give great Outdoor Staff. 223 trouble. They are frequently impecunious, and the general con- ditions obtaining with regard to them render satisfactory treat- ment difficult. 614. There have been several prosecutions in the Division, only one of which proved unsuccessful. Two defendants had been prosecuted previously, and further proceedings were found to be necessary. Eefusal to pay arrears and costs in the two latter cases resulted in the issue of distress warrants. 615. The outworker question has provided considerable work in Birmingham, Coventry, Eedditch, and other smaller centres in which work is carried on in this way. The special difficulty in deaUng with this class of employment consists in the mass of detailed investigations involved and in the intricate net- work of relationships between employers and workpeople. One visit to the proprietors of a large factory might dispose satis- factorily of 1,000 cards. A single visit, on the other hand, to an employer on the outwork system would not, as a rule, result in the satisfactory inspection of a single card. The employer would not, save in a very exceptional case, retain an outworker's card in his possession. The visit w.i-ild produce a list of perhaps four names and addresses of outworkers, who, on being severally visited, would, each in turn, indicate a number of their employers. These again would employ other outworkers, and, as a further complication, they might in some cases be themselves both out- workers and employers. The inspection thus develops on the snowball principle until the compliance of the whole body of outwork employers is secured. 616. Much time has been taken up in investigating cases where payment of benefit has been refused or delayed. Eefusal of consent to transfer from one Approved Society to another is a frequent source of trouble, especially in Birmingham. It is generally found that the insured person is at fault, chiefly through ignorance. Doubtful insurances have been regularised ; persons who joined two or more Approved Societies have been conveyed to the proper Society. Advice has frequently to be given to the officials of the larger Societies and to the branch secretaries of the Affiliated Orders, while the small club of the Dividing Society type needs constant help. 617. Bona fide complaints regarding non-receipt of benefit are generally settled satisfactorily with the Approved Societies con- cerned. Experience has shown that in many hundreds of cases the help of the Inspectorate has been justified in this way, as the ignorance of insured persons as to the proper procedure might have led to misunderstandings resulting in delay, or even non-payment of benefits due, had the claimants not sought the help of the local Inspector. The growth of the work called for from the Inspectorate in connection with the admin- istration of benefits has been remarkable. The average Inspector spends quite half his time in dealing with cases of this nature. The number of callers at the various offices shows a great in- crease. At Birmingham, where the inquiry room is open two and 224 England. a half hours daily, the visitors average 600 a month. Of this number, over half call to ask advice in connection with claims for benefit. 618. The relations of the Inspectorate with Insurance Com- mittees within the Division continue to be of the most friendly character. The Outdoor Staff are in close touch with Commit- tees, and it can confidently be reported that all these bodies are working smoothly and without especial difficulty. 619. On the whole, very considerable satisfaction may be felt at the situation in the Division. The operation of benefits has re- moved the opposition and indifference which were once frequently encountered. Those who were once not unwilling to escape the contributions are now found willing to present cards to former neglectful employers. Callers inquire about arrears and how they can pay them off. Persons who secured exemption are not re- newing their certificates. The general effect is well shown by the naive remark of a domestic servant in a recent letter addressed from a hospital. She writes : " As a servant I did not care to press the matter while I was in good health, but now that I am very ill I begin to feel concerned about the sickness benefit." Central Division (Leicestershire, Derbyshire, NottSy Rutland, Northants, Hunts, Beds, Bucks, Herts). 620. The Central Division contains a large variety of indus- tries, and it is a matter of no little difficulty for Inspectors to acquire the necessary familiarity with manufacturing processes and trade customs. This applies particularly to the manu- facture of lace, boots, and hosiery in which many outworkers are employed. In estimating the net earnings of these workers deductions must be made in respect of material supplied by the worker and for use of machines, &c., and many other difficulties are involved. Inquiries have also been made to determine the status of many individuals employed in a diversity of trades ; for instance, as to whether persons were employed under a contract of service or were independent contractors, or whether per- sons hiave been employed by way of manual labour, or as to the application of Subsidiary Employment Orders to certain indi- viduals. Again, in connection with farming, it has-been neces- sary to make numerous investigations into local customs to determine the liabilities of the persons concerned. This applies particularly to the * * ganger ' ' method of employing men and women in the Fen country, piece-work methods in Leicestershire and Northants, the employment of women in grape-thinning in the Cheshunt area, hay-tying in Herts and Bucks, and difficulties connected with low- wage earners in field work in several counties. The chief difficulty connected with this inquiry work has been that of obtaining preliminary agreement as to facts between the parties concerned, but by patient inquiry facts have been ascer- tained, questions have been determined, and difficulties have been removed. In all cases where it has been decided that there is Outdoor Staff. 225 liability to compulsory insurance, the employers have unques- tioningly paid contributions in respect of the persons affected. 621. It was originally anticipated that irregularities would be brought to light mainly through systematic survey by Health Insurance Officers, but experience has shown that the Approved Societies, in receiving cards from their members, are informed of irregularities, and it is consequently from that source that the great bulk of complaints has been received. Whilst, however. Approved Societies may be made aware by blank spaces on cards of failure by employers to pay contributions, they do not learn of cases where both employer and employee conspire to evade their obligations, nor do they call attention to many irregularities such as stamping at improper times, stamping with wrong value stamps, making im- proper deductions from employees' wages, &c. It has therefore been necessary, in addition to dealing with the complaints re- ceived from Approved Societies, to carry out survey work as far as the staff available has permitted. 622. It is estimated that the total number of industrial and commercial employers in the Division amounts to 150,000, and the estimated number of insurable employees is 950,000. The former figure does not include private residents employing domestic servants. 623. From October, 1912, to January 10th, 1914, nearly 50,000 employers have been visited, over half a million cards have been inspected, and more than 24,000 irregularities have been rectified on survey alone. During the last three months the irregularities rectified on survey affected 1,262 employers and 7,258 employees; about one-fourth of the total inspected during that period. Daring the first few months determined opposition was met with in many quarters, and the staff was compelled to devote the larger part of its attention to the more important cases of resistance. Such resistance has now died out, except in a few isolated cases. All the principal employers in industrial areas are now fully complying with the Acts and Eegulations. The more important requirements affecting the stamping of cards are now matters of common knowledge both to employers and employees, and many firms take a pride in the excellent methods adopted by them -for the stamping and custody of cards. The workers themselves, who were prone at first to be indifferent, now demand their stamped cards as a matter of right, and realise the value which these represent to them in anticipated benefits. 624. A steady flow of minor cases of evasion, however, continues to be received. These cases mostly concern small employers of labour, and agricultural, unorganised, casual, and women workers. . (B254— Gp. 5) H 226 England. The common experience throughout the Division is that each member of the staii' always has on hand 30 or more cases of com- plaint in regard to contributions. Many of these will take him to rm*al districts difficult of access, with the result that it is sometimes impossible to deal with more than two or three complaints a day. It is almost impossible to dispose of these complaints by letter ; the worker must be interviewed to obtain a clear statement of his complaint with definite dates, &c., and the employer must be visited to secure compliance in the case in queation and to see that any other workers are being duly insured. 625. It has been necessary to prosecute a few employers, and it is a noteworthy fact that immediately after a successful pro- secution other employers in the district, who had been refusing to comply in respect of some worker, have consented to stamp cards. 626. On the benefit side of the work, besides the help con- stantly given to Society officials at their own request, a new and serious demand has been made upon the time of Inspectors by the necessity of advising insured persons who have sought his aid in obtaining benefits. In the majority of cases in which the complainant has a genuine grievance it is possible to secure a satisfactory settlement. If this fails, the course open to the member is to proceed in accordance with the dispute rule of his Society. This procedure is frequently beyond the intelligence of persons who may desire to make use of the right of appeal. Ap- proved Societies, as a whole, however, appear to have made a wise exercise of their large powers, and to have grappled with the problems wdth which they were confronted in a creditable manner. 627. To-day, after 12 months' experience of the benefits of the Acts, the change from the situation in the early months of last year is very marked. Workers who were indiiferent now complain immediately if their cards are not stamped ; employers who lost no opportunity of expressing their detestation of the Acts now willingly comply, and in many cases assist their workers to obtain benefit when required ; in the case of the medical pro- fession, hostility has given place to active co-operation. This change of attitude has affected the Inspector's work to a great extent. Whilst there is still a large volume of petty evasion, there is little determined resistance ; the insured person is now the willing ally of the Inspector in securing the proper stamping of cards, and often loofcs to him when any difficulty arises ^ wi,tih regard to the payment of benefit. Outdoor Staff. 227 Eastern Division (Lines, Camhs, Norfolk, Suffolk, Essex). 628. The Eastern Division is almost wholly agricultural, and the insured population is scattered thinly but evenly throughout it. Official visits are therefore spread over a wide area, and many miles have often to be travelled during the investigation of a single case of evasion. For the same reason travelling is exceed- ingly difficult, and the possible number of visits per day is greatly reduced below the urban average. Further, the areas served by market towns tend to become geographical units, between which there is little intercommunication ; so that the spread of information on new legal requirements is slow. 629. The majority of employers employ few persons, and do not keep proper records of wages paid or of periods of employment, so that it is often impossible to obtain from them any documentary evidence of compliance with the Act, especially where, as often happens, the cards are kept by the insured persons themselves. In such cases it is necessary to make lengthy inquiries at distant cottages or of men working in the fields. Moreover, most of the employers were unaccustomed to detailed Governmental inspection, having been beyond the scope of the inspection of factories, workshops, and shops. 630. The problems which have been dealt with in the past ten months fall roughly into the following groups : — (1) Overcoming the open resistance of a few individuals. (2) Detecting evasion as regards certain classes of employees among whom enforcement of the Act is difficult. (3) Bringing into insurance certain classes of persons as regards whom doubt or misconception existed. (4) Securing compliance with the Act in cases of disputes between employers and employees, where the former had refused to pay contributions in order to punish the latter. 631. The resisters of a year ago are now, practically without exception, complying, and very few prosecutions have been necessary. Evasion has been most difficult to deal with in those parts of the Division where the resistance movement was! strongest, one being the natural sequel to the other. It has been found chiefly in connection with casual labourers employed with threshing machines, and in miscellaneous farm work during the summer. Contributions have been recovered in many cases of (B254— Gp. 5) H 2 228 Efigland, this kind, on information supplied by Approved Societies, as well as by routine inspection, but settlement usually involves lengthy and careful investigations, owing to the inability or unwillingness of the employees to supply the dates on which they worked for various employers, and also to the obstructive tactics of employers. 632. Much detailed investigation has been required in bringing into insurance certain classes of persons whose insurability is disputed. Charwomen employed regularly by two or three em- ployers are often found not to be insured, especially in rural areas, owing to a prevalent belief that the wives of insured persons need not be insured, or that employment is casual if it occupies only one day per week. The latter misconception also extends to jobbing gardeners working for several regular employers. In the Fen districts, and also in the Isle of Axholme, considerable difficulty has been experienced with women employed in miscel- laneous field work. Irish migratory labourers have presented cases of difficulty during the summer. Most farmers had a vague notion that they need not be insured , whilst others , although aware of their liability, hoped to escape detection. Considerable sums, however, have been recovered in contributions for such persons, whether holding exemption certificates or not, and this season compliance should be more thorough. 633. More difficult cases have been those of hedgers^ ditchers, turnip hoers, potato pickers, and other farm hands working at piece-rates, either individually or in gangs. The farmer contends that the men are independent con- tractors, and careful investigation has been necessary in each case in order to determine whether a contract of service existed. Minute knowledge of local customs and processes has to be acquired before such questions can be satisfactorily settled. The insurability of outworker-contractors has also been doubtful in some instances in the tailoring and bootmaking trades, although this is not a Division in which outivorkers are largely employed. / 634. Cases in the last of the four groups that are enumerated above, although not very numerous, are not easy to settle. The employer has to be persuaded that his liablity under the Insurance Acts is quite independent of the justice or injustice of his quarrel with the dismissed worker. On the other hand, the complaints lodged by dismissed workers, from motives of spite, are often found to be trivial or groundless. 635. In addition to the above main branches of the work, attention has been directed to minor irregularities. Many farmers are disposed to delay stamping the cards until the end of the quarter, although wages are paid weekly. Others delegate Outdoor Staff. 229 the duty of stamping to the insured persons themselves, without satisfying themselves that the duty has been discharged. In a considerable number of instances excessive deductions have been discovered and rectified; in a few cases only have prosecutions been necessary. 636. In all branches of the work the advantages of local know- ledge, which only an outdoor staff can possess, have been apparent. Officials of Approved Societies have proved an especially valuable source of information. By interviews with them it is possible to gauge the working of the Acts rapidly and in detail. Not only can it be ascertained in which quarters non-compliance with the Acts may be suspected, but prevalent misconceptions as to the payment of contributions and receipt of benefits can also be dis- covered and explained through the medium of these officials. Much needed information has been disseminated in this way, with the assistance of the official leaflets issued by the Commission. It is possible, as it w^ere, to feel the pulse of the insured popula- tion at any moment, and discover exactly where official interven- tion is needed — an object which is attained very inadequately or tardily by routine inspection. The investigation of one com- plaint has often served as a starting point for fresh inquiries ; other employers of the same employee, or other employees of the same employer, are found to need attention. 637. With regard to urban districts, little need be said. They have not presented much difficulty, and except for reference to a few outworkers, to domestic servants in towns generally, and to the fishing and shipping industries in the seaports, the employers in these districts can be regarded as having carried out the liabilities imposed by the Act from its inception. 638. In the Division generally a marked change of feeling has been noticeable among the insured people since the principal benefits have come into operation. During the first six months when they were paying contributions but were not yet receiving benefits, insured persons were very much disposed to agree with those who were disparaging the value of the Act, but since January last the general appreciation of its benefits has been steadily growing even among those who continue to criticise the Act from other standpoints. Maternity benefit has been especially wel- comed as materially lightening the strain and anxiety of the house- hold at the time of confinement. This benefit was very rarely paid before by the Friendly Societies, and its novelty has, consequently, made it more appreciated ; in country districts nearly every male person used to be insured for sickness benefit before the Insur- ance Act was thought of. Sanatorium benefit, affecting as it does a comparatively small number of households, is less widely talked about, but among those whose relatives or friends have benefited by it one hears it spoken of with great appreciation, and the provision of domiciliary treatment has in a number of cases H 3 230 England. done much to alleviate the sufferings of those for whom there is no hope of restoration to complete health, but for whom, at any rate, suitable nourishment can be provided. Those engaged in charitable work have already found that the benefits under the Act are furnishing them with a basis of assistance which they can, where necessary, supplement, and without which, in many in- stances, it would be financially impossible to give adequate help. Metropolitan Division. 639. The most marked change that has taken place in the Metropolitan Division during the last year has been the general acceptance by the people of Health Insurance as part of the daily routine of their working lives. The public attitude seems to have gone through three stages. First of all Inspectors were received with the frequent observation that the Act would not last, and that the administration of it would break down. Next they were told that the benefits would not be forthcoming, and if they were they would not be worth having. The third stage now seems to have been reached, and there is a general recognition that the Act has come to stay, and the benefits are both appreciated and desired. Insurance has definitely begun to enter into the daily life of the workers, and it is of interest to note how wives and daughters have interested themselves in the insurance of their husbands and fathers. It is often the wife only who knows what Society the man has joined. There are, of course, difficulties and prejudices still to be over- come, but it is significant of this change that the Inspectors are now more frequently asked for information as to benefits , transfers, and the like. The novelty and excitement of the initial launching process has been gone through, a stage of calmer development has been reached, and as a consequence the work of the Inspectorate is more and more tending to become advisory rather than coercive. 640. The estimate of insurable persons in the Division has now risen to 2,000,000. The staff available in contrast to the magni- tude of the task ha/s necessitated concentration on complaints actually received, although a small amount of useful surv.ey work has been done. 641. It has been impossible for the most part to seek out irregularities. But complaints dealt with generally re- veal irregularities other than those with which they originated, and the inclination of defaulting employers w^ho are brought to book to specify similar instances among neighbours and competi- tors continues to provide a useful source of information. Outdoor Staff. 231 642. In the first six quarters, 52,431 visits were paid and 495,389 cards inspected. This shows a marked faUing ofl' as compared with the 33,870 visits and 312,150 cards inspected up to May 26th, 1913. The diminution is due in part, to the reUn- quishment of survey (i.e., place to place visitation independent of complaints received), and in part to the rarity of complaints against large employers. There are, of course, fewer cards seen where small employers are concerned, and their inferior systems of accounting as well as their smaller means involve the expendi- ture of considerably more time and labour in setting right irregu- larities. There is frequent trouble in finding the employer, and still more trouble, when he is found, in getting him to pay accumulated arrears, though he could have borne the necessary weekly payments without hardship. 643. The availability of benefits has increased the work of the staff in two ways. On the one hand, insured persons who were previously indifferent have been stimulated, by their own or their acquaintances' experience of benefits and the fear of losing their privileges, to make complaints with a view to obtaining strict compliance with the Act from their employers. In addition to this, as they have obtained better control over their routine w^ork, and as applications for benefits have come in. Approved Society officials have had more opportunity to scrutinise their members' cards and to call for explanation of blank spaces, the scrutiny leading to complaints where the omission to stamp was due to any cause other than unemployment or incapacity to work. This has apparently increased the number of complaints, but is not incon- sistent with other evidence that the actual number of irregulari- ties is decreasing. ^, 644. On the other hand, particularly in the earlier days of the administration of benefits, failure to obtain them, due to mem- bers' misunderstanding of the requirements or to inexperience on the part of the Society officials, has involved the staff in a considerable amount of investigation and negotiation. Similarly, investigation has been necessitated by the Auditors' discovery of cases of doubtful low-rate stamping ; by the discovery in later quarters that deposit contributors' cards for earlier quarters were missing ; and by doubts raised by the high age at which persons have entered insurance for the first time. As a result of this, although there is every reason to believe that each day of their operation leads to increased smoothness in the working of the Acts, the burden of work still increases, so that the staff finds it difficult to keep pace with it. 645. On the whole the nature of complaints has changed for the better. */ Eefusal to return card " is now more frequent than " refusal to stamp." In most cases the detention of a card is due to the carelessness of the employed contributor who. has (B254— Gp. 5) H 4 232 England. failed to ask for it,' or to some quarrel over the termination of employment, the employer mistakenly supposing himself justified in detaining the card because the employee left without notice or failed to pay for damaged goods or to repay money lent. But the labour involved in the rectification of an irregularity is frequently in inverse ratio to its intrinsic importance. 646. Domestic service provides more complaints than any other one employment in this Division. Out of 20 prosecution cases since the last published Eeport, 19 were against employers of domestic servants. Other complaints are mainly in regard to trades v^here there are technical difficulties or v^here irregularity of employment prevails, as in the tailoring trade, or among out- v^orkers, barge-workers, cabmen, waiters, and public-house otiiployees. 647. The administration of benefits has brought to light many cases in which complete submersion would have been inevitable in the absence of the support provided by the Act. It is in regard to this stratum on or near the poverty line that the ameliorative effect of the Acts has been most conspicuous. Among the better-off there has been a less conspicuous but probably equivalent benefit in relief from anxiety and an added sense of security. As the number of direct beneficiaries increases, the employed contributor's determination not to miss anything by falling into arrears through his employer's failure to pay contributions makes, evasion of the contributory requirements increasingly difficult. South-Western Division (Gloucestershire, Somerset, Wilts^ Dorset, Devon, Cornwall). 648. The most salient feature of the work in the South- Western Division during the past year has been the change in the attitude of the general public towards the Act. During the first few months after the Act became operative the work of the staff was mainly persuasive and educative. Many employers were at that time found to be paying no con- tributions in respect of their employees ; many more were awaiting the visit of an Inspector in order to obtain authoritative informa- tion with regard to points of difiiculty, and numerous visits were made to employers who were prepared to carry resistance to the utmost limit. The attitude of employers has, however, under- gone a marked change. They have a better understanding of the provisions of the Act, and no longer profess to regard it merely as a legislative experiment. Cases of wilful evasion are now comparatively rare, and those of non-compliance which are now received and investigated by the Outdoor Staff relate chiefly to employers who failed to pay contributions during the early quarters, but who for some time have regarded continued resist- ance as useless and unprofitable. Considerable difficulty is> however, experienced in recovering arrears. Outdoor Staff. 233 649. With the payment of benefits employees have become more anxious and active in seeing that their contributions are properly paid. Further, the penal provisions relating to the re- fusal to produce a card have become more widely known and employees recognise that they themselves have obligations under the Act, as well as their employers. Although compliance may now be said to be almost universal, there is still some evasion. This is particularly noticeable in the case of outworkers and in other classes of casual or low-paid labour. For this reason survey work must always be necessary. 650. During the year 1913-14 there has been a general re- tardation of survey work through the whole of the Division owing to the necessity of diverting the Health Insurance Officers from their ordinary duties of routine inspection in order that they might assist in dealing with the number of special cases that required investigation. The special cases usually presented special difficulties ; they frequently concerned persons dwelling in comparatively inaccessible places, where knowledge of the Act is still elementary; and, in consequence, they demanded of the staff considerable application and effort. The number of employers visited was 23,727, and the number of employees concerned was 161,406. During the course of these visits, approximately 9,000 irregularities were discovered, of which about 4,460 required one or more subsequent visits before satisfactory adjustments could be effected. 651. Survey work in the previous year was confined, more or less generally, to towns and places in which employment was fairly concentrated. During the period under review visits were made to the more scattered and sparsely populated areas, necessi- tating an expenditure of time somewhat disproportionate to tho results shown. In the course of these visits a large number of uninsured, though insurable, persons were discovered, whose non- insurance was found in many cases to be due to a genuine doubt as to their insurability rather than to a desire to evade the require- ments of the law. 652. A considerable amount of misapprehension still exists in the rural areas with regard to various classes of casual and occa- sional labour, and part-time employments. The belief that mar- ried women engaged in insurable occupations are ipso facto exempt if, as is usually the case, they are dependent mainly upon their husbands, is fairly general ; and compliance is often difficult to obtain because of a doubt as to the value, in such cases, ct insurance, and also because of the extent to which arrears have accumulated. 653. The calculation of the rate of remuneration of an agri- cultural labourer is another source of difficulty. Some farmers get over the difficulty by invariably deducting id., no matter what the remuneration. The difficulties of adjustment in such cases are very great. The custom to remunerate in kind as well as in 234 England. cash and to require service on seven days a week is also respon- sible for much misunderstanding as to the amount of the deduc- tions that may be made from the v^ages of an employee. In all such cases as these the intervention of an Inspector has been and will continue to be necessary to secure adjustment. 654. The prosecutions that took place in the Division were important, and representative of various types of offences. They included a boot manufacturer, for failure to return cards to his employees within the time limit imposed by the Eegulations ; a farmer, for delaying stamping until the end of the quarter ; and a dairyman for neglecting to pay contributions, notwithstanding the guarantee that he had given as a condition upon which previous summonses issued against him had been withdrawn. Proceed- ings were also instituted against a clergyman who had not insured his domestic servants since the Act came into force, and against a firm of bootmakers for not insuring their outworkers. In each of these two cases the summonses were withdrawn on payment of contributions and costs, and on satisfactory under- takings as to the future being given. Other cases were one in which a Bench had declined to convict, but were subse- quently directed to do so by the High Court, and the second prosecution of a clergyman in respect of whom the first pro- ceedings failed to produce the desired result. 655. A far greater number of complaints with reference to non-payment of contributions are now received from Approved Societies than was formerly the case. Societies are keenly alive to the loss of funds which they incur through the default of their members' employers, and they are encouraged to forward particu- lars of cases, even of suspected default, by the successful recovery of previous arrears by the Inspectors. Most of these cases prove to be incapable of settlement otherwise than by visit. 656. The general effect of the payment of benefits continues to be not only remedial but conciliatory. The service of the Out- door Staff are constantly being requisitioned in cases where pay- ment of benefits is delayed or withheld, and to determine the position of members of Societies whose transfer to other Societies is incomplete. The experience of the last 12 months would appear to indicate that the centre of activity of the staff is gradually moving from duties in connection w4th the payment of contributions to duties of a more general advisory character. At the same time, continued observance of the Act by employers will be secured only by regular official supervision. 657. it is to an Inspector that the insured person appeals, as a matter of course, for advice and guidance upon all questions arising out of the negligence of either his employer, his Society, or himself ; the employer finds it most convenient to consult him with reference to matters of doubt or difficulty concerning em- ployees ; and the Society official is only too glad to be able to Outdoor Staff. 235 discuss the problems which confront him with someone on the spot. South-Eastern Division {Middlesex, Surrey, Kent, Sussex, Hants, Berks, Oxon). 658. Among the characteristic conditions prevaiHng in the South-Eastern Division, the most important appear to be as follows : First, the extent to which employers emplojang only very few workers (e.g., farmers, tradesmen, and private residents) preponderate, and the large amount of travelling involved in deal- ing with comparatively trivial cases. Second, the prevalence of insurable casual employment in small and scattered industries, especially in connection with farming and allied occupations. Many of the casual workers are homeless tramps or " gypsies," and although their employment is a constantly recurring feature of the industries concerned, the difficulty of tracing or identifying individual workers w^ho move from place to place continually, and are seldom known by their cbrrect names, is very great, an-d fre- quently insuperable. Third, the wandering nature of certain minor employments of frequent occurrence, e.g., work in connec- tion with threshing machines, barges, &c. Fourth, the' reluct- ance or inability exhibited in the agricultural districts to deal with even the simplest matters by correspondence. Fifth, the marked extent to which questions as to insurability or as to who is the immediate employer, still arise and require detailed investigation. Quite apart from genuine cases of difficulty, -there appears to be a tendency -among certain small employers to endeavour to raise technical points by seeking to apply half understood legal pro- nouncements to the circumstances of their employees. 659. Survey work is steadily proceeding, and in some districts a survey of business premises and farms in large areas has been completed, but as the proportion of cards seen to employers visited is only about five to one on the. average, and the employers are extremely scattered, the process is necessarily slow. The proportion of irregularities revealed in survey is very small, vary- ing from 4 per cent, to 2 per cent., and is probably diminishing. Occasionally a whole day's survey, comprising visits to over 40 business premises, will reveal no irregularities. The utility of sur- vey work, however, is not confined to the rectifying of irregulari- ties ; especially in country districts the visits of the Inspector are welcomed, and he is able to render useful service by advising on points in relation to the general administration of the Acts. In this way a very considerable number of difficulties and misunder- standings are cleared up on the spot. Survey also helps to make officers better known in their districts, and thus enhances their usefulness as channels of information both to the public and to the Commission. 236 ' England, 660. In this Division survey work is at present entirely sub- sidiary to the investigation and adjustment of complaints and other special cases. Though the relative importance of these cases tends to diminish, their numbers appears to be increasing. By far the larger number of complaints as to non-pay- ment of contributions arise in connection with casual employment and domestic servants. In the former cases, though there is some grumbling on the part of employers at the obligation to pay a whole week's contribution in respect of only a day's or half- day's work, the complaints are seldom due to deliberate evasion; more often it is a matter of forgetfulness at a busy season, mis- understanding as to the applicability of a Subsidiary Employ- ments Order, or the fact that the casual disappears after taking the largest " sub " he can get, and does not complain imtil his Society asks him for his card, or until he requires benefit. In the case of domestic servants, an aftermath of the defunct resist- ance movement still causes trouble. Quarrels, sudden dismissakr,. or illnesses, are prolific sources of complaints in these cases. 661. Many complaints are received alleging that the employer has wrongfully detained the contribution card. More often than not these are cases in which the employee has left without giving notice* and without making any previous request for his card. Other frequent occasions for such complaints are loss of the card and disputes as to responsibility for the loss, or a misapprehension on the part of the employer to the effect that he has a lien on the card in respect of some claim against the employee. Or- ganised resistance, which was strong in parts of this Division at one time, has been abandoned. Prosecutions have, however, been necessary in a certain number of cases. 662. Numerous misapprelaensions and fallacies have had to be combated, but many of them still display remarkable vitality. The fallacy that the low-wage provisions in Part I. of the Second Schedule to the Act of 1911 apply indiscriminately to all insured persons irrespective of age is common, as is also a mistaken notion that there is a 26 weeks' waiting period for medical benefit - Married women are often erroneously considered to be excepted, especially if their employment is casual. Entire ignorance of either the existence or the use of emergency cards is frequently displayed. There are also frequent misconceptions as to the use of arrears cards. Many employers consider they are entitled to defer stamping until the expiry of the currency of the contri- bution card, irrespectively of the dates upon which wages are paid. Employers, moreover, seldom appear to realise that they forfeit their right to make deductions when the stamping of the card is postponed until after the wages have been paid. 663. The visiting of Approved Society officials has taken up a good deal of time, but the friendly personal relations established Outdoor Staff. 237 are proving of great value from all points of view, and in some cases it has been necessary to render considerable assistance. 664. Complains as to delay or non-payment of benefit occur, but are not very frequent, in this Division. Often they are due to muddles which only the Inspectorate can unravel. Careless insured persons occasionally surrender their successive cards in- discriminately to the Post Office or to the first Society official *they meet as the currency of each card expires, and on their sud- denly requiring benefit careful inquiry is necessary to discover the Society (if any) to which they really belong, and steps have to be taken to ensure that the various cards are ultimately asso- ciated and the- contributions credited to the proper account. Transfers from one Society to another are occasionally a source of confusion. One man complained that, though all his contribu- tions had been paid, his Society had told him that he was out of benefit. It was discovered that he had retained all his stamped cards in his own possession. Sometimes the Society concerned entertains a misapprehension requiring to be dispelled. 665. Except in the case of Brighton, callers at the District Offices have not been numerous, and the Staff of the Division have had to rely on other means of obtaining knowledge of matters requiring their attention. The chief sources of informa- tion have been (1) complaints by Approved Societies as to non- payment of contributions ; (2) personal communications during survey or special visits ; (3) letters addressed to the Commission or transmitted by Insurance Committees. Doctors frequently take a keen interest in assisting such of their patients as have any difficulty with regard to benefits, but they are often in the dark as to the proper agency to which to apply, or the procedure to be adopted. All officers comment on the change that has taken place in the attitude of the public towards the Inspectorate. 666. Eelations between the Staff and Insurance Committees throughout the Division are of a most cordial character, and one cannot help being struck by the devotion and enthusiasm dis- played by the officials of Insurance Committees, nor can one fail to appreciate their endeavours to promote the proper co-ordination and harmonious relationship between the various bodies on which the administration of National Health Insurance devolves. In a variety of ways the Inspectorate owes a great deal to their assistance. 238 England. CONCLUSION. 667. In concluding this record of the administrative duties carried out by the Commission during the past year, it is desirable to refer briefly to two matters for the guidance of those who read the Report from different points of view. The Eeport is, in the first place, a summary of administrative detail, and those who seek information on one or a few only of the subjects which it touches may find helpful the detailed, and paged analysis of contents with which, as last year, the volume opens. In the second place, some attempt has been made to extend the field surveyed by the Eeport in such a way as to respond to the interest which has been increasingly shown of late in the secondary results of the operation of the Acts. The Commission can only regret that the pressure of work (not only at the Com- mission, but still more upon the Societies and the Insurance Committees) during the year has compelled them to restrict within narrow limits any statistical returns or special enquiries which have not been immediately necessary in the ordinary course of administration. But it is believed that conclusions of value may be drawn from the consideration of the new information contained in various portions of the Report and Appendices, as for instance in Appen- dices VI and IX, which exhibit the varying degrees of regu- krity of payment of contributions among men and women, as regards members of Approved Societies on the one hand and deposit contributors on the other; or again, from the results (shown on page 173) of an inquiry into the importance attached by insured persons themselves to the opportunity of consulting a doctor as a right. The value attached to this right is further shown by the figures on page 186 of the applications for medical benefit received from exempt persons. Again, it may be assumed that for those who study the Eeport as a contribution to knowledge rather than as an administrative record, a special interest will lie in the statements of the Chief Actuary ; or again, in the figures shown in Appendix XV considered as indicating tlie variation in the incidence of sickness in different localities. The Commission draw attention to such points as these only to indicate that they have in mind the desirability of extending from time to time, so far as their primary duties permit, the space devoted in their Annual Eeport to the analysis of the material in their possession, and to the presentation of such con- clusions as may emerge from a wider experience in admin- istration. Egbert L. Morant, Chairman of the National Health Insurance Commission (England). John Anderson, Secretary. June, 1914. 239 PAET IV. NATIONAL HEALTH INSURANCE COMMISSION (SCOTLAND). INTRODUCTORY. 668. The arrangement of this, the Second Annual Report of the National Health Insurance Commission (Scotland) differs somewhat from that adopted for the Report for the year 1912-13. 669. In the first Section, which deals with the structure of the National Health Insurance system, will be found an account of the machinery set up under the Act of 1911 ; the changes in that machinery necessitated by the Act of 1913; and the number and composition of the population insured under the Acts. 670. In the second Section, which deals with the working of the system, will be found particulars as to — (1) the collection of contributions, and (2) the administration of the benefits conferred by the Acts. 671. The third Section deals with the finance of the Acts and the accounting arrangements. 672. The fourth Section deals with the work of the Outdoor Staff of the Commission. It has been thought desirable to describe this in a separate Section. By this means it will be possible to see the administration of the Acts as viewed by the Inspectors, who are brought into close touch with the population coming under the scheme. 673. The Report does not profess to give a comprehensive picture of the whole machinery. This was done in the Report for 1912-13, where also the special difficulties involved in forming the structure and starting its operation were dealt with at length. The information there given is, however, brought up to date. The new difficulties which have arisen are explained; the results of the Act of 1913 and the new Regulation^ are described, and fresh aspects of the administration which have become apparent within the year are discussed. 674. The statistical material has been collected in a series ot Appendices. It has thus been possible to relieve the text of the Report and to present all the figures together in a form in which they are readily accessible and comparable. It was obviously desirable that, so far as practicable, the statistical information should show the position of matters at one uniform date, and for this purpose the end of the period of currency of the sixth quarter's contribution card, namely, 11th January, 1914, 240 Scotland. has been taken. This date has the advantage of approximating to the end of the calendar year 1913. The descriptive matter containea in the Eeport has, however, been brought down to the latest possible date. 675. Although the primary concern of Part I. of the Act of 1911 and the Act of 1913 is the health of the insured population, the pro- visions re-act upon practically every aspect of economic and social conditions. This fact is impressed with increasing force upon those connected with the administration. There is constant need for knowledge and close study of industrial conditions and industrial processes, rates and methods of remuneration, social con- ditions and social structure, the problems of pauperism and unem- ployment as they bear upon contributions and benefits, and so on almost indefinitely. 676. In the course of their administration the Commission have consequently had to make calls on the resources of other Government and Public Departments and of Local Authorities for information and assistance. ' The Commission desire to place on record their appreciation of the help so readily given, and also to express their recognition of the manner in which employers of labour have co-operated with them in the solution of the many difficult problems incidental to the work. 677. The measure of success obtained has been contributed to by the ability and energy with which members and ofl&cers of Insurance Committees and officers of Approved Societies have carried through the very heavy work falling upon them, the magnitude of which will be apparent from a perusal of the Eeport. 211 I. THE STRUCTURE OF THE SYSTEM OF NATIONAL HEALTH INSURANCE. 1. The Commission and the Advisory Committee. THE COMMISSION. 678. There has been no change in the personnel of the Com- mission since the date of the previous Keport. The powers of the Commission have, however, been extended in certain directions by the Act of 1913. THE ADVISOEY COMMITTEE. 679. The Commission have to announce with regret the following resignations from the Advisory Committee, which was appointed to advise and assist the Commission in the making and altering of Begulations: — Mr. E. W. Hanson — One of the representatives of employers. Miss Agnes H. Brown — One of the representatives of insured persons. The Commission desire to express their sense of the loss which has been sustained by the death of Miss M. L. Walker, of the Dundee Social Union, who was one of the most active members of the Conamittee. Her work, both as a member of the Advisory Committee and as a member of the local Insurance Committee, contributed to the solution of many problems which arose in the early days of the administration of the Act. 680. A full list of the members of the Advisory Committee was given in Appendix I., page 545, of the last Annual Eeport. The following appointment has been made to the Committee during the year: — Mr. F. H. Bisset — ^Representing employers. 681. The Advisory Committee has been frequently consulted on the drafts of Eegulations, and its advice has been of great value to the Commission. In some cases the consultations have been made by post with the individual members, but in addition meetings of the Committee have been held both in Edinburgh and in London. The principal Eegulations on which assistance was sought related to: — (1) Payment to be made on the death of a deposit contributor; (2) Election of Panel and Pharmaceutical Committees (Medical and Pharmaceutical members only were consulted) ; (3) Claims for certificates of exemption; (4) Determination of questions under Section 67 of the Act of 1911 (Disputes); (5) Medical benefit (joint meeting of Advisory Committees); (6) Arrears of contributions (joint meeting of Advisory Com.- mittees) ; 242 Scotland. (7) Payments by Approved Societies and Insurance Committees to charitable institutions; (8) Amalgamation and transfer of engagements of Approved Societies ; (9) Dissolution of Approved Societies ; (10) Withdrawal of approval from Societies; (11) Appointment of representatives of insured persons on Insur- ance Committees. 2. Population under the Acts. NUMBERS OF INSURED PERSONS. 682. It is not possible to give any exact figures showing the changes in the number of persons insured, as the contribution cards received do not afford an accurate measure. The following Table shows, however, the number of cards for each quarter received up to date. * * * f^ f^ ;-( f-I u u 3) _S Oi ® (U -tS ■£ -g ^^ Cards received. 1 a H n pi 1 (§ a :y O* C? 5- -u T^ 'r5 5 ,^3 .c OD fi S-. ^ CO tI io cS Members of Approved Societies Employed contributors- Men 1,022,681 1,027,4431,005,961 Women ... 431,294 435,034! 419,735 Voluntary contributors- 1 1 [^1,448,098 1,382,641 1,062,296 Men - 1,229 1,875 1,857 1 Women 416 1,063! 1,634 J Deposit Contributors— 1 Men 28,514 23,620 18,861 17.255 15,217 11,489 Women 16,001 12,431 11,094 11,503 1 11,705 9,574 '^°^Hwlen :: 1,052,424 446,711 1,052,9381,026,679' 44'(,528| 432,463 ! 1 1 1,476,856 1,409,563 1,083,359 Grand Total 1499,135 1,501,466 l,4o9,142' : 1 1,476,856 1,409,563 l,0b3,359 * Statistics in respect of these quarters, so far as members of Societies are concerned, are not yet complete, and the figures given include cirds surrendered in respect of previous quarters. 683. It will be seen that the numbers of cards surrendered up to the present for the successive quarters following the second quarter (which ended on 15th April, 1913), show a decrease, with the excep- tion of the fourth quarter, in which there was a slight temporary increase. It cannot be assumed that this decrease represents a continuous diminution in the number of insured persons, as late cards for all the back quarters are being received, and the bulk of the cards still to be surrendered certainly relate to the later quarters. On the other hand, there are no facts on which to base any expectation that the number of insured persons has increased. structure of the System: Population under the Acts. 243 684. In this connection the figures published by the Kegistrar- General for Scotland are of considerable interest. The population of Scotland, estimated up to the middle of each of the past four years, is as follows : — 1910 4,737,268 1911 4,749,673 1912 ...^ 4,741,077 1913 ..r;*-^.: 4,728,132 It would perhaps.be rash to base any generalisations on these esti- mates, but they are, nevertheless, significant. The decline appears to be attributable partly to the continued fall in the natural increase, i.e., the excess of births over deaths, but to a greater degree it is due to emigration. Taking these causes together, there is no doubt that their effect is chiefly upon the classes of persons who would come within the operation of the Insurance Acts. While the actuarial basis of the Acts is of course not affected by these considerations, it is necessary to enter a warning against the assumption that the gross annual income under the Acts is continually increasing in Scotland. EXEMPT PEESONS. 685. The question of the persons exempted from liability to contribute imder the Acts has increased in importance during the year, owing chiefly to the fact that under the 1913 Act such persons are, subject to conditions, entitled to receive medical and sanatorium benefits. The arrangements made for the administration of benefits to thejn are for convenience given in Section II., page 334, below. Persons entitled to Exemption. 686. Any person employed within the meaning of the Acts is entitled to a certificate of exemption if he proves to the satis- faction of the Commission that he is either — (1) In receipt of a pension or income of the annual value of £26 or upwards not dependent upon his personal exertions ; or (2) Ordinarily and mainly dependent for his livelihood upon some other person ; or (3) Ordinarily and mainly dependent for his livelihood on the earnings derived by him from an occupation which is not employnient within the meaning of the Acts. 687. The last-mentioned ground on which a certificate of exemp- tion can be obtained was added to Section 2 of the principal Act by Section 6 of the Act of 1913, and has been operative as from the 1st of September, 1913. It may be briefly explained that, for the pur- poses of claims upon the new ground, occupations may be divided into two classes : — (1) Employments specially excluded from compulsory insurance. (2) Occupations adopted for a livelihood which are not employ- ments within the meaning of the Acts. Typical cases in Scotland falling under the first head are established Civil Servants; persons employed by a local or other 244 Scotland. public authority to whom a certificate of exception has been granted under Part II. (6) of the First Schedule to the Act of 1911; school teachers to whom a superannuation scheme under Section Z4 of the Education (Scotland) Act, 1908, applies; and persons employed otherwise than by way of manual labour and remunerated at a rate exceeding £160 a year for whole-time service. The second head includes any business or profession in which a person engages on his own account. Typical cases here are shopkeepers and persons who let lodgings for a living. All persons in these classes have an occu- pation within the meaning of the Section, and are entitled to apply for a certificate of exemption. Procedure in regard to Contribution Cards. 688. Section 9 of the Act of 1913 having altered the status of exempt persons in regard to benefits, it was deemed expedient to make certain changes in the procedure for distributing and returniDg the contribution cards of such persons. 689. Prior to 12th January, 1914, the employer obtained the appropriate contribution cards from the Post Office, noted thereon the name, &c., of the exempt person, and returned the stamped cards to the Commission. It was decided, however, that on and after that date the contribution cards should be issued by the Com- mission direct to exempt persons, who would become the custodians of their own cards, and be responsible for* returning them to the Commission. The cards were also framed to cover a period of six months instead of three. 690. The Commission were enabled to dispense with the exemp- tion book formerly in use, which the employer was required to sign each week in which there was employment involving liability to pay contributions. The employer need now only sign the contribution card on the termination of the employment of the exempt person, or on the expiry of the card. This simplified procedure has been found to be greatly appreciated by employers. 691. The new procedure also rendered it impossible for anyone other than the holder of an exemption certificate to obtain the special contribution cards for exempt persons. Formerly con- siderable trouble was experienced on account of these cards having been obtained and used in respect of persons who were not exempt. In all such cases a re-adjustment of the contributions had to be made when the cards were returned to the Commission. The procedure outlined above is prescribed in Eegulations made on 10th January, 1914, by the Joint Committee and the Commission acting jointly. (Collection of Contributions Consolidated Eegulations (Scotland), 1914.) Renewal of Exemption Certificates. 692. An exemption certificate is normally current for a period of twelve months, when it falls to be renewed. In order to facilitate the work of renewal it was considered advisable that the certificates structure of the System: Population under the Acts. 245 should be made to expire on fixed dates throughout the year. Thus, certificates issued during the first quarter expired at the end of the fourth quarter; those issued during the second quarter expired at the end of the fifth quarter, and so on. Further, as the great majority of the certificates were issued during the first quarter, and as their renewal at the end of the fourth quarter caused con- siderable congestion in the Department, it was found necessary to provide that, in future, the volume of work in connection with the renewals should be more evenly distributed over the year. Accord- ingly, as regards the certificates renewable at the end of the fourth quarter, steps were taken to grant half of them for a period of nine months and half for a period of twelve months. In addition to relieving the congestion, the Commission will thus be enabled to dispose of applications for renewal without delay. 693. The procedure for the renewal of a certificate of exemption is very simple. A form of application for renewal is sent to each exempt person some six or eight weeks prior to the expiry of the certificate. If his circumstances have not undergone any change since the previous certificate was granted, the exempt person merely signs the declaration provided on the form to that effect. If, however, a change has occurred, particulars thereof must be furnished. In the large majority of cases these particulars are sufficient to enable the Commission to issue a fresh certificate. Where investigation is necessary — usually in the case of apprentices whose certificates are obtained on the ground of dependency, and whose circumstances vary from year to year on account of increased earnings — the case is referred to the local Officer of Customs and Excise for the purpose of obtaining particulars of the precise earnings and of the value of the maintenance of the exempt person. 694. The majority of cases in which, owing to an alteration in circumstances, the certificate of exemption cannot be renewed, are those of professional and trade apprentices. Generally speaking, no objection is taken to the decision of the Commission in refusing to renew a certificate, the exempt person himself realising that he has in point of fact ceased to be entitled to exemption. The total number of cases in which renewal of the certificates had been refused by the Commission up to 11th January, 1914, was 359. 695. As regards cases where an exempt person permanently removes to England, Ireland, or Wales, arrangements have been made for the issue of a new certificate by the Commission of the country concerned. Information is also furnished to that Commis- sion as to the contributions previously paid, in order that the position of the exempt person in regard to benefits may not be prejudiced or affected by the change of residence. A similar procedure is adopted with regard to exempt persons removing from another country to Scotland. Numbers of Exemption Claim,8, &c. 696. The large majority of claims for exemption certificates were lodged during the first quarter of the operation of the Act (15th 246 Scotland. July, 1912, to 13th October, 1912), the number received during that period being 11,960. The number of new claims now being received is comparatively small, the average over a considerable period being less than 50 per week. Appendix XXIII., page 528, contains Tables showing the numbers of exempt persons, certificates issued and cancelled, and the grounds of exemption. The total number of exempt persons in Scotland on 11th January, 1914, was 7,935. 697. The large majority of claims now being received are on the ground of dependency. The proportion of such claims is also in- creasing. A considerable number of claims are still received from married women, most of whom are employed as charwomen or are engaged for a few weeks in the year in the fishing industry or in agricultural employment. 698. The number of claims submitted on the ground of dependence on an occupation which is not employment within the meaning of the Acts referred to in paragraph 687 above is comparatively small. 699. An examination of the contribution cards received during the first five quarters in respect of persons who held certificates of exemption on 11th January,, 1914, gives the following particulars with regard to the regularity with which contributions are paid in respect of such persons: — (a) In 56 per cent, of the cases contributions were fully paid. (h) In 9 per cent, of the cases the contributions paid were 90 per cent, of the total possible. (c) In 7 per cent, of the cases the contributions paid were between 75 and 90 per cent, of the total possible. (d) In 8 per cent, of the cases the contributions paid were between 50 and 75 per cent, of the total possible. (e) In the remaining 20 per cent, of the cases the contributions paid were less than 50 per cent, of the total possible. This class includes a large number of cases where the exempt person is engaged in seasonal employments, e.g., the mar- ried woman employed during the fishing season and the student employed during holiday periods. The examination also discloses the fact that on the average the contributions paid were about 80 per cent, of the total possible. From the above results it is clear that, with the exception of married women, exempt persons are, generally speaking, engaged in regular employments. Exemption Certificates for Institutions. 700. Thirty-three applications for certificates of exemption under Section 51 of the Act of 1911 were received from the managers of institutions carried on for charitable or reformatory purposes. After enquiry it was found that the application could be granted in practically every case. Certificates were accordingly issued, and were dated retrospectively as from 15th July, 1912. It was considered expedient that the certificates should be current for a definite period. They were therefore made to expire on Slst December, 1914, but may then be renewed on a fresh application. structure of the System: Population under the Acts. 247 701. In a few cases it appeared that the general body of inmates were not employed under contract of service. The Commission, however, took the view that as some of the inmates might occasion- ally be so employed, the managers of the institutions were entitled to receive a certificate of exemption. EXCEPTIONS. Exceptions under Paragraphs (5) and (c) of Part II. of the First Schedule to the Act of 1911. 702. Since the date of the last Keport only two certificates of exception under paragraphs (b) and (c) of Part II. of the First Schedule to the Act of 1911 have been issued — one under paragraph (h), to the Aberdeen Savings Bank, and one under para- graph (c), to the North Eastern and Great Northern Railway Com- panies. The total number of certificates now issued is 79 under paragraph (h) and 18 under paragraph (c). A summary is given below: — Class of Employment. Number of Certiticates granted. Approximate Number of Employees excepted from Insurance. Men. Women. Total. Paragraph (b) : — Asylum Officers Police Officers (County) Police Officers (Burgh) ^Miscellaneous ... Paragraph (c) : — Kail way Companies Clerks and other salaried officials... 11 31 31 6 18 460 2,068 3,703 392 8,223 471 "2 202 931 2,068 3,703 394 8,425 Total 97 14,846 675 15,521 ■^ In the case of the Certificates granted to the Treasury covering all established Civil Servants and to H.M. Commissioners of Woods, &c., no figures are available at present showing the number of employees affected. Exceptions under Paragraph (i) of Part II. of the First Schedule to the Act of 1911. — Subsidiary Employments. 703. The Joint Committee, acting jointly with the Commission, have issued seven Special Orders under paragraph (i) of Part II. of the First Schedule to the Act of 1911, specifying certain employ- 248. Scotland. ments as being of such a nature that they are ordinarily adopted as subsidiary employments only, and not as the principal means of livelihood. Only one Order applying exclusively to Scotland has been issued since the date of the last Eeport of the Commission. It excludes from the scope of compulsory insurance — " Employment in Scotland involving part-time service only as a ground officer, i.e., the employment of a person engaged as a ground officer and not otherwise ordinarily engaged in the employment of the person to whom the service is rendered." 704. Considerable trouble has been experienced in consequence of a widespread misapprehension that, because in a particular case a certain employment was in fact a subsidiary employment, it was therefore excepted from compulsory insurance. It may be pointed out that before any employment can be regarded as subsidiary for the purpose of exception it must be specified in a Special Order, and that such an Order can only be made in regard to a class of employ- ment. It cannot be made applicable to a particular individual unless he comes within the scope of a class of employment which is capable of specification. Questions as to Liability to Compulsory Insurance submitted for Decision under Section 66 of the Act of 1911 and Section 27 ( 2) OF the Act op 1913, and other Exceptions under Part II. of the First Schedule to the Act of 1911. 705. Section 27 (2) of the Act of 1913 empowers the Commission to decide any question which may arise as to who is the employer of an employed contributor in like manner as a question under Section 66 of the Act of 1911. Forms were prescribed in Eegu- lations made on 2nd December, 1913 (National Health Insurance (Determination of Questions Amendment) (Scotland) Kegulations, 1913), on which cases of this type may be submitted to the Com- mission. FoTmal Hearings of Questions. 706. Since the publication of the last Eeport only two formal hearings have been held by the Commission. These referred to the employment of men engaged — (1) in discharging pig-iron at Leith Docks; (2) in stowing and handling jute in the jute warehouses in Dundee. The Commission decided that the employment was employ- ment within the meaning of the Act in both cases, and that, as structure of the System: Population under the Acts. 249 regards the first, the shipping agents, and as regards the second, the warehouse owners or lessees, were liable as the employers of the men. 707. Altogether nine formal hearings have been held since the commencement of the Act, including the two referred to. With regard to the remaining seven (to which a passing reference was made in the last Keport) the following Statement shows the classes of employment concerned and the decision given in each case: — Classes of Employment. Decision. Benchers or assistants en- gaged with potters or throwers at pottery works 2. Licensed pilots for the Port and Harbour of Dundee 3. Coal-trimmers at Leith Docks 4. Wood-cutters, sawyers and barters engaged by timber merchants 5. Persons engaged in harvesting or other agricultural work and remunerated by the acre or otherwise. In this case two types of employ- ment were considered (1) Where the employee is engaged by the farmer to render personal ser- vice at a certain specified piece rate and is subject to the same degree of control and to the same conditions regarding dismissal as an ordinary employee. (2) Where a person contracts with a farmer to do a specified quantity of work and engages, dis- misses, controls and pays his own assistants at his discretion. That the employment was employment within the meaning of the Act. The opinion was expressed that the pottery firm was liable as the employer. That the employment was not employment within the meaning of the Act. That the principal of the squad of coal- trimmers was not an employed person, but that the men engaged by him were employed within the meaning of the Act, the principal of the squad being liable as their employer. That the employment was not employment within the meaning of the Act. The opinion was expressed that the wood-cutters, &c., were liable as the employers of the men whom they engaged to assist them. (1) That the employment was employment within the meaning of the Act. (2) That the employment was not employ- ment within the meaning of the Act. In the latter case the contractor is liable as employer of any assistants whom he may engage. 250 Scotland. Classes of Employment. Decision. in value £160 a year. 6. Sea-going Engineers at a rate As a result of this hearing the Commission of remuneration exceeding I laiddown the folio wing general principles: — {a) That, in view principally of the fact that he has a qualihed subordinate Engineer ' acting with him when on watch, the First !^ngineer on a vessel carrying a total of four Engineers or more is generally not employed by way of manual labour. (h) That the First Engineer on a vessel carrying a total of two Engineers is gener- ally employed by way of manual labour. (c) That in the case of a First Engineer on a vessel carrying a total of three engineers, the facts of each individual case must be separately considered, and no general ruling ' can be given. 7. Killers and assistant killers at the Glasgow Cattle Market In this case the conditions of the employ- ment varied according to the class of killer and assistant killer, and the Com- mission issued rulings in regard to each particular class of case. Questions submitted to the Court of Session. 708. As stated in the last Eeport, the Commission have availed themselves of the procedure authorised by proviso (iii.) to Section 66 (1) of the Act of 1911, by which they are empowered to submit to the Court of Session for decision any question as to whether any- class of employment is or will be employment within the meaning of the Act. In all cases except one so dealt with, the Commission and the respondents were able to adjust a statement of facts setting forth inter alia the duties of the various persons concerned, and accordingly it was not necessary to lead evidence. 708. The petitions presented to the Court by the Commission related to the following classes of employment : — (i.) Employment in the Edinburgh Royal Infirmary at a rate of remuneration not exceeding £160 a year as for full-time service — (a) as resident physicians and resident surgeons ; (b) as non-resident house physicians, non-resident house surgeons, and clinical assistants; and (c) as supervisors of the administration of anaesthetics. The Court held in each case that the employment was not employ- ment within the meaning of the Act. The ground of the judgment .was that as the managers of the infirmary have no control over the manner in which these members of the staff carry out their treatment of patients no contract of service exists between them and the managers. [A report of the caae is to be found in the official reports of the Court of Session — the Scottish Insurance Commissioners v. the Edinburgh Royal Infirmary, Session Cases, 1913, page 751.] (ii.) Employment as assistants to ministers, student mission- i structure of the System: Population under the Acts. 251 aries.and lay missionaries of the Church of Scotland and of the United Free Church of Scotland, remunerated at a rate not exceeding £160 a year as for full-time service. The Court decided that assistants to ministers were not employed within the meaning of the Act in respect that they hold an ecclesiastical office and perform their duties subject to the laws of the Church, and not subject to the control and direction of a master under a contract of service; that student missionaries were not employed within the meaning of the Act in respect that their services are merely incidental in the course of their studies, and not work done under a contract of service; but that the lay missionaries were employed within the meaning of the Act, in respect that they hold no ecclesiastical status and are appointed by and subject to the control of the minister or kirk session or committee. [A report of the case is to be found in the official reports of the Court of Session — the Scottish Insurance Commissioners v. the Church of Scotland and another, Session Cases, 1914, page 16.] (iii.) Employment as Collectors of Poor Eates, Inspectors of Poor, Sanitary Inspectors, and Eegistrars of Births, Deaths and Marriages, where the rate of remuneration does not exceed in value £160 a year as for whole-time service. While this petition was before the Court the Act of 1913 was passed. Section 6 of which provides that there shall be included among the employments within the Act employment under any local or public authority, except such as may be excluded by a Special Order. In view of this provision it was not thought neces- sary to proceed with the petition, and accordingly leave was obtained from the Court to withdraw it. (iv.) Employment as fishermen who are remunerated for their labour by shares in the profits of the working of a vessel registered in Scotland, and who have no proprietary or other interest in such vessel or in the nets or gear thereof; and fishermen who are remunerated by shares in the profits of the working of a fishing vessel and who receive a further share of said profits in respect of their ownership or part ownership of the nets of such vessel, but have no pro- prietary or other interest in the vessel itself. • In view of the varied conditions of employment with regard to these fishermen it was not found possible for the parties to adjust a statement of facts to submit to the Court, and a proof was taken before Lord Mackenzie on 3rd, 4th, 5th, and 6th March, 1914. The evidence having been printed and submitted to the First Division of the Court of Session, counsel were heard on the evidence on 2nd, 3rd, and 4th June. The decision of the Court (delivered on 16th June) was that the fishermen in question, with the exception of share trawl fishermen, are not employed within the meaning of the Act. The Court found it to be established by the evidence that there is on the part of these fishermen (with the exception men- tioned) an obligation sanctioned by invariable custom — although only by custom — and not an honourable obligation merely, to share in the losses of a fishing venture, and this liability to share in losses 252 Scotland. was held to be the determining factor in the case, differentiating it from one of contract of service and placing it in the category of joint adventure. Appeal Case. 710. The managers of a charitable institution appealed to the Sheriff Court against a decision of the Commission to the effect that certain inmates who, in addition to maintenance, received a monev payment, were employed within the meaning of the National Insur- ance Acts. The appeal was sustained. Other Important Decisions. 711. Nearly 1,700 decisions {see Appendix XXIV., page 531) on questions submitted under Section 66 of the Act of 1911 have now been issued by the Commission. It is not possible in this Eeport to set out the cases in detail, but a brief review of the more im- portant principles raised by them, together with particulars of a few typical cases and some of the difficulties which they presented, are given below: — (a) Fencers, drainers, hedgers, dykers, &c. — Numerous cases were submitted concerning the position under the Acts of persons engaged by farmers or landlords to erect fences, construct drains, cut hedges, &c., at a certain specified piece rate. It was, however, found that the circumstances varied considerably, and that while a person might not be insurable as regards one particular job, he might be insurable in respect of another. Inquiry was therefore necessary in each case as to the conditions of the employ- ment. (6) Rabbit catchers and mole catchers. — In cases of this class the farmer engages men to kill rabbits and moles at a certain price per head. The engagement usually extends over a certain period of the year. In some cases the farmer pays a fixed sum for the season. The employee is generally allowed his own discretion as to the method and time in which the work is to be performed, subject to the requirements of the Ground Game Act, and very often he has other similar engagements running concurrently. The Com- mission have taken the view that in such cases the employment is not under contract of service. Sometimes, however, the rabbit catcher is employed under the direct supervision of a gamekeeper or by another rabbit catcher. Here there is a strong presumption in favour of employment under contract of service, and special investi- gation of the facts is necessary in each case. (c) Clerk of works. — In cases where a clerk of works is paid a fixed salary the Commission have decided that there is a contract of service and that the employment is employment within the meaning of the Act, unless it yields remuneration at a rate exceeding £160 a year. In one case, where the clerk of works was paid at so much per visit, the Commission held that there was no contract of service, and therefore no liability to compulsory insurance. (d) Employment of a firm. — In Scots Law a firm has a structure of the System: Population under the Acts. 253 different persona from an individual, and the Commission have held that a firm employed as such cannot be regarded as employed under contract of service. (e) Working directors : shareholders. — A common misapprehen- sion has prevailed that if a person is employed by a firm in which he is also a director or a shareholder he is not employed under contract of service. The mere fact, however, that an employee is also a director or a shareholder is not material so long as his appoint- ment, control, and dismissal are subject in the usual way to a majority vote of the directors or management of the firm. In all cases falling under this category the Commission found that the employment was under contract of service. (/) Working partners. — In considering the case of a person taking an actual part in the management and conduct of a business, where there is no written deed of partnership, and where the partner- ship has merely arisen out of custom, considerable difficulty obtains in determining whether in fact a partnership does exist. Each case necessitates investigation, and in a number of cases the Commission have been satisfied as to the existence of an actual working partner- ship, although there was no documentary evidence to that effect. (g) Chi'inney sweeps and window cleaners. — Generally speaking, there is no contract of service where a person is engaged directly by a private individual to sweep chimneys or clean windows at a fixed sum for the job, assuming that he is allowed his own discretion as to the method of performance of the work, subject to its being done properly. Several cases, however, have come before the Commission where a person in regular business as a chimney sweep or window cleaner employs men to assist him in the work, paying them generally according to the work done, but retaining a certain portion of the earnings in respect of his ownership of tackle, &c. In such cases the Commission decided that the employment was under contract of service. Bates of Contribution. 712. Misunderstanding still prevails in regard to the contributions payable in respect of part-time workers, such as charwomen, office cleaners, &c. The contribution in such cases depends not on the amount actually earned by the worker, but on the rate of remunera- tion for a full working day in the particular kind of employment. 713. A question of considerable importance was raised as to whether a bonus granted to shop assistants at the end of each year could properly be taken into account for the purpose of calculating the rate of remuneration for a working day. In the particular case submitted it was ascertained that the bonus was a normal incident of the employment, and accordingly the Commission decided that it might properly be taken into account for the purpose of reckoning the rate of remuneration. The Commission also took the view that, as a rule, the amount received for the previous year might be taken as the estimate of the bonus for the succeeding year. 714. Payments for special services, including payments made by 254 Scotland. farmers to employees in respect of extra work during harvest, raised questions as to the extent to which such payments should be taken into account in calculating the rate of remuneration. The Commis- sion decided that the payments were applicable only to the particular weeks in which the services were rendered, and could not be included in reckoning the rate of remuneration for the rest of the year. Agricultural Employments. 715. In several parts of Scotland misunderstanding still con- tinues as to the meaning of the term " outworker " as used in the National Insurance Acts. The term is locally applied to women workers on farms, regarding whom it has been erroneously assumed that they were excepted from the scope of compulsory insurance. A considerable number of cases have also been brought before the Commission where a husband and wife were jointly em- ployed by a farmer, but liability had' been assumed only in regard to the husband's insurance. A typical case is that in which the wife is employed on such work as tending poultry, making butter, and milking. It has usually been found that there' is a joint engage- ment of husband and wife, and that accordingly the latter is liable to be insured. Where, however, the wife is employed only as a milker, and is not otherwise ordinarily engaged in the service of the person to whom services as a milker are rendered, the employment is excepted from compulsory insurance in terms of a Special Order. (National Health Insurance (Subsidiary Employments) Provisional Order, 1912, No. 1.) 716. A case arose in which a farm servant employed under a six- monthly agreement broke his engagement before the stipulated period had expired, and before any wages had been paid. In this case it was urged that the exception in paragraph (/) of Part II. of the First Schedule to the Act of 1911 — which excludes from com- pulsory insurance employment on an agricultural holding without wages or other money payment — applied, but the Commission were unable to accept this view, and the employer was required in such circumstances to pay contributions up to the date on which the employment ceased. 717. Investigation has been made into the case of " bound- workers " on a farm, which arose in the South- West of Scotland. In certain areas it is the practice to engage male workers who are able to provide the services of women to perform work for the farmer whenever he may so require. The services usually consist of milking, turnip shawing, harvesting, &c., and the male worker, in addition to money wages, receives benefits which vary according to the number of ** bound- workers " whose services he is able to supply. The bound-workers participate in the benefits in question, but receive no cash wages from the farmer, except in respect of periods during which they are rendering services. In such cases the Commission took the view that the farmer is liable for the pay- ment of contributions in respect of the women only during periods when services are rendered. structure of the System: Population under the Acts. 255 Manual Labour. 718. An employed person whose rate of remuneration from his employment exceeds £160 a year is not required to be insured in respect of such employment unless it is employment by way of manual labour. In the early stages of the Act, considerable doubt existed as to the precise interpretation to be placed upon the term " manual labour," and numerous cases of varying difficulty were referred to the Commission for decision. 719. In dealing with such cases, the Commission have been guided largely by the principles embodied in Mr. Justice Swinfen- Eady's judgment in the cases of the tailor's cutter and dairyman's foreman submitted by the English Commission to the High Court. Eegard has been had as to what is the real and substantial nature of the employment, to the exclusion of merely incidental and acces- sory elements. 720. The majority of the cases submitted to the Commission were those of foremen, overseers, and managers. Each case, however, had to be decided upon its merits, as it was impossible to lay down any hard and fast rule. Some indication of the general principles adopted may be obtained from the decisions in the follow- ing instances : — (1) Employment hy way of manual labour. Professional footballer ; Chauffeur (who cleans the car and effects minor repairs). (2) Employment not hy way of manual labour. Tailor's cutter ; Furrier's cutter ; Piano tuner ; Gymnastic instructress employed by an education authority ; Lithographic artist. Employment under a Local or other Public Authority. 721. Under the Act of 1911, persons employed by a local or other public authority were only compulsorily insurable if the em- ployment was employment under contract of service. In some cases doubt existed as to whether such a contract could be deemed to exist, and, as has already been stated (see paragraph 709), a petition was submitted to the Court of Session for decision as to the position of certain officers holding statutory appointments, but, in view of Section 6 of the Act of 1913, which came into operation on the 1st October, 1913, and in terms of which ** employment under any local or other public authority, unless excluded by a Special Order," was. brought within the scope of the compulsory provisions of the Acts, the petition in question was rendered unnecessary and was withdrawn. o 722. A Special Order (National Health Insurance (Employment .upder Local and Public Authorities) Provisional Exclusion Order .(Scotland), 1913), dated 18th October, 1913, has been issued under Section 6 of the Act of 1913, excluding from compulsory insurance '256 Scotland. the following classes of employment under local or other public authorities: — Employment as Analyst ; Employment as Assessor ; Employment as Chaplain or other Minister of Religion ; Employment as Public Prosecutor ; Employment of a duly qualified Medical Practitioner as Medical Officer of Health, Medical Inspector, Medical Adviser or otherwise in his professional capacity ; Employment as Registrar of Births, Deaths and Marriages ; Employment under contract of apprenticeship without money payment ; Employment as an unpaid officer of any Local or other Public Authority ; Employment, otherwise than as an officer or servant, of a Local or other Public Authority, not being an employment specified in Part I. (a), (b), (c) or (d) of the First Schedule to the National Insurance Act, 1911. 723. Persons employed under any local or public authority not coming under one of the above excluded classes are, therefore, liable to be insured as from 1st October, subject to the ordinary conditions of exception, e.g., on account of the rate of remuneration in indi- vidual cases for an employment (otherwise than by way of manual labour) being over £160 a year on a basis of whole-time service, or on account of the grant of a Certificate of Exception to a particular authority. 724. In cases where contributions had been paid prior to 1st October, 1913, some doubt existed as to whether they had been properly paid. In order to make the position clear, therefore, the Commission issued an Order under Section 78 of the Act of 1911 legalising the payment of such contributions and allowing them fco be carried to the contributor's credit, where, in virtue of Section 6 of the 1913 Act, he was rendered definitely insurable as an em- ployed contributor on or after the above date. Arrears of contribu- tions which accrued prior to 1st October, 1913, will, however, be deemed not to exist. 725. On the other hand, a person whose position was reasonably in doubt up to 1st October, 1913, and for whom no contributions were previously paid, has been treated as insurable from that date, if all parties interested so agree. 726. Having regard to the widespread uncertain tjr known to exist respecting the application of the National Insurance Acts to local authority employments, the whole question was made the subject of careful and extensive investigation by the Outdoor Staff of the Commission, covering practically the whole field of these employments. 727. It appeared that misapprehension was most common in regard to the employment of Inspectors of Poor, Collectors of Parish Rates, Clerks to Parish Councils, and Clerks to School Boards in rural areas. None of these offices is excluded by the Special Order issued under Section 6 of the Act of 1913. Each involves, strictly speak- ing, a separate appointment. Not infrequently, however, it hap- pens that all the offices are held by one person. In this case a point of importance to be considered is whether the rate of remunera- structure of the System: Population under the Acts. 257 tion in respect of each or any of the appointments does or does not exceed £160 a year. In determining this matter it has often been found impracticable to estimate even approximately the time devoted to each of the several employments, and in such circum- stances the Commission have usually found that a reasonable solu- tion of the difficulty is to consider the total earnings from all the employments with reference to the total time involved. The rate of remuneration thus obtained has been taken to represent fairly fche rate of remuneration from each employment. Thus in most cases the rate of remuneration has been found to be under £160 a year, and the ofi&cer has been regarded as compulsorily insurable. If he has been employed under two authorities, they have generally agreed to share the liability for contributions. In a very few cases only has it been found that the rate of remuneration exceeds £160 a year. 728. In some localities the appointments are held separately by different persons. Often a local merchant or a school teacher (ex- cepted in respect of his teaching employment) holds one or more of the appointments and performs the work in his spare time. In such cases the employment may be excepted in terms of Provisional Order No. 4, relating to subsidiary employments, as employment in the performance of clerical duties involving only occasional service or service outside the ordinary hours of work, or the employee may be in a position to claim exemption on the ground that he is ordinarily and mainly dependent for his livelihood on an occupation which is not employment in the sense of the National Insurance Acts. 729. School cleaners. — The investigation also revealed the fact that in a large number of districts no contributions had been paid in respect of school cleaners, under the misapprehension that because the employment was not the women's chief source of liveli- hood they were not required to be insured. Even where contribu- tions were paid they were frequently paid in error at the reduced rate {5d. a week), whereas in nearly every case it was found that, having regard to the actual number of hours taken to earn the wages paid, the rate of wages for a full day (from eight to ten hours) was considerably over 2s. 730. In certain districts it is the custom for School Boards to delegate to their janitors the appointment, dismissal, control and payment of school cleaners, and consequently it was frequently urged that the janitor, and not the School Board, is the employer. In every such case, however, a full consideration of the circum- stances has shown that the School Board is the responsible employer, and therefore liable for the payment of contributions. 731. Compulsory officers. — A difficulty in connection with com- pulsory officers has been the disinclination of some authorities to assume liability for contributions in respect of weeks in which the officer rendered no actual services. Where the appointment is a yearly appointment and services are rendered intermittently through- out the year, the School Board are liable for contributions. (B254— Gp. 5) I 258 Scotland. CASUAL LABOUE. 732. From the outset difficulty has been experienced in the appli- cation to casual labourers of the provisions of the Acts and Regu- lations, in regard more particularly to the payment of contributions. Under the 1913 Act the matter may be dealt with by means of a Special Order, and a careful investigation has been in progress for the purpose of ascertaining as far as possible what modifications of the general provisions are necessary or desirable. The results of this investigation are detailed in the Section of the Eeport on the work of the Outdoor Staff {see p. 359 below). DEPOSIT CONTRIBUTORS. 733. It was suggested in the last Report that the expectation as to the nature of the problem presented by the deposit contributor would prove to be very wide of the mark. The anticipation that deposit contributors would constitute a homogeneous class consisting solely of insured persons who, by reason of ill-health, were not able to obtain admission to an Approved Society, has certainly not been realised. It has been apparent to the Commission from the outset that, so far at least as Scotland is concerned, the problem is easily manageable as regards numbers, the chief difficulty being that of finding some method of treatment to meet the widely varying circumstances of the contributors which even a preliminary investi- gation disclosed. 734. There has throughout been great difficulty in keeping in touch with the individual deposit contributor. Changes of address, incom- plete addresses on cards, similarity of names (especially in the Highland districts), negligence or indifference, and many other factors have rendered communication a laborious task. It has been found that on the average of any given number of letters despatched only 20 per cent, elicit replies, while at least 10 per cent, are returned endorsed " Gone, no address." 735. Progress has, nevertheless, been made in the opening of ledger accounts for deposit contributors. In order that an account may be opened it is necessary that the Commission should have information as to the name, exact address, age, &c., of the con- tributor. It was originally intended that the contributor, on surren- dering his contribution card to the Post Office, should complete a declaration (Form 301), giving these and certain other particulars. A large number of cards, however, are received without any declara- tion or other evidence on which an account might be opened. The number of deposit contributors " established," that is, with accounts opened and insurance books issued, is 32,730 (23,465 men and 9,265 women). 736. The difficulties are not at an end when the account is opened. Contribution cards for back quarters are continually being received. With every new quarter a large proportion of cards are not accom- panied by the insurance books, and in many instances it is structure of the System: Population under the Acts. 259 impossible, owing to change of address, to connect them with cards surrendered for previous quarters or with accounts opened. The numbers of such " unassociated " cards in hand for the second to the sixth quarters respectively are as follows: — Second quarter 4,733 Third „ 5,460 Fourth „ ... 6,660 Fifth „ 6,993 Sixth „ 3,131 737. It will be seen from Appendices XXVI. and XXVII., page 533, that the number of deposit contributors shows no tendency to rise. There are, however, indications that the personnel is changing. Up to date, 16,653 deposit contributors have transferred to Approved Societies, while others must have died, emigrated, or ceased to be employed within the meaning of the Act. On the other hand, there must have been a considerable accession of new contri- butors in order to maintain the total figure. 738. Details of the benefits paid to deposit contributors are given in Appendix XXVIII., page 534. Compared with the experience of Approved Societies the claims made by deposit contributors are ex- ceptionally light. The following is a Statement of the sickness and maternity benefit claims paid during the year from January, 1913, to January, 1914 : — Sickness Benefit Maternity Benefit No. of Claims received. 2,548 333 No. of Claims paid. 2,233 314 Amount Amount per paid. I Claim paid. £ 976 325 £ s. d. 8 9 1 9 Of the claims paid 530, or 20 per cent., were not paid in full owing to the amount at the credit of the contributor having been exhausted. The number of claims rejected entirely owing to the amount at the credit of the contributor being exhausted, or the statutory number of qualifying contributions not having been paid, was 334, or 12 per cent, of the total claims submitted. 739. The results up to the present go to show that a large part of the problem is due solely to ignorance or apathy on the part of the contributors. It has been the policy of the Commission to point out to such contributors the advantages of joining Approved Societies, and the Commission have reason to believe that this policy has been attended with some degree of success. 740. As regards the regularity of payment of contributions, the following Table shows, for contributors who entered on 15th July, 1912, and were insured for three to six quarters, the percentage of (B254— Gp. 5) I 2 260 Scotland. cases in which contributions were on the average paid for certain numbers of weeks per annum : — Average No. of Contributions per Percentage of Deposit Contributors. . annum. Men. Women. 52 contributions ... 48 to 51 „ 44 „ 47 „ 40 „ 43 „ ... ... ... 26 „ 39 „ ... Under 26 „ 42-2 18-7 9-3 7-8 14-9 71 55-0 9-9 7' 7 6-9 iro 9-5 100% 1 iw% 741. The following Statement gives the results of a personal visitation of deposit contributors, and shows the attitude or position of the deposit contributors with regard to insurance. Three Insurance Committee areas are dealt with, the types being respec- tively a county area both agricultural and industrial, a mining and industrial town, and an agricultural and fishing county: — Area 1. Area 2. Area 3. (i.) Contributors taking steps to join Approved Societies ... (ii.) No intention of joining Approved Societies (iii.) Ceased to be insured ... (iv.) Insured in error (v.) Contributors not seen— gone abroad, removed, &c per cent. 27 * 11 13 8 41 per cent. 26 19 6 2 47 per cent. 35 23 7 1 34 742. The reasons given for becoming or remaining deposit con- tributors were as follows in order of frequency : — Indifference. Ignorance or misapprehension. Convenience (only occasionally employed, nearing the age of 70, &c.). Refused by Societies on account of ill-health. One or other of the first two reasons was given by more than half of the persons seen. PERSONS INSURED UNDER SECTION 47 OF THE ACT OF 1911. 743. The comparatively slight extent to which during the first year of the Act's operation advantage was taken of the provisions of Section 47 was the subject of comment in the last Report. structure of the System: Population under the Acts, 261 No indication has been given during the past year of any growth of interest in the Section on the part of employers generally. In the last Eeport it was stated that the number of employers who had given the prescribed notice under the Section was 620. Of these, 20 have w^ithdrawn their notices as from 1st January, 1914, while 57 fresh employers have given notice of their intention to adopt the provisions of the Section. The number of employers now author- ised to pay the reduced contributions is therefore 657. According to the latest available figures, the number of persons insured under the Section is 12,740 men and 3,493 women, making a total of 16,233. The provision of the Act in pursuance of which a with- drawal from the special arrangement can take effect only as from 1st January in any year, and after three months' previous notice has been given, is often lost sight of by employers who desire to give notice of withdrawal. 744. Three Special Orders have been made since the last Eeport. The first of these, made on 25th April, 1913, under subsection (1) of the Section, brought within its scope the following classes of employment under the Crown in the Royal Observatory, Edinburgh : Assistant computers; Mechanics ; Porters. The other two Orders were made under subsection (7) of the Section, and applied to cases where there was no general custom or practice of paying full remuneration during sickness. Before the issue of these Orders the workers concerned were placed in possession of full information as to the effect which Section 47 would have on their insurance, and each was asked to vote by ballot for or against the proposal. It was made clear both to the employers and the workers that the Order would be granted only if the majority of the employees in each class concerned were in favour of it. The ballot was taken by correspondence. Under the two Orders, which were made on 15th July and 24th December, 1913, respectively, the pro- visions of the Section have become applicable to some 752 employees, who are in the employment of 50 employers. 745. In Appendix XXV., page 532, will be found particulars of the classes of employment which have been specified in the Special Orders made under subsection (1) of the Section, and of the number of employers who have adopted the special provisions in respect of these classes. 746. Reference was madb in the last Report to the number of difficult legal and administrative questions to which Section 47 had given rise. Further problems have emerged during the past year. One or two of these, which appear to be of general interest, may here be referred to : — (a) Where a person insured under Section 47 ceases temporarily to be employed, the reduced contributions continue to be payable in respect of him, and he remains disentitled to sickness (B254— Gp. 5) I 3 262 Scotland. benefit for the first six weeks of sickness, but no special provision is made for the case of a person who becomes per- manently unemployed, but is entitled to remain in insurance as an employed contributor. For example, a person insured under the Section ceased permanently to be employed by reason of a disease or disablement which will incapacitate him for life. Such a person was entitled to remain an employed contributor and to complete the 104 contributions necessary to qualify for disablement benefit. He desired to continue paying contributions with that object, and his Society asked the Commission at what rate the contributions should be paid. The Commission held that in the absence of any special provision the rate payable should be the full employed rate. (6) A person insured under Section 47 ceased permanently to be employed, being compelled to resign his post by reason of disable- ment, after having received from his employer six weeks' full re- muneration. Subsection (4) provides in effect that in the case of a person insured under the Section the six weeks of remuneration from the employer shall count towards his full term of 26 weeks' sickness benefit. The Society, in the belief that this provision ceased to apply to the member when he resigned his employment, paid 26 weeks' sickness benefit. The Commission held, however, that the provision was applicable in respect that the person was insured under the Section at the time when the incapacity arose, and that in the circumstances it was not competent to pay more than 20 weeks' sickness benefit. 747. The Commission have found it necessary to consider carefully the effect of subsection (9) of Section 47, which provides that the payment of contributions purporting to be at the reduced rate authorised by the Section as respects any persons employed by an employer in any class of employment, shall be conclusive evi- dence that he is, as respects those persons and all other persons employed by him in the same class of employment in the same locality, under the liability imposed by the Section. They have expressed the following opinions: — (i.) The subsection imposes a liability to pay full remuneration during disease or disablement for the specified period on an employer who pays contributions purporting to be at the reduced rate autho- rised by the Section {i.e., who pays such contributions designedly, professing to the employee that they are paid in terms of the Section), although the prescribed notice may not have been given, or the employee may not be engaged in a class of employment specified in a Special Order. (ii.) The employer, though rendered liable to pay full remunera- tion as above explained, is not freed from his obligation to pay the difference between the reduced contributions irregularly paid by him and the full contributions which ought to have been paid. The employee is regarded as being in arrears to the extent of such difference. (iii.) Where reduced contributions have been irregularly paid, sub- structure of the System: Population under the Acts. 263 section (4) is not applicable, and accordingly sickness benefit cannot be withheld from the employee in respect of the period over which his employer's liability under subsection (9) extends. MAREIED WOMEN. 748. Under Section 44 (Ij of the Act of 1911, a woman who has before marriage been an insured person is suspended from ordinary benefits on marriage unless she proves that she continues to be employed. The Commission have indicated that a reasonable oppor- tunity for furnishing such proof must be given, and that a month might be regarded as a suitable period for the purpose. In the case of a long period of unemployment after marriage, the woman would require to prove that such unemployment was due to causes other than the fact of marriage, e.g., inability to find work. The nature of her calling before marriage and the status of the married persons would be guides to the probabilities of the case. 749. Where women are suspended from the ordinary benefits Societies are bound to give them full information regarding the options open to them. Model forms have been provided by the Commisson for this purpose. Where a woman chooses the alterna- tive of application to her benefit of the sum representing two-thirds of her transfer value, the Society ascertains from the Commission the amount to be placed to her credit. The number of such cases dealt with during the year to 12th January, 1914, was about 800. 750. Questions have been raised with reference to the case of a married woman who, having elected to become a special volun- tary contributor, subsequently becomes employed and obtains under subsection (8) of Section 44, a certificate exempting her from liability to become an employed contributor. The Commission have made Eegulations providing that such certificates of exemption may be issued by Approved Societies. (National Health Insurance, Claims for Exemption, Regulations (Scotland), 1913, dated 26th March, 1913.) In such circumstances the employer is, nevertheless, liable to pay ordinary contributions in respect of her. Of each contribu- tion so paid by the employer, Sd. is to be treated as the contribution of the woman as a voluntary contributor, and the balance is to be applied for the woman's benefit in such manner as the Society may determine. The Commission were advised that difficult legal ques- tions might arise in regard to the balance if the woman died before it was disposed of. In view of these possible difficulties, a circular was issued to Societies recommending that when a suspended woman obtains a certificate of exemption they should, without delay, determine the manner in which the balance of contributions is to be used for her benefit. (B254---Gp. 5) I 4 264 Scotland. 3. Approved Societies. / Number OP Approved Societies. 751. The number of Approved Societies entitled to operate in Scotland is shown in the following Table: — Admitting both Men and Women. Admitting Admitting Men only. \ Women only, Total. (a) Approved by Scot- ' t i 8 h Insurance i . Commission ...1 66 24 6 96 (h) Approved by the | Joint Committee, ; . ' and entitled to \ ■ ■ operate in Scot- " • land 126 75 9 210 Total 192 99 15 306 In Appendix XXIX., page 536, will be found a statement showing the types of Approved Societies. 752. A few of the Societies under {h) have as yet no members in Scotland. Some of these will no doubt avail themselves of the opportunity given under the Act of 1913 to relinquish approval for Scotland. Two Societies recently approved by the Joint Committee have both been authorised to transact business in Scotland, and another Society already approved for other Countries sought and obtained extension of approval to Scotland. Of the Societies ap- proved by the Joint Committee, 38 have their headquarters in Scotland. 753. The difference between the number of Societies now ap- proved by the Scottish Commission (96) and the number given in the last Eeport (102) is due to the fact that four Societies have become merged in larger Societies; two have extended their operations beyond Scotland, and therefore have obtained approval from the Joint Committee; one has decided to confine its operations to Scotland, and has accordingly relinquished approval by the Joint Committee and become approved by the Scottish Commission; and the Commission have recently approved a Society admitting only women members. Small Societies and Amalgamation. 754. When Societies were being approved for the purpose of transacting business imder the Acts approval was given to a few Societies with very small membership. These Societies anti- cipated that through different channels they would receive a sufficient number of new members to enable them to carry on State Insurance business economically and successfully; a»d with reasonable ex- structure of the System: Approved Societies. 26o pectation of solvency. In some cases a sufficiently large acces- sion of members has not been obtained. The Commission have, therefore, requested seven small Societies to take action with a view to the transfer of their engagements to suitable Societies with larger membership. , Previous to this step, however, reports were obtained from the Societies as to the possibility of increasing their member- ship, and opportunity was given them of making further efforts in this direction. Three of the Societies are connected with Trade Unions; the remainder are Friendly Societies. Some, it may be •added, were excellently conducted and their sickness experience was less than the expectation. The Commission, however, deemed the step expedient because of the serious risks constantly open to a small Society with no prospect of substantial increase in its member- ship. These small Societies are experiencing little difficulty in finding larger Societies willing to absorb them, and the Commission are affording every assistance in the important step which they are taking. 755. Two Societies concerned with insured persons serving in the mercantile marine took action on their own initiative to transfer their members to the Seamen's National Insurance Society. County Society. 756. There was submitted on behalf of the Inverness County Benefit Society a scheme of reduced benefits for insured persons who failed to pass the Society's medical test, and could not therefore be accepted as first-class lives. The scheme was tentative, no data which would give even an approximate idea of the probable sickness experience of such a class of insured persons being available. Its main features were that the persons to whom it applied would be entitled to sickness and disablement benefits at three-fifths of the normal rates. They would, however, receive medical, sanatorium, and maternity benefits to the same extent as ordinary members, and on producing satisfactory evidence of improvement in health would be transferred to the first-class section of the Society. It was pro- posed that the scheme should be subject to revision at 1st January, 1915. During the consideration of the scheme it was found thai there were very few existing members to whom it would apply, and accordingly the Commission advised that the ordinary benefits should be paid to all members of the Society. The scheme of reduced benefits has since been abandoned. Movement towards larger Units of Administration. 757. Many of the Friendly Societies which administer the National Insurance Acts are divided into Branches registered under the Friendly Societies Acts. Each Branch has to a considerable extent local autonomy and sole control of its funds. A number of these decentralised Friendly Societies have found that the account- 266 Scotland. ing work involved in the administration of the Acts is too arduous to be efficiently discharged by the Branch secre- tary. In most cases he is able to devote only a portion of his spare time to the work, and is therefore unable, from this and other causes, to master the Regulations, instructions, and forms of account. Soon after the commencement of the Act, therefore, it became evident that some changes in the administration of such Societies were necessary, and during the year under review a movement in the direction of the formation of larger units of administration has gained considerable strength. The movement began with the centralisation of the accounting arrangements, the District {i.e., a group of Branches) or the Society being substi- tuted for the Branch as the accounting unit. Under this system the members remain members of their respective Branches. The Branch receives the contribution cards and insurance books and pays the necessary benefits. The Branch is also the channel through which the member takes part in the management of the Society, by means of the election of delegates to the annual meeting of the District or of the Society. The adoption of the system thus relieves Branch secretaries of a great deal of accounting work, while at the same time it preserves the local responsibility of the Branches for the con- servation of their benefit funds. So long, however, as each Branch remains a unit, separate ledger accounts must be kept for each Branch at the District or the Head Office, as the case may be. 758. In the case of a number of important Societies more drastic proposals are in contemplation or in process of being carried out. These involve the abolition of the registered Branches as such for State purposes and the centralisation of their work in the District. Under the existing organisation of a number of Societies, the District is the authority having jurisdiction over a group of Branches in a geographical area which may include one or more Counties, but under the proposed arrangement the District will become the Branch for State purposes. The present Branches will, however, continue to exist as such for carrying on the non- State business of the Society. They will also, under the State scheme, collect and distribute contribution cards and insurance books and pay benefits, subject to the direction of the District Executive. One of the chief arguments put forward by Societies in favour of cen- tralisation in the District is that it dispenses with the necessity of passing a transfer value in respect of any person transferring from one Branch to another within a District, the District and not the Branch being the unit for valuation purposes. Such a cen- tralisation scheme, however, raises important questions as to the government and internal administration of Societies, and can only be carried out after careful consideration by the members and with their consent. 759. The whole question has been fully considered by the Com- mission in conjunction with the other Commissions and the Joint Committee, and a common policy has been agreed upon for dealing with such cases and with inquiries on the subject. Any steps taken for reconstituting a Society must be in accordance with its rules, structure of the System: Approved Societies. 267 and with the National Insurance Acts and Kegulations, and any transfer of engagements from one Branch to another, or amalgama- tion of one Branch with another, must be subject to the provisions of the Eegulations made under paragraph (A) of the First Schedule to the Act of 1913. Amendments of Rules. 760. Arrangements have been made with the Assistant Regis- trar of Friendly Societies in Scotland whereby amendments of the rules of Registered Societies will not be approved until they have been adjusted in detail to meet his requirements. 761. Since 1st April, 1913, the Commission have dealt with amend- ments of rules of 39 purely Scottish Societies, seven of these making complete amendments. The Commission are consulted by the Joint Committee in regard to all amendments on the rules of International Societies operating in Scotland, and since 1st April, 1913, 95 such Societies have proposed amendments to their rules ; 15 of these have made complete amendments. 762. In addition to the amendments noted above, the passing of the National Insurance Act, 1913, necessitated the amendment of the rules of all Approved Societies. Section 17 of that Act empowered the Commission, on the application of the Committee of Management, to authorise the amendments to come into force immediately, and to remain in force until the first meet- ing at which the amendments could be properly passed. For the convenience of Societies a leaflet containing the necessary amend- ments was issued in such a form that it could, without altera- tion, be inserted in the rules of any Approved Society which had adopted rules based on the model rules. A copy of the leaflet was sent to all Scottish Societies with a circular stating the pro- cedure to be followed in order to adopt the amendments. Special attention may be drawn to the rule which Societies were required to adopt in regard to the second maternity benefit payable in respect of an insured married woman in terms of Section 13 (3) of the 1913 Act. The rule suggested by the Commission was to the effect that such a woman must abstain from remunerative work for a period of four weeks after her confinement, and that any penalties imposed for breaches of this rule in the period of four weeks should not exceed in the aggregate the sum of 30^. Membership Questions. 763. Many insured persons, through misunderstanding or igno- rance, have made application for membership to two or more Societies, and the Commission have had to deal with a large number of cases of disputed membership. Insured persons did not at first fully realise that by joining a Society they thereby contracted to 268 Scotland. return to it their stamped contribution cards, and that it was not open to them to hand their cards to another Society. Such persons have frequently found themselves in a position of difficulty when claiming benefit. Some Approved Societies, or their agents and representatives, have also collected cards from persons without in- quiring whether they were already members of other Societies. It would appear, however, that insured persons are now beginning to appreciate the importance of having dealings with only one Society, and that Societies themselves realise that only by respecting the interests of other Societies can they properly protect their own. 764. In the settlement of cases of disputed membership a con- siderable correspondence has taken place with the Societies con- cerned, and frequently it has been necessary to have the facts investigated by the Inspectorate. The number of cases dealt with has been on the average between 60 and 80 a week, but the number is appreciably diminishing. As evidence of the manner in which Societies have on the whole co-operated with the Commission in the matter, it is worthy of note that in very few cases have Societies applied for a decision under Section 67 of the Act of 1911 or Section 27 of the Act of 1913. Transfer Questions. 765. Another difficult question with which the Commission have had to deal is that relating to transfers between Societies. Section 31 of the 1911 Act provides that on a member transferring from one Society to another there shall be transferred to the other Society in respect of the- member a sum representing the liability under the Act of the first-mentioned Society in respect of him. This sum is called the " transfer value," and is calculated in accordance with tables prepared by the Joint Committee. In the proviso to subsection (1) of Section 31 it is provided that no trans- fer value shall be transferred in any case where the first-mentioned Society proves that the insured person voluntarily ceased to be a member of that Society without the consent of the Society, and that that consent was not unreasonably withheld. 766. In the last Eeport reference was made to the special arrangements for dealing with transfers during the first two quarters of the Act's operation, which were set out in Memorandum 119, and adopted by a large number of Societies. These arrangements being provisional, and merely intended to overcome the initial difficulties, were superseded by the procedure laid down in a Circular No. A.S. 68. Difficulties, however, arose under this procedure in the case of insured persons who withdrew from one Society without effectively joining another. It was further realised that it would be neces- sary to provide some method whereby the question of consent to transfer, and the passing of transfer value, would be settled before membership with the old Society was terminated. structure of the System: Approved Societies. 269 767. These difficulties have been overcome by detailed arrange- ments, the main features of which are as follows : — (1) The member is required to obtain from the Society he wishes to join a provisional acceptance of his membership. The condition of acceptance by the Society is that the old Society should give its consent to the transfer, and thus allow the transfer value to pass to the new Society ; or that, if consent should not be given, that it is established that such consent was unreasonably withheld ; (2) Having received this acceptance the member is required to seek the consent of his old Society to his withdrawal; (3) The procedure to be followed by a member who is refused consent to transfer is as follows : He either accepts the' situation and remains a member of the old Society; or the Society he proposes to join may submit to the Commission an application for a statement as to whether the transfer value will pass on the transfer taking effect. This procedtire results in the burden of proof that consent is not unreasonably withheld being placed upon the Society refusing con- sent, where Section 31 (1) of the 1911 Act contemplated that it should lie, whereas the procedure by way of appeal to the tribimal appointed under the Society's rules to determine disputes resulted in the initiative of any further action, in cases where a Society refused consent, being transferred to the member himself. 768. Under these revised arrangements the Commission have received a large number of applications from Societies asking whether, in the cases submitted, transfer values will pass. Meeting Places of Approved Societies and Branches. 769. As mentioned in the last Eeport, Eegulations were made providing generally that meetings of Societies and Branches should not be held in licensed premises, power being reserved by the Com- mission to allow meetings in such premises during the currency of an existing lease. These Kegulations have been generally observed, only one case of infringement having been brought to the notice of the Commission. In this case steps were taken to secure that the practice should be discontinued. It is significant also that no application has been made by any Society or Branch for permission to continue to meet in prohibited premises until the termination of an existing lease. Section 16 of the National Insurance Act, 1913. . 770. The following is a Statement of the Societies on behalf of which representations have been made under the proviso to 270 Scotland. Section 16 (1) of the 1913 Act for separate Scottish valuation and of the membership of each of these Societies in Scotland: — -Approval Name of Society. Membership. 127 National Independent Order of Oddfellows 18,479 152 Ancient Order of Foresters 70,047 153 Ancient Order of Hibernians 25,210 122 Loyal Order of Ancient Shepherds 76,399 150 Independent Order of Eechabites 66,898 188 Orange and Protestant Approved Society 9,966 215 Order of Sons of Temperance 11,340 119 Liverpool Victoria Approved Society ... 11,565 125 National Amalgamated Approved Society 98,231 136 Prudential Approved Society for Men 155,624 137 „ „ „ „ Women 80,924 199 „ „ „ „ Domestic Ser- vants 21,102 272 „ „ „ „ Laundresses... 1,004 277 „ „ „ „ Miners 526 333 „ Agricultural and Rural Workers 3,369 193 Post Office Employees Approved Society Irish National Foresters ... 2,444 222 29,647 242 National Catholic Benefit and Thrift Society ... Total 5,026 687,801 771. Two cases have occurred where Societies, with offices in Scotland and with a small membership in England, seek to relinquish approval for the latter country. 772. This Section affects the guarantees of solvency given to the Commission by certain international Societies approved as Employers Provident Funds in respect of the membership in Scotland, and the Commission are at present considering what alterations are necessary in regard to these guarantees in view of the altered conditions. The guarantees were, of course, taken on the conditions laid down by the 1911 Act that the members in each part of the United Kingdom would be valued separately, and separate guarantees were taken by the various Commissions. These Societies are for the most part small, and as no representations have been made on their behalf under Section 16, each will become for valuation purposes a single Society with nationality according to the location of the head office. There is, therefore, no need for separate guarantees of solvency, but each guarantee must cover the whole membership of the Society. Voting of Collectors and Agents. 773. The Commission were advised that in view of the terms of Section 76 of the National Insurance Act, 1911, and of Section 8 of the Collecting Societies and Industrial Assurance Companies' Act, structure of the System: Insurance Committees, &c. Ill 1896, agents and collectors who act as such in connection with the business of an Approved Society which is a Separate Section of a Collecting Society or Industrial Assurance Company are dis- qualified from voting at meetings of the Society. Disputes and Appeals. 774. So far, only six cases, two of them dealing with membership questions, and the remaining four with the question of payment of benefit, have been brought to the Commission under the Eegulations as to Disputes and Appeals. 775. The rules of some Societies provide that the Commission are to appoint an arbiter or a chairman of arbiters to decide any dispute arising in the Society under the National Insurance Acts. This appointment is, of course, independent of the power to settle such disputes on appeal as described above, and it is competent for either party to the dispute to appeal from the decision of the arbiter so appointed to the Commission. The Commission have made several such appointments at the request of the Societies concerned. 4. Insurance Committees, Local Medical Committees, &c. Representation of Insured Persons on Insurance Committees. 776. It was necessary to establish Insurance Committees before the commencement of the National Insurance Act, 1911, at a time when the representation of those who were shortly to be " insured persons " could be arranged for on a provisional basis only. The provisional arrangements were described in the last Report. Regulations governing the appointment of representatives of insured persons to hold office for three years from 15th July, 1913, on which date the Orders under Section 78 authorising the provisional arrangements expired, were made on 2nd April, 1913. (National Health Insurance (Appointment of Representatives of Insured Persons on Insurance Committees) Regulations (Scotland), 1913.) 777. The scheme of representation embodied in the Regulations was based on the numbers of deposit contributors and of members of each Approved Society resident in the area of the Committee as dis- closed by their index register of insured persons. The carrying out of the details of the scheme was entrusted to the Clerks to the Committees. 778. An " electoral unit " was ascertained by dividing the total number of insured persons in the Committee's area by the number of members of the Committee (three-fifths of its total membership) falling to be appointed to represent insured persons. Societies operating in the Committee's area fell naturally into two groups, viz. : — (a) Those having not less than one electoral unit of members residing in the area; and 21% Scotland. (6) Those having less than an electoral unit of members so resident. 779. The Committee of Management of each of the former (termed " A " Societies) was authorised to appoint a direct repre- sentative on the Insurance Committee for each electoral unit of members which the Society possessed in the Committee's area. 780. The Committee of Management of the " B " Societies (as those of the second group were called) had each to appoint one dele- gate to attend a meeting convened by the Clerk to the Insurance Committee for the purpose of electing joint representa- tives, the number of whom depended on the . number of electoral units comprised in the total membership within the Committee's area of all the " B " Societies. If such total membership did not amount to a complete electoral unit one representative was never- theless assigned to the group. 781. Provision was made for submitting to the Commission for revision and for the subsequent publication of a return showing the allocation of representatives between " A " Societies, " B '* Societies, and deposit contributors. Objections thereto on the ground of inaccuracy might be lodged by any of the parties having an interest. The duty of determining upon such objections was laid on the Insurance Committee, but any party affected by their decision might appeal to the Commission, whose determination was final. 782. In only one case was an objection lodged against the pub- lished return. The objection was dismissed by the Committee on the ground that it was incompetent, being directed against the clear effect of one of the provisions in the Begulations. 783. The Clerk to the Insurance Committee acted as returning officer at the meeting of " B " delegates, and called to the chair the delegate from the Society which had the largest number of members in the Committee's area. If more persons were nominated and seconded for election than the required number, a vote was taken. Each delegate had a number of votes equal to the number of persons to be elected, and " plumping " was prohibited by a provision that each delegate must use all his votes and give only one to each person he voted for. Any delegate dissatisfied with the result of the voting might demand a " card " vote, and if at least one-third of the delegates present supported him, the votes of each delegate as originally recorded were multiplied by the number of members of his Society resident in the Committee's area, thus giving him a voting power in direct proportion to the interests he represented. 784. The object of giving each delegate in the first place equal voting power was to secure to the smaller ** B " Societies a chance of obtaining a fair share of representation on the Insurance Com- mittee. On the other hand, it was thought the provision for a card vote, if demanded by one-third of the delegates, would restrain the delegates from the smaller " B " Societies from attempting by organised combinations to out-vote the larger Societies. structure of the System: Insurance Committees, &c. 273 785. Deposit contributors were entitled to a representative for each electoral unit of contributors, and to one representative if their number did not amount to a unit. If an association of deposit contributors recognised by the Commission existed in the Commit- tee's area, the appointments were to be made by it in terms of the Act. If no such association existed, the Insurance Committee itself was vested with the power of appointment. Kegulations pro- viding for the establishment of associations of deposit con- tributors were made on 11th April, 1913 (National Health Insurance (Associations of Deposit Contributors) Eegulations (Scot- land), 1913), and in terms thereof meetings of deposit contributors were summoned by Clerks to Insurance Committees by means of newspaper advertisements, but deposit contributors generally dis- played no interest in the matter, and did not in any area proceed to form an association. 786. A County or Town Council which defrays part of the cost of medical or sanatorium benefits in terms of Sections 15 or 17 of the Act is entitled to increased representation on the Insurance Com- mittee, the number of representatives of insm^ed persons being cor- respondingly increased. In. the case of Dumfries County and Hamilton Burgh Insurance Committee the representation of insured persons was, in accordance with this provision, diminished, and that of the County and Town Council, respectively, increased by three members. 787. In order to secure an adequate number of women repre- sentatives of insured persons, the Commission recommended that where a Society contained both men and women members, or where there was comparatively a considerable number of women deposit contributors, the question of appointing women representatives or, as the case might be, of instructing delegates to vote for women representatives, should be considered by the body electing or appoint- ing the representatives or delegates. 788. The elections were completed well in advance of the date, 15th July, 1913, on which the members whose places were to be filled demitted office. Difficulties experienced by returning officers which necessitated reference to the Commission were remarkably few in number. In only one area was there an irregularity of any moment, and this was due to a misapprehension on the Clerk's part as to the manner of reckoning the votes where a card vote was taken. The matter was, however, put right in good time by means of a recount of the votes. 789. Under the Eegulations the Commission were to determine the fees of the Clerks and to decide what expenses had been properly incurred by them in connection with the elections. These charges were to be paid out of the administration funds of the Insurance Committees. The Commission made a valuation of the various items of work involved in the conduct of the elections, and fixed the Clerks' fees on that basis. The aggregate amount of the fees determined by the Commission was £570 12s., and the aggregate expenses held by them to have been properly incurred amounted to £464 9s. ^d. The total cost to the Committees of the elections was, therefore, '^74 Scotland. £1,035 Is. 3d. The respective cost m Counties and Burghs was £528 17s. 9^d. and £506 3s. 5^d. 790. The Regulations provided for the filling of casual vacancies in the same manner as the original appointments. Where the vacancy occurred amongst the representatives of " B " Societies, this involved the holding of a meeting of delegates to elect a repre- sentative to fill the vacancy. In view of the consequent expense, not only to Insurance Committees, but also to the Approved Societies concerned, the Commission decided to make amending Regulations providing for the filling of any vacancy in the " B " group by the remaining representatives of " B " Societies on the Committee. 791. Under the Regulations a representative of insured persons is deemed to have ceased to be a member of the Committee if he has been absent from meetings of the Committee for a period of six consecutive months. The Commission have had under consideration the question of the application of this rule to other members of Insurance Committees. Local Medical Committees. 792. Reference was made in the last Report to the provisional recognition of 47 Local Medical Committees in Scotland, such recognition being due to expire at 31st March, 1914. 793. One or other of the model forms of constitution suggested by the Commission was adopted without substantial modification by the great majority of the Committees which applied for statutory recognition. In the case of the County of Argyll, however, sanction was given to the election of divisional representatives at five divi- sional practitioners' meetings, and in the case of the Burgh of Glasgow the electoral area was divided into four parts. The Glasgow constitution further provided, with the approval of the Commission, that of the 51 members of the Committee one should be elected by the Senate of the University of Glasgow, one by the Royal Faculty of Physicians and Surgeons of Glasgow, and one by the Association of Registered Medical Women for Glasgow and the West of Scotland. Panel Committees. 794. Section 32 of the Act of 1913 provided for the appointment of a Committee by the medical practitioners who are under agree- ment with each Insurance Committee. The Committee so appointed (called the Panel Committee) is to be consulted by the Insurance Committee where it is the duty of the latter to ascertain, in respect of any matter affecting the administration of medical benefit in their area, the opinions and wishes of the panel practitioners. The Com- mittee is to perform such duties and exercise such powers as the Commission may determine. 795. Powers are conferred on the Commission to make Regula- tions as to the appointment of Panel Committees. The National Health Insurance (Panel and Pharmaceutical Committees) Regula- tions (Scotland), 1913, which were made on 3rd November, 1913, structure of the System: Insurance Committees , &c. 275 prescribed the constitution and provided for the appointment of the first Panel Committees. For a Panel Committee it is laid down that not less than two-thirds of the members must be electors, that is to say, practitioners on the panel for the area as at 13th October, 1913, while the remainder may be any duly qualified medical practitioners whether on the panel or not, and whether resident in the area or not. The term of office of the first Committees expires on the 31st March, 1916. 796. The Eegulations provided for the appointment of the first Panel Committees by election at meetings of the electors summoned by the Commission. The normal method of voting was by show of hands, but where at least one-fifth of the electors present at the meeting so demanded, or where the meeting so decided, a vote by ballot was taken. Where the voting was by ballot, voting by proxy was allowed. The returning ofiicers appointed to conduct the elections were members of the Inspectoral Staff of the Com- mission. The Commission anticipated that this method of elec- tion would be expeditious, convenient and practicable in almost every Insurance Committee area, and so it proved. In view, how- ever, of representations which had been made, the Eegulations pro- vided for alternative methods of appointment. 797. The first alternative was embodied in a provision that if, before 24th November, 1913, one-fourth of the electors or any 30 electors in any area (whichever number was the less) submitted for the approval of the Commission a scheme for the appointment of a Panel Committee in a manner other than the normal method, the Commission would consider the scheme, and, if they thought fit, would suspend the election in that area. It was provided that before approving the scheme, the Commission might require to be satisfied that particulars of it had been brought to the notice of the electors, and that the Commission would consider any objections to the scheme made by any electors. Where the Commission ap- proved a scheme, the Panel Committee was to be appointed in accordance therewith. 798. The second alternative was that if, before 24th November, 1913, a representation were made to the Commission to the effect that, owing to the small number of electors or difficulties of commu- nication or otherwise, it was desirable that the electors should them- selves constitute the Panel Committee for the area, the Commission might, if they thought fit, declare that the electors should be the Panel Committee, and that the ordinary proceedings for election should therefore be dispensed with. 799. Eight schemes submitted in pursuance of the first-men- tioned alternative were approved by the Commission. Six of these provided either that the Panel Committee should be the Local Medical Committee, with or without additional members to bring its membership up to that fixed by the Eegulations, or that the Local Medical Committee should nominate the members of the Panel Committee. The Commission decided to approve these schemes only if the electors acquiesced. Each scheme, including a list of the proposed members of the Panel Committee, was accordingly sub- 276 Scotland. mitted to the electors of the area, each of whom was asked to state his objections, if any, to the scheme. In the case of each of three areas, one practitioner objected to the scheme, but one of these subsequently withdrew his objection. In the case of another area, two objections were received. After consideration, the Commission decided that none of the objections which had been submitted were such as they could reasonably sustain, and accordingly they approved the six schemes. 800. Of the two other schemes under the first alternative ap- proved by the Commission, one provided for the carrying out of the election of the Panel Committee for the Burgh of Dundee by means of a postal vote, and the other for the division of the Burgh of Glasgow into four sections, the practitioners in each of which were to meet separately and appoint a prescribed proportion of the members of the Panel Committee in accordance with the normal method of election described above. 801. In three areas, the electors themselves were constituted the Panel Committee in pursuance of representations made on the grounds specified in the provision embodying the second alternative. 802. Eepresentations in favour of one or other alternative were rejected by the Commission in the case of 15 areas. In four cases the Commission, having no power to disregard the time limit fixed by the Regulations, refused to consider schemes submitted after 24th November, 1913. The first meetings of the Panel Committees were summoned by the Commission. The Commission have been indebted to the courtesy of Insurance Committees, County Councils, and Town Councils in placing at their disposal rooms in offices for the appointment and first meetings of Panel Committees, thereby greatly lessening the difficulty of finding suitable meeting places, as well as effecting a very appreciable saving of public money. Pharmaceutical Committees. 803. Section 33 of the Act of 1913 provided for the election of a Committee of the pharmacists and others who are under agreement with each Insurance Committee to supply medicines, &c., to insured persons. The Committee so elected (called the Pharmaceutical Committee) is to be consulted by the Insurance Committee on any general question affecting the supply of drugs, medicines, and appliances to insured persons, and is to perform such duties and exercise such powers as the Commission may determine. 804. The National Health Insurance (Panel and Pharmaceutical Committees) Regulations (Scotland), 1913, made on 3rd November, 1913, prescribed the constitution and provided for the election of the first Pharmaceutical Committees, whose term of office is due to expire on 31st March, 1916. Not less than two-thirds of the members of a Pharmaceutical Committee must be registered pharmacists, and all must be electors; that is to say, pharmacists and others and representatives of firms and bodies corporate on the panel of the area as at 13th October, 1913. 805. The methods of election of Pharmaceutical Committees structure of the System: Insurance Committees, &c. 277 were in outline similar to those already described with respect to Panel Committees, excepting that the procedure for Pharmaceutical Committees did not provide for the submission of proposals for alter- native methods of election. It was, however, found necessary to make special Eegulations for the appointment of Zetland Pharma- ceutical Committee. The first meetings of Pharmaceutical Com- mittees were summoned by the Commission. Index Register. 806. The machinery of index slips by which Insurance Commit- tees are informed of the persons in their areas who are entitled to medical and sanatorium benefits was explained in the last Report. 807. Intimations of membership in the form of index slips were originally prepared by Societies on the basis of the first quarter's con- tribution cards handed in, the index register as thus compiled repre- senting the membership of Societies in Committee areas at the end of the first quarter. It was, however, essential in order that Com- mittees might be in a position to make proper arrangements for administering medical and sanatorium benefits, that the register should be kept up to date. It was accordingly necessary that Societies should, from time to time, supply to Committees particu- lars of all new members, and should also give notice of any removals and alterations in their membership affecting the register. 808. To assist Societies in making the above notifications the following arrangements were made early in 1913: — Societies were supplied with " removal slips " on which to notify changes of address of members for transmission to the Insurance Committee for the area in which the old address was situated, that is, the Committee in pos- session of the index slip, so that the Committee, after taking any action which might be necessary, might transfer the index slip to the Committee in whose area the new address was situated. In the same way instructions were given to Societies relative to the notifi- cation on appropriate cards of other matters involving changes in the index register, such as: — (1) Particulars of new members entering into insurance. (2) Particulars of members who have ceased to be insured, or ceased to belong to the Society or Branch from any reason except transfer to some other Society or Branch, and par- ticulars of members who have become suspended from medical and sanatorium benefits. (3) Particulars of reinstatement; that is, members who were previously suspended from medical or sanatorium benefits, but have again become entitled to them. (4) Marriage of women members. 809. In order to secure uniformity, supplies of the various slips referred to above were furnished to Societies by the Commission. Societies were, however, informed that the Commission would be prepared to consider applications from Societies desirous of sub- stituting for the " removal slips " a form of their own. Committees 278 Scotland, were asked in all cases to re-allocate any notifications incorrectly addressed to them. The system of sending to the Commission ac- knowledgment forms and schedules for Societies' members when transmitting index slips to other Committees was at this stage dis- continued. Covering schedules to be forwarded with the slips were substituted, and as it was desirable that the procedure of Com- mittees in this respect should, so far as possible, be uniform, a form of schedule (to be prepared in duplicate, one copy being re- tained by the transmitting Committee) was suggested. 810. Immediately a Society or Branch had notified all changes occurring since the end of the first quarter which had come to its knowledge, a post-card intimation to that effect was required to be signed and forwarded to the Commission. The Society was then instructed to notify changes weekly as far as possible as they occurred. 811. With a view to the ascertainment of a mean figure which would indicate the number of insured persons at the commencement of the year, a count of the register fell to be taken when it was representative of the insured population in Committee areas as on 14th April, in order to average it with a previous count taken as at 29th October, 1912. Societies were accordingly requested to notify all changes taking place after 29th October, 1912. Com- mittees then sorted the slips inserted in the register which should not be included in the return as on 14th April, and the slips removed from the register which should be so included. 812. The Commission arranged for the third count to be taken at 15th September, 1913, and to exclude suspense slips therefrom, as for various reasons it was not practicable to include them in the count, pending identification or verification. It was anticipated that suspense slips relating to persons who had removed from one area into another would approximately cancel each other over the country as a whole, and that suspense slips relating to new entrants, in respect of whom index slips had not been received, would be counter- balanced to a large extent by index slips in the register of the Committee relating to insured persons whose death or lapse from insurance had not been notified. Although the process of clearing the suspense slips would have the effect of correcting the register so far as individuals were concerned, it would not materially affect the total of the index slips in a Committee's register. Further, the total of the funds available for distribution amongst Committees would not be prejudicially affected by the delay which had taken place in the notification by Societies of changes in membership, inasmuch as these funds are constituted by debits to each Society on the basis of separate returns as to membership. Nor would the delay inequitably affect one Committee as compared with another in the distribution of funds, inasmuch as the delay of Societies in notifying changes would affect all Committees approximately to the same extent. Further counts of the index register were taken at other times, making a total of six counts. 813. The Commission, however, viewed with some concern the fact that approximately only 60 per cent, of the Societies and structure of the System: Insurance Committees, &c. 279 Branches had intimated that they had informed Insurance Commit- tees of changes affecting the index registers in accordance with instructions issued to them in the month of June, 1913, and that none of the larger Societies was included amongst those which had completed intimations. Eeminders were sent to Societies on several occasions in the hope that they would result in the Societies for- warding the outstanding notifications without further delay. 814. The Commission, however, took into consideration the feasibility of proceeding with the assignment to doctors on the panel of persons who had not up till then exercised their right of selecting a doctor, without waiting, as was originally proposed, the completion of the notifications by Societies. It had been brought to the know- ledge of the Commission that certain Committees had already taken action in that direction, and in two instances, where practically com- plete assignment had been effected, the first step was to ascertain by means of a prepaid post-card whether the persons named in the index slips in the possession of the Committee who had not selected a doctor were still resident in the area. In particular, Dun- fermline Insiurance Committee had succeeded in reducing its list of suspense cases from 2,075 to about 370 under this method, the Local Medical Committee for the area co-operating. The Commis- sion accordingly suggested to Committees generally that such a system might with advantage be adopted where no steps had so far been taken. A form of post-card was suggested, and relative in- structions were given for its issue and for dealing with such cards as were returned to the Committee undelivered. The adoption of the post-card system by Committees had the effect of considerably reducing the number of suspense slips. 815. In October, 1913, in order to facilitate and expedite the allocation of insured persons to practitioners, the Commission further endeavoured to clear the registers of suspense slips by a process of centralisation. The following were the arrangements made: — Insurance Committees were instructed to transmit the whole of the suspense slips in their possession so as to reach the Com- mission not later than 23rd October, the slips being arranged on a convenient system and suitably marked for identification. On receipt by the Commission the slips were counted and an acknow- ledgment was sent to the Committee. Thereafter the slips from all Committees, now amounting to about 120,000, were arranged alphabetically in Societies (and Branches) according to the names of the members. A printed list of names, addresses, Society, Branch and number, and different cipher of every slip was pre- pared, and copies sent in daily instalments to each Insurance Committee. The actual work of printing and distribution was carried through in 10 days. On receipt of an instalment of the list each Committee was advised to compare it with the corresponding portion of its index register and to mark on its list whether an index slip was held for a suspense slip appearing in the list. The Com- mittee holding the index slip was then to communicate with the Committee holding the suspense slip with a view to its being deter- mined which Committee was entitled thereto, or in what proportion 280 Scotland. each was entitled to credit where there had been transfers during the course of the year. By the above procedure it was hoped to eliminate the great majority of cases where both a suspense slip and an index slip were in circulation in respect of the same person, and also to identify those cases where the Society had failed to issue an index slip or the slip had been lost in course of transmission, and so to enable the Committee to communicate with the Society. As an immediate result, index slips to the number of about 20,000 were transferred as between Committees. It is hoped that the intro- duction of the medical card system will further reduce the number of suspense slips. The main purpose of the medical card, so far as the index register is concerned, is to enable an Insurance Com- mittee to ascertain at once to which Committee they should apply for the index slips in respect of persons who have changed their residence. The use of the medical card as a voucher whereby in- sured persons may obtain medical benefit when required is explained in paragraph 945. Miscellaneous Administrative Questions. Administrative Expenses. 816. Frequent representations both in correspondence and in the course of interviews have been received during the year as to the insufficiency of the administrative income available to a number of the smaller Insurance Committees in Scotland. The matter was referred to, more particularly as regards the Highlands and Island Counties, in pages 337-8 of the last Eeport. Further experience has, however, made it clear that the difficulty is not confined to these Counties, but affects all the smaller Burgh and County Insurance Committees. The amount of detailed work to be performed by the staff of Insurance Committees, even in small areas, is very consider- able, and its extent can be realised when it is remembered that the index register of Committees is practically a census of a constantly changing insured population. Much clerical work and great care are necessary in recording changes so as to keep the register up to date. 817. The matter has engaged the serious attention of the Commis- sion, and they have now under consideration proposals for supple- menting the administrative income of the smaller Insurance Com- mittees in order that they may be enabled to carry on their work efficiently, but subject to the exercise of due economy. The Com- mission have also suggested to Committees that it might be eventu- ally helpful both to them and to the Commission if an officer of the Commission were to visit the Clerks in order to discuss with them the details of their work. The suggestion was very cordially re- ceived, and the visitation is now in progress. Subsistence Alloivancc and Compensation. 818. Section 31 of the Act of 1913 empowers Insurance Com- mittees to pay subsistence allowance and compensation for loss of remunerative time, in addition to any allowance for travelling ex- structure of the System: Insurance Committees, &c. 281 penses paid under Section 61 (2) of the principal Act. A number of schemes have been submitted by Insurance Committees for payment under this head, and are receiving consideration. 819. With a view to indicating the general principles on which claims for subsistence and loss of remunerative time might proceed; the Commission, in the course of a circular dated September, 1913, expressed the view that schemes should show evidence of discrimina- tion as to the circumstances in which such compensation is to be allowed, and of the provision of proper safeguards in order to prevent abuse, e.g.- — (1) Compensation should not be paid to a member who {a) is remunerated at a fixed weekly or yearly salary and does not incur pecuniary loss (either by reduction of salary or by having to provide a substitute) on account of his absence at meetings of the Committee; {h) is not in employment; (c) is himself an employer. (2) A certificate to the effect that the member had actually incurred loss m respect of remunerative time through being absent from his employment or business should be obtained in every case before the claim is passed for payment. A further communication to Insurance Committees on the whole question, including suggested rates under both heads, is in course of being issued. Insurance Committee Contracts with Members, 820. In response to inquiries as to the power of an Insurance Committee to enter into a contract with a member, the Commission took occasion to issue a circular to Insurance Commit- tees on the subject. Various Statutes and precedents affecting other Local Authorities were referred to in the circular, and the view was expressed that where the effect of a contract with a member would be to exclude a contract with other persons carrying on business, and where the member might thereby obtain personal advantage, the Insurance Committee would, by entering into the contract, render themselves liable to criticism. The circular accordingly urged upon Committees the desirability of passing a resolution that in such cases no member should be allowed to contract with the Committee. 821. As regards contracts with Insurance Service prac- titioners and chemists who may be members of Insurance Com- mittees, it was pointed out that as the individual representatives on the Committee could secure no better terms for themselves than for the general body of practitioners or chemists, they had no special individual interest, and that accordingly the foregoing considerations would not apply. Other Questions. 822. Among other matters of administrative detail which have come under consideration from time to time the following may be noted: — 282 . Scotland. 823. A medical member of an Insurance Committee was informed that the National Insurance Acts do not contemplate attendance at Insurance Committee meetings by deputy. 824. In reply to inquiries by a Local Medical Committee and by chemists, the Commission stated that bank charges on cheques in payment of amounts due to doctors or accounts rendered by chemists must be borne by the recipients of the cheques, and cannot be met out of Insurance Committee funds. 825. The Commission were unable to approve the suggestion of the Finance Committee of an Insurance Committee to defray the cost of providing the Chairman of the Committee with a telephone in order that he might more readily communicate with the Clerk to the Committee. ^^ 826. The opiiiion wag expressed that an Insurance Committee has no funds out of which it could competently pay or assist to pay the arrears of an insured person, whether such person is in receipt of institutional treatment or not. 283 II. THE WORKING OF THE SYSTEM. 1. Contributions. Contribution Cards and Books. Introduction of Half-yearly Cards. 827. The system of collecting contributions by means of quarterly cards was discontinued as from January, 1914, and replaced by a system of half-yearly cards. The period embraced by fche first half-yearly card is from the week commencing 12th January to the week commencing 29th June, 1914, a period of 25 weeks. The second half-yearly card will extend for a period of 26 weeks. * It is anticipated that the adoption of the half-yearly card will greatly reduce the work of Approved Society ofl&cials, as the distribution and collection of cards, the writing up of insurance books and contribution registers, and the preparation of returns will now only require to be done half-yearly. This change should also enable Societies to reduce slightly the cost of administration. 828. Contribution cards continue to be despatched by the Stationery Office to all Societies approved for the transaction of business in Scotland. As a rule, the distribution of cards to Societies commences six weeks prior to the end of a contribution period, and the despatch of the necessary packages (2,500 in number) is com- pleted within a fortnight. Special Cards for Low-Wage Earners. 829. Prior to the fourth quarter, contributors who came within the operation of the low-wage clauses of the Act were required to use the ordinary cards and to submit covering low- wage declarations. As from that quarter, however, special cards for low-wage earners— A (L) men and E (L) women — have been issued to Societies. The first supplies were accompanied by a memorandum explaining by whom the cards should be used. 830. The chief objection to the low-wage declaration was that, as a rule, the contributor whose duty it was to complete the form, either omitted to do so or did not complete it properly. In many cases, too, the form became detached from the card or was lost before it reached the Commission. The new card meets these objections, as the declaration now falls to be made by the employer, who is asked to certify the contributions at the low-wage rate by inserting his initials above the stamp in the space provided on the card, and by giving a certificate in the space provided at the foot of the card. In the fourth and fifth quarters employers did not appear to appreciate the necessity for giving this certificate, and a consider- 284 Scotland. able amount of work devolved on the Inspectorate in interviewing those employers who had not complied with the Kegulations. 831. It was found that Societies frequently sent in requisitions for cards which were far in excess of their normal requirements. In order, therefore, to prevent waste, it was decided to base the issue of the first half-yearly employed contributors' cards on the first quarter's actual membership of Societies, allowing a margin of 10 per cent., exclusive of the A (L) and E (L) cards, which were sup- pliesd on a 5 per cent, and 15 per cent, basis of the membership of men and women respectively. Societies were notified of the neces- sity of limiting supplementary demands to their requiremei;ts. Deposit Contributors* Cards. 832. As regards deposit contributors, attempts have been made to get into direct touch with members of this class by a modification of the system under which their cards were surrendered to the Post Offices. Towards the end of the sixth quarter all Post Offices throughout the country received a supply of special addressed enve- lopes, and, with the consent of the Postmaster- General, were in- structed to hand one to every deposit contributor who offered to surrender a contribution card at a Post Office, so that he could send his card direct to the Commission. Up to September, 1913, deposit contributors' cards came to the Commission almost exclusively through the Post Office, but accordingly from that dat« to 11th January, 1914, the cards reached the Commission from two sources: — (i.) From the Post Offices throughout Scotland; (ii.) Direct from the contributor. 833. During the sixth quarter, 16,716 cards were received from Post Offices, while 12,550 were received direct from the contributors. The latter, whether accompanied by the insurance books or not, are easily identified, as the deposit contributor's number, or other dis- tinguishing number, is inserted on the card and the return envelope before issue. Cards received through the Post Office, however, seldom have a number, and these, if unaccompanied by the insur- ance books, require to be associated with the accounts of the con- tributors. Over 18,000 cards were received during the sixth quarter without books ; of these about 15,000 had no number. The difficulty of associating such cards is further increased owing to the many changes in the addresses of the contributors. On average 5,000 cards per quarter are still imassociated. New Insurance Books. 834. With the change in the method of dealing with arrears con- sequent on the passing of the Act of 1913, it has been necessary to devise new insurance books. The books cover a period of three years, and contain information bearing on all points of insurance likely to be of use to insured persons. The employed contributor's book gives in a simple form a record of contributions and arrears paid, and shows the penalty arrears outstanding at the beginning Working of the System: Contributions. 285 of each benefit year on which the reduction of benefits will be based. It also provides for a complete record of " sickness " and of " benefit paid," which should meet the requirements of both members and Societies. The voluntary contributor's book shows in detail how the arrears to be deducted from benefit have been calcu- lated, and also gives a record of " sickness" and of ** benefit paid." Lost Cards. 835. Contribution cards bear the request that any person finding a lost card should drop it into a Post Office letter-box. Cards so lost are thereupon forwarded to the Commission, and an alphabetical index record of them is kept arranged in quarters so that applications for their recovery may be readily dealt with. Cards of workmen who have left their employment without claiming their cards are also sent to the Commission, employers having been instructed to this effect. In addition, advertisements and press notices as to the disposal of cards left with employers have been inserted in all the principal newspapers. A very large number of cards left in the hands of employers have thus been collected, and an endeavour is made to dispose of the cards either by sending communications to the addresses given, or by drawing the attention of Societies to the arrangements for dealing with lost cards and supplying post-card forms of application for cards lost by members. One application only is necessary for a lost card, as arrangements are made for the card to be forwarded to the Society should it be received by the Commission subsequently. Contributors in many cases apply for the cards themselves, giving a new address to which their cards are to be returned. During the year ended 31st March, 1914, 16,770 cards lost and left with employers were received, and 1,430 cards were returned. About 4,000 inquiries for lost cards were made to the Commission during the same period. The total number of un- claimed cards lying with the Commission is 22,450, the contribu tions thereon representing an approximate value of £2,530. Quarterly AND Half- Yearly Stamping Arrangements for Employers. 836. Eef erence was made in the last Eeport to the special arrange- ments by which large employers could, on application, be allowed to defer the stamping of cards until the end of the quarter. 837. At 31st March, 1913, there were 69 employers under the quarterly stamping arrangement, the gross number of stamps issued to employers in respect of the first six quarters being 1,061,315, representing a total value of £138,172 10s. 8|d. In consequence of the introduction of the new half-yearly cards in January last it was necessary to consider the substitution of a system of half-yearly stamping in place of the quarterly stamping arrangement. The con- ditions of this new scheme are on much the same lines as those relating to quarterly stamping. In place of making a deposit with the Commission in one sum at the beginning of the half-year, em- 286 Scotland. ployers have the option of making up the required total by two instalments, one being sent at the beginning and the other m the middle of the half-year. The procedure as to weekly, fort- nightly, and monthly remittances is the same as formerly. 838. In order to meet the requirements of the first half-yearly cards, the currency of which is 25 weeks, stamps representing 12 weeks' contributions at Id., 6d., and 4^d. are being issued. 839. The number of employers who are now under the half-yearly stamping arrangement, viz., 65, involving 50,847 men and 11,623 women, shows a slight decrease as compared with the number under the quarterly stamping arrangement. The net cash received from employers under the two schemes up to 11th January, 1914, amounted to £139,559 13s. S^d. 840. For a considerable time after the commencement of the Act numerous applications for high-value stamps were received from employers whose custom it is to pay wages quarterly or at longer intervals, but who had not adopted the special arrangements for quarterly stamping. As the Act and Eegulations stipulate only that cards must be stamped not less frequently than wages are paid, the Commission decided (after correspondence and consultation with the Postmaster- General) that stamps, representing 13 weeks' contributions, should be .put on sale at Post Ofi&ces, subject to the following conditions : — (1) That the employer is prepared to pay all the contributions for any insurance quarter at the beginning of the quarter; (2) That the wages are paid quarterly or at longer intervals, and the date of payment of wages is near the end of an insurance quarter. 841. There are four denominations of stamps available under the conditions, viz., 7s. 7d., 6s. 6d., 5s. 5d., and 4s. 10|d. In each case an undertaking must be signed that the stamps will be used only under the conditions above set forth. When this concession was originally granted, employers were somewhat slow in availing themselves of its advantages, but as the arrangement became more generally known, the number of purchasers increased to such an extent that all doubts as to the necessity of the scheme vanished. 842. In connection with the sale of these high-value stamps at Post Ofi&ces it has recently been decided to make them available to employers of fishermen and of men engaged on foreign-going ships who use a card having currency for the period of the voyage. In this case a stamp representing 13 contributions may ordinarily be used in payment or part payment of the contributions for any voyage lasting for 13 weeks or upwards. Special Arrangements for the Stamping of Contribution Cards DURING THE WeeK AFTER PAYMENT OF WAGES. 843. Many employers, after a short experience of the working of the Act, found it almost impossible, in view of the large numbers Worliing of the System: Contributions. 287 of employees in their service, to stamp all the cards at the right time, i.e., after the making up of the pay-sheets and prior to the payment of wages. An arrangement was accordingly devised whereby, on pay- ment to the Commission of a deposit equal to or greater than the maximum estimated contributions payable in respect of his workers on any pay-day, an employer may defer the stamping of the cards until the week after payment of wages, and may continue to do so as long as the deposit remains with the Commission. Under this arrangement stamps are purchased in the ordinary course at a Post Office. 844. Up to 11th January, 1914, nine employers had adopted this arrangement. The total deposits amounted to £400 Os. lOd., and covered the contributions of 10,450 men and 400 women. Kefunds and Adjustments. Refunds of Contributions paid in error. 845. During the past year difficult questions have arisen in con- nection with applications for the refunding of contributions paid in respect of members of Approved Societies who were insured as employed contributors, but were subsequently ascertained not to be employed within the meaning of the Acts. So long as benefits were not payable there was no difficulty in dealing with these cases. Since then, however, the position has materially changed. A total refund of contributions could not continue to be made, as the con- tributor had been treated as a person entitled to benefits, and accord- ingly his Society had incurred expenditure in respect of him. 846. Where the contributor is not entitled to continue in insurance as a voluntary contributor, or, if so entitled, does not desire to do so, the question of refunding arises, and in dealing with these cases the Commission considered that it would be necessary to have regard to the claim of the Society to be recouped for any expenses incurred in respect of the member. 847. A scheme was accordingly adopted which, while involving loss to the Society in particular cases where benefits have been paid and gain in others where no benefits have been paid, is believed to be equitable on the average. The scheme is as follows: — (a) The Society claims and receives credit in the usual way for the contributions on all cards surrendered to it by the con- tributor ; (b) The reserve value, if any, originally credited to the Society in respect of the contributor is cancelled. The Society is debited with the amount of the original reserve value, if any, increased by compoimd interest for the whole period between its creation and cancellation; (c) The Society is credited with the total amount deducted from the contributions on account of reserve values ; (d) The Society is debited with the whole amount of any State grants previously credited to it under Sections 47 (4) (d), 48 (2) (b), and 81 (10) of the Act of 1911, and also with any State grants previously credited under Sections 4 (1) 288 Scotland. proviso and 40 (2), in respect of the contributions paid for the first 26 weeks during which the contributor was treated as an insured person; (e) The Society is debited with the excess, if any, of the amount previously credited to it in respect of the contributions paid for the first 26 weeks during which the contributor was treated as an insured person over the charges for benefits and administration in respect of that period. 848. The object of these adjustments is to allow the Society to retain such portion of the contributions credited to it in respect of the first 26 weeks during which the contributor was treated as an insured person as will meet the charges for that period, and to give credit to the Society for the gross contributions on all cards sur- rendered to it without deduction on account of reserve values in respect of the period subsequent to the first 26 weeks. The balance of the contributions for the first 26 weeks is refunded to the em- ployer for division between him and the contributor. 849. Treasury sanction was obtained to the non-recovery in refund cases of certain Exchequer contributions so far as these related to any period subsequent to the first 26 weeks of insurance and of all sums payable to Insurance Committees out of the special grants-in-aid towards the cost of medical attendance and treatment and the cost of administration of medical benefit. 850. The Commission decided that the scheme should also be applied to the following cases where the contributor had joined an Approved Society: — (a) Voluntary contributors who were subsequently ascertained not to be qualified as such; (fe) Voluntary contributors who have been admitted at a lower rate than is applicable to their case, and who do not desire to remain in voluntary insurance at the higher rate pay- able; (c) Certain cases where contributions are paid in error in respect of persons prior to attaining the age of 16 or subsequent to attaining the age of 70. 851. As regards cases where contributions are paid before 16 or after 70, the Commission also decided that in certain special circum- stances a total refund of the contributions so paid should be made, e.g., in cases where, prior to attaining the age of 16, the Society had not regarded the contributor as an insured person, and in cases where the Society were unaware of the correct age of the contributor. 852. In regard to deposit contributors, the Commission decided that a refund should be made, subject to the necessary deductions in respect of administration and other charges. In such cases the whole of the State contributions are recovered, except those payable to an Insurance Committee out of the special grants-in-aid. 853. In a few cases, mainly resulting from the ante-dating of certificates of exception under Part II. (6) and (c) of the First Schedule to the Act, or from delay in issuing decisions under Section 66 of the Act, contributions were paid on the understanding Working of the System: Contributions. 289 that a refund in full would be made of any contributions subsequently found to have been incorrectly paid. The above procedure does not, therefore, apply to these cases, which, however, are very few and will gradually disappear. Allowances for Lost and Destroyed Cards. 854. During the past year the Commission have received a large number of applications for allowance of credit in respect of contribu- tion cards which have been lost or destroyed. The procedure of the Commission in such cases is briefly indicated below. 855. In the case of destroyed cards the Commission have made allowance on being furnished with satisfactory evidence of the destruction of the card, and with evidence as to the stamping which had been performed. 856. As regards lost cards, no allowance is made in cases where the card is lost while in the custody of the contributor. Similarly, where a stamped card has been lost after delivery by the contributor to his Approved Society, the contributor is credited with the con- tributions paid, the Society being required to make good the loss from their general administration account, unless the circumstances are such as to warrant recovery from the responsible officer. 857. As regards stamped cards lost while in the custody of the employer, credit is given to the contributor in every case, no loss falling on the employer unless he is unable to show that reasonable precautions were taken to insure its safe custody. 858. As regards cards lost in the custody of the Commission or lost in transit through the post, allowance is made where the Com- mission are reasonably satisfied that the card was duly posted, and that it was not delivered to the addressee. 859. In all cases of lost or destroyed cards, the Commission re- quire that application for refund must be made on the appropriate form, which contains declarations suitable to the type of case. Refunds and Adjustments of Contributions paid at the Wrong Rate. 860. In adjusting contributions incorrectly paid, the Commission have ordinarily required the employer, or other person responsible for the stamping, to re-stamp correctly, and formally to claim a refund of the value of the contributions incorrectly paid. Where, however, incorrectly stamped cards have been surrendered to an Approved Society or to the Commission, other considerations arise and special arrangements for adjustment are necessary. The cases of wrong stamping which are usually raised by the employer and involve re-stamping are briefly those where: — (a) the wrong type of contribution card has been used ; (6) stamps have been affixed to unemployment insurance books or exemption books; (c) unemployment insurance or postage stamps have been used ; (B254— Gp. 5) K 290 Scotland. (d) stamps have been affixed to the,wroDg places on the cacd; and , ^^tJiauio .^i ^ (e) too m^ny contributions . have 'b©«n paid on one card. -^^ ,-ou 861. Where cards are insufficiently stamped, the adjustment involves further payment by the employer, and where, as is often the case, the question of adjustment is raised by the Commission, investigation is necessary in order to ascertain the rate of contribu- tion properly payable. The adjustment is made "either by re- stamping, or, if more convenient — e.g., in the case of surrendered cards — by stamping arrears cards to the value of the deficit. Such cases are, for example, those where contributions have been paid: — (a) at the low- wage rate instead of at the full rate ; (6) at reduced rates prior to the date of the notice required by the provisions of Section 47 ; (c) at the exempt rate prior to the date of issue of a certificate of exemption ; (d) at the exempt rate for persons who were over 65 years of age, and in respect of whom full contributions were properly payable. 862. Where the Commission are satisfied that the stamping has been at too high a rate or in excess of the correct amount, a refund has been made after re-stamping. Typical cases arising under this head are those in which contributions have been paid : — (a) at the full employed rate after the date of issue of a certifi- cate of exemption under Section 2 ; (6) at the full employed rate by an employer who has adopted Section 47, and in respect of weeks subsequent to the date upon which notice was given applicable to the employment in question ; (c) on exemption cards at too high a value ; (d) for weeks in which no contribution was payable (on exemp- tion cards and on unsurrendered employed contributors^ cards). 863. Cases have also arisen where contributions have been paid in duplicate : — (a) by the same employer; (6) by different employers ; (c) by a contributor or his Approved Society to replace those on a lost card subsequently found ; (d) in respect of soldiers engaged in civilian employment con- currently with the payment of Army contributions. In such cases investigation, is usually necessary in order to adjust the matter. 864. Where contributions have been paid at the full rate instead of at the low- wage rate, adjustment on unsurrendered cards is made by re-stamping. As regards surrendered cards, the sanction of the Treasury was obtained to the payment of the State penny, and the procedure was simplified by refunding direct to the employer. As considerable misapprehension has existed in regard to the low- wage rate, investigation is made locally in all applica- Working of the System: Contrihutions. 291 tions under this head in order to verify that the low-wage rate was actually payable. 865. If repayment is claimed on the grovmd that the person has been insured in error, investigation is necessary to decide the question whether the employment of the contributor is employment within the meaning of the Act. If this point is not settled by means of correspondence, inquiry is made by an Inspector, or the matter is formally submitted to the Commission for decision under Section 66 of the Act. 866. Inquiries as to the age of a contributor or the rate of con- tribution properly payable, or the names of the employers con- cerned, are undertaken by the local Officer of Customs and Excise. In- cases where a refund is claimed in respect of contributions paid prior to the age of 16 no difficulty arises in proving the age. In cases, however, where contributions are alleged to have been paid after 70, the question of age is often a matter of difficulty owing to the fact that compulsory registration of births did not come into operation in Scotland until 1855. The experience which the Officers of Customs and Excise have gained in this matter in connection with their duties under the Old Age Pension Acts has proved very valuable to the Commission. Normal Rate of Eemuneration. 867. Section 25 of the Act of 1913 provides that where it appears to the Commission that the persons employed by any employer or group of employers in any class or classes of work are in general in receipt of a rate of remuneration which, although liable to fluctua- tion, is normally within any of the following limits, viz. : — (a) not exceeding Is. 6d. a working day; (h) exceeding Is. 6d. but not exceeding 2s. a working day; (c) exceeding 2s. but not exceeding 2s. 6d. a working day; the Commission may, by Special Order, declare that all the persons employed by that employer or group of employers in the class or classes of work shall, for the purposes of the principal Act, but subject to any exceptions contained in the Order, be treated as if they were constantly in receipt of the normal rate of remuneration, notwithstanding that those persons or any of them may b: any week in fact receive a higher or lower rate of remuneration. 868. Under Treasury Regulations the Special Orders are to be made by the Joint Committee, but the applications from em- ployers for the fixing of normal rates of remuneration are received by the Commission, who also undertake the investigations necessary to determine the limits between which the normal rate of remunera- tion of the employees affected lies. Recommendations as to the issue of the Special Orders and the terms of such Orders are to be submitted to the Joint Committee by the Commission. 869. In certain cases the necessary investigations have been completed, but a number of difficult questions have arisen in con- nection with the Section, and, pending full consideration of these questions by the Commission, no Orders have been made. (B254— Gp. 5) K 2 292 Scotland. Outworkers. 870. When the last Eeport was prepared, the method of paying contributions in respect of outworkers by reference to the work done, instead of to the weeks in which the work is done, had been adopted by 53 employers in respect of approximately 1,770 out- workers, of whom 1,420 were insured persons and 350 holders of exemption certificates. Of the insured persons about 70 were men and 1,350 women. The system is now applicable to 74 employers in respect of about 3,250 outworkers, 3,040 of these being insured and 210 holders of exemption certificates. Of the insured persons 310 are men and 2,730 women. The figures given are based on the applications by employers for cards — the only data readily avail- able — and may therefore be taken as being in excess of the actual numbers. 871. Since the issue of the last Eeport {see pages 294 and 295 of that Eeport)* special units of work have been fixed in respect of out- workers employed by the employers mentioned, and in the classes of employment shown in the following Table : — Unit Claimed Name and Address of Employer. Classes of Work. (if any). Decision or Unit Men. Women. Fixed. *. d. *. d. *. d. Bonsor, Jas. & Co., 14, Buc- Trimming hosiery — ■ — 10 9 cleuch Street, Hawifk Dinwiddle, Jae. & Co., Dumfries Trimming hosiery underwear — 10 9 10 9 Fleming, Reid & Co., Ltd., *Hand knitting of socks — 13 9 refused. The Worsted Milb, Greenock and stockings Fleming, Reid & Co., Ltd., ^Crocheting and hand — 13 9 10 6 The Worsted Mills, Greenock knitting of garments otber than socks or stockings Fleming, Reid & Co., Ltd., The Worste \ Mills, Greenock ♦Finishing, seaming — 13 9 10 6 and sewing partly- finished garments in knitted underwear Gibson & Paterson, 85, Queen Manufacture of chil- — 17 6 refused. Street, Glasgow dren's frocks Gibson, J. L. & Co., Maxwell- Manufacture of woollen — 11 6 refused. town Factory, Dumfries gloves Hawick Hosiery Co., Ltd., •Manufacture of hosiery — 11 6 10 9 Trinity Milh, Hawick underwear and jackets Kirkness, D. M., 14, Palace Manufacture of straw 10 — 10 Road, Kirkwall work for Orkney chairs Members of Dundee Associa- Sack sewing ._ — 7 tion of Public Calenderers (For men and women workers. ProTi- sional.) * In these cases the decisions now shown superseded provisional units which had previously been fixed. Working of the System: Contributions. 293 872. In one case an application by an employer for a special unit was subsequently withdrawn. It will be seen from the Table that in three of the eight cases in which special units were claimed the application was refused, thus leaving the general unit of 8s. 9cZ. applicable to the outworkers (women) concerned; in three cases a lower unit than that claimed was fixed; while in two cases the imit asked for was granted by the Commission. The provisional special unit for sack-sewers was fixed after an investigation initiated by the Commission themselves. 873. Advantage was taken of the fact that the introduction of. half-yearly cards necessitated consequential amendments of all the- Regulations dealing with the collection of contributions in respect of various classes of insured persons to make consolidated Regulations, in regard to the collection of contributions. The Regulations of 1913- as to the payment of contributions in respect of outworkers by reference to a unit work done were embodied in the consolidated. Regulations without substantial change. 874. A Special Order was made on 26th June, 1913, under para- graph (c) of Part I. of the First Schedule to the Act of 1911, pro- viding that blind persons to whom work is given out by or on behalf of any charitable or philanthropic institution, and who are not wholly or mainly dependent for their livelihood on their earnings, in respect of such work, shall not be deemed to be employed within, the meaning of the Act in respect of that work. 875. So far, it has not been found necessary in Scotland to- exercise the power conferred by Section 26 of the Act of 1913 to. determine by Special Order who is to be deemed to be the employer of any outworkers or class of outworkers. Cheap Birth Certificates. 876. The form of requisition for a cheap birth certificate pre- scribed by the Local Government Board for Scotland under Section 114 of the Act of 1911 has been amended by an Order made by the Board on 3rd October, 1913. The amendment consists of the inser- tion of a question asking the name of the Approved Society, Insu- rance Committee, or other body or person for whom the certificate is desired. The ground on which the Registrar-General desired to have this additional enquiry inserted in the form was that representations had been made to him by the Association of Registrars of Scotland that they had reason to believe that demands made upon them for certificates at the reduced fee were not always hona fide for the purposes of the National Insurance Acts, and it seemed to him, as to the Commission and the Local Government Board for Scotland, that the legitimate interests of the Registrars should be protected as far as reasonably possible. 877. On the form of requisition as first printed by the Registrar- General there appeared a Departmental instruction to the effect that the form was not applicable to persons under 16 years of age. After some correspondence on the subject the Registrar- General informed the Commission that he was prepared to concur in the removal from the form of the statement relative to the limitation of the issue of (B254— Gp. 5) K 3 294 Scotland. certificates to persons over 16, and that he would shortly give effect to this decision in a fresh imprint of the form. Cheap Marriage Certificates. 878. Section 35 of the Act of 1913 provides facilities for obtaining at a cheap rate copies of marriage certificates required in connection with National Health Insurance. In pursuance of this provision a form of requisition was prescribed by the Local Government Board for Scotland on 3rd October, 1913, after consultation with the Eegistrar-General for Scotland and the Commission. With a view to preventing dishonest applications, a question has been inserted in the form similar to that above referred to in connection with the issue of cheap birth certificates. Prosecutions for Non-Payment of Contributions. 879. As mentioned in the last Report (page 282), appeals were taken to the High Court of Justiciary against two of the convictions ^obtained in prosecutions of employers at the instance of the Com- mission. The appeals were heard by the High Court in March, 1913 ; but at the conclusion of the hearing the Court thought it proper, in the circumstances, to order a re-hearing before a fuller Court. The second hearing took place in May, 1913, and in July following the Court gave judgment quashing the convictions, on the ground that the Commission had no title to prosecute. 880. Thereafter prosecutions for failure to pay contributions and to obtain cards were instituted at the instance of the Procurators Fiscal, and this procedure has since been followed. In all, since July last, papers in 103 cases have been forwarded to the Crown Office with a view to the prosecution of 116 alleged offenders for failure to stamp or to obtain cards. Convictions were obtained in 66 cases, and fines ranging from £50 downwards were imposed. Six complaints were dismissed. In 37 cases the prosecutions were dropped, as the arrears of contributions were paid prior to the service of the complaints. In two cases proceedings were discon- tinued for other reasons. Five cases are still before the Courts at various stages of procedure. There have been three appeals to the High Court of Justiciary ; in one of these the conviction was sus- tained, in another it was quashed, and the third appeal is still pending. 881. In addition to the power to recover arrears of contributions following on a conviction under Section 69 (2) of the Act of 1911, a very important new provision specially confined to Scot- land appears in Section 41 (6) of the 1913 Act, which empowers the Commission to sue an employer in a civil process for arrears of contributions. This power is of considerable importance, as it will enable the Commission to raise, by means of civil, instead of criminal, process, questions of employment. In view of this pro- vision, the Commission are considering the question of taking steps by civil process for recovery of arrears of contributions due from 15th July, 1912. Working of the System: Sickness Benefit. 295 882. Under Section 70 of the 1911 Act, if an employer has failed or neglected to pay contributions in respect of a person who is a member of an Approved Society, and by reason of such failure or neglect, that person has been deprived of benefits which would otherwise have been payable to him, he may take proceedings against the employer for the value of the right of which he is so deprived, and the employer may be ordered to pay a sum equal to the value of the right to the Commission, to be placed to the credit of the Society of which the person is a member. Great difiiculty has been found in Scotland in the application of this Section, in view of its inconsistency with the general procedure obtaining in the Scottish Courts. Under the Section proceedings are to be at the instance of the insured person, while the money is to be payable to the Commission, and it has been suggested that the Commission should have had themselves sisted as parties to the action. As- this would mean in practice their taking an active part in the con- duct of such proceedings, and such a course would seem to be at variance with the statute and might have serious consequences in regard to expenses, the Commission have not seen their way to- sist themselves. 883. It has not been found necessary in any case to take civil proceedings under Section 71 of the 1911 Act for the recovery of benefit wrongly paid, as in those cases where proceedings would have had any practical result arrangements have been made for repay- ment. 2. Sickness Benefit. Enquiries by Insured Persons. 884. As was to be expected, a considerable number of enquiries^ with reference to the payment in particular cases of benefits was received during the year under review. These questions which insured persons have raised have ranged over the whole area of administration entrusted to Approved Societies. Most of them may, however, be classified under the following heads: — (a) Delay in paying benefit. (h) Doubt as to qualification. In this connection paragraph 887 dealing with medical certificates, mentions that owing to various causes medical certificates furnished by members were unacceptable to Societies. (c) Non-observance of rules. The rules chiefly in question were those relating to conduct during sickness and to the time within which notification of illness should be furnished to the Society. (d) Disputed membership. Many disputed claims for benefit were complicated by the insured persons having applied for member- ship to more than one Society, and surrendered some cards to one Society and some to another. 885. Where a question arises as to payment of benefit the right of determining it is in the hands of the Approved Society ; an appeal against the Society's decision may be made to the Commission under Section 67 of the 1911 Act. The Commission's policy in dealing (B254— Gp. 5) K 4 296 Scotland. with a point of difference has been to put before the Society the facts and circumstances of the case as reported to the Commission 'by or on behalf of the member, and to correct any misunderstanding as to the effect of the provisions of the Act or of the rules of the Society which it may transpire has existed on the part of the Society. 886. The assistance of the Inspectors has been very largely utilised in dealing with complaints. The number dealt with, however, has grown so large that the work occupies a disproportionate amount of the time of the Inspectors. The Commission are therefore con- sidering whether and in what way the procedure hitherto adopted can be modified. The measures taken in connection with enquiries as to benefits have been amply justified. They have been the means of enabling the Commission to give instruction and assistance in the detailed working of the Act to a great many Societies. They have also obviated the submission of formal disputes under Section 67, of which very few have up t6 the present been received. Medical Certificates. 887. The certification of incapacity has given rise during the year to questions both on the part of Approved Societies and of insurance practitioners. It was mentioned in the last Eeport that the matter was under consideration in view of representations made by the -insurance practitioners. These representations were to the effect that unnecessary trouble and delay were -caused owing to the fact that Societies had their own forms of medical certificate which they insisted on having completed before claims for sickness benefit were met. Practitioners were thus frequently required to handle many forms of certificates, and asked to furnish duplicate certificates sbecause the first certificate was not on the Society's form. 888., The Commission, therefore, reviewed the whole question, %nd obtained the advice and assistance of representatives on the Advisory Committee of the medical profession, and of the various Approved Societies. The result was to secure the general acceptance of a uniform initial certificate, and a considerable degree of uni- formity in the continuing and final certificates. 889. Arrangements were made whereby the forms of initial certificate were provided by the Commission without cost to the Approved Societies. Supplies thereof were sent to each Insurance Committee for distribution among insurance practitioners. The practitioner has thus at hand, when required, a form of certificate ordinarily acceptable to the member's Society, and so far as this aspect of the certificate question is concerned, the matter appears to be now on a satisfactory basis. 890. The Commission have, however, under consideration at present a revised sickness certificate which contains, in addition to the certificate to be signed by the practitioner, a form for use by the member in declaring " on " and " off " the funds of the Society. 891. Questions as to the specification on the medical certificate of the disease from which the insured person is suffering have con- tinued to cause difficulty. Under his agreement with the Insurance Working of the System: Sickness Benefit. 297 Committee a practitioner is bound to furnish in connection with •a claim for sickness benefit such certificates as are required by an insured person on his list in pursuance of the rules of the person's Society. In accordance with their rules, Societies have required the nature of the disease to be stated, but in numerous cases practitioners refused to do more than certify that the insured person was incapacitated by illness. In support of their attitude it was urged that to disclose the cause of incapacity would be a violation of professional confidence, that the disclosure might in certain circumstances render the doctor liable to an action of damages, and that in special cases it was essential in the interests of the patient that he should not know the nature of the disease from which he suffered. 892. On the forms of medical certificate issued by the Commis- sion it is made clear that the certificate furnished by the doctor is given not to a third party, but to the patient himself at his own request and for his own purposes. As regards those cases where the doctor would not state, even to the patient himself, the nature of his disease, the Commission thought that, on the whole, they were exceptional and capable of being met as they arose, by special, arrangement. The point raised on behalf of the practitioners that,, in specifying the nature of the disease, they might render themselves, liable to actions of damages is under Scots law one of much diffi- culty. The Commission have given the matter careful considera- tion, and are advised that in the circumstances the granting of such, certificates is privileged, and that accordingly such an action against . a doctor who has acted in good faith and with reasonable care in, connection with a certificate furnished to an insured person would, not be successful. 893. Further difficulty has been experienced on account of the terms used by practitioners in describing certain ailments. For example, free use has been made of such general terms as " debility " and " anaemia," and many Societies have refused to pay sickness benefit on such certificates on the ground that these illnesses do not necessarily connote incapacity for work. It is, doubtless, true that there are many cases where an exact diagnosis is difficult or even impossible, but where the prac- titioner may nevertheless be satisfied that there is genuine incapacity which, so far as his examination shows, can only be truly described' in general terms. The Commission have had rnuch correspondence on this question, and have made it clear that the matter is one within the discretion of Societies. They have, however, advised that where a Society has in its rules a requirement that a claim for sickness benefit must be accompanied by a medical certificate of incapacity and the cause thereof, it is justified in requiring the member to state the nature of the disease before the claim is. entertained. The circumstances which render it essential for a. Society to know the nature of the disease are that the Society is. entitled to be put in a position to enforce its rules, e.g., the rule as to the withholding of sickness benefit where the incapacity is duft to misconduct. 298 Scotland. 894. Correspondence has also taken place in regard to claims for sickness benefit in cases where pregnancy was certified as the cause of incapacity. The Commission have indicated that the question is one for the Societies to decide in accordance with their rules after ascertaining the facts of each case. 895. Questions were submitted in regard to the duty of insurance practitioners under their agreements to examine insured persons on their lists for the sole purpose of furnishing the medical certificates required in order to claim sickness benefit —such persons not being in receipt of medical treatment. Cases brought to the notice of the Commission were : — (a) that of an insured married woman who wished to claim sick- ness benefit in respect of confinement; (b) that of an insured person who had been attending a bone- setter. In both cases the Commission expressed the opinion that the doctor was bound to furnish the certificate provided he had a reasonable opportunity of satisfying himself of the incapacity. In the latter case the doctor was advised that the matter was one which might Jbe brought to the notice of the General Medical Council. Donations to Hospitals. 896. On 6th December, 1913, Kegulations were issued under 'Section 21 of the principal Act prescribing that any subscriptions or donations granted by an Approved Society to hospitals, infirm- aries, or other charitable institutions, or for the support of district nurses, and any sums expended by an Approved Society on nurses appointed for the purpose of visiting and nursing insured persons, should be treated as expenditure on sickness benefit. The Com- mission deemed it advisable to issue a circular to Societies explain- ing the Eegulations, and pointing out that subscriptions or dona- tions of the kind contemplated by the Section must come out of the ordinary benefit funds, and that no margin had been provided in those funds specially for the purpose of meeting this expenditure. It was for the Society to decide for itself whether judicious expendi- ture of this kind in return for which members of the Society would obtain skilled attendance in illness, might be expected to have the effect of promoting the recovery of sick members and so of relieving the ordinary expenditure on sickness benefit. Societies were further warned that as such relief might not be experienced immediately, they should, before incurring expenditure under the Section, have regard to their immediate liabilities for expenditure out of their benefit funds, and it might even be thought advisable to take actu- arial advice on the subject. Some Societies have communicated with the Commission in regard to this Section, and while their powers have been pointed out to them they have been advised to exercise caution until their position on valuation warrants them in- curring such expenditure out of benefit funds. Working of the System: Sickness Benefit. 299 Misapplication of Benefit. 897. Section 69 (1) of the 1911 Act provides that if, for the purpose of obtaining any benefit or payment, any person knowingly makes any false statement or false representation, he is to be liable on summary conviction to imprisonment for a term not exceeding three months. Various cases have occurred where insured persons have made false declarations, and have, in point of fact, been work- ing during the period in respect of which they were in receipt of sickness benefit. A few cases under this head have been reported by the Commission to the Crown Office, but in most instances reports have been sent direct by the Societies concerned to the Procurators Fiscal. A number of prosecutions on this account have taken place throughout Scotland, and it is hoped that these proceedings with the consequential punishment will deter others from making similar false declarations. Medical Keferees. 898. Following the model rules issued by the Commission, almost every Society has adopted a rule empowering it to call upon a member in receipt of sickness benefit to submit to medical examina- tion by a doctor appointed by the Society for the purpose. Advan- tage has been taken of this power, and it. is understood to have been of assistance in checking fraudulent or doubtful claims. 899. Many inquiries were made as to the account to which the cost of such special examinations should be charged. It was urged' by Societies that in equity the cost should not be charged to the administration account, and that, in view of the possibility of the examination resulting in a direct saving to the benefit* fund, the- expenditure should be charged against that fund. It was clear to- the Commission, however, that as the service was really of the- nature of administration the expenditure should be charged against the administration account. In order to assist Societies in the matter, the Joint Committee, on 24th October, 1913, issued Eegu- lations which allowed as a provisional arrangement an additional amount not exceeding Id. per member to be carried to the admin- istration account if the Society during the period of six months ending 31st March, 1914, incurred expenditure in connection with the employment and payment of medical referees, and if in conse- quence thereof a deficiency resulted in the account. 900. It was pointed out that if a Society did not by itself care to make arrangements with a doctor or doctors it might do so in co-operation with other Societies, or it might be possible to arrange that the Insurance Committee should make arrangements with the doctors. In explaining this proposal to Insurance Conmiittees it was made clear that in so acting they would merely be the agents for the Societies, who would bear not only the full cost of the fees chargeable by the doctors, but also any administrative expenses involved in the arrangements. 300 Scotland. Benefit when in Hospital. 901. Many Societies have consulted the Commission with refer- ence to the question of dependency arising under Section 12 of the Act of 1911. Under that Section any benefit withheld owing to the fact that the insured person, or, in the case of maternity benefit, the mother, is in hospital, may, if the insured person or the mother has dependants, be applied in whole or in part towards their relief or maintenance. It has been pointed out that dependency is to be tested as at the time before the insured person, or, in the case of maternity benefit, the mother, became ill. 902. The Commission have received representations from the authorities of hospitals with reference to various aspects of this question. Societies are empowered to enter into agreements with hospitals supported by charity or by voluntary subscriptions in cases where the inmate of the hospital has no dependants. Such agree- ments may provide that the amount of benefit- may be paid in whole or in part, according to the terms of the agreement, towards the maintenance of the person in the hospital. The Commission issued a circular fully setting out the effects of the Section, and containing two model forms of agreement between Approved Societies and hospitals. Workmen's Compensation. 903. Section 11 of the 1911 Act requires that where an agree- ment is made to pay compensation at a weekly rate of less than 10s., or by way of a lump sum in redemption of a weekly payment, the employers shall, within three days thereafter, or such longer time as may be prescribed, notify the Insurance Commissioners, the Approved society, or the Insurance Committee concerned. Owing to the exigencies of Scots Law in connection with the Workmen's Compensation Act, 1906, the statutory period of three days has not been extended by the Commission. 904. It is found that by far the greater number of notifications are forwarded to the Commission. In such cases particulars of the injured person's Approved Society are obtained and an extract of the agreement is then forwarded immediately to the Society secre- tary. It may be mentioned that some insurance companies are, as .ja matter of courtesy, forwarding notifications of agrements where the r.<3ompensation paid is equal to or greater than 10s. per week, although r^he statutory obligation on employers does not extend to such cases. The information thus received constitutes a valuable check against j)0ssible payments by Societies to members who may not disclose •;the fact that they are in receipt of compensation. 905. The notifications received are examined for the purpose of seeing that they comply with the requirements of Section 11 of the 1911 Act and of the Kegulations issued thereunder. In any cases of apparent contravention, or where it seems that there is a discrepancy in the particulars given, the matter is investigated. Satisfactory explanations are in general received, but in a few cases it has been WoTking of the System: Maternity Benefit. 301 necessary to communicate with the employers indicating their obliga- tion to furnish information under the Section and the penalties for non-compliance with its requirements. 906. This continued vigilance has had the effect of adding to the number and completeness of the notifications, and during the last few months the number received per week has increased by about 35 per cent. Of the notifications so obtained, over 80 per cent, are subsequently communicated to Approved Societies or Insurance Committees. In the remaining cases the persons are not insured persons, or, owing to removals, their whereabouts are not known. 907. Societies have been advised that, in their own interests, they should notify the Commission of all accidents sustained by their members. It has been found in practice that a very small proportion of accidents are thus intimated. Where such intimation* is received, however, a communication is addressed to the employers requesting notification of the agreement. In this way it has been possible to acquaint many employers with their obligations under the Section. 908. The following is an analysis of the notifications under Section 11 (1) (c) received during one week: — No. from Insurance Companies 190 No. from Agents other than Insurance Companies 10 No. from Employers ... ... ... ... ... 20 Total 220 909. The Commission are informed that at least in three instances several Societies have agreed in combination to retain the services of a law agent as adviser in compensation cases. 3. Maternity Benefit. Changes introduced by the Act of 1913. 910. Owing to the changes introduced by the Act of 1913 regard- ing maternity benefit, the Conmiission deemed it advisable to issue a circular informing Societies of the position. The special pro- visions making maternity benefit the mother's benefit, and providing a second maternity benefit for insured married women, did not come into force until 12th January, 1914. The other important pro- vision of the 1913 Act, designed to secure that a woman should in no case be worse off because her husband was insured than she would be if he were not insured, came into force on 13th October, 1913. 911. In response to requests, the Commission also revised the model forms for claiming maternity benefit which were first issued by them at the beginning of 1913. In accordance with the provisions of the 1913 Act the forms provide for either husband or wife claiming the benefit in respect of the husband's insurance, and, where the wife desires the benefit to be paid to her husband, a form is pro- 302 Scotland. vided for her signature and authorisation. This form authorises the husband to sign the receipt for the benefit on her behalf. 912. The form ordinarily used in connection with women's insurance is applicable where the woman is claiming the second maternity benefit provided under the 1913 Act for insured married women in lieu of the sickness benefit to which they were entitled under the 1911 Act. It has, however, been thought advisable to suggest a special form to be used where such a claim is made by a woman whose husband is not insured, and who is, therefore, entitled to a double maternity benefit from her own Society. This form is also applicable in cases where further benefit is pay- able by the woman's Society owing to the fact that although her husband is insured he' is entitled to no benefit, or to less than the full benefit, by reason of some defect in his insurance. 913. Before a Society meets a second claim for maternity benefit from a woman member it must be satisfied — (1) that the husband is not an insured person, in which case the woman signs a declaration on the form to that effect ; or (2) that the husband, being an insured person and a member of a Society, is not qualified for benefit, in which case a certificate from the husband's Society that no benefit is payable is to be forwarded by the woman; or (3) that the husband, being an insured person, but a deposit contributor, is not qualified for benefit or is qualified for partial benefit only owing to the state of his account. In this case the woman forwards with her claim a certificate from the Commission showing how much, if any, benefit is payable in respect of the husband's insurance. These forms have been generally adopted by Approved Societies. 914. Mention has been made elsewhere (paragraph 762) of the rule suggested by the Commission which Societies must adopt with reference to cessation from remunerative work on the part of a woman receiving the second maternity benefit. The result of the provision of the 1913 Act i? that a Society does not require, and is not entitled to demand, any evidence of incapacity for work in respect of four weeks after confinement. Evidence of the confine- ment only is required, and Societies therefore pay the full maternity benefit at once, subject only to a fine afterwards for breach of the rule if the woman in found to engage in remunerative work during the period referred to. 915. The following advice has been given by the Commission in connection with this special benefit : — (a) The payment of a second maternity benefit will not count as the payment of four weeks' sickness benefit for the pur- pose of determining when the 26 weeks of sickness benefit to which a member may be entitled are exhausted. (b) The payment of a second maternity benefit does not dis- entitle a woman to sickness benefit in respect of incapacity after the end of the four weeks (whether due to confinement or not). If she remains incapable, a woman will be entitled Working of the System: Maternity Benefit. 303 to sickness benefit after the end of the four weeks and con- tinuing for 26 weeks, or for the unexhausted part of that period if she has been in receipt of sickness benefit in respect of an illness before the confinement which is deemed " continuous " under Section 8 (5) of the 1911 Act. (c) No arrears of contributions during the two weeks before or four weeks after a confinement are counted towards reduc- tion of benefit. (J) The second maternity benefit should be accovmted for as maternity benefit. 916. The maternity benefit payable in respect of the insurance of an alien member whose wife was before marriage a British subject was, by the provisions of the 1913 Act, increased by two-sevenths, subject to Eegulations, the amount of the increase being met from moneys provided by Parliament. The maternity benefit in such cases will be at the uniform rate of 80s., the charges against the Societies' funds and the State grant being £1 3s. 4d. and 6s. 8<:L respectively. 917. A further provision of the 1913 Act relates to the benefits payable in respect of the insurance of an insured woman who, having been a British subject before marriage, marries an alien. She is not included within the special provisions relating to aliens, and accord- ingly the maternity benefit to which she is entitled is 30s. It is thus only where both husband and wife are aliens by birth and neither has become naturalised, or, if the woman's insurance only is concerned, she is herself an alien by birth, and has not obtained naturalisation, that the reduced amount of maternity benefit is pay- able, namely, £1 3s, 4d. in the case of a man's insurance and 18s. in the case of a woman's insurance. Mid WIVES and Approved Institutions. 918. In some districts women with training or practical experience have been more in demand for maternity cases since January, 1913, than in the past. In others, there are no comparative data, though women without any qualification are known to have been largely employed. 919. Complaints have been received that persons not qualified in terms of paragraph (2) of the National Health Insurance (Qualifi- cations of Midwives) (Scotland) Regulations, 1912, were acting as midwives and signing certificates for maternity benefit. Inquiries made have had the effect of warning off obviously unqualified women. No complaint, however, was so presented as to raise a question in the sense of the Regulations, under which it would have been necessary for the Commission to determine whether the woman was qualified. 920. The exercise of greater stringency on the part of Approved Societies should have some effect in repressing the activity of unskilled women. But no substantial or permanent improvement in the situation can be anticipated so long as any woman in Scotland who elects to call herself a midwife is at liberty to do so. 304 Scotland. 921. Five institutions engaged in the teaching of practical mid- wifery were approved by the Commission under Section 2 (h) of the Begulations above referred to. The approval of the Commission was given for a stated period, and after investigation. The institu- tions in question are : — The Edinburgh Eoyal Maternity and Simpson Memorial Hospital ; The Glasgow Eoyal Maternity Hospital ; The Dundee Royal Infirmary ; The Hospice, Edinburgh ; and The Cottage Nurses' Training Home, Govan. 922. To another institution which applied approval was granted conditionally, and subsequently withdrawn. Maternity Hospitals. 923. At conferences held in October, 1912, and January, 1913, between the Commission and representatives of Scottish Maternity Hospitals, to which reference was made in the last Report, the representatives expressed their apprehension that the National In- surance Act, taken in conjunction with the rules of Approved Societies, would bring the work of their outdoor departments to a close, and would seriously diminish the number of their indoor cases. The questions involved have been the subject of further recent cor- respondence between the Commission and the hospitals, and it is hoped that some satisfactory conclusion will shortly be reached. 924. Negotiations were also opened between the Maternity Insti- tutions and Approved Societies, but the determination of a suit- able fee proved a stumbling block. The number of Societies which ultimately entered into agreements was comparatively small. The charges made varied from a flat rate of 15s. for both intern and extern cases at the Edinburgh Maternity Hospital to 10s. for intern and 7s. 6d for extern cases at Aberdeen Maternity Hospital. 925. The experience of the past year at the four great Scottish Maternity Hospitals has shown a falling off in cases as compared with 1912. The rate of decrease ranged from 15 per cent, in Dundee to 35 per cent, in Aberdeen. The reasons for this decline were dis- cussed at a joint meeting of maternity representatives held in Edinburgh on 4th February, 1914. It was alleged that the diminu- tion arose from the calling in of neighbours and unskilled women to attend confinements, and not from -the employment of a larger number of doctors or trained midwives. It was felt by the confer- ence that the fees proposed to be charged by the hospitals were too high, and it was agreed that a sum not less than 5s. nor more than 10s. would be a fair remuneration. Increased Employment of Doctors. 926. While it is, in itself, a regrettable circumstance that cases lost to the wards and extern departments of Maternity Hospitals should fall to the care of unskilled persons rather than to doctors or Working of the System: Maternity Benefit. 305 expert mid wives, and while it cannot be doubted that a proportion of the cases in question are insured persons or the wives of insured persons who are to this extent failing to derive full advantage from the maternity benefit, it must at the same time be recalled that Maternity Hospitals for the most part minister to the needs of a restricted class, and that therefore their experience is not neces- sarily representative of the general population of the country. In certain Scottish cities, among the inhabitants as a whole, there is reason to believe that there has been, since the coming into opera- tion of maternity benefit, a perceptible increase in the number of cases of labour attended by medical men. 927. The question is one upon which statistics are not very widely available, but, by the courtesy of the Medical Ofiicers of Health in Aberdeen, Glasgow, and Edinburgh, the Commission have been supplied with figures showing the kind of attendance given to confinements in these cities in 1912 and 1913 respectively. The data, which are presented in the subjoined Table, cover all births occurring in each city which were notified under the Notification of Births Act, and subsequently investigated by the Health Visitors. In Glasgow 97 per cent, and in Edinburgh 90 per cent, of the total births are notified to the Medical Officer within 36 hours. In Aber- deen the percentage is less, but in all three cities it may be accepted that, for practical purposes, all births among the industrial popula- tion come to the knowledge of the Health Departments. Thus the information furnished includes most cases where maternity benefit was obtained, and all for which unskilled assistance was likely to be called in: — Attended by private Doctors. (1) Attended through Institutions. (2) Otherwise. (3) Aberdeen. 1912 1913 52 -3 per cent. 600 „ 13-7 per cent. 7-6 „ 34-0 per cent. 32-4 „ Glasgow. • 1912 1913 40-5 „ 42-5 „ 20-4 „ 15-6 „ 39-1 „ 41-9 „ Edinburgh. •x- 1912 1913 65-4 69-3 * 34-6 „ 30-7 * Included in Column 3. 928. In all three cities, as indicated by column 1, the proportion of cases attended by private doctors appears to have increased 306 Scotland. during the year 1913 by contrast with 1912. The percentage attended through Maternity Hospitals and similar institutions shows the diminution which was the subject of comment at the joint meeting above referred to. Column 3 relates to all other cases, and includes those attended by trained midwives, neighbours, and unskilled women. In the case of Edinburgh, the information afforded did not distinguish between confinements attended through institutions and those attended otherwise. In Aberdeen, the pro- portion attended otherwise has slightly fallen, whereas in Glasgow it has somewhat increased. 929. It emerges, therefore, that in the three cities during 1913 the services of doctors were in somewhat greater request than in the previous year, and that the change is broadly coincidental with the operation of maternity benefit. Direct Payment for Attendance. 930. In the administration of maternity benefit it is competent for an Approved Society, under a general or an individual agree- ment, to pay directly to the doctor or midwife who has attended the case a sum in complete or partial settlement of the fee due. Meetings between representatives of Approved Societies and the medical profession have been held in various parts of Scotland, but owing to differences of opinion on the subject of the fee, general agreements have been the exception. 4. Medical Benefit. 931. The initial quarter of medical benefit under National Insur- ance was a provisional period. The agreements entered into by insurance practitioners to give medical attendance and treatment to insured persons as from 15th January, 1913, were subject to renewal on 14th April succeeding. In the course of the first quarter many obstacles had been smoothed away, but a number of problems still remained outstanding, and required for their settle- ment a more prolonged experience than was possible within the compass of three months. 932. It appeared to the Commission to be desirable at this juncture that practitioners in Scotland who might regard such un- adjusted questions with disquiet, and who might in consequence be in uncertainty as to the renewal of their agreements, should be made acquainted with certain matters of importance. On 4th April, 1913, they issued a " Further Statement to Scottish Medical Prac- titioners," which contained the following passages, among others: — ''^Mileage. — In our previous Statement we let it be known that from an early period the subject of mileage had received our most careful attention. We have never deviated from tlie view that this is one of Working of the System: Medical Benefit. 307 the most far-reaching problems raised by the Medical Service of the Act. As a result of representations made by us, the Highlands and Islands Medical Service Committee was appointed. Their report has been submitted, and a sura of £10,000 a year has been voted for mile- age and other special services in the Highlands and Islands of Scotland. The money is now in our hands, and its disbursement will begin when- ever the scheme, which we are expediting for its distribution, is sufficiently advanced. " In consequence of further representations a Mileage Fund has been voted for Great Britain, excluding the Highlands and Islands, amounting to £50,000 per annum. In order that medical men in the Scottish Low- lands might secure a tangible share of this sum, we placed their claims strongly in the appropriate quarter, and as a result they are to receive for mileage £16,000 a year. "Since these matters were decided we have taken measures to ascertain the amount which will be available for each individual practitioner. It will readily be gathered that this is a work of considerable magni- tude and complexity. We had already in our j)ossession, through inquiries made by a special Committee appointed by Scottish County Insurance Committees, approximate information as to the mileage question in all the Scottish Counties. This information, however, wa not sufficiently precise to bring the Grant to the doors of medical men. We therefore instituted a detailed inquiry, which is in active progress. Our Inspectors are now dealing with the Highlands and Islands — that is to say, with the Counties of Orkney, Shetland, Caithness, Sutherland, Ross and Cromarty, Inverness, and Argyll. In the case of the Lowlands, inquiry will be made immediately on the completion of the work in the Highland Counties. " In the meantime, for the purpose of the inquiry which is under way, the provisional standard is a three-mile limit from the residence of the nearest available doctor on the punel, but all sea journeys are being noted, whether within or without three miles. The final tariff remains to be determined. It is necessary — but we think entirely obvious — that the scale of charges can only be arrived at when the whole mass of figures now being compiled has been reduced and set in order. How much we shall be able to pay per mile can only be stated when the total miles have been ascertained, and when we are in a position to determine how far the money in our hands will go. More definite information as to the mileage tariff cannot be issued at this juncture, but the work of investigation will be urged with all speed, and a statement made whenever the facts are known. * Change of Residence. — In the course of the negotiations which led to the formation of panels in Scotland, it came under our notice that medical men in watering-places along the coasts, and in other country resorts, were keenly interested in the manner in which holiday-makers, seasonal workers and other persons visiting such places were to receive their medical benefit. We ourselves and our officers have had conferences with medical men in various parts of the country on this subject. We have made representations on the matter in the proper quarter, and as a result it has been determined that Regulation 22 of the Medical Benefit Regulations will be amended, and an arrangement made for the formation of a pool to defray the cost of medical treatment on an attendance basis for holiday-makers, seasonal workers, and other persons changing residence. Efforts will be made to give effect to the fresh arrangements before the approaching summer, but the administrative difficulties in the way of so speedy a settlement are very material. ": Conclusion.— We have deemed it well to place the above considerations before Scottish medical practitioners. While we are bound by the terms of the National Insurance Act, and by the limits of the funds at our disposal, we desire it to be understood by all who are in suspense as to mileage or change of residence, that we are wholly sympathetic with regard to the necessity of solving these important problems," 308 Scotland. 933. There had been prepared a form of agreement between practitioners and Insurance Committees, under which practitioners '^.greed that the agreement terminating on 14th April should continue in force thereafter for the remainder of the medical year. This continuation agreement was signed by Scottish panel practitioners with few exceptions. Further accessions to the number of practi- tioners on medical lists continued to take place during the re- mainder of the year. The number of practitioners on the lists of Insurance Committees, and the total number of individual practi- tioners in the Scottish insurance service as at 12th January, 1914, are shown in Appendix XXXII., page 538. Changes due to the Act of 1913, and the Issue of new Regulations. 934. From April, 1913, onwards the administration of medical benefit in Scotland pursued in general a tranquil current. Its course was altered, but not disturbed, by several noteworthy events which took place during the year, including the passing of the 1913 Act, which brought medical benefit within the reach of persons previously debarred, but excluded voluntary contributors whose total income from all sources exceeded £160 a year, under a compensating reduc- tion in their weekly contribution. The 1913 Act further permitted the making of alternative arrangements for the panel system where satisfactory medical treatment under that system was not being given, and made provision for the appointment and election of the bodies, which are now known as the Panel and Pharmaceutical Com- mittees, to represent respectively the practitioners on the medical lists of Insurance Committees and the persons supplying drugs and appliances. 935. Owing to the necessity of giving effect in the Medical Benefit Regulations to the provisions of the 1913 Act, it was resolved by the Commission to replace the existing Regulations (No. 2) (Scotland), 1912, by amended Regulations, to take effect as from the commence- ment of the next medical year. The proposal, in view of the fact that the existing Regulations (No. 2), 1912, were incorpo- rated with and formed part of the practitioners' agreements with Insurance Committees, involved a variation in the terms of agree- ments, of which it was necessary that notice should be given to prac- titioners not later than two months before the date of revision of the medical list. This date of revision, by Article 13 (4) of the Regulations (No. 2), 1912, was required to be so fixed by an Insu- rance Committee under its rules, and after public notice, as to lie between 1st November and 1st December. In order that these matters might be accurately carried through, the Commission, on '9th September, 1913, issued to Insurance Committees a Memo- randum drawing attention to the necessity to fix a date of revision in accordance with the Regulations, and appending a model rule, form of public notice, and form of intimation to insurance prac- titioners, of a proposal to vary the terms of agreement. Working of the System: Medical Benefit. 309 936. On 14tli November, 1913, the Commission, acting jointly with the Joint Comniittee, made the National Health Insurance (Medical Benefit) Eegulations (Scotland), 1913. These Eegulations, which reflected the experience of the administration of medical benefit since its inception on 15th January, 1913, and which gave effect, where applicable, to provisions contained in the Act of 1913, were due to come into operation at 12th January, 1914, the beginning of the new medical year. 937. In the course of November the Commission issued a model agreement between Insurance Committees and practitioners. The 'revised agreement gave effect to the altered conditions of service as set out in the First Schedule to the Eegulations, 1913, and, in accordance with the desire of the medical profession and the recom- mendation of the Advisory Committee, made provision among other matters to obviate the necessity of appeal to the Law Courts in disputes between practitioners and Insurance Committees. 938. On 15th November, 1913, the Commission issued to Insu- rance Committees a Memorandum explaining the terms of the Eegulations, 1913, with special reference to the allocation of insured persons and calculation of doctor's credits ; removals and changes of address of insured persons ; procedure in dealing with com- plaints ; the Pharmaceutical Service Sub-Committee and the Joint Services Sub-Committee ; attendance on patients of deceased doctors ; the Panel and Pharmaceutical Committees ; exempt per- sons and "persons over 65 on entry into insurance ; finance ; drugs and appliances ; and the revised agreements with doctors and chemists. Copies of the Memorandum were furnished to Com- mittees, who so desired, for distribution among practitioners on their medical lists. 939. Negotiations were immediately entered into between Insur- ance Committees, Local Medical Committees, and Panel Prac- titioners, and a number of modifications in the model agreement were put forward for the consideration of the Commission. 940. On 12th January, 1914, when the new medical year began, ipart from an occasional practitioner handing in his agreement after the appointed time — to whom grace was extended — the medical lists of 52 out of 56 Scottish Insurance Committees were complete. In two Committee areas, owing to difficulty of communication and similar retarding causes, there was delay in receiving the agreements of a few practitioners. In the case of two Committees the prac- titioners in the area postponed signature in a body pending the adjustment of minor points in question. Such differences of opinion, however, had no effect on the treatment of insured persons, which continued to be carried on by practitioners without interruption. By the close of January details in dispute had been finally disposed of, and medical benefit was in operation under the Eeguintions, 1913, in all Scottish Insurance Committee areas, though the formal completion of several Orkney agreements remained outstanding for some wxeks longer. 310 Scotland. Medical Benefit and the Insured Person. General. 941. With respect to the steps to be taken by insured persons for obtaining medical treatment from insurance practitioners, the transition from the first quarter of medical benefit at 15th April, 1913, was effected without substantial departure from the procedure described on pages 351-352 of the last Report. An insured person who desired to be placed upon the panel list of a practitioner continued to make use of the applica- tion form Med. 5 XII (Scotland) as the normal or standard means of choice. 942. There had also been issued prior to the 15th January, 1913, as explained on page 352 of the last Eeport, a medical ticket, principally intended to be used by insured persons for the purpose of obtaining medical benefit in an emergency, before choice of doctor had been duly made by means of the application form. The ticket was current until 30th April, 1913. 943. Prior to the date of expiry representations were made to the Commission that the medical ticket as an aid in the identification of insured persons had proved of great service, and that it was to be desired that the ticket itself or a similar voucher should continue to be employed. The Commission therefore decided to extend the currency of the medical ticket until the close of the medical year. Medical Card. 944. The new medical year, beginning 12th January, 1914, ushered in a method of choosing a doctor which alike on the ground of accuracy and convenience possesses many advantages. As from the date referred to the application form Med. 5 XII (Scotland) and the medical ticket ceased to be available, being superseded by a medical card issued by Insurance Committees. The medical card serves other purposes than original choice of doctor. It may be used by persons already on panel lists when removing to a new address and ceasing thereby to be able to get treatment from the doctor who had accepted them. Reference will be made in the section on case value to its use by persons on holiday or otherwise temporarily away from home. The card contains instruc- tions to insured persons as to their rights and obligations in connection with medical benefit, and also brings to their notice the rules for the administration of medical benefit in force within the area of the Committee issuing the card. 945. To insured persons who had already chosen a doctor, medical cards were issued by the Committees with the name of the doctor duly entered upon the card. Insured persons who have not chosen a doctor are required to apply for a card to the Insurance Committee by means of a form to be obtained at a Post Office. To new entrants into insurance, cards are issued by the Insurance Committee on receipt of an index slip from an Approved Society. On receiving his card the insured person presents it to the doctor by whom he desires to be attended. The doctor, if he accepts the insured person, signifies his acceptance Working of the System: Medical Benefit. 311 by signing and forwarding the card to the Insurance Committee ; and the Committee, after making the necessary entries and impressing the card with their stamp, return it to the insured person. Correspondiiig provisions obtain in the case of deposit contributors. Change of Residence. 940. The question of the medical benefit of insured persons changing residence, in one or another of its aspects, has claimed the attention of the Commission with occasional brief intermissions throughout the year. When medical benefit was still in prospect and Scottish panels were forming, the problem of the treatment of holiday-makers and seasonal workers at coast resorts was already under consideration. Article 22 of the Medical Benefit Regulations (No. 2) (Scotland) 1912, prescribed that where an insured person changed his residence from the area of one Insurance Committee to that of another, he should give notice on arriving in the area of that other Committee, and should thereupon be entitled to have arrangements made for his attendance at the capitation rate. Provision was also made for a corresponding financial adjust- ment, as might be equitable under the circumstances. 947. Alike in the interests of insured persons and of medical practitioners, it appeared to the Commission that the arrangement above described was not wholly free from objection, and they so indicated in the Further Statement to Practitioners referred to above., stating that they for their part favoured a change, but that it might not be possible to effect an immediate settlement. Case Value. 948. Early in April,' 1913, the Commission conferred with the English Commission with respect to that method of dealing with temporary residents which has come to be known as the Case Value System. The features of the system were mainly these : — (1) Payment for the treatment of temporary residents on an attendance basis, and ' (2) Provision of the necessary funds from a central pool instead of by adjustment between individual Committees. 949. The proposal for payment by attendance did not appertain exclusively to the case value system. It was possible also under Article 22 of the Medical Benefit Regulations, and was in fact given effect to later in the year under that Article in certain Scottish areas. But while Article 22 admitted either of attendance or capitation payments, payment by attendance was the only method of remuneration contemplated under the case value system. 950. The proposal of a central fund was new, and had for its object to spread the risk of attendance on illness in accordance with the law of averages. Payments into the central pool were to be made by Com- mittees whose insured persons had received treatment while temporarily resident away from home, at a rate representing the cost to them of treating a case of illness in their own area. Payments out of the central 312 Scotland. pool were to be made to Committees within whose borders temporary residents from other areas had received treatment, in proportion to the amount of the fees due to their practitioners for giving- treat- ment, calculated under a general tariff and with regard to the total sum available from the central pool. 951. The Commission had also under consideration an alternative method of constituting a central pool, by means of quarterly contributions from all Scottish Insurance Committees, representing the redistribution of a fractional amount of the value of each capitation fee. It was not possible in the absence of accurate data to forecast this fraction with precision : but any contributions to the centi'al pool in excess of the charges against it were proposed to be duly restored to the funds of the contiibuting Committees. 952 With a view to ascertaining opinions on the above proposals, the Commission on 11th April, 1913, met in Edinburgh with medical members of the Scottish Advisory Committee, representatives of Local Medical Committees who were believed to be interested in the question, and Clerks of Insurance Committees to or from whose ai'eas holiday-makers and seasonal workers were likely to go in substantial numbers. At this meeting, it was agreed by the Commission to submit the alternative proposals of a case value contribution and a capitation contribution for the observa- tions of Scottish Local Medical Committees. A memorandum was there- fore prepared, and was issued on the 18th April. It set forth both schemes in considerable detail, and indicated among other matters that the formation of a central pool would enable arrangements to be made for the treatment of persons moving from place to place in the course of their employment who could not, owing to their frequent migrations, be included in panel lists. 953. The Local Medical Committees in due course reported the results of their deliberations, which revealed much diversity ; and in consequence the Commission thought it essential at this stage that further light should be thrown on some aspects of the question which were still involved in obscurity. They directed an iuquiry to be made with the object of disclosing the dimensions of tlie problem, with special reference to the conditions of medical attendance upon summer visitors to Scottish coast resorts, who form in general a well-marked group readily dis- tinguishable from the permanent seaside population. The places to be dealt with were divided into two groups — «ne for detailed enquiry ; the other for rapid suivey. Tho detailed enquiry included Rothesay, Millport, Largs, Gourock and Dunoon, which are visited annually in the summer season by many thousands of holiday-makers of the insured class. Estimates of the number of these during recent seasons were formed from pier returns, censuses taken for the purpose of Burgh extension, and similar figures. Estimates of the cost of treatment of the visitors were obtained from local practitioners, who made a special scrutiny of their books. The rapid survey touched upon Aberdour, Burntisland, Carnoustie, Crail, Dunbar, Elie, Montrose, St. Andrews, and other localities. The results of the enquiry appeared to suggest that the problem of the treatment of summer visitors and seasonal workers at coast resorts was not incapable of solution. 954. Holiday-makers, however, and seasonal workers connected with Working of the System: Medical Benefit. 313 holiday -mak'ng, were not the only temporary residents in Scotland whose medical treatment called for settlement. Prior to the consideration of the alternative methods for the formation of a central pool, the position of the fishworkers at stations in the North of Scotland had been under the notice of the Commission. The arrangements made for the effective carrying out of Article 22 of the Regulations in their case, which are referred to more fully in the section entitled Scottish Fishworkers, had been found in general to achieve the object aimed at, and the Commission, after conference with the Joint Committee and the English Commission, agreed that in Scotland generally for the remainder of the year temporary residents should continue to be dealt with by the application of Article 22 to the special conditions arising, allowance being made for the remuneration of practitioners either on an attendance or a capitation basis as might be found convenient ; but that, in view of any difference in procednre prevailing in English or Welsh Insurance Committee areas, all necessary financial adjustments should be made as between the countries, for the medical year which ended on 11th January, 1913, to meet the case of English or Welsh insured persons treated as temporary residents in Scotland, and of Scottish insured persons so treated in England or Wales. 955. On 12th January, 1914, under the new Medical Benefit Regula- tions, the case value system became current in Scotland. The principle of the system has been outlined. Its details are set forth in the Regulations, 1913, of which Article 41 deals with the formation of the central medical fund and Article 42 with the payments to be made there- from. The Fifth Schedule presents the scale of charges. Article 29 provides that the period of temporary residence qualifying for treatment under the system shall not exceed three months. 956. Insured persons desiring to receive medical treatment as temporary residents are enabled to do so by means of the medical card, of which the portion lettered C is for use in temporary residence. The insured person enters his name and temporary address, declaring that he does not expect or intend to remain in the locality for more than three months from the date of his arrival. He presents the card to a practitioner on the panel of the Insurance Committee area in which his temporary address is situated, and the practitioner signs the card in token of acceptance. Scottish Fishworkers. 957. Curing is an essential feature of the Scottish herring fishing industry. It is carried on at the stations, many of them remote, where the fish are landed. The winter heri'ing fishing, which gives employment chiefly to local workers, occupies the first quarter of the year. The summer fishing, beginning in Ma^^, is at its height in July, and continues in Scotland and the North-East coast of England until September. The season closes with the East Anglian fishing which begins in October and lasts from six to eight weeks. The centres of activity in curing vary from year to 3'ear, and even during one season. The failure of the fishing in a district may induce curers to desert it suddenly in favour of one 314 Scotland. promising a better return. In some cases workers engaged by curing firms are employed with only short intervals throughout the whole year, but for the most part the period of employment does not exceed six months. 958. The workers are mostly women di'awn from a healthy class. Only those who are physically strong engage in the industry as a rule, and despite its arduous nature and the exposure to the weather which it entails, they appear not to suffer inordinately from serious illness. They are liable, however, in the course of their occupation to sores and severe cuts of the hands. The constant use of stdt, unavoidable in their work, tends to aggravate this mischief. 959. P'rom the information available it would seem that in Scotland probably about 16,000 women are employed each year by curers, while men (coopers and labourers) number about 4,000 more. It is ditficult to form an accurate estimate of the number who may be classed as migratory, but it is safe to say that at least 50 per cent, change their iH^sidence temporarily for the purpose of their livelihood. Orkney, Shetland, Wick, Peterhead, Fraserburgh, and Aberdeen are the chief centres of curing, but Stornoway, Barra, and Eyemouth give employment also to a substantial number of workers. The places of origin of the workers are various. Many come from the Hebrides, chiefly Lewis and Barra. On the mainland the villages along the Moray Firth and the Aberdeenshire Coast send large contingents. Considerable numbers are derived also from Caithness, Fifeshire, and Berwickshire. Few coastal counties are quite unrepresented in the total. 960. It was early realised that it was not to be expected that these scattered workers would of themselves grasp the importance of giving the notice required by the Regulations, in order that they might receive medical treatment if necessary when away from home. The Commission therefore took steps to enlist tlie interest of employers, and made arrange- ments with the Clerks of fnsurance Committees to facilitate the giving of the necessary intimations, with the result that medical treatment of a competent and satisfactory character was made available widely for fish- workers temporarily resident at the Scottish fishing centres. The Commission also secured the co-operation of doctors, of Approved Societies, and of the Fishery Board for Scotland, whose officers gave valuable assistance. They desire to acknowledge the help so received. 961. For the benefit of Scottish fishworkers proceeding to England for the autumn fishing, a scheme on a somewhat similar plan was carried out. Information shows that in 1913, over 6,000 women went from Scotland to Great Yarmouth and Lowestoft for the fishing there. With the co-operation again of employers and others, notices of temporary change of residence for about half the total number of women were sent fully completed, as to Society and membership number, at the beginning of the fishing to the English Insurance Committees concerned. Where the intimations were incomplete, employers were asked to arrange for the workers to add the missing details, and a large number of blank forms were issued to employers and others for use in the case of workers coming under notice at a later date. Ready assistance was given by the English Commission and by the Insurance Committees of Great Yarmouth and East Suffolk. It is understood that the arrangements Working of the System: Medical Benefit. 315 made were found to be of much service in securing medical treatment for the fishworkers while in England. Travellers. 962. A special arrangement was made during the year for the pro- vision of medical and sanatorium benefits to insured persons who fre- quently move from place to place in the course of their employment. Nurses, actors, showmen and commercial travellers are examples of this class. Their needs appeared to be insufiBciently met by the ordinary jianel arrangements. Even if placed on the panel list of a particular doctor, they might when ill be unable, through their absence from the area in which the doctor resided, to have the advantage of his services. 963. The arrangement, which came into operation in September, 1913, is in outline as follows : — Insured persons desirous of being admitted to the special arrange- ment apply to their Insurance Committee, or to their Society, for the appropriate form of application. The form when filled in by the insured person and countersigned by his employer is sent to his Approved Society to certify as to his title to medical and sanatorium benefits. The Society, after completing the necessary certificate, send the form to the Insurance Committee, who then consider whether they will recommend the applicant for admission to the special arrangement. Deposit contributors send the form to the Committee through the Com- mission. If the Committee recommend the applicant for admission they forward the form to the Commission with the insured person's index slip, care being taken that the insured person is removed from any panel list on which his name may have been placed, and that the medical index is corrected in this respect. 964. Insured persons who by means of the form have shown them- selves qualified for special arrangements, are provided with a traveller's voucher which they may present to a doctor on the panel in any area in Great Britain where they happen to require medical benefit. The voucher provides for medical records being kept. Payment is on an attendance basis according to a scale. Drugs are ordered on the usual order forms, prescriptions being specially distinguished. The special traveller's voucher is current for six months only from the date of issue, and holders of vouchers are instructed to make application for renewal not later than a month prior to expiry. The number of trav-ellers' vouchers issued in Scotland up to 11th January, 1914, was 216. Own Arrangements. 965. The year has witnessed a reduction in the number of insured persons allowed by Insurance Committees to make their own arrangements for receiving medical benefit by a method other than the panel system. 966. The changed position is principally due to a diminution through- out the country generally of individual own arrangements. The most 316 Scotland. salient departure from this normal tendency was witnessed in the Connty of Argyll where the number of individuals outwith the insurance medical service rose from 396 to 438. 967. Except in one Burg'h and one County the arrang-ements were mainly — and in some cases exclusively — of the collective order, that is to say wei'e arrangements made on the ground of administrative con- venience, by members of staffs of hospitals, infirmaries, asylums and similar institutions, to be attended by their own Medical Officer. Allocation of Insured Persons. 968. By Article 17 (3) of the Medical Benefit Regulations, No. 2 (Scotland), 1912, it w^as provided that after the date indicated in the announcement of an Insurance Committee, prior to which insured persons who desired, or were entitled, to select a practitioner on the panel were required to submit an application form to the doctor of their choice, the Committee should provide for the distribution amcmgst practitioners on the panel, and so far as practicable under arrangements made by them, of those insured persons for whose treatment no arrangements had been made. This group of insured persons included those who had neglected to exercise their right of selection and those whose application had been refused by the practitioner to whom it was submitted. Their number was found to be appreciable, and it was determined in the first place by most Committees with the approval of the Commission to extend the period within which application might be made, beyond that fixed in the orighial announcement. 969. The method of distribution of tho unallocated proposed ia the Regulation referred to implied the placing upon practitioners' panel lists of insured persons known to be resident in the ar^a of the Committee at the date of distribution. For reasons explained more fiiUy elsewhere in this Report, an allocation of actual persons in the manner prescribed by the Regulation presented serious difficulty. The registers of Committees, representing the index slips transmitted to them by Approved S:cietieSy were kuowm to be inaccurate, and it was plain that a personal allocation founded upon the registers in their then existing condition would have offered an unreliable basis for the financial adjustments subsequently necessary, inasmuch as it w^as not possible to determine with precision the total amounts properly due to Committees for the index slips in their possession. 970. While Committees in genei^al were naturally desirous of arriving at an early settlement with their practitioners and were therefore disposed to proceed with an allocation in terms of the Regulation at the earliest date permissible, it appeared to the Commission to be the preferable course to advise delay in the distribution of the unallocated until the index registers of Committees bad been corrected, or had at the least been so far cleared as to reduce the balance of error to a negligible figure. But the process of clearing, though advanced with all speed by various methods, proved difficult and tedious. While a few Committees took the responsibility of making a personal allocation on a partially cleared register, the great majority, as the close of the medical year approached, Working of the System: Medical Benefit. 317 were not yet in a position to carr}^ out the distribution of persons as- prescribed by the Reg-ulation. 971. Tlie actual allocation of individuals, though desirable on general grounds, would not in itself have been a matter of immediate urgency had it not been for the fact that delay in making it involved at the same time delay in the distribution to practitioners of the balance of the panel fund. An indefinite postponement in the distribution of this amount was, in the view of the Commission, to be deprecated, and they therefore proposed to Insurance Committees that they should proceed to distribute their funds as if a personal allocation had been made, that is to say, that the total number of index slips of persons who had not chosen or had been rejected by doctors which remained in the hands of the Committee should be proportionally divided among practitioners according to a scale agreed upon, and that the number on the panel list of each practitioner for the purpose of a distribution of funds should be held to be the number of persons who had actually chosen him, increased by his proportionate share of the number of the unallocated. The Commission were also prepared to sanction as a part of such a scheme payment to practitioners for acceptances in the case of persons whose index sUps were not held by the Committee provided that practitioners agreed to take their share of the balance of the panel fund so calculated in full settlement of their claims against the Committee for the year. As these proposals, though equitable, were not in accordance with the method laid down in the Regulation, the Commission informed Committees that the consent of the practitioners on the panel would require to be obtained. 972. Arrangements on the above lines were in course of being given effect to by a majority of Scottish Insurance Committees at the close of the period covered by this Report. Post Office Medical Service. 973. In the Medical Benefit Regulations (No. 2) (Scotland), 1912, provision was made for the approval by Insurance Commit teas and the Commission of systems or institutions existing at the time of the passing of the Act of 1911. No institution has been ajiproved in Scotland, and the only system approved has been the Post OfiSce Medical Service. Under the Post Office Medical Service, when approved in any area by the Insurance Committee and the Commission, insured members of the Post Office staff resident in the area, nmy, if they so desire, obtain medical treatment and attendance under the system as their medical benefit under the Act. Any insured member of the staff, however^ who so elects, may be placed on the panel-list of an insurance service practitioner on the medical list of the Committee. The Commission informed Insurance Committees of the particulars of the system, and it was approved by all Committees in Scotland with com- paratively few exceptions. The total membership in Scotland as at 12th January, 1914, was 888. Medical Records. 974. The conditions of the special Parliamentary grant for medical benefit require that records of the diseases and treatment of insured 318 Scotland. persons yhall be kept by insurance practitioners. Having obtained the views of Local Medical Cornmittoes, the Commission offered to the practitioners in each Insurance Committee area the choice between a simplified day book and a card register. In areas whose Local Medical Committees expressed a preference for the day book, the modified day book was introduced on the exhaustion of the original «tock. 975. In the Counties of Argyll, Dunbarton,' Fife, Inverness, Kincar- dine, Kirkcudbright, Peebles, Perth, Renfrew and Wigtown and in the Burghs of Aberdeen, Dundee, Greenock, Inverness, Paisley, Perth and Rutheiglen, whose Local Medical Committees decided in favour of the card system, cards were introduced on or before 1st August, 1913. In the Counties of Clackmannan and Kinross, Dumfries, Haddington, Linlith- gow, and Midlothian, and in the Burghs of Ayr and Glasgow, card records were brought into operation on 1st January, 1914. The card system is now in operation in twenty-four Scottish Insurance Committee areas, of which fifteen are County areas and nine Burghal. 976. Considerable difficulty was experienced at the beginning of the year in securing medical records, or at any late records which were at all complete. It was found necessary to conduct a voluminous corres- pondence with practitioners on such points as the nomenclature of diseases, and of occupations, for statistical purposes. Towards the middle of the year, however, the returns were much more satisfactory, and at the present time, except for a number of points of detail, com- paratively little trouble is experienced. The question of the ultimate use and treatment of the information obtained is a matter of great importance and is receiving careful consideration. The number of day book sheets received during the year was about 60,000, and the number of medical record cards (for the last six months of the year 1913) was about 200,000. 977. As stated above the keeping of proper medical records is a con- dition for the payment of the special Treasury grant of 2s. 6d. per insured person towards the cost of medical benefit. Owing to non-compliance with this condition, the Commission have found it necessary to withhold from Insurance Committees payment of a portion of the grant in individual cases. Drugs and Appliances. Negotiations with Chemists. 978. In the last Report reference was made to a contention advanced by Scottish pharmacists that the current tariff of prices was likely to leave the drug fund of many Insurance Committee areas in Scotland with an appreciable balance at the end of the year, and to the decision of the Commission, that if at the end of twelve months it should be found that there was an unexpended balance in the drug fund sufficient to justify an additional proportionate i etrospective pa^ ment not exceeding 10 per cent, on the amount of the accounts of individual chemists, they would consent to such additional payment being made as might be approved by them- selves and the Insurance Committee. Working of the System: Medical Benefit. 319 ^97^: In the course of 4b6 -autumn the question of a revised Drug Tariff for 1914 was submitted to the Commission by the Pharmaceutical Standing Committee for Scotland, who suggested an adjustment of prices to current market quotations, and an increase in dispensing Cfharges. 980. These proposals were considered by the Commission in the light of reports received from a number of Insurance Committee areas as to the actual outlay on drugs under the current tariff during the first six months of medical benefit. The reports showed much diversity in the proportion of the drug fund expended. It was patent thathop^s for a substantial balance in every area could not be realised. In certain places it was evident that the charge on drugs would not merely absorb the total drug fund of Is. 6d. per insured person, but would also encroach upon the drug suspense fund of sixpence, or even wholly consume it. 981. At a meeting of Scottish insurance chemists, held in Edinburgh on 31st October, 1913, the Chairman of the Commission, who was present by invitation, explained the impossibility of making accurate deductions from incomplete returns in regard to a period which was largely experi- mental. He suggested that chemists should wait until the full results of one year's working oF the Act were available, and undertook that the necessary information would be forthcoming at as early a date as possible in the new year. In order to allow time for subsequent consideration it was also intimated that the Commission would be prepared to entertain an alteration in the chemists' agreements for the ensuing year so as to admit of a break at the close of the first three months. On the question of possible encroachment upon the floating sixpence as a result of increase in dispensing charges and adjustment of prices of drugs, it was stated to Mr. Leishman at the meeting that infonijal enquiries by chemists had been made among doctors in different areas, and that they had generally replied that they would have no objection to the chemists' demands. Mr. Leishman indicated to the chemists that the Commission would require definitely to ascertain the views of the doctors before proceeding in the matter. 982. The meeting resolved : — That this meeting of Panel Chemists in Scotland agrees, without prejudice to further bargaining, to accept, as suggested by Mr. Leishman, the principle of discounting for one year, provided that the Commissioners accept the new scale of dispensing fees put forward by our represen- tatives. The meeting fm'ther agrees that in the event of the Insurance Commis- sioners not accepting the new scale of dispensing fees on the foregoing conditions, prior to the time fixed for terminating the existing agree- ments, the Pharmaceutical Standing Committee (Scotland) be authorized to proceed as indicated in the following paragraph of the resolution. This meeting of Scottish Panel Chemists renews the protest made at the Mass Meeting on March 31st, 1913, as to the inadequate remunera- tion provided for vScottish (_^hemists under the present drug tariff, and adheres to the stated case for revision of terms submitted to the Scottish Insurance Commissioners on October 1st, 1913, as being their minimum demand. In view of a promise given at this meeting by the Chairman of the Scottish Insurance Commissioners that an endeavour will be made to secure all necessary information within an early date after January 14th, 1914, to enable a definite reply to be made by the Insurance Commissioners to the claim lodged on behalf of Chemists ; and in view, also, of an offer at the same time made by the Chairman 320 Scotland. of the Scottisli Insurance Commissioners to insert a proviso in tlie existing agreement, or any other agreement, making it terminable at the close of the first three months of the Medical Year beginning on January 15th, 1914, this meeting recommends that, subject to the foregoing proviso, the present arrangement as to dispensing charges be allowed to continue till the date on which the aforesaid proviso makes the agreement terminable, and that a final decision be deferred till a date prior to the foregoing after the Insurance Commissioners haA^e obtained the information which they consider necessary. Such adjustment of the drug tariff as to prices of drugs and appliances, as may be sanctioned by the Commissioners, to take effect from the beginning of the second Medical Year. 983. The Commission thereafter by letter of 10th November, 1913, confirmed acceptance of the proposal for the issue of an agreement terminable at three months, and agreed further to extend the option to the close of the second quarter. They also undertook that where the accounts of an Insurance Committee for 1913 permitted such expenditure they would sanction the payment of a bonus to the chemists in that ai'ea up to a maximum of 1^. 6d. per insured person. 984. The chemists accordingly renewed their agreements for 1914, and further negotiations in regard to the Drug Tariff were postponed for consideration in the^light of the complete figures for 1913. The total number of chemists on the lists of Insurance Committees as at 12th January. 1914, is shownjn Appendix XXXIL, page 538. Prescription Forms. 985. The prescription forms originally issued for the use of insurance practitioners were of two varieties, the one green for the purpose of ordering drugs and appliances included in the drug tariff, the other pink for drugs and appliances not so included. Prescriptions were made in triplicate by means of carbon paper and two copies were given to the patient. In the course of June, 1913, an improved style of model order form for medicines and prescribed appliances was sent out to Insurance Committees. Under the new style the same form was employed for ordering all drugs and appliances proper to be ordered whether included in the drug ta'iff or not. The necessary distinctions between list and <»x-list drugs were made by means of an index mark written by the practitioner. Two copies of each prescription were still required to be handed to the insured person by the practitioner. It was within the discretion of the practitioner to make a third copy as his own reminder if he so desired. Dispensing hy Doctors. 986. By Article 30 (1) of the Medical Benefit Regulations (No. 2) (Scotland), 1912, a panel practitioner had the right, if he so desired, to dispense for any insured person on his list resident in a rural area at a distance of more than one mile from the nearest insurance chemist. Under such conditions the Insurance Committee might, and at the instance of the practitioner were required, to make such special arrangements as they thought fit for the supply of drugs and appliances. 987. This arrangement was altered by Article 12 (1) of the Medical Benefit Regulations (Scotland), 1913, which provides in similar circum- Working of the System: Medical Benefit. 321 stances for the supply of drugs and appliances to the insured person by the practitioner attending him, subject to the consent of the Commission and to consultation by the Insurance Committee with the Panel and Pharmaceutical Committees. Where, however, the Insurance Committee decide to permit dispensing- by a doctor on the ground that an insured person will have difficulty in obtaining any necessary drugs and appliances from a chemist, the consent of the Commission to the consequential arrangements is not required to be obtained. By Article 38, where a doctor has been allowed to dispense, the Committee may, subject to the consent of the Commission, agree to pay him on a capitation basis instead of on accounts rendered. If the Committee elect to insist on the rendering of accounts, the Commission are not empowered to intervene. Emergency Drugs. 988. By Article 30 (2) of the Medical Benefit Regulations (No. 2),- 1912, as noted in the Annual Report of the Commission for last year, Insurance Committees were at liberty to make arrangements for the supply by practitioners on the panel of drugs and appliances required for immediate administration and application, or required for use before a supply could conveniently be obtained otherwise under the Regulations. Any arrangements so made were subject to the sanction of the Commission. 989. In the course of the year 1912-13 the Commission approved arrangements under this Regulation for the supply of Emergency Drugs in 20 Insurance Committee areas, of which 12 were County areas and 8Burghal. The drugs and appliances proposed to be included in the emergency lists varied with local conditions. Before submitting lists to the Commission for approval Committees were advised by their Local Medical Committees and by representatives of chemists in the area, and the views of these bodies were taken into consideration by the Com- mission in arriving at a decision with regard to the several items. The approval given was current for the medical year 1913-14. 990. In the year 1914-15, by Article 12 (3) of ihe Medical Benefit Regulations, 1913, it became obligatory for Insurance Committees to make arrangements of the character referred to, and a circular was issued by the Commission in January, 1914, drawing the attention of Committees who had not taken action in the previous year to the require- ments of the Article. Committees whose lists had been approved for the previous year were requested to put forward any alterations which they might desire. It was also pointed out that where an arrangement had been made under Article 12 (1) of the Regulations, 1913, for the supply to insured persons by a practitioner of all necessary drugs and appliances, the supply of emergency drugs and appliances to such persons is included within the arrangement. Thus a practitioner who is dis- pensing under Article 38 on a capitation basis is required to provide emergency drugs and appliances without extra charge. 991. Emergency drugs, when desired b}^ a practitioner who is not himself dispensing to be kept as stock reserved for the treatment of insured persons, are ordered from an insuranc3 chemist on the order form of the Committee, and distinguished by an appropriate index mark. (B254— Gp. 5) L 322 Scotland. Expenditure on Drugs. 992. In Appendix XXXIII, page 540, will be found a Statement showing- in respect of each Insurance Committee in Scotland, for the year January, 1913, to January, 1914, the total number of prescriptions dispensed by chemists under arrangement with the Committee, the total cost of such prescriptions, the average cost per prescription and the average cost per insured person entitled to medical benefit. As regards the first three items of information the figures are compiled from returns supplied to the Commission by the Committees, and may thus be taken as representing actual prescriptions and accounts. It will be seen that the cost per prescription varies in the counties from 6|cZ. in Ayrshire to Is. Ojc?. in Caithness and Ross and Cromarty, while in the burghs the extremes are 6c?. in Kilmarnock and Is. O^d. in Dunfermline. 993. As regards the last column of the Table in the Appendix, reference must be made to the difficulty, mentioned in another part of this Report, of ascertaining the exact number of insured persons entitled to medical benefit in any area. For the purpose of calculating the average cost of drugs per insured person, it was necessary to arrive at some such number, and accordingly the mean was taken of two counts of the index registers — at October, 1912, and April, 1913, respectively. The resulting figure was slightly higher than the number of insured persons in Scotland as indicated by the contribution cards surrendered, and the average cost of drugs shown in the table — being the total cost divided by the mean total of the index registers — is therefore somewhat understated. The error is not great, however, and should not exceed between 2 per cent, and 3 per cent, over all. Subject to these qualifications, the average cost of drugs prescribed per insured person entitled to medical benefit varied in the case of counties from 7^d. in Argyll to Is. lO^d. in Zetland and in the case of burghs from 8jc?. in Kilmarnock to 2s. l|d in Aberdeen. 5. Sanatorium Benefit. Medical Advisers of Insurance Committees. 994. In the administration of sanatorium benefit by Insurance Com- mittees, it is an essential function of the Committees to judge of the claims of applicants, determining that one person is suited for treatment in a sanatorium, that another would benefit by dispensary treatment, or that a third might most suitably be cared for in his own home. 995. In order to discharge this duty, Committees should be able to turn for advice to expert medical men, and it was suggested by the Commission in a circular that in the early days of sanatorium benefit Committees should endeavour, subject to the necessary sanctions, to enlist the co-operation of the Medical Officers of Ilealth in their respective areas. This proposal was favourably received by Local Authorities and their officers. In every Scottish Insurance Committee area, with scarcely an exception, the Medical Officer of Health rendered highly appreciated service in bringing the sanatorium benefit provisions of the Act into effective working. Working of the Systetn: Sanatorium Benefit. 323 996. The tenure of office of Medical Advisers was at first of a pro- visional character, but it was speedily evident, as the possibilities of sanatorium benefit became unfolded, that it would be to the advantage of Committees that their officers should be established on a more permanent footing. Committees were therefore encouraged by the Commission to appoint Medical Advisers at an annual salary. With a view to the continuance of co-operative action between Committees and Local Authorities, it was felt that the same person, wherever practicable, should advise on the affairs of both. The appointment of the Medical Officer of Health as Medical Adviser was duly confirmed by all except four County and three Burgh Insurance Committees. In the three Burghs and one of the Counties, where the Local Authority had in the interval appointed a special officer on their Public Health staff to deal with tuberculosis, the officer in question was expressly designated the Medical Adviser of the Committee. In the remaining County areas (Orkney, Roxburgh, and Zetland) no appointment was made. Approved Institutions. 997. The duty of approving sanatoria and other institutions for the treatment of insured persons suffering from tuberculosis, and of con- tinuing or withdrawing such approval, is committed under the National Insurance Acts to the Local Government Board, to whom the Commission have been indebted for information as to the status of institutions throughout the year. 998. The approval of the Board is granted to institutions subject to certain conditions, devised to ensure that the standard of treatment is maintained at an efficient level, and that the records of cases are dulj^ kept. On 14th January, 1914, the Board issued a Circular (Public Health No. II, 1914), setting forth the nature and extent of these records. In the case of residential institutions, the records are : — (a) Admission Records^ showing local and general condition of patient on admission, with diagram of the chest in cases of pulmonary tubercu- losis ; history of the illness of the patient and of his family ; description of his environment at home ; character of his employment. (b) Temperature Charts, upon which, in addition to temperature and pulse and respiration rates, there are recorded the weights of patients at weekly intervals, and details as to any special forms of treatment, e.ff., graduated labour, injection of tuberculin, &c. (c) A hist(yry of the case while in the institution, written at weekly or monthly intervals, and kept with such accuracy and completeness as are usual in the hospitals to which medical schools are attached. In the case of dispensaries the records are : — (a) Records showing local and general condition of the patient on first coming to the dispensary, with diagram of the chest in cases of pulmonary tuberculosis ; history of the illness of the patient and of his family ; description of his environment at home ; character of his employment. (b) Case records showing the general and local condition of the patient at each visit to the dispensary. This record should contain the weight of the patient and give details of any special treatment, such as the injection of tuberculin. 999. In the course of their circular the Board make the further per cent, of tlie population. Occupied Married Women. Occupation. Wales. England. Food, Drink, Lodging, Tobacco Domestic ... Dress Professional Textile Manufactures Others'*'' Percentage to total occupied population. 40 18 13 8 4 17 Percentage to total occupied population. 20 21 15 5 23 • 16 ** Occupations which employ less than 5 per cent, of the population. 1393. Fifty-two per cent, of women (spinsters and widows) are occupied in England, as against 31 per cent, in Wales, while only 5 per cent, of married women are occupied in Wales, as against 10 per cent, in England. 1394. These figures serve to indicate generally the nature of the problems that are likely to arise in Wales in connection with the organisation of insured persons in separate Approved Societies. On the whole, the occupations followed by women in Wales may be regarded as more favourable to health, and on that account the position of women's Societies generally might be expected to show somewhat better results in Wales than in England. The fact that these occupations are of the less organised type will, however, prob- ably tend to make the work of Society administration more diffi- cult, and, although excessive sickness may be less, the difficulty of controlling claims may make for a greater prevalence of malinger- ing. The smaller percentage of occupied married women should also have a favourable effect on the funds of Welsh Societies. 1395. The position with regard to men is the reverse. The bulk of the male population is engaged in highly organised industries, and the social and industrial conditions in the densely populated areas in Wales are such that the scheme of National Health Introductory. 423 Insurance has been grafted on to existing conditions more easily than in areas where a greater diversity of industries are followed. As will be seen from Appendix LIII., page 565, the contributions of nearly one-foui'th of the insured persons in Wales are collected by means of the " bulk stamping " arrangements, which are fully described in paragraphs 1443-1451 below. Similarly, nearly six per cent, of the insured persons receive medical benefit through the agency of approved medical systems and institutions. This tends to facilitate the work of Societies and Committees, and should result in a higher standard of administration on the part of those bodies. 1396. Against this, however, has to be set the fact that the indus- tries which occupy such a large proportion of the male population are of the type from which, from their inherent nature and from previous experience of Friendly Society work, a high average of claims for sickness benefit may be expected. Underground workers in mines, persons engaged in metal working — particularly iron and steel — and labourers engaged in the tinplate, lead, chemical, and glass industries, compose nearly one-third of the insured population of Wales. The alleged excessive Claims for Sickness Benefit. 1397. Closely connected with the industrial conditions outlined in the preceding paragraphs is the sickness rate of the Principality and the consequent claims for benefit. 1398. The Commission have given much attention to representa- tions which have reached them of excessive claims for sickness benefit. Many of the representations were too indefinite to permit of exact inquiry. Others on investigation proved to have been made on imperfect and misleading information. But a substantial and well- founded number remained which called for closer examination. In some cases an abnormal age and sex distribution provided the explanation; in others it was not easy to determine how far initial difficulties connected with bringing the Act into operation were responsible. Want of experience on the part of those engaged in the administration of sickness benefit, both Society officials and medical men, and unfamiliarity with the new machinery, have undoubtedly led to a certain amount of laxity in investigating and certifying claims. 1399. The Commission communicated with those Societies which from the returns of their expenditure from January to October, 1913, appeared to be experiencing claims in excess of expectation, with a view to calling the attention of the Committees of Management to the position, and of eliciting information as to the methods adopted by them in considering claims for benefit. Many of the replies showed that the certificate of the doctor is accepted as complete authority for payment, and that no scrutiny of the certifi- cate is thought possible, nor further evidence of incapacity demanded. As might have been expected, the prevalence of such views resulted in failure to set in motion the powers conferred on Societies by their rules to investigate doubtful cases, and, where necessary, to supplement the evidence of the medical certificate. (B254— Gp. 5) 4 424 Wales. 1400. Eepresentatives of the Commission visited many of the Societies and indicated the powers vested in their rules for checking imposition. At the same time advantage was taken of the recently formed Panel Committees to approach the medical profession on the subject. These inquiries have undoubtedly resulted in im- proving the administration of Societies and in impressing upon the doctors their serious responsibilities under the Act. 1401. It has, however, to be borne in mind that the stability of any particular Society may be threatened, even when carefully ad- ministered, by reason of the smallness of its membership or an aggregation of bad lives or of persons following an unhealthy trade. 1402. It is obvious that in the case of a Society with a small membership anything which tends to vary its normal experience' will affect its position to a greater extent than the position of a large Society. It is, therefore, not surprising that of the Societies which have come under the notice of the Commission in relation to their financial position a large proportion have a membership of less than 200. While a small Society is entitled to the same medical services as the larger bodies, it is not able to maintain the same complete organisation; any administrative weakness is accen- tuated, and its margin of administrative expenses available for dealing with exceptional cases is relatively smaller, and extra super- vision more costly. Of the 169 Societies originally approved for operation in Wales no fewer than 58 have a membership of less than 100. 1403. Where to a small membership there is added a dangerous occupation, the penalty of any laxity in management will speedily show itself. Some 210,000 persons — a number equal to nearly one-third of the insured persons in Wales — are employed in the coal-mining industry, and of these, roughly, some 200,000 are underground workers. Allowing for the percentage of this number below the age of 16 or over 70, and including the numbers employed in other unhealthy or hazardous occupations, it may be gathered that fully one -third of the insured persons in Wales follow occupations which tend to make them less desirable, from a purely financial stand- point,, as members of Societies than other classes of the com- munity. On the other hand, in the mining industry the rate of wages is relatively high, and there is some evidence that ** over- insurance " is not uncommon. Sickness insurance was general in Wales before the advent of the State scheme, and as a result of the schemes submitted under Section 72 of the Act of 1911 these private insurances have for the most part been retained, in addition to the insurance under the Act. 1404. The effective operation of the provisions of Section 11 of the Act of 1911 is for similar reasons of great importance in Wales. The industries in which a high rate of sickness is expected are, speaking generally, those in which accidents on account of which compensation is payable occur most frequently. The provisions of that Section are intended to relieve the Insurance Fund of sickness Approved Societies. 425 due to accident, but inasmuch as the loss of contributions while compensation is being received is not met by penalty arrears, and there is the possibility of sickness proper to be borne by the com- pensation funds falling in fact upon the Insurance Fund, it follows that careful administration and control of sickness claims by Societies composed of these classes is essential if their financial- stability is to be maintained. 1405. The Commission believe that as the experience of doctors and Society ofl&cials of their duties under the Act increases, and as insured persons become familiar with the principles underlying the scheme, a reduction in the number of doubtful claims will ensue. II.— APPROVED SOCIETIES. Number of Approved Societies. 1406. Of the 169 Societies which were approved by the Welsh Commission at the date of the last Keport, a certain number have during the year ceased to administer the Acts. The experience of the first year's working showed that the difficulties before a Society of small membership are considerable, a number having come under the notice of the Commission by reason of appli- cations for issues of funds in excess of the normal. As a result of inquiries necessarily instituted in such cases, anxiety on the part of the Committee of Management as to the financial position of the Society has, in the case of 34 Societies, led to a decision in favour of transferring engagements to larger and financially stronger bodies. Eighteen of these Societies transferred their members in bulk, but in each case care was taken to secure to the individual insured person the right to transfer to a Society other than that to which the Society's engagements were being transferred. The total membership of the 34 Societies which have ceased to administer the Act was 1,730. Scope of the Work. 1407. The work of the Commission in relation to Approved Socie- ties during the year under review falls easily into two categories, namely (1) advising and assisting Societies with reference to the changes brought about by the provisions of the Act of 1913, and (2) developing and improving the machinery already established to enable Societies to deal effectively with the calls made upon them in the normal process of their work. Steps taken to assist Societies in connection with the Act OF 1913. 1408. As soon as the Act of 1913 had become law, steps were taken to make available for Societies all necessary information to enable them to advise their members as to the effect of the new provisions. 426 Wales, A circular (A.S. 103), explanatory of the changes in the conditions attaching to benefits, and generally of those provisions demanding the more immediate attention of officials of Societies, was issued at once to all Societies operating in Wales. This was necessarily of a general character, and was supplemented at a later date by more detailed information of the effect of the amendments of the law and of the consequential alterations which had become necessary in the administrative methods of Societies. Amendment of Rules. 1409. As it was most important that the rules of Societies should be immediately brought into line with the provisions of the Act of 1913 in regard to the changed conditions attaching to benefits, &c., the Commission, in notifying to Approved Societies the necessity of changes in their rules (Circular A.S. 120), at the same time issued a booklet containing all the necessary amendments of rules, and a form on which application for approval of these amendments and authority to bring them into force at once could be made. On receipt of this form, duly signed by the secretary and three members of the Committee of Management, an endorsed copy of the amend- ments was returned with instructions that they should be incorpo- rated in the existing rules and laid before the next meeting of the rule-making authority of the Society. Extensions of Time. 1410. The persons most particularly and immediately affected were employed contributors entering into insurance between the 15th July, 1913, and the 12th October, 1913, and voluntary contributors entering into insurance between the 15th January, 1913, and the 12th October, 1913. Section 2 of the 1913 Act, which extended to 12th October, 1913, the time during which advantage could be taken of the reduced rates of contribution for voluntary and compulsory insurance, had retrospective effect in reducing the contributions payable by — 1. Voluntary contributors entering into insurance after 15th January, 1913, and 2. Employed contributors over the age of 17 entering after 15th July, 1913. 1411. Circulars were issued at an early date giving in detail the necessary instructions to enable Societies to deal with the excess contributions paid by these classes of persons, and to carry through with as much expedition as possible the changes in their records necessitated by the new classifications of insured persons (see para- graph 1426 below) resulting from the concessions with regard to persons over 50 years of age at date of entry into insurance and persons who are no longer classified as aliens. * Maternity Benefit. 1412. The conditions attaching to the payment of maternity benefit have been radically changed by the passing of the 1913 Act, which Approved Societies. 427 provides that in future the benefit shall be the mother's benefit, even though the husband only is the insured person. The husband's Society must administer the benefit in the interests of the mother and child, in cash or otherwise, as the Society thinks fit. The wife's receipt, or, if authorised by her, the husband's receipt, is a sufficient discharge to his Society. 1413. Furthermore, the effect of the new provision is that an in- sured woman can in no case be worse off because her husband is an insured person than if he were not insured. If the husband, for example, is a member of a Society but through the insufficiency of his contributions or on account of arrears is not entitled to maternity benefit, the woman's Society now has to pay the two maternity benefits, as if he were not insured. 1414. Instead of any sickness benefit being payable for the period of four weeks after the confinement of an insured married woman employed contributor, she is now entitled to receive a second maternity benefit. Societies were required by the Act to make rules to the satisfaction of the Commission providing that any woman receiving a second maternity benefit should abstain from remunera- tive work for four weeks after her confinement. 1415. Circular A.S. 117 was issued to Societies to make clear the obligations imposed on them by the new conditions. Other Steps taken to assist Societies. 1416. The work of the Commission in assisting and advising Societies as to the effect of the 1913 Act may be regarded as special to the year under review and superimposed upon the ordinary work of controlling and assisting them in their normal operations of collecting contributions and dispensing sickness, disablement, and maternity benefits. Much of the work falling to Society officials has now ceased to be novel, and is consequently being accomplished with a greater degree of ease and accuracy than hitherto. The guidance of the Commission is not so constantly sought, and Societies are gradually becoming more or less capable of dealing with inquiries from their members which a year ago would unfail- ingly have been passed on to the Commission. 1417. It has also been necessary in the course of the year to over- haul the procedure which had been adopted to deal with such questions as transfers from one Society to another, uniformity in methods of notifying claims for sickness benefit, refund of contri- butions paid in error, &c. A general indication of the action taken by the Commission is given in the following paragraphs : — Medical Referees. 1418. It having been brought to the notice of the Commission that certain Societies deemed it advisable to adopt some method for the purpose of checking excessive claims for sickness benefit, a circular was issued dealing with the question of medical referees, with a view to assisting Societies in solving this important problem. In this 428 Wales. circular it was pointed out that it was open to Societies to engage medical referees, and that the arrangements adopted could be such as to be suitable to the requirements of the various Societies and geographical areas. Most Societies had already a provision in their rules by which an insured member claiming, or in receipt of, sickness benefit could, if the Society thought fit, be required to submit himself for special medical examination, and the Commission have reason to believe that a number of Societies have adopted this system of checking doubtful claims, with quite good results. Administration Account Deficiencies. 1419. Administration Account deficiencies, as at 12th January, 1913, have been certified by the National Insurance Audit Depart- ment in respect of 16 Societies operating in Wales, the total of the deficiencies amounting to £133 14s. Id. only. 1420. Permission to carry forward the deficiency to the following year has been or will be granted to any Society which has either saved a sufiicient sum in the subsequent year to clear the deficiency or has undertaken to make good in some other way {e.g., by volun- tary subscriptions, donations, &c.) any administration deficiency arising at 11th January, 1914. In most of the cases the amount of the deficiency is such that it can apparently be included in the 1913-14 account without being likely to cause a deficiency on that account. No levies on members in respect of administration defici- encies have had to be made up to the date of this Report. Payment of Contributions for Disablement Benefit. 1421. The Commission have received many inquiries as to the position with regard to disablement benefit of insured members of Approved Societies who have already received sickness benefit for twenty-six weeks and are still incapacitated. It does not appear to have been generally understood by secretaries of Approved Societies and insured persons that persons in such circumstances may pay contributions on their own behalf during incapacity con- tinuing after sickness benefit has ceased, in order to qualify for disablement benefit at the earliest possible date. Expulsions. *1422. The rules of every Approved Society contain provisions for the summary termination of membership consequent upon certain offences against the rules. Up to the present notifications have been received that about 50 persons have been expelled from Approved Societies in Wales, chiefly on account of (1) false declarations on proposal forms or wilful omissions of material facts therefrom, or (2) imposing on the funds of the Society. Approved Societies. 429 In all these cases the Commission has communicated with the insured person concerned, informing him of his right of appeal against the decision of his Society, and indicating the courses open to him should he not desire to appeal. No cases have arisen in which appeals have been referred to the Commission for decision. Amalgamation of Branches. 1423. The attention of the Affiliated Q^^^ers, whose registered offices are situated in Wales, has been drawn to the possibility of strengthening their organisation for National Health Insurance work by reducing the number of Lodges or Branches engaged in the administration of the Act. The United Industrial Order of Odd- fellows, which originally had 15 Branches, has been reconstructed and the number of Branches reduced to three by a process of amal- gamation. The Wales -Unity of Oddfellows, which had 16 Branches, has decided to centralise its State business by forming a " Separate Section," to which the present Branches will transfer their engage- ments in respect of insured persons. Under this arrangement the Branches will act as agencies for the purposes of collection and dis- tribution of cards, sick visiting, &c. Proposals are also under consideration by two of the larger Welsh Affiliated Orders and several international Orders with a view to the centralisation of their State business in large districts; in these cases it is proposed that the State members should continue to be attached to" their present lodges for voting purposes, &c. . Associations. 1424. The Commission have received intimation that the formation of Associations under the provisions of Section 39 of the Act of 1911 is receiving the careful attention of Societies having less than 5,000 members, and it is understood that certain Associations have already been established, but as the Eegulations to be prescribed in accord- ance with this Section have not yet been issued, no formal recog- nition of these Associations is at present possible. 1425. The Associations of Friendly Societies formed in accord- ance with Section 22 of the Friendly Societies Act, 1896, which were fully described in paragraphs 105 to 113 of the last Report are working satisfactorily on the whole, and during the year several of the small Societies which ceased to administer the Act inde- pendently became constituent Societies of such Associations. It is understood that several other small Societies contemplate the estab- lishment of Associations of this character in areas not covered by those now in existence. Persons over 65 years of age at the Gommencem,ent of the Act. 1426. As the result of the repeal of Section 49 of the Act of 1911, the necessity for distinguishing between employed contribu- 430 Wales. tors who were over 65 years of age on 15th July, 1912, and other employed contributors no longer exists; the classification of con- tributors has been simplified. Transfers between Approved Societies, 1427. Many ihsured persons who became members of Approved Societies on their entry into insurance have since desired to transfer their membership to other Approved Societies. Under the con- ditions of Circular A.S. 68, Part II., it was foimd that many persons in attempting transfer found themselves in the position that they had withdrawn from one Society before being effectively admitted to membership in another Society. The process of transfer was in many instances very protracted; enquiries from insured persons who were uncertain as to the Society to which to apply for benefit were numerous; and the whole matter had been complicated by the practice, followed in many instances, of handing contribution cards to unauthorised persons. 1428. To meet these difficulties a new procedure was adopted. In order to ensure that a member wishing to transfer would be pro- visionally accepted by his new Society before he withdrew from his old Society, the old Society was required to notify to the insured person, within a month of its receipt of the " application for consent to transfer," the Society's decision in the matter. If the Society withheld consent, the member desirous of persisting in his appli- cation had to proceed in accordance with the Society's rules relating to disputes. This left the onus of proving whether consent was unreasonably withheld on the insured person rather than on the Society. 1429. At the commencement of the year 1914 a revised Circular, A.S. 92, was issued to meet the altered conditions brought about by the adoption of half-yearly contribution cards. Transfers may still be effected quarterly, i.e., at the end of the first thirteen weeks of the half-yearly period, or at the end of the half-year. The procedure in cases of disputed transfers has also been revised. In every instance where consent to transfer is withheld, or no reply is received to the application, the case may now be referred by the new Society to the Commission. Over 150 cases of this nature have already been received, and are being dealt with by the Com- mission. 1430. The number of transfer notes which have been received by the Commission in respect of transfers between Approved Societies, or between the Welsh and other sections of the same international Society, is as follows :-— Transfers taking effect at end of Ist Quarter, 326. 2nd „ 623. 819. 802. 409. 137. 3rd )) )) >» 4tli )) a " f) 5th )> »> » » 6th jj Approved Societies. 481 1431. The figures for the fifth and sixth quarters are at present incomplete, as the transfer notes have to be dealt with by both Societies concerned before being finally forwarded to the Commission for the crediting of transfer values. Issue and Use of Uniform Medical Certificates. 1432. The rules of all Approved Societies require an insured member, when claiming sickness or disablement benefit, to send notice of illness on a form provided by the Society. 1433. These forms embody the medical certificate generally re- quired in connection with a claim for benefit, and difficulties had arisen owing to the variety of terms in which doctors are called upon to certify incapacity for work. In order to obtain uniformity in the wording of the certificate, a model form was issued. This, as well as the model continuing-on and declaring-off certificates, appears to have been generally adopted by Welsh Approved Societies. 1434. In the case of a few of the larger Societies, however, a card combining all these forms has been adopted, after having been sub- mitted to the Commission for their consideration and approval. These, however, follow in all essentials the lines of the model forms which have been recommended after consultation with repre- sentatives of the medical profession, although modifications in un- important details have been made to suit the requirements of particular Societies. Married Women. 1435. Section 44 (11) of the Act of 1911 makes it incumbent upon Societies to inform women members who marry of their rights and options under the Act. Circular A.S. 95 was issued in August, 1913, drawing the attention of Approved Societies to this requirement. Forms 171 A.D. and 171 (a) A.D. were also issued to Societies to be filled up in respect of insured women members who married, and who, through ceasing to be employed, were suspended from the ordinary benefits. 1436. The Society is required to state on these forms whether the member has elected to become a special voluntary contributor under Section 44 (2) of the Act of 1911. An examination of the forms received up to date shows that about 35 per cent, of the women members who are suspended from the ordinary benefits on or after marriage do not elect to become special voluntary contributors, but prefer to have any sum available applied to the payment of the benefits specified in Part III of the Fourth Schedule to the Act of 1911. The number of members whose suspension from the ordinary benefits has been notified to the Commission is 984. Meeting Places of Approved Societies. 1437. A considerable number of Approved Societies and Branches of Approved Societies have taken steps during the year to comply with the Eegulations as to meeting places. 432 Wales. III.— THE COLLECTION OF CONTRIBUTIONS, THE RECEIPT AND ISSUE OF FUNDS, AND INYEST^ MENTS. Collection of Contributions. Distribution of Cards. 1438. The despatch of contribution cards to Approved Societies for distribution to members has been made quarter by quarter (in future every six months) direct from the printing works at Cardiff, without specific requisition, on the basis of the ascertained membership of the various Societies, a margin being allowed for contin- gencies. With a view to minimising the clerical work of Societies, the date of issue of the cards has been put forward to enable Socie- ties to supply a card for the next ensuing quarter when returning the insurance book written up in respect of the previous quarters. This step was taken by the Commission not only as a means of saving trouble and expense to Approved Societies, but in order to put no obstacles in the way of the respective duties of employed persons, employers, and secretaries of Approved Societies being carried out with smoothness, certainty, and promptitude. This aim has been fairly well attained, and it may be said in general that the supply of cards to members, and their subsequent production to employers, is now being carried out with very little inconvenience. At the same time, the Commission found it necessary, in consequence of information received, to issue a general notice to workpeople, calling their attention to the duty laid upon each employed person to produce a contribution card to his or her employer in time to ensure its being stamped for the first week of the period of currency. The notice stated that the Commission attached great importance to the proper performance by the insured person of his statutory duty in this respect, and, further, that proceedings would be instituted in cases where grave breaches of the law were discovered. Changes in the System of Collection. 1439. Since the date of the previous Eeport certain changes have been made in the system of collection of contributions. The chief of these is the substitution of a six-monthly contribution card for the card of a quarter's currency previously in use. The change was made in response to a widespread feeling amongst Approved Society officials that the card of the shorter currency gave rise to an amount of clerical labour which it was difficult to perform concurrently with the other duties falling upon them. The cost of postage, &c., was also an important consideration. The six-monthly card, it was felt, approximated more closely to the Collectio7i of Contributions. 433 custom prevailing amongst Friendly Societies prior to the inception of the Act. The Commission, having ascertained that the feeling among Societies was generally in favour of the card of longer cur- rency, though not to the same extent in all cases, the change was decided upon in January, 1914. 1440. In order to make the period of 26 weeks coincide as nearly as possible with the calendar six months, it was necessary to make the first card current for 25 weeks only, a part of January having been included in the sixth quarterly period. The cards will henceforth continue to be current for periods of 26 weeks, save that some years hence it will be necessary to issue one for a 27-week period. New Insurance Book. 1441. The original insurance book issued to each insured person as a record of contributions paid and benefits received contained spaces for entries in respect of five quarters. Owing to the change from quarterly to half-yearly cards which took place at the end of the sixth quarter, the book already in use was adapted so that the entries in respect of the sixth quarter could be made therein, and Societies w^ere instructed accordingly. 1442. The new book, in which provision is made to show clearly at the end of each contribution year the position of the insured person in regard to arrears, has been designed for use in conjunction with the half-yearly cards, and will not be issued by Societies until the surrender of the first of those cards in July, 1914. The book is current for a period of three years, and has been revised in regard to all necessary information. Quarterly and Halj-y early Stamping of Contribution Cards. 1443. The arrangements made by the Commission whereby employ- ers may, under certain conditions, be allowed to stamp the cards of their employees with high-value stamps at the end of each card's period of currency, as explained in paragraph 123 of the last Report, are still extensively in use. A Statement showing, as regards each quarter, the number of employers and employees concerned, and the value of the stamps supplied, is given in Appendix LIII., page 565. It will be observed that the number of insured persons covered by the arrangements during the quarter ended January, 1914, was almost one-fourth of the whole insured popula- tion in Wales. 1444. The experience derived from the early working of the scheme led to the introduction of certain amendments to meet the conveni- ence of employers. Under the original scheme they were required to make their deposits either in one sum at the commencement of the quarter or by weekly instalments. Monthly or fortnightly deposits were subsequently permitted to meet the cases of employers 434 Wales. who paid wages monthly or fortnightly. Other plans were also devised to meet the requirements of various classes of employment, and the following is a summary of the several methods available to employers during the year under review for the making of deposits : — 1445. Method 1. Applicable in all cases. — The employer may deposit not later than four days before the first pay day in the quarter an amount sufficient to cover the contributions payable during the quarter in respect of the maximum number of employees to whom the arrangement applies. 4-446. Method 2. Applicable in all cases.— The employer may deposit not later than four days before the first pay day (or four days before the first Saturday, if that is earlier) in the quarter an instal- ment equal to one-thirteenth of the amount payable under Method 1, and thereafter a weekly instalment of the same amount on the corresponding day of each week up to and including the twelfth week of the quarter. 1447. Method 3. Applicable only where wages are paid weekly. — The employer may deposit not later than four days before the fijrst pay day in the quarter an instalment equal to one -thirteenth of the ainount payable under Method 1, and thereafter remit on the corre- spondiug day of each week, up to and including the twelfth week, the actual amount payable on account of contributions in the previous week. 1448. Method 4. Applicable only where wages are paid fortnightly or monthly. — The employer may deposit not later than four days before each pay day an instalment of the total deposit payable under Method 1, according to the number of weeks for which contributions will be payable on the next pay day. 1449. Method 5. Applicable only where wages are paid fortnightly or monthly. — The employer may deposit not later than four days before the first pay day in the quarter the maximum amount payable on account of contributions on any pay day in the quarter, and there- after, not later than four days before each subsequent pay day, remit the actual amount of the contributions payable on the previous pay day. 1450. As from 11th January, 1914, these methods have been slightly varied to meet the changes caused by the introduction of the half-yearly card. 1451. Employers were originally required to cancel every stamp space on the contribution card to which the high-value stamp related if the stamp did not represent contributions for 13 weeks. To avoid the inconvenience thus caused, labels marked " Contribution not payable by employer," which should be affixed in any stamp space for any week for which the employer is not liable to pay a contribution, are supplied by the Commission. The weeks for which contributions have not been paid can thus be readily ascer- tained for the purpose of the administration of sickness benefit, &c. Stamping during Week after Payment of Wages. 1452. As mentioned in paragraph 124 of the last Eeport, arrange- ments were instituted to meet the needs of employers who did not Collection of Contributions. 435 desire to adopt the quarterly stamping scheme, but who found that the necessity for stamping the cards of their employees at or prior to the payment of wages caused inconvenience. Such arrangtments are suitable also to those employers who are unable to adopt the quarterly stamping scheme owing to the migratory habits of their employees. Employers adopting this method must deposit with the Commission a sum sufficient to cover the estimated maximum value of one week's contributions, and they may then stamp the cards six days later than the time otherwise fixed by the Eegulations. Particulars of the arrangements entered into during the year under review are given in Appendix LV., page 567. Condition of Societies' Contribution Registers and Quarterly Returns. 1453. It is satisfactory to record that the improvement in point of accuracy of the quarterly returns, which was mentioned in para- graph 128 of the previous Eeport, has continued. The work of com- piling the returns, necessarily somewhat difficult while the work was still novel to the secretaries, is now of a routine character, and is, on the whole, correctly accomplished. Errors, however, still persist which could be avoided by closer adherence to the instructions which have been sent out by the Commission. For instance, many secre- taries omit the precaution of securing agreement of the totals appear- ing in their contribution registers with the amount claimed on the quarterly return. It is frequently found that the figures arrived at after an independent examination of the stamped cards by the Com- mission differ materially from those on the return, although in agree- ment with the register, in which the cards have been individually entered. A few cases have arisen where it has been necessary, owing to the impossibility of securing agreement otherwise, to make a thorough comparison at the office of the Commission between the stamped cards surrendered and the Societies' contribution registers. 1454. Particulars of the sums placed to the credit of Approved Societies in the books of the Commission appear in the following Table:— In respect of Cards for Quarter ended : Gross Contributions. Deduction in respect of Reserve Values. Net Contributions. £ 8. d. £ *. d. £ 8. d. 13th October, 1912 238,870 8 7 53,595 18 11 185,274 9 8 12th January, 1913 240,934 15 8 54,078 10 5 186,856 5 3 13th April, 1913 207,267 6 6* 46,468 19 10* 160,798 6 8* * These figures represent only the amounts actually passed for credit to date. 436 Wales. Refund of Contributions paid in Error. 1455. Kefunds, generally speaking, fall under the following heads : — (1) Contributions paid in respect of (a) persons under 16; (h) persons over 70; (c) persons excepted from compulsory insurance; (d) seamen who are neither domiciled nor have a place of resi- dence in the United Kingdom (Section 48 (3) of the 1911 Act). (2) Duplicate contributions paid in respect of the same persons. (3) Contributions paid by voluntary contributors under a mis- apprehension as to the correct rate payable. 1456. All applications for refunds are closely scrutinised, and often necessitate considerable inquiries. Where the claim is based upon the age of the contributor, documentary evidence in support is called for. Difficulty has sometimes been experienced in obtaining this. In the case of persons over 70 years of age baptismal certificates, marriage certificates, copies of entries in family Bibles and old documents, or evidence submitted for the purpose of the Old Age Pensions Act have been accepted, and the facilities provided by the Act for obtaining cheap birth certificates have now been made avail- able for persons under 16 years of age. 1457. Claims based on the ground that the claimant is excepted from the compulsory provisions of the Act involve careful consideration of the grounds of exception advanced. The cases most frequently arising are those in which a person comes within the ambit of a Special Order, or passes out of insurance under Part II (d) or (g) of the First Schedule to the Act of 1911. Part 11 {d) excepts from compulsory insurance a teacher to whom the Elementary School Teachers (Superannuation) Act, 1898, applies, and by arrangement with the Board of Education the date upon which a teacher is excepted from . compulsory insurance is that upon which he is notified by the Board, or, if he is not then in recorded service, the date upon which he enters on recorded service. 1458. Where a person passes out of insurance on the ground that the rate of remuneration exceeds £160 a year, it often happens that the increase of salary is to take effect as from a date prior to that upon which the increase is actually made. Claimants for refunds on this ground have been informed that as contributions were pro- perly payable up to the date on which the increased salary is paid, their applications cannot be granted. 1459. Seamen who are neither domiciled nor have a place of resi- dence in the United Kingdom present their claims for refunds in increasing numbers. The difficulty in this class of refund is chiefly that of tracing the cards, exact information as to their disposal being rarely obtainable. 1460. Where claims for refunds are made on the ground of dupli- cate payment of contributions, production of both contribution cards is called for, and an explanation of the circumstances invited. Collection of Contributions. 437 1461. The number of applications for refunds by voluntary con- tributors who were under a misapprehension as to the correct rate of contribution payable, which was at one time somewhat consider- able, is now diminishing, undoubtedly on account of a better under- standing of the Act. The general impression that the flat rate of contribution was payable irrespective of the age of the proposed contributor has now to a very large extent been removed. 1462. A further difficulty is met with in dealing with those refund cases in which expenditure has been incurred by Societies on account of persons who have become members under the belief that they were qualified for insurance. The Commission have had under con- sideration the procedure to be adopted with the view to making such a refund in these cases as is equitable in the circumstances, whilst at the same time recouping Approved Societies for the expenditure they have incurred. 1463. It would, of course, have been open to the Commission to treat the matter as though it concerned only the persons by and in respect of whom the contributions had been paid in error, and to have refused Societies credit for any part of these contributions, leaving them to recover in each individual case the amount of any expenses incurred. On consideration, however, of all the circum- stances, it appeared that the fairest course would be to deal with these claims as a whole, and to adopt a comprehensive arrangement applicable to all cases which, though it might involve loss in some individual instances and gain in others, would be equitable on the average. A scheme has therefore been proposed to Approved Societies, of which the following is an outline: — (a) Where the person concerned has been entitled and elects to become a voluntary contributor, the contributions paid in respect of him will remain to the credit of the Society in respect of his voluntary insurance. He will be treated as having been insured as from the date when the contri- butions were first paid, and the Society will be advised of the adjustments to be made in the registers and accounts. (b) Where, however, the person does not elect to continue in insurance and to be treated as in (a), or where he is not entitled to become, a voluntary contributor, the Society will be allowed to retain such portion of the contributions credited to it in respect of the first 26 weeks during which the contributor was treated as an insured person as will meet the charges for that period. Credit will also be given to the Society for the gross contributions on all cards surrendered to it in respect of the period subsequent to the first 26 weeks. The balance of the contributions for the first 26 weeks will then be refunded to the employer for division between himself and the contributor. 1464. It is also proposed to apply the scheme to refunds claimed of contributions paid in respect of persons xmder 16 or over 70 years of age, subject to the qualification that if the Society knew the correct 438 Wales. age of the contributor (and therefore did not in fact treat him or her as *' insurable " in respect of or on account of the period for which contributions were wrongfully paid) repayment will be made in full. 1465. An essential condition of the scheme is that it should apply uniformly to all cases affecting any particular Society. As Societies gain by the method in the case of all members to whom little or no benefit has been paid, this should be set against any apparent loss in cases where a relatively large expenditure has been incurred. It follows, therefore, that Societies can avail themselves of the arrange- ment only on the understanding that they consent to forego any right of recovery they may have in particular cases. If any Society, instead of taking advantage of the scheme, prefers to seek its own remedy against particular individuals, the Commission will not be able to allow it credit for any contributions paid in error in respect of persons not liable to compulsory insurance, and Societies which are not prepared to accept the scheme were therefore requested to notify the Commission accordingly. Allowances for Cards lost or accidentally destroyed. 1466. A subject somewhat akin to that of refunds is that of allow- ances in respect of destroyed or lost contribution cards. No allow- ance can be made in respect of a card lost while in the possession of a contributor or of an official of a Society, but where a card has been lost while in the custody of an employer, and it is shown that reasonable precautions had been taken for its safe custody, the question of making an allowance is considered. Cases in which allowances are made for lost or destroyed cards may be summarised as follows : — (1) Cards lost or destroyed while in the custody of the employer. (2) Cards accidentally destroyed while in the possession of the contributor. (3) Cards accidentally destroyed while in the possession of an official of an Approved Society. (4) Cards lost in postal transit. (5) Cards lost after having been handed in at a Post Office. 1467. In every case a careful inquiry into the circumstances attending the loss or destruction is made by an officer of the Outdoor Staff before the allowance is made. The result of the inquiries which have been made go to show that employers who have the custody of the cards for the period of their currency make adequate arrange- ments for the preservation of cards, and the loss generally arises when cards are distributed at the end of the quarter. 1468. The lack of evidence in cases of cards lost in postal transit renders the question of allowance very difficult, but on the whole inquiries instituted by the Outdoor Staff help very materially in arriving at a proper decision. 1469. Since the expiration of the first quarter a large number of cards have reached the Offices of the Commission as lost or un- Receipt and Issue of Funds. 439 claimed, mostly from various large collieries where they had been left by workmen. The number of cards which were forwarded after the end of the first quarter was considerably heavier than at the end of any subsequent quarter. The decrease is partly due to the issue of a circular to all large employers of labour, pointing out the duties laid upon them by the Collection of Contributions Eegula- tions, which have in the main been faithfully carried out. Another reason that accounts for part of the decrease is undoubtedly a fuller appreciation by the contributor of the value of the card. 1470. When the cards are received by the Commission further efforts, which have met with a considerable measure of success, are made to deliver the cards to the proper quarter. 1471, The following is a Statement of the adjustments and refunds made during the period 15th July, 1912, to 11th January, 1914 : — (a) Adjustvients in respect of Destroyed cards 112 Cards lost in the post 44 Cards lost while in the custody of employer ... 8 Other cases, incorrect stamping, <^c 568 732 (h) Refunds : — Number of refunds 861 Amount of refunds £573 15s. 4d. Receipt and Issue of Funds. Security to he given by Approved Societies. 1472. As stated in paragraph 117 of the previous Keport, all the Welsh Approved Societies that have given security as required under Section 26 of the Act have joined the Central Guarantee Fund. During the year three small claims on the Fund have been made in respect of defalcations, but as yet no repayment from the fund has been made. In every case of a claim on the Central Guarantee Fund the Commission require the Society to take proceedings against the officer concerned, if his whereabouts can be traced, and there is, in the opinion of the Committee of Management of the Society, sufficient evidence to justify proceedings on a criminal charge. In each case the books and accounts of the Society are specially examined by a member of the Audit Staff, who certifies the amount of the loss and whether such loss was due to lack of proper precautions by the Society, in which case the amount may be debited to the account of the Society in accordance with the rules of the Fund. 440 Wales. Issue of Funds to Approved Societies. 1473. During the year funds for the purpose of providing sickness and maternity benefits and for expenses of administration were issued to 154 Welsh Societies and 153 international Societies operating in Wales. Of these, 150 Welsh and 114 international Societies which had given security to the Commission under Section 26 of the Act received advances of funds to meet their estimated expenditure at monthly intervals. Funds were issued to the re- maining Societies as applied for in reimbursement of sums previ- ously expended, their expenses having, in the first instance, been defrayed from private funds. 1474. Normally, advances to Societies were restricted to 4d. a week per male member, and Sd. a week per female member, but in cases where the amount available on this basis appeared to be inadequate to meet the expenses of a Society, the above rates were respectively increased to 4Jd. and 3Jd. 1475. Any Society requiring advances of funds in excess of the amounts available at the extended rate was required to furnish a certified statement of its total administration and benefit expendi- ture, in order to satisfy the Commission that abnormal issues were really necessary. In the case of two small Welsh Societies composed almost entirely of miners, it was found necessary in addition to ascertain provisionally the amounts which could be credited to them in respect of reserve values, before the sums required could be issued. • 1476. Issues to Societies which had not given security to the Commission and consequently received funds only in reimburse- ment of sums previously expended were restricted until completion of audit, (a) as regards administration, to 90 per cent, of the maximum allowance, or, to 90 per cent, of the actual expenditure, if below the maximum, and (b) as regards benefits, to 90 per cent, of the sums expended. 1477. The amounts deducted are retained by the Commission pending the receipt of the auditors' certificates as to expenditure, or, in the case of a Society whose administration expenditure exceeds the maximum allowance, until the Society receives the Commission's sanction to carry forward the administration deficiency to the subse- quent year. 1478. Statistics as to the total amount of funds issued to Welsh Societies and international Societies operating in Wales are given in the following Table : — Receipt and Issue of Funds. 441 Amount paid to Societies in advance. Amount paid to Societies in reimbursement. Total Issues to Societies. Welsh Societies International Societies ... £ s. d. 85,823 16 6 518,819 16 5 £ s. d. 514 6 5 37,350 13 9 £ s. d. 86,338 2 11 556,170 10 2 Totals 604,643 12 11 37,865 2 642,508 13 1 Book-keeping hy Affiliated Orders. 1479. Each separate Branch of an Affiliated Order is a separate valuation unit under the Act, and a complete set of accounts must be kept in respect of it. It was apparent at an early stage that while it was essential to efficient administration that the member- ship, contribution, and sickness registers should be kept at the Branches, the ledger accounts could most efficiently and economi- cally be entered up on behalf of Branches at the head offices, the consequent aggregation of work at one centre justifying the employ- ment of an official possessing full knowledge of book-keeping. While this arrangement involves some adjustment of remuneration as between Branch secretaries and the head office, the autonomy of the Branch as a distinct unit is not disturbed, the head office occupying in relation to this matter merely the position of agent to the Branch. A model scheme of accounting for a Society with Branches has been devised, and all Welsh Affiliated Orders, together with most of the international Orders operating in Wales, have now sub- stantially adopted the same. Audit Certificates. 1480. The accounts of expenditure of Approved Societies have to be audited by the National Insurance Audit Department. 1481. Eeturns are submitted by Societies to the Auditors for ex- amination, and these returns, after examination, are forwarded to the Commission for the purpose of calculating and crediting the propor- tionate State grant. 1482. The certificates given by the Auditor may be divided into three classes, viz. : — (1) Clear Certificates, where the Auditor certifies that the cash account, administration account, and administration appro- priation statement are in order. (2) Interim Certificates, where the Auditor certifies as in (1), subject to the examination of registers, comparison with Commission's advices. &c. 442 Wales. (3) Qualified Certificates, where the Auditor qualifies his certifi- cate by drawing attention to (a) payments which are improper or are not authorised by the Society's rules; or (6) other matters which may be irregular {e.g., con- stitution of Committee of Management). 1483. The Commission is at present in consultation with the other Commissions with a view to arriving at a uniform line of policy to be pursued as regards improper expenditure on the part of Societies. 1484. Where the expenditure is of such a character that it is not capable of ratification by the Society, Or is in contravention of the Acts and Regulations made thereunder, the State grant cannot be allowed. 1485. When improper expenditure is brought to the notice of the Commission, the governing body of the Society (or Branch) con- cerned is requested to take steps to obtain repayment, and in several cases this course has produced a satisfactory result. In naany cases, however, the qualifications attached to the audit certificates relate merely to technical matters which are capable of ratification, or regularisation, by the Society. Accounts of the Welsh National Health Insurance Fund. 1486. A Statement showing the receipts into and payments out of the Welsh National Health Insurance Fund up to 11th January, 1914, is given in Appendix LIV., page 566. Investments. 1487. The first ascertainment of sums standing to the credit of Societies in the Welsh National Health Insurance Fund and avail- able for permanent investment was made for the period ended 13th April, 1913. A circular informing Societies that an ascertainment had been made was issued in September, 1913, and Societies were re- quested therein to notify the Commission whether the proportion available for investment by them should be — (i.) placed to the credit of the Society in the Investment Ac- count of the Commission; (ii.) transmitted to the Society for investment, by payment to the joint account of the trustees of the Society; (iii.) invested by the Commission on behalf of the Society in securities selected by the Society. Investments. 443 Beplies were very slow in coming to hand, and even at 31st March, 1914, three Welsh centralised Societies and six Affiliated Orders (five international and one Welsh) had not intimated their decision in the matter. 1488. The following is a Statement of the transfers and payments made in respect of investments. Societies Societies approved by the Welsh approved by the Joint Total. - Commission. Committee. No. of No. of No. of So- Amount. So- Amount. So- Amount. cieties. cieties. cieties. Amount automatically transferred to the In- £ £ £ vestment Account 16 2,376 53 35,309 69 37,685 Amounts available for in- vestment by Societies : — (i) Transferred to In- vestment Account 10 1,649 15 4,109 25 5,758 (ii) Paid over to trus- tees of Societies for investment 1 150 24 23,510 25 23,660 (iii) Invested, by the Commission in Se- curities selected by the Societies 1 75 2 510 3 585 Total Amount ... — 4,250 — 63,438 — 67,688 Note. — Owing to the necessity for retaining a reasonable working balance, it was not considered worth while to make any issue for investment to Societies having a membership of less than 400. 444 Wales. lY.— INSURANCE COMMITTEES. Constitution, Powers, and Duties of Insurance Committees, &c. Appointment of Insurance Committees. 1489. In the light of the experience gained during the lifetime of the provisional Insurance Committees set up in July, 1912, the Commission determined, in pursuance of their powers under Section 59 of the Act of 1911, that the numbers of the members of the Committees should be as follows: — Glamorganshire ... ... 60 members. Monmouthshire 60 members. Carmarthenshire 50 members. Carnarvonshire 50 members. Denbighshire ... ... 50 members. All other areas 40 members. 1490. The Orders under Section 78 of the Act of 1911 constituting provisional Insurance Committees as from 15th July, 1912, pro- vided that the persons appointed thereunder should hold office only until persons should be appointed to be members in accordance with the provisions of Section 59 of the Act. Accordingly, as soon as the necessary information as to the distribution of insured per- sons among the various Societies was available, steps were taken to secure the appointment of Committees on a permanent basis. 1491. Section 59 of the Act lays upon the Commission the duty of (a) determining within limits the number of persons of which a Committee shall consist; (b) making Regulations prescribing the manner in which the representatives of insured persons shall be appointed ; and (c) making Regulations prescribing the manner in which the representatives of medical practitioners shall be appointed. Regulations providing for the representation of insured persons were made on 9th May, 1913, and Regulations for the election of repre- sentatives of the medical practitioners were made on 21st May, 1913. 1492. The Act secures (1) to Approved Societies the right to appoint the representatives of their members; (2) to an association of deposit contributors (if any such has been formed) the right to appoint the representatives of deposit contributors. The scheme for carrying these provisions into effect, as embodied in the Regula- tions, was as follows : — 1493. The Regulations provided that only persons whose prin- cipal place of residence at the date of nomination or appointment was within the area of the Committee should be eligible to be members of the Committee as representatives of insured persons. 1494. The Regulations provided for the ascertainment of the number of insured persons resident in a Committee area, and for a statement of the number of members of each Society, and the number of deposit contributors, so resident, to be furnished by the Insurance Committees : Constitution, Powers, and Duties. 445 Clerk of the Committee. From the information supplied in this statement (a) the number of representatives of deposit contributors to be appointed was determined; (b) Societies were divided into those entitled to direct repre- sentation (" A " Societies) and those entitled to take part in the nomination and election of members ("B " Socie- ties), the classification being determined by the strength of the Society's membership in the area. 1495. The appointment of representatives of " A " Societies pre- sented no difficulty, all that was required being a notification to the Commission on the prescribed form of the persons appointed. 1496. The Eegulation governing the election of representatives of ** B " Societies provided that at least two of these representatives should be women. Each " B " Society was therefore given the right to nominate one man and one woman candidate, and to vote for as many male candidates and as many female candidates as there were vacancies to be filled. The vote of each Society was given a value according to its membership in the area in which the vote was cast. 1497. Speaking generally, little difficulty was experienced in carrying through the election by means of a postal vote, but some Societies failed to appreciate the necessity of complying with the Eegulations as to the dates by which nomination papers or voting papers had to be returned. Several Societies equally failed to comply with the Eegulation as to the place of residence, and in consequence lost their power of nomination. 1498. The total number of candidates nominated for the 194 seats allotted to ** B " Societies on the 17 Committees was 382, and the number of voting papers returned was 1,051, of which 95 had to be declared invalid owing to various defects. In all 52 women were nominated as candidates, and of these 13 received a sufficient number of votes to ensure their election. The only area for which a contest was unnecessary was Cardiganshire. 1499. The Eegulations further provided that where no associa- tion of deposit contributors had been formed in any area, the power of appointing the representatives of deposit contributors should be vested in the provisional Committee. No such associations having been formed by the prescribed date, the representative of deposit contributors was in each case appointed by the provisional Com- mittee. 1500. The Eegulations made under Section 59 (2) (c) for the appointment of medical representatives on Insurance Committees provided — (1) for the formation of associations of medical practitioners resident in a County or County Borough for the purpose of electing representatives to serve on the Insurance Com- mittee, and (2) where no such association had been formed, for the nor^ination and election of representatives by the practi- tioners resident in the County or County Borough. 446 Wales. 1501. In four Committee areas, associations for the purpose of electing representatives were formed, and, approval having been granted by the Commission, these associations carried out the neces- sary election. 1502. In the remaining 13 Committee areas, forms of nomination were sent to all medical practitioners for the area in which they resided. The Regulations provided that any two duly qualified medical practitioners could nominate candidates. Owing to the excellent organisation of the profession, not more than the number of candidates required to fill the vacancies were nominated in any area except the County of Anglesey and the County Borough of Cardiff; and contests were thereby avoided. 1503. In Anglesey and Cardiff six and five candidates were nominated respectively. The resulting election was carried out by means of a postal vote, each practitioner resident in the area being entitled to vote. 1504. The number of women members of Insurance Committees in Wales is 110, and varies from six to eight in the respective areas. The number of medical practitioners in each area who are members of the Committee is not less than one-tenth of the total number of the members. The Commission have also secured that there is one member on each Committee to represent chemists and other persons and bodies supplying drugs and appliances. Staff of Insurance Committees. 1505. In eight areas the Committees are served by Clerks who devote their whole time to the duties of their office. In three areas the Clerks of the Peace have continued as Clerks to the new Com- mittees constituted in July, 1913. 1506. The task of completing the register of insured persons in each area was undertaken with varying degree of success, but in all areas this work has necessitated the employment of a considerable number of assistants. The obligation upon Approved Societies to notify Insurance Committees of their acceptance of new members and of removals, transfers, marriages, and deaths of members, has been fulfilled but indifferently (frequently because insured members do not notify their Societies of changes), with the result that Com- mittees have experienced great difficulty in trying to make their registers reflect even approximately the insured persons in their areas at any given time. The work in connection with the issue of the new medical card has added to the difficulties of Committees in the first months of 1914, and it cannot yet be said that the work has been reduced to the normal. Index Begisters. 1507. The index register of insured persons in each Committee's area required adjustment on account of the extension of medical and sanatorium benefits, as from 12th January, 1914, to exempt persons, and to insured persons between 65 and 70 years of age at Insurance Committees : Constitution, Powers, and Duties. 447 entry into insurance. The issue of the new medical card to each person entitled to medical benefit, it is hoped, will eventually lead to its being possible to rely upon the numbers shown by the registers as being so entitled in any area being approximately the number of insured persons for whose medical benefit the Insurance Committee is responsible. The system of notification of removals, and changes in status of members, by the Approved Societies has led to the index registers being behindhand. Conferences were held at Chester and Cardiff with representatives of the Insurance Com- mittees, and it was generally felt that the medical card system would be of great assistance in making the Committees' registers correct and reliable. 1508. Counts have been taken at quarterly intervals of the number of insured persons for whom index slips have been returned to each Committee, and the figures so ascertained have been utilised as the basis for the division of the various national funds between Insurance Committees. 1509. With a view to assisting the Insurance Committees in clearing their index registers and eliminating suspense slips there- from, the Commission, towards the end of 1913, initiated a scheme for dealing with the suspense slips centrally at the offices of the Commission, and a beginning was made by obtaining from the Com- mittees the suspense slips relating to a group of Societies, and also the index slips in respect of members of those Societies who were not shown as having chosen doctors or institutions. In all, 32,665 index slips and 16,321 suspense slips were received. 1510. In the first place comparisons were made of the index slips in each Society with the suspense slips from all the other Societies, and in this way 2,264 suspense slips were eliminated. Inquiries were then made of the insured persons in cases where the suspense slips were defective. The suspense slips from all the Insurance Com- mittees were then sorted together and a general compari- son was made with the index slips. The total number of suspense slips eliminated by these processes and returned to the Insurance Committees amounted to 5,250, which was almost a third of the total number of suspense slips received from the Committees. Lists have now been prepared of the remaining suspense slips, and circulated amongst the Committees with a view to the examination of their registers and in order to see whether they hold slips in respect of any of these remaining cases. The lists have not yet all been returned by the Committees, so that it is not possible at pre- sent to state how many suspense slips may have been eliminated in this way; but in view of the results already obtained by the centralisation scheme, the Commission have under consideration the extension of the scheme in respect to slips of other Approved Societies in the registers of the Insurance Committees. Income of Insurance Comm^ittees. 1511. The income which is available to meet the administrative expenses of the smaller Committees has hitherto been insuflBcient, 448 Wales. and has been supplemented out of a special grant provided by Par- liament for the period ending 14th January, 1914. The sum of £1,650 was made available for this purpose. The normal income of Committees at present for administrative expenses is derived from sums received from Approved Societies in accordance with Section 61 (2) and Section 15 (6) of the Act of 1911. There are also certain sums received in respect of deposit contributors, while amounts due under Section 12 (2) (fe) of the Act of 1911 are credited to the Committee's general purposes fund. In certain areas sums have been transferred from the sanatorium benefit fund to the Committee's administration fund. Association of Insurance Committees. 1512. Section 31 (3) of the 1913 Act provides for the establishment of Associations of Insurance Committees. A meeting of represen- tatives of the Insurance Committees of Wales (which was attended, by invitation of the conveners, by the Chairman and the Deputy Chairman of the Commission) was held at Shrewsbury on 15th January, 1914, to form an Association of Welsh Insurance Com- mittees. At a subsequent meeting held in March a scheme for tho constitution of the Association was adopted. The objects of the Association were approved by the Commission in February, 1914. All the Welsh Insurance Committees have arranged to join the Association, which it is hoped will be of great assistance in the administration of the Insurance Acts in Wales. District Committees, 1513. A scheme for the constitution of District Insurance Com- mittees was approved for the area of the County of Carmarthen for the period ending 15th July, 1913. No application has been re- ceived for the further approval or amendment of that scheme, and at the present time there are no District Committees in being in Wales. The matter has been under consideration by various In- surance Committees, but it is generally felt that with the limited amount of income available for the administrative expenses of the Committees, the constitution of District Committees would not necessarily conduce to the more efficient and economical adminis- tration of the Acts. 1514. In all the areas sub-committees have been set up to assist in the work of the Insurance Committees. Panel Committees. 1515. The Act of 1913 provided that where Insurance Committees are required to ascertain the wishes and opinions of the practitioners who have entered into contracts with them, they are to do so through Panel Committees set up under Section 32 of that Act. The Commission are empowered to assign by Begulations such powers and duties to these Committees as they may determine. Insurance Committees: Constitution, Powers, and Duties. 449 1516. The Eegulations made under Section 32 of the Act of 1913 lor the election of persons to serve on Panel Committees provided — (1) that the Committees should hold office till 15th July, 1914 ; (2) that Committees should be elected either (a) under a scheme approved by the Commission, or (5) by postal vote of the practitioners on the panel ; (3) that only duly qualified medical practitioners should be eligible for membership ; (4) that three-fourths of the Committee should be practitioners on the panel; (5) that all practitioners on the panel should be entitled to vote in the election; (6) that any two practitioners on the panel should have power to nominate candidates. 1517. Five schemes for the appointment of Committees were sub- mitted to the Commission, of which four were approved. In 12 areas, only the number of candidates necessary to fill the vacancies were nominated, and contests were therefore unnecessary. In the County Borough of Cardiff, 52 candidates were nominated for 20 seats, and the necessary election was carried out by means of a postal vote. 1518. In nearly every area in Wales the members of the Panel Committee have been recognised as the Local Medical Committee, as this has been found to be administratively convenient. Pharmaceutical Committees. 1519. Provision is made by Section 33 of the Act of 1913 for the setting up, subject to Eegulations, of statutory committees representing chemists and other persons and bodies supplying drugs and appliances to insured persons (now called Pharmaceutical Committees) to be consulted by the Insurance Committees on all general questions affecting the supply of drugs and appliances. 1520. The Eegulations made under this Section for the election of persons to serve on Pharmaceutical Committees provided — (1) that the Committee should hold office till 15th July, 1914 ; (2) that the electors should be the persons, firms, and bodies corporate engaged in the supply of drugs, &c., to insured persons on a prescribed date; (3) that two-thirds of the members of the Committee should be registered pharmacists ; (4) that any two electors should have power to nominate candidates. In 16 areas, only the number of candidates necessary to fill the vacancies were nominated, and contests in these areas were therefore unnecessary. In the County Borough of Swansea eight registered pharmacists were nominated for seven seats, and the necessary election was carried through by postal vote. (B254— Gp. 5) P 450 Wales. The Administration of Sanatorium Benefit. 1521. Section 42 (1) of the Act of 1913 substitutes the Welsh In- surance Commissioners for the Local Government Board as the authority whose approval of sanatoria and other institutions and of the method of undertaking non-institutional treatment must be obtained under Section 16 (1) of the Act of 1911, for the purposes of enabling Insurance Committees in Wales to enter into arrange- ments for providing treatment for insured persons suffering from tuberculosis. 1522. The number of insured persons and their dependants who have received treatment during the 18 months ended 11th January, 1914, is set out in Appendix III., page 479. The appropriate forms have been issued for the use of claimants and the Committees, and in most areas the Committees have received reports from the Medical Officers of Health as to the state of the dwelling-houses of the patients. In some areas it has been found advantageous to issue the forms of application for benefit in the Welsh language. Arrangements have been made by the Committees in most areas for dealing with re- commendations promptly, without necessarily waiting for a meeting of the Committee, by authorising certain persons (usually the Chair- man and Clerk), subject to later confirmation by the Committee, to take the necessary steps on receipt of claims for securing the requisite form of treatment. The Participation in Sanatorium Benefit of the King Edward VII. Welsh National Memorial Association. 1523. The 17 Insurance Committees in Wales have, with the approval of the Commission, entered into agreements with the King Edward VII. Welsh National Memorial Association to provide, for such insured persons and their dependants suffering from tubercu- losis as are recommended by the Committees, treatment at resi- dential institutions or at dispensaries or institutes. The agree- ments provide for payment to the Association of 9d. per insured person in each Committee's area out of the sanatorium fund. The Position of Local Authorities. 1524. The Commission, in their circular addressed to the County and County Borough Councils in April, 1913, indicated the steps which, in their opinion, would best give effect to the decision of the Councils to co-operate in a national scheme for the treatment of tuberculosis. The position was affected by the provisions of sub- section (2) of Section 42 of the Act of 1913, which authorises the Council of a County or County Borough in Wales to agree with the Welsh National Memorial Association to make such annual or other payments, subject to such conditions and for such periods, as may be approved by the Commission, and further appoints in what manner any expenses incurred under the sub-section shall be de- frayed. This sub-section removes any doubt that may have existed Insurance Committees: Sanatorium Benefit. 451 as to the powers of County Councils to contribute towards the expenditure of the Association on a comprehensive scheme for the treatment of tuberculous patients, including those who are neither insured persons nor the dependants of insured persons ; and the special authorisation of the Local Government Board, which was previou'sly required under Section 64 (2) of the Act of 1911, to enable County Councils to provide for the treatment of tuberculous per- sons, is no longer required. 1525. The Commission, in October, 1913, approved of the esti- mates of expenditure of the Association and of the scheme which the Association proposed to undertake on behalf of the Councils of Counties and County Boroughs. A summary of the scheme is set out in Appendix LVII., page 568. The Commission also approved the form of an agreement between the Councils and/ the Association, and the operative parts of that model form are set out in Appendix LVIII, page 571. All the Welsh Councils concerned, with the exception of Pembrokeshire County Council, have made arrangements with the Association whereby the Association provides dispensary treatment at its dispensaries or institutes and visiting stations and treatment in one or other of the sanatoria and hospitals specified in the scheme. The first agreement was entered into for the financial year ending 31st March, 1914, and negotiations are being conducted for the renewal of the agreements, and of the arrangements arrived at. The Acl7ninistratio7i of the ** Hobhouse Grant.'' 1526. The special grants voted by Parliament for the treatment of tuberculosis (generally known as the ** Hobhouse Grant ") amounted for the financial year ended 31st March, 1914, to £305,000 for the United Kingdom. These grants are administered in Wales by the Commission, and are calculated on the basis of 50 per cent, of the net expenditure, as ascertained by audit, incurred upon the cost of schemes by or on behalf of the Insurance Committees or the local authorities (or combinations of local authorities), as the case may be, after taking into account the sums applicable thereto out of funds under the National Insurance Act, 1911, and other receipts in connection with the schemes. Inasmuch as in the case of Wales the income from investments of the Welsh National Memorial Association is applied for the purposes of schemes under- taken by the Association on behalf of local authorities, the grant in the case of such schemes consists of (i.) one-half of the income from investments so applied, and (ii.) one-half of the net cost of the schemes after deducting such income from investments and the grant under (i.) as well as other receipts.* * For the financial year ending 31st March, 1915, the income from invest ments will include for the purposes of the grant interest calculated at 4 percent, per annum on any capital funds applied by the Association towards the provi- sion of sanatoria, &c., under approved schemes. (B254— Gp. 5) p 2 452 Wales^ 1527. The Council for the County of Pembroke has not entered into an agreement with the Association, but it has submitted to the Commission certain proposals as to which further information has been requested. 1528. The number of persons suffering from tuberculosis, other than insured persons and their dependants who have been treated by the Association, is shown in Appendix LIX., page 571. The Administration of the Capital Grant under the Finance Act, 1911. 1529. The only body which has made application to the Commis- sion for a share of the capital grant available for the erection of sana- toria and hospitals is the Welsh National Memorial Association. Ob- jections were received by the Commission to proposed sites for institutions put forward by the Association in two cases; and inquiries were held, one into the suitability of a site for a tuber- culosis hospital at Talybont, Merionethshire, and the other into the suitability of a site at Plas Llangwyfan, in the Vale of Clwyd, for the North Wales Sanatorium. In both cases the Commission approved the sites objected to subject to certain conditions. 1530. The Association had, up to 31st March, 1914, expended £59,000 of its capital on the provision and erection of institutions and equipment. The Commission, with the consent of the Treasury ^ have advanced to the Association £15,000 out of the grant available under Section 16 of the Finance Act, 1911. In making any grants to the Association the Commission lay down the following general conditions: — 1. That all institutions (sanatoria, hospitals, or dispensaries), towards the cost of which capital grants are made to the Association, shall be open to inspection by the Commission or their officers, and shall be fully available for the treat- ment of insured persons recommended for sanatorium bene- fit by Insurance Committees under Section 8 (1) (h) and Section 16 (3) of the Act of 1911, or for similar treatment recommended by County or County Borough Councils oq terms agreed with the Association, or, in default of agree- ment, as may be determined by the Commission. 2. In the event of any of such institutions ceasing to be so available for the treatment of insured persons, the institu- tions shall be surrendered to such public health authorities,, or joint committees of public health authorities, as may,, in the opinion of the Commission, reasonably desire them to be so surrendered, upon such terms as to payment and otherwise as may be agreed; or in the event of any public M health authority (or joint committee of public health authorities) desiring to withdraw either wholly or partly^ for reasons which appear to the Commission to be adequate, from participation in the proposed general scheme to be undertaken by the Association for the whole of Wales and Monmouthshire, such authority (or joint committee) shall Insurance Committees: Sanatorium Benefit. 453 be entitled, on so withdrawing, to obtain the surrender of such institution or institutions as the Commission may deem reasonable and just in the circumstances upon such terms as to payment and otherwise as may be agreed. In ascertaining such terms regard shall be had to the esti- mated amounts approved by the Commission for capital outlay on the institutions and the amounts certified by art. architect appointed by the Commission to have been pro-- perly expended thereon, but the amount of the capital - grant made by the Treasury through the Commission shall,, for this purpose, be disregarded. In default of agreement in either of the above cases the- institution shall be surrendered upon such terms as may be settled by a single arbitrator to be agreed upon by the- parties, or in default of agreement, to be appointed by the Commission, or failing such surrender, the amount of the capital grant, less such allowance as the Commission may consider equitable in view of the depreciation of the objects on which the grant has been expended, shall be repaid to the Treasury. In the event of such surrender or repayment being made within five years from the date of the making of the capital grant, no deduction shall be made in respect of depreciatiort-- in the value of the property affected. 3. The site or situation selected and arrangements for the erec-- tion of buildings, or for the adaptation, enlargement, or equipment of new or existing buildings, shall be subject tO' the approval of the Commission. 4. Such records will be kept in connection with the institutions as the Commission may from time to time require. 1531. The accommodation which is at present available under the arrangements made by the Association is : — No. of Sanatoria : Beds. Dousland Grange Sanatorium, Yelverton, Devon Penhesgyn Sanatorium, Anglesey Pontywal Sanatorium, Brecon Udal Torre Sanatorium, Yelverton, Devon ... West Wales Sanatorium, Llanyby ther 38 16 52 43 82 Hospitals : Baasaleg, Highfield Nursing Home ... ... ... ... 55 Carmarthen Infirmary ... ... ... ... ... ... 4 Carnarvon Isolation Hospital ... ... ... ... ... 28 Conway and Penmaenmawr Isolation Hospital 28 Cymla Hospital, Neath .. . ... ... ... ... ... 16 Mochdre Smallpox Hospital 7 Merthyr County Borough Isolation Hospital ... ... 33 Newport County Borough Isolation Hospital ... ... 16 Newtown, Mont., Voluntary General Infirmary 2 Ogmore Smallpox Hospital, Bridgend ... ... ... 14 Swansea County Borough Isolation Hospital ... ... 16 Wrexham Infirmary ... ... ... ... ... ... 7 (B254— Gp. 5) P 3 454 Wales. Dispensaries : Bangor, Arvonia Buildings. Barmouth, 7, Aelfor Terrace. Brecon, Honddu House, Castle Street. Cardiff, The Parade. Carmarthen, 5, Guildhall Square. Haverfordwest, Castle Square. Merthyr, Glebeland Street. Neath, 107, London Road. Newport, 4, Palmyra Place. Newtown, Mont., Memorial Institute. Pontypridd, Gelliweion House, Morgan Street. Swansea, 10, Grove Place. Wrexham, 3, Temple Row. and 73 visiting stations. There are also provisional arrangements made with institutions for the use of 120 beds which are not directly controlled by the Association. 1532. In addition, the Association has adopte'd or has under consideration plans for : — No. of Sanatoria : Beds. North Wales— Plas Llangwyfan, Denbighshire 184 South Wales — Pontywal, Brecknockshire 304 Hospitals : Bryn Seiont, Carnarvon 35 Glan Ely, Cardiff (Extensions) 70 Llangefni, Anglesey Meadowslea, Hope, Flint .. 22 .. 30 Newtown, Montgomery .. 22 Talybont, Merioneth 22 Swansea .. 50 Domiciliary Treatment. 1533. A memorandum dealing with the arrangements made under the Act of 1911 for the domiciliary treatment of tuberculous insured persons was circulated to practitioners on the panel during the year. It has been found that in a very large number of cases tuberculous insured persons show a great disinclination to make application to the Committee for sanatorium treatment, either from fear of losing their employment, or from sentimental reasons. This disinclination results in a considerable number of cases not being brought to the notice of the Tuberculosis Officers, and must seriously affect the suc- cess of the national scheme inaugurated by the Association in Wales. The Administration of Medical Benefit. Issue of New Regulations. 1534. The various difficulties encountered during the first yeai of medical benefit have been, so far as possible, met by the revised Medical Benefit Eegulations, dated 12th January, 1914. Under these Begulations Insurance Committees are relieved of the obliga- tion of allocating each individual insured person to a doctor, but they are required to make arrangements with the Panel Committees Insurance Committees : Medical Benefit. 455 for the personal assignment of such insured persons as may be in need of medical attendance and treatment. 1535. The Eegulations provide for the appointment for each In- surance Committee area of three " Service " Sub-Committees for dealing with complaints, and to those Sub-Committees certain matters stand referred for examination before they are considered by the Insurance Committee. 1536. Specific provision has been made for financing the arrange- ments for medical treatment for insured persons who are tem- porarily absent from their usual place of residence, or who are frequently moving from place to place. 1537. The numbers of doctors and of persons supplying drugs and appliances who have entered into agreements with the Insurance Committees in each area is shown in Appendix LVI. There are also 18 systems approved by the Commission and the Insurance Com- mittees under Section 15 (4) of the Act of 1911. {See paragraphs 1555 to 1559 below.) Ordinary Method of selection of Doctor. 1538. The Commission had at various times recived representa- tions urging them to reconsider the procedure for selecting a method of treatment. After the conferences referred to in paragraph 1507, the Commission, acting on similar lines to those being adopted in England and Scotland, decided upon a uniform voucher system, and accordingly arranged for the issue to every insured person entitled to medical benefit of a " medical card." This card not only serves a& a voucher in the holder's own area, but can be used when he is tem- porarily away from home and in need of medical treatment. The issue by post of the medical cards has revealed the fact that a large proportion of the members of Approved Societies remove from one area to another without the Insurance Committees concerned being notified of the fact. It is anticipated that, with the realisation by the insured person of the importance of selecting a method of treatment immediately upon removal, the difficulties which Com- mittees experience in keeping their registers will be materially reduced. Travellers* Vouchers. 1539. Insured persons who, by reason of their employment or occupation, frequently change their place of residence, are enabled to obtain their medical benefit as if they were temporary residents in each place which they visit. To such persons the Commission, acting on the recommendations received from Committees, issue travellers' vouchers, which are presented to a practitioner on. the panel wherever the holder requires medical treatment. The whole of the sum available in respect of the persons to whom such vouchers are issued is paid into a central fund, and the index slips withdrawn from the registers of the Committees. (B254— Gp. 5) P 4 456 Wales. 1540. In January, 1914, the Commission issued posters drawing the attention of migratory labourers, and other insured persons who are frequently changing their place of residence, to the arrangements, and giving instructions how to obtain travellers' vouchers. The Com- mission have had every assistance from employers in this respect. 1541. Difficulties are sometimes met in obtaining the requisite information from Approved Societies before issue of the vouchers, but the Approved Societies are frequently handicapped by the diffi- culty of tracing insured persons who have no permanent address. 1542. There were 307 travellers' vouchers issued by the Com- mission current at 31st March, 1914, and there was in addition a considerable number of applications for vouchers in hand on that date. Travellers' vouchers have been issued to navvies, commercial travellers, canvassers, insurance agents, sailors, railway servants, .actors and music-hall artistes, engineers. Ordnance Survey and Land Yaluation Officers, and to members of various other classes of workers. Mileage. 1543. The population of Wales is roughly two and a half millions, of which over a million and a half are crowded together in Glamorgan and Monmouth, while the remaining million are scattered more or less thinly over the remaining 11 Couiities. Obviously, the conditions under which medical benefit is administered differ enormously in different areas •of a country in which the distribution of the population is so un- -equal, and, where medical attendance is paid for on a capitation basis simply, medical men practising in areas characterised by «parsity of population and poor travelling facilities are at a dis- advantage as compared with practitioners working in the more ■densely populated districts. The grant-in-aid of special mileage is intended to meet this disadvantage and to provide such additional remuneration to doctors responsible for the treatment of insured persons living in these areas as will so far as possible place them in €is good a position as urban practitioners. 1544. Of the Parliamentary grant of £50,000 for Great Britain the sum of £8,000 was made available for the Insurance Committees in Wales, and the problem to which the Commission had to address themselves was the determination of an equitable basis upon which this sum should be divided among the various Counties in Wales, with due regard to the factors which in each County tend to make the administration of medical benefit more than normally difficult. 1545. At the outset, every practitioner on the panels was re- quested to furnish particulars of the insured persons accepted for treatment in respect of whom a claim against the grant could, in view of the terms of the grant, be substantiated. The response to this request was not, however, encouraging. The Commission, therefore, decided to relieve doctors of the work of furnishing the desired information for the time being, and instituted inquiries with Insurance Committees : Medical Benefit. 457 a view to ascertaining, from actual examination of doctors' lists in the Committee offices, the proportions in which the various Counties were entitled to participate in the distribution of the total grant. It was felt that if the proper allocation of the grant as between Com- mittees could be carried through, it could be left to the Committees, with the assistance of the Local Medical Committees (later, the Panel Committees) to arrange for the distribution of the grant among individual doctors on whatever basis, having regard to the local difficulties, and subject only to general conformity with the terms of the grant, they deemed most suitable. 1546. The proportion in which a Committee {i.e., a County) was entitled to participate in the grant was arrived at as follows : — The officers of the Commission were instructed to ascertain : (a) the number of insured persons on the lists of panel doctors resident more than three miles distant from the nearest panel practitioner ; . (b) the distance (disregarding the first three miles) at which each such person resides from the nearest panel practi- tioner ; (c) the amount of mileage in (h) which had to be traversed over roads and ways not open to vehicular traffic. 1547. Each County was then credited in respect of the mileage so ascertained at the rate of one unit for each mile in (h) and an addi- tional one-and-a-half units for each mile in (c). By this means a credit figure was obtained for each County indica- tive of the extent of its claim against the grant, and it was proposed to divide the amount available among the Counties accord- ing to the proportion which the credit figure of any County bore to the total of the credit figures of all the Counties. 1548. The Commission had, however, to take into consideration the fact that at the time when the inquiries detailed above were made, a large number of persons had not been accepted for treat- ment by doctors, and that the proportion of persons so unallocated to doctors differed materially in different Counties. Further, they realised that, in certain areas, the exceptionally difficult and in- accessible nature of the country rendered inequitable the strict appli- cation of the '* three miles limit " which had been imposed; that claims would undoubtedly be made against the grant in respect of persons temporarily employed in remote areas on constructional works; and that exceptional payments would have to be made to provide for insured persons resident upon islands not connected by regular means of communication with the mainland. 1549. A provisional allocation of nine-sixteenths of the grant was therefore made on the basis of the credit figures ascertained in the manner detailed above, and Committees were requested, in submit- ting their schemes for the division among their doctors of the amounts so allotted, to furnish the Commission with particulars of s:u:h special difficulties in their areas as entitled them to make a claim against the balance of the grant. 458 Wales. 1550. Schemes for the distribution of the County grants have not yet in all cases been submitted to the Commission for approval, but, speaking generally, Committees show no disposition to adopt a basis of distribution among their doctors radically different from that em- ployed in determining the distribution among Committees. 1551. The diversity of the conditions under which medical attend- ance has to be provided in Wales, due to the geographical and indus- trial features of the country (and in some areas to the language question) render a just appreciation of the factors involved in the different Committee areas a matter of extreme difficulty, and the Commission have therefore been careful to point out to Committees that the present method of distribution is experimental and subject to reconsideration in the light of a fuller acquaintance with the conditions obtaining when grants for future years have to be allotted. Chemists* Accounts. 1552. The majority of the Insurance Committees have arranged for the chemists' accounts to be checked by the Pharmaceutical Standing Committee for England and Wales. In a few areas there were apparent deficiences in the Drug Fund for the medical year 1913, and these Committees are considering what steps can be taken for future years to reduce the total accounts to the limits of the sums avail- able. Those Committees which are undertaking the checking of accounts in their own offices hope to be able, with the assistance of the Pharmaceutical Committees, to make suggestions which will considerably reduce the aggregate cost of prescriptions without reducing the efficiency of the service. 1553. The Commission have approved of the inclusion in the drug tariff agreed upon between Insurance Committees and persons supplying drugs and appliances of the following general rules as to proprietary articles and galenicals: — (a) Secret remedies should not be paid for by X^surance Com- mittees, as they cannot be considered " proper and suffici- ent drugs and medicines." (6) No proprietary remedies of known composition that can be prescribed under their appropriate non-proprietary designa- tion should be paid for by the Insurance Committees. (c) Where some particular manufacturer's proprietary medicine of known composition is prescribed, it may be supplied by the chemist, but subject to the right of the Panel Com- mittee to declare the prescription extravagant and to deduct the extra cost from the practitioner and credit it to the Drug Fund in accordance with the procedure indicated in Article 40 of the Medical Benefit Regulations, 1913. Certification of Illness. 1554. During the course of the year the Commission have received representations from Approved Societies as to alleged laxity on the Insurance Committees : Medical Benefit. . 469 part of practitioners in giving certificates in support of claims for payment or sickness benefi.t. They have also received representations from practitioners of alleged unreasonable demands made upon them by Approved Societies with regard to certificates. They accord- ingly took the opportunity of discussing the whole subject of certifi- cation with the Panel Committees in the early months of 1914, and in a Memorandum issued to practitioners in April, 1914, they laid down the following considerations for practitioners undertaking the responsible duty of signing certificates of incapacity for work: — ** (a) Certificates should be strictly limited to the actual dura- " tion of incapacity, and should be so worded as to make it ** impracticable for the insured person to claim sickness ** benefit for even a day beyond the actual period of in- ** capacity. ** (6) The cause of the incapacity should be stated with the " greatest possible precision, as far as the personal know- ** ledge and professional skill of the practitioner permits. ** This is obviously of great importance when the possi- ** bility of the condition being due to accident or to mis- ** conduct has to be considered. When specific disease or ** bodily disablement is due to traumatism or to venereal ** disease the certificate should be so worded that these " facts are not concealed. It will then be open to the» ** Approved Society to make such inquiries from the in« " sured person as they may think desirable, with the ** object of determining the member's eligibility for sick- **'ness benefit, in accordance with their rules and the ** National Insurance Acts. ** (c) The date of the certificate should always be that of the- ** day on which it is signed, and should under no circum- ** stances imply that the patient has been seen or exam- ** ined when he has not actually been seen. ** In respect of malingering, the Commissioners are of ** opinion that practitioners should, without fear or favour, ** resist all attempts to secure sickness benefit to which the? ** claimants are not entitled." Approved Institutions. 1555. A list of the systems and institutions providing medical attendance and approved by the Insurance Committees and the Commission under Section 15 (4) of the Act of 1911 is given in Appendix LX. Owing to difficulties which had arisen in some districts in the Counties of Glamorgan and Monmouth, the Com- mission convened a Conference on 8th July, 1913, consisting of repre- sentatives of the Insurance Committees concerned, of the Colliery Surgeons* Association, and of the medical systems and insured per- sons affected. The findings of that Conference were arrived at unanimously, and were to the effect that " systems '* approved under Section 15 (4) of the Act of 1911 should have in each case a 460 Wales. Committee of Management representative of and elected annually by the contributing members, such Committee to include representa- tives of the medical men attached to the system. 1556. The medical members of the Conference agreed that where a salaried service was desired, and the amounts of the salaries and the collateral and general conditions of the service provided were satisfactory, no objection would be taken by the doctors to such a service. 1557. Various conditions relating to the auditing and publication of the accounts, banking arrangements, and the administrative ex- penses were also settled, and these have been incorporated in the Commission's model rules for approved institutions and in the con- ditions of approval. 1558. It was further agreed that, for the purpose of dealing with all differences that might arise, a Conciliation Board be constituted consisting of representatives of the doctors and of the workmen's organisations in equal numbers, with an independent chairman, and that the decisions of this Board should be accepted in every case as final. Pending the formation of the Conciliation Board, the repre- sentatives of the doctors' and workmen's organisations present at the conference undertook to act as a temporary emergency committee to deal with existing differences, on application being made to them through the Commission from any district. 1559. The medical bodies concei»ned with the establishment of the permanent Conciliation Board have not as yet been able to report to the Commission their decision in the matter, but the temporary conciliation committee has been once convened to consider the diffi- culties in connection with two medical systems. The Insurance of Deposit Contributors. Special Inquiry. 1560. In October, 1913, it was decided to insititute an inquiry on the lines of the following questions: — (1) Has the deposit contributor ever applied to become a member of an Approved Society? ^2) If rejected, on what ground? {3) If no application made, the reason why? .(4) Does the deposit contributor know the difference between the relative advantages of the two systems? ^5) Has any officer of an Approved Society ever tried to induce the deposit contributor to join an Approved Society? (6) Has the deposit contributor any intention of joining an Approved Society 1561. The services of the Outdoor Staff were utilised to obtain the required information. Strict instructions were issued that in calling upon contributors, although the opportunity of explaining the ;advantages of membership of an Approved Society might be taken, nothing should be done to induce them to change their status. Insurance Committees : Deposit Contributors. 461 Speaking generally, the information asked for was readily given by the persons called upon. 1562. A full analysis of the results of the inquiry is given in Appendix LXVII., page 578. A brief Statement as to the number falling into the four different classes into which deposit contributors naturally range themselves is given herewith : — Class. Men. Women. Total. No. % No. % No. % Persons who are ignorant or in- different. Persons unwilling to join an Ap- proved Society. Persons in intermittent employ- ment or about to emigrate or to cease to be insured. Persons unable to join an Approved Society on account of ill-health. 343 64 48 36 69-9 13 9-8 7-3 120 29 7 1 76-4 18-5 4-5 •6 463 93 55 37 71-4 14-4 8-5 6-7 1563. It should, however, be added that a number of the persons who had been unable to join one Society were subsequently success- ful in their application for membership of another Society. 1564. A further analysis of deposit contributors in respect of whom the inquiry was made has been prepared in regard to their age at the date of entry into insurance, and their occupations, and is given in Appendix LXVIII., page 579. As the names of the con- tributors were taken at haphazard, they may be regarded as forming a representative group of the deposit contributors in Wales. Special Difficulties. 1565. The chief difficulties in dealing with deposit contributors have arisen — (a) in obtaining the necessary particulars to establish, as de- posit contributors, the persons who had surrendered cards at Post Offices or sent them direct to the Commission ; (b) by reason of the lack of variety in surnames in Wales, in conjunction with the migratory character of a large number of deposit contributors ; (c) in consequence of the failure of certain Approved Societies to notify the Commission and the Insurance Committees of the acceptance of a deposit contributor into membership. 1566. The action taken to meet or to minimise these difficulties has been as follows: — (a) An alteration of procedure for dealing with surrendered 462 Wales, cards whereby every contributor surrendering a card at a Post Office who stated he was not an Approved Society member was provided with a special envelope for the trans- mission of his card direct to the Commission. On the in- ... ;. ,.r side of the flap of this envelope certain questions were, printed, the replies to which assisted in — (1) tracing previous relative cards, or (2) establishing new entrants. (h) The issue of cards to all established deposit contributors bearing their cipher and number with an envelope for the return of the expired card. (c) The issue of a circular to all Approved Societies suggesting a review of the names of all persons who had been accepted into membership after the close of the first quarter, so that immediate application for transfer from the Deposit Contri- butors Fund might be made wherever necessary. Incidentally, the issue of cards mentioned in (b) disclosed the fact that nearly 2,400 deposit contributors had joined Approved Societies, although no notification had been received by the Commission. Numbers of Contributions paid by Deposit Contributors. 1567. The Table in Appendix LXIII., page 574, shows the contri- butions paid by deposit contributors during the first four quarters, so far as they have been scheduled. The high average of the number of contributions paid each quarter is particularly noteworthy. Charges for Medical and Sanatorium Benefits and for Administration Expenses. 1568. The figures in the same Table show the total of the amounts debited against the accounts of the same contributors. The ad- minstration expenses and sanatorium benefit charges for the first two quarters are based on the Administration Expenses Order (Wales), 1912, and the Sanatorium Benefit Order (Wales), 1912, re- spectively. The charges for the year 1913 were fixed at Is. Sd. and Is. 9d. respectively by two fresh Orders made early in that year, whilst a charge of 6s. for medical benefit was authorised by all the Insurance Committees. The total charge for 1913 thus became 9s., of which 7s. (6s. 9d. in the case of a woman) was debited to the account, the balance being met by the State, except in the case of aliens, where the full charge was made. The administration charge for persons of the age of 65 and over was fixed at Is. 6d. 1569. As, however, medical tickets had been issued upon their establishment to contributors who had surrendered a first quarter's card, and it was found that large numbers had not 7s. (6s. 9d. in the case of a woman) to meet the yearly charge which was made in January, it became necessary to suspend such contributors from medical and sanatorium benefit for a period until the state of their accounts once more was such as would cover the charge for a further quarter. Insurance Committees : Deposit Contributors. 403 1570. To regularise this procedure, the Deposit Contributor's Benefits Order (1913) was made, which also gave a title to benefits to second quarter entrants as from 1st May, 1913, if their credit allowed, and empowered the Commission to recover in a subsequent quarter the balance of the charge due for the period ending 30th April, 1913, where the full charge for that period could not be made in January. 1571. As many contributors who had surrendered cards since the first quarter were not established owing to various causes until after 1st May, some not until after 15th July, and some not until after 12th October, 1913, it was considered equitable to charge them only with the proportion of the full charge sufficient to cover them from the beginning of the benefit period in which they were estab- lished to the end of that benefit period or to the end of the year, according to the state of the individual account. Sickness and Maternity Benefit Claims. 1572. Tables I. and II. of Appendix LXVI., page 576, show the number of sickness and maternity benefit claims paid, the amounts paid during each quarter, together with the average sum paid per claim. Attention should, perhaps, be called to the fact that the number of claims for benefit is considerably below expectation. Payments to (a) Married Women suspended from Ordinary Benefits, (h) Emigrants, and (c) the Representatives of deceased Deposit Contributors. 1573. Payments to (a) married women suspended from ordinary benefits, (b) emigrants, and (c) the representatives of deceased deposit contributors are shown in Table III. of Appendix LXVI., page 577. Variation in Numbers. 1574. The Table in Appendix LXV., page 575, shows the position in regard to — (1) the net number of cards received, i.e., after the return of cards belonging to members of Approved Societies which had been wrongly surrendered at Post Offices, and the transmission to other Commissions of cards bearing ad- dresses outside Wales; (2) the number of cards in which accounts have been opened, or which have been credited to accounts ; and (3) the number of cards in respect of which no account has yet been opened. 1575. A further Table in Appendix LXIV., page 575, shows the number of contributors who entered into insurance each quarter. 464 Wales. Transfers to Approved Societies. 1576. The number of applications for the transfer of contributors sent in by Approved Socities up to and including 31st March, 1914,, was 11,028, in regard to which the position was then as follows: — 1 Established. Unestablished. No Trace. Total. Total dealt with 4,680 911 1,235 6,826 To be dealt with 1,560 663 1,979 4,202 International Transfers. 1577. Arrangements have been made for the transfer of the accounts of deposit contributors upon their removal to England, Scotland, or Ireland. In such cases the index slip is recalled from the Insurance Committee ; the doctor on whose list the name of the contributor appears is advised of the removal ; the contribution book is recalled for cancellation ; and the Commission into whose juris- diction the contributor moves, issues a fresh index slip and a fresh book. QUESTIONS AS TO LIABILITY TO INSURANCE AND PARTICULAR CLASSES OF INSURED PERSONS. Exempt Persons. 1578. Now that the National Insurance Act has been in force for nearly two years, the general public are undoubtedly more ac- quainted with its provisions, and consequently the work of dealing with the question of exemptions is greatly facilitated. The chief difficulty at the commencement appeared to be that persons claiming exemption were doing so under a misapprehension. Many certifi- cates were issued to persons who did not take advantage of the pro- visions of Section 4 (4) of the Act, but continued as ordinary em- ployed contributors, whilst others who held certificates regarded themselves as outside the Act altogether. The circulation of ex- planatory memoranda has now made clear to all exempt persons their position under the Act. 1579. It will be seen from the Table in Appendix LXIX., page 580, that after a year's experience a considerable number of exempt persons have deemed it advisable to become employed contributors, and thus entitled to full benefits under the Act. 1580. The Eegulations made governing the administration of benefits for exempt persons, in accordance with the provisions of Section 4 (4) of the Act of 1911 and Section 9 of the Act of 1913, provide that no exempt person shall be entitled to benefit Exempt Persons. 465 until the Commission have been furnished with a statement as to age, sex, place of birth, nationality, and the number of contributions paid in respect of the claimant. A form requesting this information was accordingly sent out to all exempt persons holding certificates from the Commission on 4th December, 1913, with a request that the same should be returned, duly completed,, as soon as possible. The Eegulations entitled exempt persons with at least 13 contributions to their credit on 13th October, 1913, to medical and sanatorium benefits on and from 12th January, 1914. Exempt persons not coming within this category are required to send the necessary information to the Commission when 20 contribu- tions have been paid in respect of them. They are then entitled to benefit six weeks from the date when the application is received. If such notice is not given the exempt person becomes entitled to benefit from the commencement of the benefit period next after the end of the contribution period in which the twentieth contribution has been paid. The " contribution " periods are those for which contribu- tion cards are issued; the '* benefit " periods are from 1st April to 30th September (both dates inclusive), and from 1st October to 31st March (both dates inclusive). 1581. Early in December steps were taken to ascertain the names- and addresses of the exempt persons who had at least 13 contribu- tions to their credit on 13th October, 1913, and as the forms showing the age, &c., were returned, red index slips showing the name, address, &c., of the exempt persons were prepared. These index slips were despatched at weekly intervals to the appropriate Insur- ance Committees in order that they might be added to the register of persons entitled to medical and sanatorium benefits, and as authority for the issue of medical cards. The number of slips issued up to date is 1,100, and the number of exempt persons who had the requisite number of contributions to their credit to entitle them to benefit, but who did not furnish the Commission with the necessary information as to their age, &c., was 258. A letter was sent to each of these persons towards the end of March enclosing a duplicate form and requesting its immediate return, with the result that this number has now been reduced to 176. 1582. It was anticipated that the effect of Section 5 of the Act of 1913 would be that the number of persons holding certificates of exemption would soon be greatly increased. It is interesting to note that the number of persons holding certificates of exemption from the Commission on 31st March, 1914, is less than that on 31st March, 1913, by 288. 1583. Statistics with reference to payment of contributions in respect of exempt persons will be found in Appendix LXX., page 580. Questions under Section 66 of the Act of 1911. 1584. Since the issue of the previous Eeport the Commission have- issued 14 decisions in accordance with the Eegulations under Section 66 of the Act of 1911. Of these 14 decisions 13 were upon questions- 466 Wales. submitted as to whether the employment was employment within the meaning of the Act, while the remaining one was as to the rates of contribution payable. 1585. Among the employments held to be insurable were those as a stone-breaker, second engineer in the mercantile marine, grave- digger employed by a burial board, caretaker, bill-distributor, and a terrier-man employed by a master of foxhounds. The following, among others, were held not to be employed under contract of service: — A boat builder, a hirer of a vehicle for the purpose of collecting rags and bones, a hauling contractor for a colliery com- pany, and a Minister of Religion. Application of the Provisions of Section -i? of the Act of 1911. 1586. At the date of the previous Report 115 employers had given notice of their intention to avail themselves of the provisions of Section 47 of the Act of 1911. Since that date notices have been received from 26 other employers in respect of persons engaged prin- cipally in the following classes of employment: — Commissionaires or watchmen, commercial travellers, gardeners, foremen or mana- gers, housekeepers. 1587. Section 47 (10) provides that an employer who has given the prescribed notice may, by giving three months' previous notice, withdraw his notice as from the commencement of the next calendar year. Five notices of withdrawal have been received from employers, such notices operating as from the 1st January, 1914. Applications have been received from two employers for Special Orders under the provisions of Section 47 (7). The Commission having ascertained the views of the persons employed have made Special Orders accordingly. Casual Labour. 1588. Under the provisions of Section 99 of the Act of 1911, an arrangement has been in operation since the commencement of the Act at the South Wales ports whereby the Board of Trade Labour Exchanges undertake, on behalf of the em- ployers, the custody, stamping, distribution and exchanging of the contribution cards of all employees connected with the ship-repairing industry. The scheme embraces 49 employers and approximately 10,000 workmen of all trades. 1589. The arrangement synchronised with the coming into opera- tion of the Act. All the workmen were registered at the Labour Exchanges established at Bute Docks, Cardiff, Barry, Newport, Swansea, and Port Talbot, and received in exchange for health cards and unemployment books numbered metal tallies, bearing the symbols " E " and " W." The ** E " tally is tendered to and retained by the employer during the period of employment, and the ** W " tally remains in the custody of the workman. In view of Casual Labour. 467 the interchange of labour between the ports the tallies also bear a distinctive letter showing the issuing Exchange. When a work- man possessing a Cardiff tally is employed at Barry, the employers insert in their returns the distinctive letter of Cardiff in order to facilitate the adjustment of stamping the cards, which are retained at the issuing Exchange. 1590. The accounting system provides effective safeguards. When the scheme came into force all the employers deposited with the Board of Trade a sum equivalent to two weeks' full contributions based on the estimated maximum number of workpeople employed. This sum is retained by the Board of Trade as a stationary balance, and the employers are rendered weekly accounts of the value of the stamps actually used. These weekly accounts are payable within three days of the date of rendering. 1591. Owing to the intermittent nature of employment and the interchange of labour between the respective ship-repairing yards and general dock work, a voucher system is adopted in regard to workpeople who cease their engagement with firms within the calendar week, for the adjustment of health insurance contributions. These vouchers are issued to employers in book form, serially num- bered, and a record kept of all books issued at the Labour Exchange. The. vouchers are duly stamped with the date of availability, the workman's name and tally number inserted, and if presented to an employer within the scheme this is indicated in the appropriate column of the returns rendered to the Labour Exchange. 1592. If after employment within the calendar week in the scheme, the workman is employed by a firm having no special arrangement, the voucher is presented at the Labour Exchange and the health card stamped up to date and handed to the workman. When a workman enters the scheme and has his card stamped for the current week, he presents it upon registration at the Labour Exchange, and a Board of Trade official issues a voucher as evidence that no further contribution is payable for that week. The voucher is an effective safeguard against over-deductions. 1593. Employers have agreed to pool their contributions under the scheme. The assessment is arrived at from the weekly returns rendered by the employers, which consist of a carbon copy of the pay sheets showing the actual days worked by each employee, but not the wages. The returns are forwarded to the Exchange imme- diately the pay sheets are completed, and the Labour Exchange renders an account of the employers' liability to the fund within a period of three days. 1594. In addition to the ship-repairers' scheme, similar arrange- ments for stamping are in force with firms engaged upon works of construction at Newport, Pontypool, and Pontypridd. 1595. A different feature exists at the two large waterworks at Merthyr. The custody and stamping of the cards are not under- taken, but all the labour is recruited through the Labour Exchange, 468 Wales. and all applicants for work have to be possessed of health insurance cards and unemployment insurance books before being engaged. YI.— THE WORK OF THE OUTDOOR STAFF OF THE COMMISSION. 1596. The lines laid down for the work of the Outdoor Staff in the summer of 1912 were maintained throughout last year with such modifications as experience has proved to be necessary. The number of Outdoor Officers consists of one Chief Inspector, two Inspectors, nine Assistant Inspectors (including three women), and twelve Health Insurance Officers (including one woman). The work of card inspection has been performed by the Health Insurance Officers, working in their respective districts. During the year these officers visited 25,600 employers of labour, employing 247,300 men and 24,700 women. The Officers actually inspected the contribution cards of 115,000 imured persons, and made reports to the Chief Inspector in all cases where the Act had been in any way contravened. The work done by these Officers has been of a useful kind, not only to the Commission, but also to the employers and employees, and it may be stated that the relation- ship between the Outdoor Officers and the general public has been of a very satisfactory nature. The more difficult work of outdoor inspection and inquiry has been entrusted to the Inspectors and Assistant Inspectors, who follow up all inquiries which Health In- surance Officers are unable to complete. The members of the Out- door Staff were employed throughout the year on inquiries set on foot by the other branches of the Commission, and the results of these investigations are given in the appropriate sections of this Report. Some particulars of inquiries and duties undertaken which are not referred to elsewhere in the Report are set forth in the following paragraphs. The Position in Rural Areas. 1597. In the industrial districts the activities of the Outdoor Officers, in so far as card inspection is concerned, are mainly directed to seeing that the Regulations in their general import are being observed; that the contribution cards are stampe.d at the proper times: and that they are delivered up to insured persons without delay. In the agricultural districts, however, a closer supervision was necessary, and systematic inspections of the cards of agricul- tural employees were carried out throughout the year. Special Investigation in Cardiganshire. 1598. In order to test whether there was any considerable degree of non-insurance in a typically agricultural district, it was decided to Work of the Outdoor Staff. 469 undertake a special investigation in the County of Cardigan. It had been reported to the Commission that a large number of persons in that County were not insured, and these reports were apparently borne out to a certain extent, inasmuch as the number of insured per- sons returned as resident in the County was considerably less than had been expected. As a result of the enquiries, however, the Commission was satisfied that practically all regular agricultural workers have been brought within the scheme of National Health Insurance. Special attention was also paid to the question of casual workers on farms. Inquiry at Workhouses. 1599. With a view to ascertaining the degree to which the casual and vagrant classes perambulating the country and seeking shelter of the workhouses were being insured, the Officers of the Outdoor Staff were instructed during the autumn to make inquiries at the workhouses throughout Wales. The Officers were assisted in their labours by the masters and officers of the workhouses, who very kindly undertook to keep the necessary records. In some cases the matter was definitely mentioned to the Boards of Guardians. The Commission very much appreciated the assistance thus rendered. Some of the results of the inquiry are here given. 1600. In the month of August, at the Cardiff Workhouse, 569 men were admitted, of whom 296 had cards, whilst 273 had none. The bulk of the cards had but few stamps on them, as would necessarily be the case if they belonged to the quarter beginning on the 14th July, but towards the end of the month the number showing five, six and seven stamps increased. 1601. In September, out of 519 men admitted to the Cardiff Workhouse, 289 possessed cards ; of these 30 had no stamps affixed, but a gratifying circumstance was that the majority contained from four to nine stamps, whilst 23 had 10, 11 or 12 stamps; those who were members of Approved Societies numbered 106 out of the 289. The results in October were somewhat similar, and they showed that as a matter of fact the vagrant class are careful to obtain new cards at the termination of the insurance periods. 1602. In Glamorganshire (excluding Cardiff and Swansea), of 1,288 persons admitted to the workhouses in September, 1913, 793 persons possessed cards, the average number of stamps per card being 4*9 out of a possible 11. Two hundred and seventeen of the persons were members of Approved Societies. 1603. In Carmarthenshire, out of 1,116 persons received in the workhouses in November, 1913, 562 had cards, which contained 1*9 stamps out of a possible seven. Two hundred and two of the men were members of Approved Societies. 1604. In Cardigan, Pembroke, and Eadnor, for periods of one month in the case of the first two and two months in the last, 376, 322 and 280 vagrants respectively were admitted into the work- 470 Wales. houses, and of these 240, 90 and 97 of the men had cards. Out of a possible eight, eight, and seven, the average number of stamps per card worked out at 3, 3'2, and 3' 7 respectively. 1605. The particulars relating to the other Counties and Boroughs of South Wales are very similar in their general characteristics. 1606. In North Wales, in the three Counties of Montgomery, Denbigh and Flint, particulars were taken with respect to the 10 unions, and the following figures relate to a period of three days (17th— 19th November). Of 194 men admitted, 68 had cards, 16 of the men being members of Approved Societies. 1607. In the remaining Counties of North Wales (Anglesey, Car- narvon, and Merioneth) the total number of persons admitted into the workhouses of the 10 unions over a period of one month was 713, of whom only 149 had insurance cards, and though the insurance quarter was well advanced before the records were made, 41 of the cards contained no stamps. The great majority of the persons concerned were deposit contributors. Barrowmen. 1608. The question of the insurance of commercial travellers* barrowmen has been constantly engaging the attention of the Out- door Staff, and in all the principal towns the local barrowmen are now fairly well-known to the Health Insurance Officers, who have lists of the names and addresses of the men. The practice has been to visit the barrowmen whilst engaged in their work in the streets fairly early in the week, and in the event of their not being insured at the end of the day the Officers have usually arranged to obtain particulars on the next day with a view to reporting the matter to the Commission. If the commercial traveller con- cerned has declined to stamp the card the Commission thereupon have sent a letter to his employers, and in all cases the cards are returned duly stamped. As a result of these systematic inspections, this part of the work 'is in a much more satisfactory condition than previously. The question has been complicated in some measure by the fact that many commercial travellers are in the habit of giving a gratuity to barrowmen over and above the actual amount of the daily wage, and as in some cases the travellers have stipulated that the gratuity was to cover the cost of insurance, some difficulty has been occasioned by the barrowman taking the whole gratuity for himself and omitting to stamp his card. Sandwichmen. 1609. The Health Insurance Officers gave attention throughout the year to the insurance of sandwichmen engaged at football matches and elsewhere, and, generally speaking, the position with respect to these men may be stated to be satisfactory. Work of the Outdoor Staff. All InspecUons at Theatres, &c. 1610. A great deal of attention was given to the inspection of cards at theatres, music-halls, cinemas, &c. The permanent workers at these places were generally found to be properly insured, but the temporary employees at theatres were either local super- numeraries engaged for brief periods, or members of touring com- panies making short visits of a week or so, and in these cases it was frequently found that the persons concerned were not insured. In- spections in the larger towns of Cardiff, Swansea, and Newport have been made at the beginning of almost every week, and the position of many persons previously uninsured has been regularised. Some of the questions which presented difficulties with this class of em- ployees related to remuneration. Many performers in places of amusement enter into contracts of varying rates depending upon the season of the year, length of service, &c., and in some cases the rate of remuneration would exceed £160 for a portion of the period contracted for. School Cleaners. 1611. Inquiries were made of all Education Authorities through- out Wales with respect to the insurance of school cleaners. In many cases difficulty was experienced in fixing the rate of remunera- tion of the cleaners, but this was eventually surmounted with the aid of the Outdoor Officers, and it is gratifying to be able to state that all the cleaners concerned have now been properly insured. Boatmen and Riggers, 1612. Some difficulty was again experienced during the year by reason of some of the large shipowners neglecting to instruct their shipping agents to effect the insurance of men engaged as boatmen for the berthing of steamers in entering the docks. The Outdoor Officers have kept well in touch with the men concerned, and in all cases where complaints have been made that contributions were not paid the usual procedure has been followed with satisfactory results. Sett-maker Apprentices at Quarries. 1613. Owing to some misapprehension it was discovered that ap- prenticed sett-makers at some of the quarries in North Wales had not been insured. An Inspector was instructed to visit all the quarries in North Wales, as a result of which it was found that all the apprentices concerned were ultimately insured by the principal employers. 472 Wales. Outworkers. 1614. The special inquiry with regard to the insurance of tailoi outworkers was completed in the early months of the year. Lists of outworkers registered with the Medical Ofi&cers of Health for the County Boroughs of Cardiff, Swansea, Newport, and Merthyr Tydfil were obtained, and all the employers and employees were visited and cards inspected. It was found that for the most part regularly em- ployed outworkers were duly insured, but with occasional workers a number of cases of non-insurance were discovered. A considerable amount of misunderstanding had arisen as to the inclusion of married women. The provisions of the Special Order, which removed into the insurable class the previously excepted class of outworkers who were the wives of insured persons, and were not wholly or mainly dependent for their livelihood on their earnings in their employment, were very little known, and very few of these workers were, in consequence, insured. The number of employers visited in the four County Boroughs was 122, and the number of outworkers em- ployed by these employers was 180 men and 187 women. Few outworkers were discovered in the country districts outside the County Boroughs mentioned. Practically all the outworkers had been insured under the ordinary method, applications to use the unit method having been very few. 1615. Eeluctance is felt by employed persons in making use of rotation books owing to the fact that they disclose the names of their other employers, especially when work of a lower grade is undertaken occasionally. DifiQculties are sometimes experienced where outworkers are employed by a large number of firms, but they yield readily to treatment, employers as a rule being quite willing to meet their obligations under the Act.^ An interesting instance of an outworker employed by a large number of firms was the case of a tailor who, since the beginning of the Act, had been employed by 25 employers. As a result of inquiry, the appropriate shares of contributions were duly paid. 1616. After practically every tailor employing outworkers had been visited, a larger inquiry relating to boot-repairer outworkers was instituted later in the year. This is still being prosecuted. It is found in a large number of cases that boot-repairer outworkers have not been insured since the commencement of the Act. As they are generally employed by a considerable number of employers, and as, in many instances, no records of the employment are kept, the question is often a difficult one in which to bring about a satis- factory settlement. 1617. One result of the Act apparently has been to decasualise labour, more especially among the outworkers engaged in boot- repairing. Several of the large firms with branches in various towns who had previously sent their repairs to some of the smaller boot- makers and repairers have now established repairing depots at various centres so as to avoid the necessity of the employment of outworkers. Work of the Outdoor Staff. 473 Seasonal Vocations. 1618. Constant attention was given by members of the Outdoor Staff during the year to persons engaged in seasonal vocations, including persons engaged temporarily for the Christmas toy and fancy trade, and persons employed in the summer at the seaside and health resorts at hotels, lodging houses, and fancy shops. Assistance to Shipowners. 1619. The Officers of the Outdoor Staff have been employed to some extent in assisting shipowners in filling up the forms necessary in respect of persons for whom only the employer's contributions are payable, where the employed persons are not domiciled nor have any place of residence in the United Kingdom. Nursing. 1620. The Women Officers of the Outdoor Staff have kept in touch with the efforts made by various organisations to provide maternity and sick nursing. In the rural districts the Officers have found that there is still a great need for competent nurses, though the various Societies that have come into being during the last few years are making strong endeavours to overtake the requirements. Employers using Cards for ulterior purposes. 1621. A few complaints have been made that in cases of dis- agreement between an employer and his servants the former endeavours to use the card as a lever for exercising pressure upon the employed person, and it is possible that inconvenience can be occa- sioned to an employed person by such action. The Commission always take notice of these complaints through personal visits of the inspectorate or by correspondence. Prosecutions. 1622. The number of prosecutions during the year (13) was not large, considering the large number of employers throughout the country. The prosecutions undertaken related to contraventions by employers, and were in all cases successful. During the year two prosecutions were instituted by the Commission under Section 69 of the Act of 1911. One was for making a false statement or repre- sentation for the purpose of obtaining benefit, and the other for making a false representation and committing forgery for the purpose of obtaining benefit. Convictions were obtained in each case. Compliance with the Act. 1623. Organised opposition to the Act or deliberate evasion of its provisions has practically disappeared in Wales. This is not to 474 Wales. say, however, that reports of non-compliance with the provisions of the Act are not frequent. These are still being received from many- parts of the country, but they do not apparently arise from deliberate intention to evade the obligations placed upon employers by the Act, but rather from ignorance, or personal disagreement between employer and employed, arising from causes not connected with Insurance. T. J. Hughes, Chairman of the National Health Insurance Commission (Wales). T. Jones, Secretary. June, 1914. Appendices. — Joint Committee, 475 APPENDICES TO PART II. NATIONAL HEALTH INSURANCE JOINT COMMITTEE. PAGE. I. Statement showing the dates on which the various Sections of the National Insurance Act, 1913, came into operation, otherwise than on the 1st September, 1913 476 II. Membership of the Medical Research Committee and the Advisory Council for Research ... ... ... ... ... ... ... 477 III. Return as to the administration of sanatorium benefit from 15th July, 1912, to 11th January, 1914 479 IV. Return as to the administration of sanatorium benefit for the twelve months from 15th January, 1913, to 11th January, 1914 484 V. Report of the Actuarial Advisory Committee on the basis for the calculation of transfer values 488 VI. Tables showing the results of an investigation made into the experience of 26,015 established deposit contributors in London, of 51,528 established deposit contributors in England, out- side London, and of all established deposit contributors in Wales, Scotland, and Ireland 491 476 Appendices. — Joint Committee. APPENDIX I. Statement showing the Dates on which the various Sections of the National Insurance Act, 1913, came into operation^ otherwise than on the 1st September, 1913. Provisions of Act. Subject Matter. Date of coming into Operation. Section 1, Sub- section (2). Section 3, Sub- section (1). Section 3, Sub- section (2). Section 6 Section 7 Section 8 Section 9 Section 10, Sub- section (2). Section 12 Section 13 Section 14, Sub- section (1), Section 14, Sub- section (2). Section 14, Sub- section (3). Section 15, Sub- section (1). Section 15, Sub- section (2). Section 16 Application of additional sums con- I tributed out of moneys provided ' by Parliament towards payment of medical attendance and treat- ment of certain lion-insured persons. Abolition of reduction of benefits in certain cases. Extension of Part I. of principal Act to persons aged 65 and upwards at date of entry into insurance. Employment under local or public authority, to be deemed employ- ment within meaning of principal Act. Redemption of arrears of contribu-^ tions. Calculation of arrears Benefits of exempt persons ... Extension of medical attendance and treatment to certain persons not entitled under principal Act to medical benefit. Sickness benefit, provisions as to illnesses deemed to be continuous. Commencement of sickness benefit... Maternity benefit, " the mother's benefit." Maternity benefit ; further amend- ment of Section 18 (1) of princi- pal Act. Additional maternity benefit in lieu of sickness or disablement benefit for four weeks after con- finement. (Employed married women). Sickness, disablement and maternity benefits in the case of inmates of hospitals, &c. Maternity benefit in the case of inmates of hospitals, &c. Provisions as to Societies having members in more than one part of the United Kingdom. 12th January, 1914. 13th October, 1913. 13th October, 1913, except for medical and sanatorium benefits for which the date is 12th January, 1914. 1st October, 1913. 12th January, 1914. 12th January, 1914. 12th January, 1914. 12th January, 1914. 13th October, 1913. 13th October, 1913. 12th January, 1914. 13th October, 1913. 12th January, 1914. 13th October, 1913. 12th January, 1914. 13th October, 1913. Appendices. — Joint Committee. 477 Provisions of Act. Subject Matter. Date of coming into Operation. Section 20, Sub- section (1). Section 20, Sub- section (2). Section 21 Section 22 Section 32 Section 33 Section 43, Sub- section (4) and Third Schedule to the extent shown in second column. Full benefits for insured woman of British nationality married to an alien. Increase of maternity benefit of wife of insured alien, if of British nationality before her marriage. Special provision for aliens Extension of Section 46 of princi- pal Act to warrant officers of marines ; meaning of " soldier." Consultation with practitioners who have entered into agreements with Insurance Committees-Panel Com- mittees. Pharmaceutical Committees Eepeal of certain provisions of principal Act, namely : Sub-section (4) of Section 1 Paragraph (a) of Sub-section (4) of Section 4. Sub-section (5) of Section 8, the words ("and at least fifty weekly contributions have been paid "). Sub-section (3) of Section 9 Proviso (i) of Sub-section (2) of Section 12. ^ub- section (3) of Section 45 Section 49 Table C in Part I. of the Fourth Schedule. Sub-section (6) of Section 10 13th October, 1913. 12th January, 1914> 13th October, 1913. 6th October, 1913. 13th October, 1913. 13th October,. 1913. ^13th October, 1913. 12th January, 1914. APPENDIX II. Membership of the Medical Research Committee and the Advisory Council for Research. MEDICAL KESEARCH COMMITTEE. The Right Hon. Lord Moulton of Bank, LL,D., F.RS. (Chairman). Christopher Addison, M.D., M.P. Waldorf Astor, M.P. Sir T. Clifford Allbutt, K.C.B., M.D., F.R.C.P., F.R.S., Regius Professor of Physic, University of Cambridge. Charles John Bond, F.R.C.S., Senior Honorary Surgeon, Leicester Infirmary. William Bulloch, M.D., F.R.S., Bacteriologist to the London Hospital and Professor of Bacteriology in the University of London. Matthew Hay, M.D., LL.D., Professor of Forensic Medicine and Public Healthy Aberdeen University. Frederick Gowland Hopkins, M.B., D.Sc, F.R.S., Reader in Chemical Physiology in the University of Cambridge. Brevet-Colonel Sir William Boog Leishman, M.B., F.R.S., Professor of Pathology, Royal Army Medical College. 478 Appendices. — Joint Committee. ADVISORY COUNCIL FOR RESEARCH. The Right Hon. Lord Moulton of Bank, LL.D., F.R.S. (Chairman). Miss L. B. Aldrich-Blake, M.D., M.S. Sir W. Watson Cheyne, Bart., C.B., F.R.C.S., F.R.S. Sir William S. Church, Bart., K.C.B., M.D. Sidney Coupland, M.D. David Davies, M.P. Sheridan Delepine, M.B. Sir James Kingston Fowler, K.C.V.O., M.D. Sir Rickman J. Godlee, Bart., F.R.C.S. Sir Alfred Pearce Gould, K.C.V.O., F.R.C.S. David Hepburn, M.D. E. C. Hort, F.R.C.P., Edin. Arthur Latham, M.D. Sir John McFadyean, M.B. W. Leslie Mackenzie, M.D. . J. C. McVail, M.D. W. J. Maguire, M.D. S. H. C. Martin, M.D., F.R.S. Robert Muir, M.D. Alexander Napier, M.D. Sir George Newman, M.D. Arthur Newsholme, C.B., M.D. J. M. O'Connor, M.B. Sir William Osier, Bart., M.D., F.R.S. A. C. O'Sullivan, M.B. Marcus S. Paterson, M.D. Sir Robert W. Philip, M.D. Sir William H. Power, K.C.B., F.R.C.S., F.R.S. H. Meredith Richards, M.D. Lauriston E. Shaw, M.D. Albert Smith, M.P. J. Lorrain Smith, M.D., F.R.S. T. J. Stafford, C.B., F.R.C.S.I. T. H. C. Stevenson, M.D. Harold J. Stiles, F.R.C.S., Edin. Sir Stewart Stockman, M.R.C.V.S. W. St. Clair Symmers, M.B. Miss Jane Walker, M.D. Norman Walker, M.D. J. Smith Whitaker, M.R.C.S., L.R.C.P. Sir Arthur Whitelegge, K.C.B., M.D. G. Sims Woodhead, M.D. Appendices. — Joint Committee. 479 APPENDIX III. Return as to the Administration of Sanatorium Benefit from 15th July, 1912, to 11th January, 1914. [Cd. 738G.] Table I. — Number of applications for Sanatorium Benefit, and of INSURED persons AND DEPENDANTS OF INSURED PERSONS RECEIVING Sanatorium Benefit. Table II. — Number of cases of tuberculosis receiving treatment in VARIOUS FORMS. Table III. — Analysis of cases — (a) Residential. (b) Dispensary. Table IV. — Approximate Expenditure of Insurance Committees on Sanatorium Benefit. Table V. — Arrangements in force on 11th January, 1914. NOTE. Sanatorium Benefit consists of treatment of insured persons, and in some cases of dependants, suffering from tuberculosis, under arrangements made by Insurance Committees with local authorities or persons having the management of institutions or undertaking treatment. The treatment for which Insurance Committees have made arrangements may be divided under three heads : (1) Treatment in a residential institution, or (2) Treatment at a dispensary, or (3) Treatment at the patient's own home. It must be clearly understood, however, that though these headings arc convenient for purposes of reference, the methods of treatment indicated thereby are not distinct and independent methods of treatment, but form part of a general system for the treatment of tuberculosis. The course of treatment of any particular patient may include treatment at the patient's own home by his own doctor in consultation with a Consulting Officer, or treatment at a dispensary, or treatment in a residential institution, the different forms of treatment being given in the relatively appropriate sequence. It is not therefore possible to consider the condition of patients on the conclusion of periods of any particular form of treatment as affording any indication of the results of the treatment as a whole. Further, since in the treatment of tuberculosis the continued observation of the patient by his own medical attendant for a considerable period after leaving an institu- tion is often found desira]>le, it is not possible to give any general results of value at a date when the system has only been working for 18 months. Tables II and III show certain details as to the numbers of patients undergoing treatment in the various forms, and as to the progress of patients during that portion of their treatment which has been given in a residential institution or at a dispensary. The figures in Table III are compiled from the independent reports of Tuberculosis Officers and of the medical officers in charge of the institutions concerned, and it must not, therefore, be assumed that their returns of the progress of the patients have been made according to a strictly uniform clinical standard. 480 Appendices. — Joint Committee. Tablb I. KUMBER OF APPLICATIONS FOR SANATORIUM BENEFIT, AND OF INSURED PERSONS AND DEPENDANTS OF INSURED PERSONS RECEIVING SANATORIUM BENEFIT DURING THE PERIOD FROM 15TH JulY, 1912, TO IItH JANUARY, 1914. {In this Table a person toho received treatment within the period appears once, and once only, even though he has received treatment in more than one forniy except in the vase of a person who, owing to a change of residence during the eighteen months, received treatment under arrangements made hy more than one Committee^ * (I) Number of appli- cations. (•2) Not recom- mended for reasons other than those of health, e.g., applicant not insured. (3) Not treated for reasons such as those stated in foot-note § below. Eeceived treatment. (a) Pulmonary cases. (6; Non- pulmonary cases. Total. England : — Males Females 26,192 13,766 1,656 1,027 1,787 1,063 22,140 11,161 609 505 22,749 11,666 Total 39,948 2,683 2,850 33,301 1,114 34,415 Scotland : — Males Females 3,246 1,436 109 61 488 204 2,637 1,163 12 8 2,649 1,171 Total 4,682 170 692 3,800 20 3,820 Ireland:— Males Females 2,616 2,037 118 104 450 261 1,863 1,488 185 184 2,048 1,672 Total 4,653 222 711 3,351 369 3,720 Wales :— Males Females 1,923 859 66 18 277 181 1,475 569 105 91 1,580 660 Total 2,782 84 458 2,044 196 2,240 United Kingdom :— Males Females 33,977 18,088 1,949 1,210 3,002 1,709 28,115 14,381 911 788 29,026 15,169 Total 52,065 3,159 4,711 42,496 1,699 44,195 5 Note to Col, 3— (i) On expert examination found not to be suffering from tuberculosis, (ii) Removed to another area and accordingly do not appear as receiving treatment in the area in which application was first made, (iii) Declined the treatment recommended. iiv) Application under consideration. Appendices. — Joint Committee. 481 Table II. Number of cases of Tuberculosis receiving (1) residential, (2) dispensary, (3) domiciliary treatment during the period from 15th July, 1912, to 11th January, 1914. {A person receiving treatment under more than one heading appears in this and the following table as a separate case under each heading.) Residential. (1) Dispensary. (2) Domiciliary. (3) Total. England :— Males .. Females Total Total Total Total 13,636 6,267 5,631 3,190 13,162 6,228 32,429 16,680 19,903 8,821 19,385 48,109 Scotland : — Males ... Females 2.132 946 269 121 375 195 2,776 1,262 3,078 390 570 4,038 Ireland :— Males .. Females 1,315 748 117 113 763 906 2,195 1,767 2,063 230 1,669 3,962 Wales :— Males ... Females 911 347 544 258 389 198 1,844 803 1,258 802 587 2,647 United Kingdom:— Males Females 17,994 8,308 6,561 3,682 14,689 7,522 39,244- 19,512 Total 26,302 10,243 22,211 58,756 (B254— Gp. 5) i82 Appendices. — Joint Committee. Table III. Analysis of Cases. (a) Residential. Total cases treated. (1) Discharged from Institution. Died. (4) Treatment discontinued in other cases. (5) Still under treatment, 11th Jan., 1914. (6 Improved. (2) Without Improve- ment. (3) England : — Males Females 13,636 6,267 7,694 3,640 1,475 614 821 227 857 247 2,789 1,539 Total 19,903 11,334 2,089 1,048 1,104 4,328 Scotland :— Males Females 2,132 946 1,093 463 223 112 234 90 77 22 505 259 Total 3,07« 1,556 335 324 99 764 Ireland : — Males Females 1,315 748 562 347 255 141 129 58 88 31 281 171 Total 2,063 909 396 187 119 452 Walks :— Males Females... 911 347 471 161 63 15 64 15 73 9 240 147 Total 1,258 632 78 79 82 387 United Kingdom : — Males .... ... Females 17,994 8,308 9,820 4,611 2,016 882 1,248 390 1,095 309 3,815 2,116 Total 26,302 14,431 2,898 1,638 1,404 5,931 The figures in columns 2, 3 and 5 do not show the number of cases in which the treatment of the patient was concluded, since, after ceasing to attend the dispensaries, patients may receive continued treatment in other forms. The figures in columa 5 relate to cases as to the progress of which no definite report is available for various reasons, e.g., the withdrawal from the dispensary treatment of tha insured persons themselves before the expiration of the period recommended. Appendices. — Joint Committee. 483 (6) Dispensary. Total cases treated. (1) Discharged from Institution. Died. (4) Treatment discontinued in other cases. (5) Still under treatment, nth Jan., 1914. (6) Improved. (2) Without Improve- ment. (3) England :— Males Females 5,681 8,190 1,178 686 454 232 261 72 613 328 3,125 1,872 Total 8,821 1,864 686 333 941 4,997 Scotland :— Males Females 269 121 109 53 33 7 20 2 35 16 72 43 Total 390 162 40 22 51 115 , Ireland :— Males Females 117 118 46 47 10 7 2 1 3 5 56 53 Total 230 93 17 3 8 109 Wales :— Males Females 544 258 135 53 24 19 11 5 24 14 350 167 Total 802 188 43 16 38 517 United Kingdom :— Males Females 6,561 3,682 1,468 839 521 265 294 80 • 675 363 3,603 2,135 Total 10,243 2,307 786 374 1,038 5,738 The figures in columns 2, 3 and 5 do not show the number of cases in which the treatment of the patient was concluded, since after leaving residential institutions patients may receive con- tinued treatment in other forms. The figures in column 5 relate to cases as to the progress of which no definite report is available for various reasons, e.g., the withdrawal from the institution of the insured persons themselves before the expiration of the period recommended. (B2o4— Gp. 5) Q 2 484 Appendices. — Joint Committee. Table IV. Approximate Expenditure of Insurance Committees, from 15th July, 1912, TO llTH January, 1914, on the provision of Sanatorium Benefit, INCLUDING payments TO PRACTITIONERS IN RESPECT OF DOMICILIARY TREAT- MENT, BUT EXCLUDING THE COST OF ADMINISTRATION. England. Scotland. Ireland. Wales. United. Kingdom. £651,600 £103,200 £31,700 £50,000 £836,500 Table V. Arrangements in force on 11th January, 1914. (1) Number of beds provided under permanent arrange- ments. (2) Number of beds provided under provisional arrangements made Number of beds obtained for individual patients. Number of dis- pensaries in use. (5) Number of shelters in use. (a) •with local authorities. iP) with institu- tions direct. England Scotland Ireland Wales* 494 329 316 2,428 219 145 1,071 204 58 a. 1,136 374 397 37 241 17 85 13t 937 80 89 115 United Kingdom ... 1,139 2,792 1,417 1,944 356 1,221 * The provision of treatment for persons (insured and non-insured) suffering from tuberculosis in Wales is undertaken by the King Edward VII. Welsh National Memorial Association. t In addition to these dispensaries 70 visiting stations are provided. APPENDIX IV. Return as to the Administration of Sanatorium Benefit for the Twelve Months from 15th January, 1913, to 11th January, 1914. [See paragraph 403, page 136.] Table I. — Number of applications for Sanatorium Benefit, and of insured persons and dependants of insured persons receiving Sanatorium Benefit. Table II. — Number of cases of Tuberculosis receiving treatment in various forms. Table III. — Analysis of cases — (a) Eesidential. (6) Dispensary. NOTE. [See Note to Appendix III, page 479. Appendices. — Joint Committee. Table I. Number of applications for Sanatorium Benefit, and of insured persons AND dependants OF INSURED PERSONS RliCFIVING SANATORIUM BENEFIT DURING THE PERIOD FROM 15tH JaNUARY, 1913, TO IItH JaNUARY, 1914. (In this Table a person who received treatment within the period appears once, and once only, even though he has received treatment in more than one form , except in the case oj a person who, owing to a change of residence during the twelve months, received treatment under arrangements made hy more than one Committee.'). (1) Number of appli- cations. (2) Not recom- mended for reasons other than those of health, e.^r., applicant not insured. (3) Not treated for reasons such as those stated in foot-note § below. (4> Eeceived treatment. (a) Pulmonary cases. (6) Non- pulmonary cases. (0) Total. England : — Males Females 20,898 10,620 966 671 1,444 187 17,921 9,290 567 472 18,488 9,762 Total 31,518 1,637 1,631 27,211 1,039 28,250 Scotland : — Males Females 2,599 1,168 57 29 421 178 2,119 960 2 1 2,121 961 Total 3,767 86 599 3,079 ' 3,082 Ireland :— Males Females 2,229 1,823 86 81 318 197 1,645 1,363 180 182 1,825 1,545 Total 4,052 167 515 3,008 362 3,370 Wales :— Males Females 1,590 784 31 8 251 179 1,220 508 88 89 1,308 597 Total 2,374 39 430 1,728 177 1,905 United Kingdom:— Males Females 27,316 14,395 1,140 789 2.434 741 22,905 12,121 837 744 23,742 12,865 Total 41,711 1,929 8,175 35,026 1,581 36,607 Note to Col. 3— (i) On expert examination found not to be suffering from tuberculosis, (ii) Removed to another area and accordingly do not appear as receiving treatment in the area in which application was first made, (iii) Declined the treatment recommended, (iv) Application under consideration. (B254— Gp. 5) Q 3 486 Appendices, — Joint Committee. Table II. Number of cases of Tuberculosis receiving (1) residential, (2) dispensary, (3) domiciliary treatment during the period from 15th January, 1913, TO llTH January, 1914. {A person receiving treatment under more than one heading appears in this and the following table as a separate case under each heading.) Besidential. (1) Dispensary. (2) Domiciliary. (3) Total. (4) England :— Males Females 12,891 5,930 5,426 3,100 12,528 5,960 30,845 14,990 Total 18,821 8,526 18,488 45,835 Scotland : — Males Femalea 1,967 895 241 110 339 175 2,547 1,180 Total 2,862 351 514 3,727 Ireland :— Males Females 1,235 706 117 113 748 895 2,100 1,714 Total 1,941 230 1,643 3,814 Wales :— Males Females 800 330 530 253 359 190 1,689 773 Total 1,130 783 549 2,462 United Kingdom :— Males Females 16,893 7,861 6,314 3,576 13,974 7,220 21,194 37,181 18,657 Total 24,754 9,890 55,838 Appendices. — Joint Committee. 487 Table III. Analysis of Cases. (a) Residential. Total cases treated. (1) Discharged from Institution. Improved. (2) Without Improve- ment. Died. (3) (4) Treatment discontinued in other (5) Still under treatment, 11th Jan., 1914. (6) England : — . Males ^^ Females, 12,891 5,930 7,215 3,400 1,384 577 726 210 776 203 2,789 1,539 Total 18,821 10,615 1,961 936 979 4,328 Scotland : — Males Females 1,967 895 994 432 201 102 199 81 68 21 505 259 Total 2,862 1,426 303 280 89 764 Ireland : Males Females 1,235 706 521 325 237 133 119 50 77 27 281 171 Total 1,941 846 370 169 104 452 Wales : — Males Females 800 330 406 148 52 15 46 13 56 7 240 147 Total 1,130 554 67 59 63 387 United Kingdom :— Males Females 16,893 7,861 9,136 4,305 1,874 827 1,090 354 977 258 3,815 2,116 Total 24,754 13,441 2,701 1,444. 1,235 5,931 The figures in columns 2, 3 and 5 do not show the number of cases in which the treatment of the patient was concluded, since after leaving residential inotitutions patients may receive continued treatment in other forms. The figures iu column 5 relate to cases as to the progress of which no definite report is available for various reasons, e.g., the withdrawal from the institution of the insured persons themselves before the expiration of the period recommended. (B254— Gp. 5) q4 488 Appendices. — Joint Committee, (b) Dispensary. Total cases treated. (1) Discharged from Institution. Died. (4) Treatment discontinued in other cases. (6) Still under Improved. C2) Without Improve- ment. (3) treatment, llth Jan., 1914. (6) England :— Males Females 5,426 3,100 1 102 642 400 214 237 68 562 304 3,125 1,872 Total 8,526 1,744 614 305 866 4,997 Scotland :— Males Females 241 110 92 48 25 6 18 2 34 11 72 43 Total 351 140 31 20 45 115 Ireland :— Males Females 117 113 46 47 10 7 2 1 3 5 56 53 Total 230 93 17 3 8 109 Wales :— Males Females 530 253 127 52 22 19 11 4 20 11 350 167 Total 783 179 41 15 31 517 United Kingdom :— Males Females 6,314 3,576 1,368 788 457 247 268 75 618 331 3,603 2,135 Total 9,890 2,156 704 343 949 5,738 The figures in columns 2, 3 and 5 do not show the number of cases in which the treatment of the patient was concluded, since, after ceasing to attend the dispensaries, patients may receive continued treatment in other forms. The figures in column 5 relate to cases as to the progress of which no definite report is available for various reasons, e.g., the withdrawal from the dispensary treatment of the insured persons themselves before the expiration of the period recommended. APPENDIX V. Report of the Actuarial Advisory Committee on the Basis for the Calculation of Transfer Values. To the Rt. Hon. C. F. G. Masterman, M.P., Chairman, National Health Insurance Joint Committee. Sir, 1. The Actuarial Advisory Committee have had under consideration the question of the proper transfer value to be credited to an Approved Society upon the transfer to such Society of an insured person. 2. In fixing the principles on which the reserve values were calculated in respect of persons entering insurance, account had to be taken of the option that could be exercised by the Societies of rejecting unsuitable lives Appendices. — Joint Committee. 489 at the outset, but bearing in mind that the reserve values to be credited to the Societies represented the whole of the assets with which they would enter upon their career as insurance institutions, it was important in the interests of the successful working of the scheme as a whole that the probable effect of this power of selection on the part of the Societies should be very conservatively estimated. It was to be expected that at the commencement of the Act, when considerable competition was to be looked for on the part of the various Societies to obtain their share of the business, the selection of the lives would be less stringent than it would eventually become, and that persons would in many cases be accepted for insurance who were not properly speaking select lives. From the point of view of the successful introduction of the Act it was desirable, indeed, that within reasonable limits Societies should take this broad view. It was considered, therefore, that the calculation of the reserve values should be made upon such a basis as would provide for the acceptance of a certain proportion of persons who though employed at the time of entry into insurance could not strictly be termed select lives, and would consequently bring upon the Societies a heavier liability for sickness and disablement benefits in the first few years of the Act than would be experienced if select lives only had been admitted. The specific recommendations of the Committee in their Reports to the Joint Committee were dictated by these considerations, and, as they under- stand, the reserve values were computed in accordance with those recom- mendations. 3. In the case of the transfer values, however, different considerations arise. There is a considerable difference between the aggregate amount of the reserves required to support the benefits of the whole body of members in a given Society and the reserves required by a body, similar in respect of both numbers and ages but consisting entirely of healthy lives ; this difference represents the aggregate provision to be made in the case of a normally con- stituted Society for lives that have fallen below the average. In the calcu- lation of transfer values it must be assumed, on general principles, that healthy lives only will transfer. It is so clearly to the interest of Societies to scrutinise applications for transfer, with the view of excluding undesirable risks, that they must be expected to exercise particular care in this branch of their work. It becomes of importance, therefore, so to fix the transfer values as to protect transferor Societies from paying away more in respect of transfers than is necessary to support the particular class of liabilities of which they are relieved. This course is the more necessary in that an onus lies upon transferor Societies when objecting to transfers to show that their consent is not unreasonably withheld. Practically this amounts to com- pulsory acquiescence on the part of the transferor Societies, while the transferee Societies have full liberty to accept or refuse the applications made to them. 4. In applying these principles some discrimination must be made between transfers arising in the first twelve months after the commence- ment of the Act and those arising subsequently. During the first three months there is reason to think that the conditions governing transfers were generally the same as those under which persons were admitted to insurance in that exceptional period. In dealing with transfers during the first three months, therefore, we consider it will be sufficient to adopt the same basis as for the reserve values. These early transfer values will con- sequently include the small sum by which the reserve values of men (and to a lesser extent those of women) were increased to provide for the anticipated admission to insurance of a number of persons who, as above explained, could not properly be termed select lives. The necessity for this special provision will, we consider, gradually disappear during the first twelve months from the commencement of the Act, after which period only the normal transfer values should be granted. We advise, therefore, that the special provision above referred to should be allowed in full in respect of transfers occurring during the first three months and thereafter should be proportionately diminished month by month until it disappears at the end of the first year. 490 Appendices. — Joint Committee. 5. The considerations advanced in the previous paragraph refer directly to transfers of persons who entered into insurance on 15th July, 1912, but since in the early period of insurance the duration of membership is a specially important factor in the transfer value (in consequence of the waiting period before the payment of benefits) it is convenient, as avoiding the duplication of tables, to assume that the special conditions which we have described, extended to all persons who entered into insurance at any time during the first year after the commencement of the Act. Any varia- tions from the theoretical value due to this cause are financially unimportant since, in fact, a great preponderance of the insured population came into insurance on or immediately after 15th July, 1912. 6. We recommend that the transfer values should be calculated upon the same basis as that adopted for the reserve values, subject to the necessary modifications of the rates of sickness and disablement to give effect to the special conditions to which we have referred. We have had a very careful analysis made of the rates of sickness and disablement applicable to in- capacity of various durations with a view to determine how far these rates should be modified to meet the conditions which have to be dealt with, and we recommend, as the result of this investigation, that the deductions shown in the following Table should be made from the tabular rates. Period of Sickness. Y ear of Insurance i following transfer First Second i Second Remainder 1 six months. six months. twelve months. after 2 years. per cent. per cent. per cent. per cent. 1 12-5 75 100 100 2 — — 50 100 3 — — 89 4 — — — 69 5 — — — 54. 6 .. — — — 43 7 — — — 33 8 — 23 9 — — — 14 10 — — ' 5 7. Careful consideration has been given to the question as to how far arrears should be taken into account in determining individual transfer values, particularly in those cases in which the sickness benefit is temporarily reduced in consequence of the average arrears amounting to four weeks per annum or over. The Committee has not reached a final conclusion on this subject, but having regard to the fact that important questions of principle can be settled without consideration of the matter of arrears, thus enabUng the calculation of transfer values to proceed, they have not deemed it neces- sary to delay the submission of this Report until their conclusions as to adjustments for arrears can be presented. I am, Sir, Your obedient Servant, G. F. HARDY, Chairman. 29th May, 1913. ^ Appendices. — Joint Committee. APPENDIX VI. 491 Tables showing the Results of an Investigation made into the Experience of 26,015 Established Deposit Contributors in London, of 51,528 Established Deposit Contributors in Eagland, outside London, and of all Established Deposit Contributors in Wales, Scotland and Ireland. England. Table I. Accounts Examined. British. /Llibn. Men. Women. Men. Women. 3^ ii' ^1 ii 3^ 1- ii 3^ Entrants on 15th^July, 1912 Entrants after 15th July, 1912 :— In 1st Quarter „ 2nd „ „ 3rd „ „4th , „ 5tli „ „ 6th „ 10,846 2,819 988 672 663 662 19,032 4,952 3,332 2,617 1,913 1,282 5,509 1,128 488 290 287 291 9,947 1,877 1,597 1,257 926 624 585 119 69 60 50 37 859 233 135 132 93 56 299 64 45 21 13 10 394 79 85 53 33 20 Total 16,660 33,128 7,993 16,228 920 1,508 452 664 Table IT. Age Distribution of Persons who had completed Waiting Periods for Sickness and Maternity Benefits. British. Alien. Men. Women. Men. Women. Age Groups. ii side fldon. •%i 03 S 4 i^ 1^ +3 O 3^ 5^ s-< s^ ;^^ 3 J o^ §^ per cent. per cent. per cent. per cent. per cent. per cent. per cent. per cent. 16-20 12-6 14-2 13-3 17-6 10-3 11-1 13-8 12-9 20-25 12-6 12-9 16-0 18-1 35-3 33-1 37-7 38-0 25-30 10-9 11-9 14-7 13-8 21-4 19-2 18-3 19-4 30-35 10-3 10-8 10-4 9-8 10-8 11-5 9-4 10-1 3&-40 10-0 10-0 9-0 7-9 5-3 7-2 6-9 6-7 40-45 9-1 8-5 9-0 6-9 4-3 4-9 3-8 5-3 45-50 8-4 7-3 7-6 6-1 3-7 4-9 6-3 3-4 50-65 7-7- 6-8 6-3 6-0 3-1 2-7 1-9 2-1 66-60 6-7 6-2 4-8 4-9 1-6 31 1-6 1-2 60-65 5-5 5-4 4-9 4-6 2-4 2-2 -3 •7 66-70 6-2 6-0 4-0 4-3 1-8 -1 — •2 Total 100-0 100-0 100-0 100-0 100-0 100-0 100-0 100-0 492 Appendices. — Joint Committee. Table III. Claim Experience, British. Men. Women. o =s a> o O See 21. .382 5,444 4,547 1,127 1,318 334 29-1 29-6 1,326 - 410 — 30-9 - — © o O Alien. Men. 1^ CO o is O o Women. O cj d ■S^ a .S-' a ■S^ n oi ^ ts :S'o ° «s .^■^ o ci .^'C ■Si 2-^ ■73 (D S i=t •73 (D 50 O T3 S GQ d GQ d -s o a ^H ■§ o i=l S -2 O a >H •2 O ;^^ S^ ^^ 5^ ^^ s^ 3^ 5^ Cases examined 12,806 24,114 5,639 10,469 508 906 180 358 Number who claimed " Parlia- 494 497 381 923 2 8 1 1 mentary Id" at any time. Percentage of cases examined 8-9 2-1 6-7 8-8 •4 •9 •6 •3 Number who have claimed " Parlia- 285 326 230 386 2 5 1 mentary Id.'' during part only of time for which they were employed. Percentage of the last number to 57-7 65-6 60-4 41-8 100-0 62-5 — 100-0 the number who have claimed " Parliamentary Id." at any time. Percentage of low wage con- 48-8 38-0 45-9 51-2 72-3 63-8 — 14-3 tributions to total contributions paid by the part-time low wage group. 494 Appendices. — Joint Committee. United Kingdom — British Subjects. Table VII. Accounts Examined. Men. Women. 'i ♦ -6 s •d '6 » '6 d •r) § l |£>£ si S 1^ 1 1 1 1 1 1 1 1 g Arre mplo buto: c^ hsas ,-( T-l t> 1-1 o ^. ^ a3 eg ecoco , . CO No. paidi Con 1^^^'^ 1 1 1 1 1 [ 1 Average No. of Contri- butions per Contri- butor. ••^-^t-OCCMOSiOOOOOO Ci Oil— lt^^t^l-^iOCOr-<000 (^^T-lrHoeoeoc^'J<^{^5THeo (N tH - . . 00Tf.' cf Th i^coo^eo loooco O CO 00 "0 so i-H >0 r-T ctT QO 00 C5 CO tH CO . 1 I 1 Oi (M CO 1 1 1 1 1 uo ^ •^ 1 1 1 coo 1 1 1 1 1 C5 •^ a5 (M os'-^' co" CO ^ C^ s 11? 1 1 1 1 1 1 1 1 CO 1 "a 5<) _ .^ r-< -^ 1 1 1 1 ' 1 1 ■ r-T o P QQ 05 Oi tz; ^'5-s| ^ CO 1 '-1 1 1 1 I 1 1 1 tH Hd-fH a, PI t>- r4 1 1 1 1 1 1 1 1 "^M^ o' CO' s^i (M CO !M t. CO "O Ttl «l'«-l 1 1 1 1 1 1 1 1 o_ ».j^ 00 ^ 1 1 1 1 1 1 1 1 S5 ^ s «C lO •«*< l->. O 00 T-l ^ 00 "0 (N O 05 il._^0^'^^'0 CO 00_ i s^i CO 1-H l>r" 00 CO 1 00 1 1 1 c,-l O 1 00 1 1 1 o 00^ CO 00 1-1 T^ CO ! ^ co" QO 00 o ■■: M ^ •* ^ ^ tH (N T-l t^ CO cooo , . . . t^ No. Cont buto undi Sec. of IS Aci T-ii-ICO 1 1 CO „- III ?2 ?f No. of Contri- butors at Low Wage Bates. 1 :;- 1 1 1 1 1 1 1 1 i - . t>CO0 tH OOi lO (>r (^f o' i->.' !?f lo -<*<' 3iO Oi-I CO' -t— ::;'.'.::'.'.'.'. , '' 03 m D tH (N CO >* lO CO ^r-l(M*0 »^ 5S tH O 00 (5. 00 I I IS I I I 1 I I I I I I I S- M M I I I I i I I I I i I I M 3 05 a 1 i^ 'QQ 00 d I I I I I 1 I I I I :i^ ^a I I I I 1 i I ! I OOJ o ICS O T-1 i i I 1 I I I M lO o 000 (»00__ CO eo"i 05 o ' O T-H ' CO !> eo lO Ms I III c i-( «- S ^ '-' ^i 'OQ^O CD o S O fl^ I I I II I II I t>> i^c6 d ^^ 8 1 s ^ ^^ d -2 p-s-j: 00 "S d d -«3 oQ d S a"" ^ d 2 i >^!=l „ •;3 oj £ 2 a^ <> 1 • • • • : : : CO eo CO eo -^ (M CO S^ 05 I I I II I I I I ec (M t>. OS «o CO C<» CO CO ■ 1-t 00 •* eo 00 o Tf o>_oo^05^eo o_t^ «o^ 110" 00 o" I I ""i^" 5. t^ CN 1— t F— 1 CD .-H rH 00 rH iO o »0 l-H lO 05 lO CD Oi 00 00 00 cq CN »0 « Tt< CN "^ r— t t— t CO 00 Tj< CD CN 05 O S C+^ lO o CD O o ^ .2 1 > o O ' ocq ^ i-H (D 73 -t-a OSfH .2* "I 5a2 ^ ^^ C t, m an >i (V *^ .02 (T) a 02 a •rt (U a 3 .1 ^^ C^ -J OQ O ^ " » d) -f3 ^ t3 c s « a o ^ 2§ gs ft 4) S O QQ S : g >^ : ^•^ 1-5 "^ a-^1 : fl : •I • • > • o o 9 o i> «2 ^^ © CJT3 'J 3 c fl g ce 03 ^ <35 _, -K ^ ^ U ^V. ft, ^ f^t^ a ^ 2 ?ftci^:g o o I— I CO CD I— I CD Tj* CO CO O O CC g be fl S rt o o o 2 m '^ O ^ CD 05 CO r^ CO i-t o oi O cm cd lO oj'Ooor^O'yj CO CD 00 O'^""* 00 Tt*i>. O Ci 00 00 CO O O Oi 00 05 O CD t^ 00 O O ^ !>• 800 t- l-H CO I-H lO^ !i o as a. a (D X o !<1 03 ^ ^ (ID — I— • 05 ^ -p-i ,- r— I (D • S I— ' 03 d^ C gj :^o fl"*^ 2 03 s ■+3 13 ^ «4H 02 ee ig 504 Appendices. — England. APPENDIX XIII. England. Draft Model Agreement between County or County Borough Councils and Insurance Committees for the provision of Institutional Treatment of Persons suffering from Tuberculosis. AN AGREEMENT made the day of One thousand nine hundred and BETWEEN THE COUNTY COUNCIL (or the CORPORATION) OF (hereinafter called " the Council ") of the one part and THE INSURANCE COMMITTEE FOR THE ^ being the Insurance Committee constituted under section 59 of the National Insurance Act, 1911, for the (hereinafter called " the Committee ") of the other part. WHEREAS the Council have approved the Scheme for the institutional treatment of persons suffering from tuberculosis set forth in the Schedule hereto. AND WHEREAS the Scheme has been approved by the Local Government Board and has been recognised as suitable for grants from the Local Government Board in aid of the expenses of the Council in relation to the treatment of tuberculosis. AND WHEREAS it is contemplated that further or other provision for the insti- tutional treatment of persons suffering from tuberculosis may be made by the Council. NOW IT IS HEREBY AGREED by the parties hereto as follows :— 1. The expression " Tuberculosis Officer " means a Medical Ofi&cer ap- pointed by the Council with the approval of the Local Government Board for the purposes of the said Scheme, and shall include the Medical Ofi&cer of Health for the and each of the Tuberculosis OflScers if there shall be more than one. 2. In consideration of and in return for the payments to be made by the Committee to the Council pursuant to this Agreement the Council shall — (a) Appoint one or more Tuberculosis Officers whose duties shall include advising the Committee in regard to the administration of sanatorium benefit, the examination of insured persons apply- ing for sanatorium benefit, and advising the Committee as to the cases in which insured persons should be recommended for sanatorium benefit and the form of treatment in each case. (b) Provide one or more dispensaries under the said Scheme where insured persons applying for sanatorium benefit may be examined and where insured persons who are to receive sana- torium benefit in the form of dispensary treatment may from time to time be treated and treat in those dispensaries any insured persons nominated for treatment therein by the Com- mittee after consultation with the Tuberculosis Officer. (c) Provide shelters in cases in which the Tuberculosis Officer recom- mends them for the use of insured persons. {d) Provide accommodation for the treatment of* insured persons in any sanatorium (or sanatoria) and for the treatment of* insured persons in any hospital (or hospitals) provided under the said Scheme, and treat in the sanatoria and hospitals in which accommodation is so provided any insured persons (not exceeding the number* in the case of sanatoria nor* in the case of hospitals) who are nomi- nated for the purpose by the Committee after consultation with the Tuberculosis Officer, subject in each case (1) to the power of the Council to refuse to admit any person if the Tuberculosis Officer certifies that the patient would derive greater benefit Insert numbers. Appendices. — England. 606 from some other form of treatment than that provided in the institution concerned, or that the patient's physical condition is such as to render him inehgible for admission under the rules of the institution concerned, and (2) to the observance by the person under treatment of any regulations made either by the Council or the managers of the sanatorium or hospital, as the case may be, for the control and management of the institution in which he is treated. Nothing in this provision shall derogate from the power of the Council to treat in the sanatoria and hospitals in which accommodation is so provided insured persons in excess of the numbers herein mentioned as well as and upon the same terms and conditions as uninsured persons. 3. No insured person shall be entitled to treatment under this Agreement imless the Committee, after consulting the Tuberculosis Officer, shall recom- mend the case for sanatorium benefit. 4. The Committee shall pay to the Council a sum calculated at the rate of * pence for every sum of ninepence remaining available to them for defraying the expenses of Sanatorium Benefit, in each year after the appropriation of a sum sufficient to meet the liability of the Committee in respect of the domiciliary treatment of tuberculosis at the rate of sixpence per head of insured persons eligible for sanatorium benefit in respect of whom the Committee are so liable. 5. The payments to be made to the Council by the Committee in pur- suance of. this Agreement shall be made by quarterly instalments and the first such instalment shall be paid in the quarter commencing the 6. This Agreement shall come into operation on the , and shall remain in force for a period of years from that date, unless either party to the Agreement with the prior approval of the Local Government Board shall give to the other party at least twelve months' notice of their desire to determine this Agreement. 7. This Agreement may be modified or extended in such manner (except as to the period of its continuance) as the Council and the Committee may from time to time mutually agree, or in default of agreement as may be determined in accordance with Clause 9 of this Agreement. 8. Notwithstanding anything in this Agreement the Council may, with the approval of the Local Government Board, extend or modify the Scheme hereinbefore referred to, provided that the Council shall not in so doing make for the Committee arrangements less adequate than those specified in the said Scheme. 9. If any question, dispute or difference shall arise between the parties hereto in respect of any subject-matter of this Agreement or of the inter- pretation of this Agreement or in respect of any payment to be made or of anything done or to be done hereunder or of any other matter arising out of the provisions of this Agreement, or as to the decision of the Council to refuse to admit an insured person who has been nominated by the Com- mittee for admission to a sanatorium or hospital, such question, dispute or difference shall, on the application of either of the parties, be referred to the Local Government Board for determination by them as arbitrators or other- wise or, at the option of the Board, by an arbitrator appointed by them. 10. This Agreement is subject to the approval of the Insurance Cornmia- sioners of the arrangements proposed herein. SCHEDULE. (Here insert the Scheme.) * Insert the figure agreed on. 506 Appendices. — England . APPENDIX Eng- Account of the General Medical Fund Sums credited to Insurance Committees in respect of Medical Benefit for period from 15th January, 1913, to 11th January, 1914 Less Estimated rebate in respect of Mercantile Marine Members Amount carried to Central Medical Fund in respect of Travellers Proportion (3^^) of charges, carried to 1914 Account Balance retained for subsequent allocation... i; 8. a. 4,381,138 8 9,524 8 s. d. 4,371,614 86 14 36,334 7 6 3,209 4 11 £4,411,244 6 5 The above Account shows the method of constitution of the General Medical population amounting in the aggregate, as it will be seen, to over 10,400,000), apportionment among the several Insurance Committees of the net amount Marine Members, for distribution in connection with the present settlement, Insurance Committee. £ s. d. Insurance Committee. £ 8. d. Counties : — Counties — cont. 1 1 Bedfordshire 26,305 18 Rutlandshire 2,362 8 Berkshire 22,791 17 Salop 27,363 18 Buckinghamshire ... 26,300 15 Soke of Peterborough 5,765 4 Cambridgeshire 15,457 5 Somerset 44,940 9 Cheshire 80,956 8 Southampton 45,670 13 Cornwall 31,407 8 Staffordshire 85,343 1 Cumberland... 29,202 1 Suffolk, East 23,298 7 Derbyshire 71,546 13 Suffolk, West 14,307 4 Devon 48,289 16 Surrey 77,285 2 Dorset 24,364 7 Sussex, East 27,621 15 Durham 123,394 14 Sussex, West 19,618 18 Essex 123,525 2 Warwick 37,843 12 Gloucestershire 38,961 12 Westmorland 6,827 4 Herefordshire 11,105 4 Wiltshire 34,431 10 Hertfordshire 38,455 19 Worcestershire 35,712 12 Huntingdonshire . . 6,292 Yorks., E. Riding .. 16,487 12 Isle of Ely 7,454 8 Yorks., N. Riding.. 34,156 14 Isle of Wight 9,355 11 Yorks., W. Riding.. 212,478 16 Isles of SciUy 138 Kent ai2,480 8 County Boroughs : — Lancashire ... 260,045 15 Barnsley 5,196 16 Leicestershire 33,509 3 Barrow-in- Furness . . 9,729 11 Lines., Holland 8,982 10 Bath 8,102 Lines., Kesteven .. 12,876 Birkenhead ... 17,023 10 Lines., Lindsey 25,974 11 Birmingham 122,728 7 London . 600,227 3 Blackburn ... 24,508 8 Middlesex ... . 133,008 14 Blackpool 6,249 3 Norfolk . 35,909 5 Bolton 28,776 6 Northamptonshire .. Northumberland . . . 28,207 18 Bootle 9,002 3 . 47,175 2 Bournemouth 9,490 2 Nottinghamshire .. . 43,998 Bradford 48,674 9 Oxfordshire ... . 15,603 18 Brighton 15,008 5 Appendices. — England. 507 XIV. LAND. for the Year ended 11th January, 1914. Charges in respect of year from 15th £ s. d. January, 1913, to 14th January, 1914 : — To Approved Societies 2,349,418 14 4 To Deposit Contributors 54,221 7 4 To Exchequer : — Ordinary Grant 716,902 10 3 Special Grant Less Estimated rebate in respect of Mercantile Marine Mem- bers 1,300,226 2 6 £ d. 4,420,768 14 5 9,524 8 £4,411,244 6 5 Fund for the year ended 11th January, 1914 (based on returns of an insured and the method of its disposition. The following Table shows the precise available, after allowance of estimated rebates in respect of Mercantile viz., £4,371,614. Insurance Committee. £ s. d. Insurance Committee. £ s. d. County Boroughs — County Boroughs- cont. cow^. Bristol 47,577 10 Norwich 16,704 17 Burnley 20,078 8 Nottingham 38,859 18 Burton-upon-Trent 6,201 4 Oldham 26,319 8 Bury 10,461 12 Oxford 6,689 12 Canterbury ... 2,534 8 Plymouth ... 12,540 1 Chester 5,163 1 Portsmouth... 22,314 14 Coventry 16,888 Preston 18,922 7 Croydon 19,052 11 Reading 11,776 Derby 16,930 16 Rochdale 16,079 4 Devonport ... 6,943 Rotherham 8,062 16 Dewsbury ... 6,594 16 St. Helens 13,418 10 Dudley 6,480 Salford 34,861 2 Eastbourne 6,624 9 Sheffield 62,703 5 Exeter 6,137 4 Smethwick ..." 10,235 4 Gateshead 15,167 16 Southampton 14,533 16 Gloucester 6,297 18 Southport 7,568 1 Great Yarmouth ... 6,633 4 South Shields 13,287 19 Grimsby 9,671 5 Stockport 16,842 17 Halifax 16,890 8 Stoke-on-Trent 35,634 8 Hastings 6,635 8 Sunderland ... 18,761 2 Huddersfield 17,347 4 Tynemouth ... 6,804 10 Ipswich Kingston-upon -Hull Leeds 9,692 5 Wallasey 5,875 9 37,820 8 Walsall 13,141 12 67,677 3 Warrington 10,524 8 Leicester 37,739 9 West Bromwich 9,072 16 Lincoln 7,700 16 West Ham 37,252 14 Liverpool Manchester ... 96,427 17 West Hartlepool ... 8,275 18 104,789 15 Wigan 13,123 2 Middlesbrough 14,187 9 Wolverhampton 13,20d 12 Newcastle-upon-Tyne 35,353 11 Worcester ... 6,493 19 Northampton 13,457 12 York 11,261 8 508 Appendices. — England. APPENDIX XV. England. Medical Benefit. — Case Value Results. Case value is obtained by dividing the Panel Fund of the Insurance Committee by the number of cases treated by the doctors in the area. As the funds of all Committees are credited to them on the basis of a uniform fiat rate per head of the insured population of the area, the relative degree of sickness present in the area, as reflected in the number of cases treated, will be indicated by the variations in the amount of the quotient in different areas. The object of this method of calculation is, so far as the temporary resident system is concerned, that the debit to the funds of a Committee in respect of the case of an insured person treated during temporary residence elsewhere shall be the amount estimated to be earned, on average, by the doctors in that Committee's area in respect of each case treated by them, the higher being the rate of sickness incidence, the lower being the rate of deduction in respect of temporary residents, and vice versa. Thus the amounts of the case values for the several areas afford some indica- tion of the varying degrees of sickness incidence as between area and area. In the following Table (which may therefore be of general interest) the case values for the areas in which the necessary calculations have already been made are given in the form of index figures, 100 representing the average for the insured population of all the areas taken together. Insurance Committee. Index Figure. Insurance Committee. Index Figure. Counties : — Counties (ctd.) : — Bedfordshire ... . 115-47 Suffolk, West 121-11 Berkshire .: 148-06 Surrey ... 133-75 Buckinghamshire . 128-67 Warwick 106-50 Cambridgeshire . 183-35 Westmorland 139-44 Cornwall . 121-00 Wiltshire 119-92 Devon . 122-06 Yorks, E. Biding 142-06 Dorset .: 108-21 Yorks, N. Biding 121-15 Durham . 102-71 Essex . 100-91 County Boroughs : — Gloucestershire ... . 109-50 Barnsley 87-73 Hertfordshire ... . 127-96 Barrow-in-Furness 90-88 Huntingdonshire . 148-91 Bath 97-35 Isle of Wight .! 106-73 Birkenhead 107-31 Isles of Scilly .1 128-77 Birmingham 78-91 Kent . 115-71 Blackburn 92-67 Lancashire .1 100-68 Blackpool 100-60 Leicestershire .' 115-87 Bolton 88-24 Lines., Holland .! 160-05 Bootle 100-02 Lines., Lindsey ... .! 125-21 Bournemouth ... 100-70 Middlesex .1 97-92 Bradford 96-12 Norfolk .i 135-00 Brighton 89-36 Northamptonshire .! 114-70 Bristol 73-01 Oxfordshire . 151-31 Burnley ... 87-72 Eutlandshire . 159-58 Burton-upon-Trent 80-45 Salop . 105-84 Bury ... 96-55 Soke of Peterborough .. .1 109-05 Canterbury 106-47 Somerset . 109-03 Chester 92-15 Southampton ... . 131-25 Coventry S4-30 Staffordshire 92-32 Croydon 98-08 Suffolk, East . 127-51 Derby 81-67 Appendices. — England. 509 Insurance Committee. 1 Index Figure. Insurance Committee. Index Figure. County Boroughs (ctd.):- 1 County Boroughs (c^d) :- Devonport 90-27 Oxford ... . 114-24 Dewsbury .! 95-39 Plymouth 88-30 Dudley . 125-62 Portsmouth 90-94 Eastbourne . 101-99 Preston ... 87-71 Exeter 95-11 Reading ... 88-42 Gateshead 92-14 Rochdale 89-60 Gloucester 99-49 Rotherham 75-90 Great Yarmouth . 101-85 St. Helens 95-50 Grimsby .1 113-11 Smethwick 73-35 Halifax .! 90-99 Southampton . . 100-86 Hastings .| 119-60 Southport . 107-00 Huddersfield .! 98-83 South Shields . . 103-95 Ipswich .' 88-08 Stockport 91-01 Kingston-upon-Hull .. . 95-17 Stoke-on-Trent . 84-58 Leeds .1 88-07 Sunderland . 82-23 Leicester .1 75-37 Tynemouth . 89-42 Liverpool . 93-98 Walsall ...■ . . 90-88 Middlesbrough .! 92-01 Warrington . 88-58 Newcastle-upon-Tyne .. .| 87-36 West Bromwich 82-15 Northampton ... .1 84-62 West Ham 77-31 Norwich... .; 87-85 West Hartlepool 86-66 Nottingham 97-75 Wolverhampton 91-04 Oldham 86-00 York . 103-85 510 Appendices. — England. APPENDIX XVI. England. Deposit Contributors. — Table showing Number of Contributors who entered into Insurance during each Quarter. Men. Women. Men and Women. Quarter ended Wished eposit ribntors. ^• Wished eposit ributors. 1 .2 41 III 73 oo 1 ^Pfl ta J SQ0 il ^fi-3 3 wio H «§o a P o wi5 o 13th October, 1912 226,178, 80,637 306,815 105,329 34,559 139,888 331,507 115,196 446,703 r2th January, 1913 24,074 28,044 62,118 10,317 12,018 22,335 34,391 40,062 74,453 13th April, 1913 19,769| 19,504 39,273 8,472 8,358 16,830 28,241 27,862 56,103 13th July, 1913 15,779 17,452 33,231 6,762 7,479 14,241 22,541 24,931 47,472 12th October, 1913 13,225 13,466 26,691 5 669 5,771 11,4401 18,894 19,237 38,131 11th January, 1914 13,032 4,938 17,970 5,585 2,116 7,701 18,617 7,064 26,671 APPENDIX XVII. England. Deposit Contributors. — Table showing Number of Insured Persons, not Members of Approved Societies, who sur- rendered Cards for each Quarter. Men. Women. Men and Women. Quarter ended hed sit utors. _0Q -i .2 hed sit utors. 1 CO •" g-^ ^ •S SrQ Xi •^ S'Q rQ 3§^-S n sS^s -fl . 3 &-n -S -fiflfl J SP\'a 3 Jfi ri s-; d "-^ w § 2 § S "^ w 153 CQ O PJ ,Q •1-4 U o O CQ o 1 ^ ^ Average mount pe Payment including ate Grant ■«" ■* ?< » ■* SMOC-H e^ ^•ojoooj o> oo«ooo 00 OS qjOOO 000 < -tc T3 50 •<1< oeco ^ .0 "3 ^-H05l« ® 00a « ^ (M»0 0» b- i"i 00 lO <«522 >o s 1 «0" r-T t-T csT eo' 0" ■«« ^J »o 00 t- ec X (E II •0 r- 00 00 (M 2 Tj< 1 '^ 1 ^ 4^ i g - 1 ". < c4' °i ■«'®»r-] ^ Tfcoeo 01 ""• ^oo> t^ t- soot- M ,_! i| 1— I =«§ii 8 i"i & t- •>*< tfT i-T » ^"• i ^ 3 Ill S CO H CO ci 2 tC t-^ ^- k. s^ •cs > n-j •wo & ^5 -*2 1 Si 2 ec ^ 1 i 2' 2 i 3 s < g § ■acooj eot- ® to®'* ,_, ecoi c^ ec if l-H eo" %^ 1 1 1 v_Y_/ v_^ "Srt rM • ■eg t- t- SV| ® 3 s< 5f f^ d 00 5 ^ c 0) c Jj5 rii s * o> OJ 00 W Si. 4 (H OQ §5 S (h 94 ^ -«1 >> r-'^ /-^*— . &H ^ 1 ;^s JS2 fe Vl "S 00 w H ec eo ^ !2; -p^s- ^-v-' ^-v-^ 3 3i§i (h ;?; o> <3» »o &^ Si 5 S5 S^ ^ Iz; N ec rrl H H -< 43 1^ Tj< ^ 00 00 iM ^^ ^ ^ a» (S Pi r-^^s S : "S : is S : 5S : 3 »' g-^- §t •s s 5i^^ S'- 00 CD 5 Is ' II 13 1 5 < ^ g ^ ^ 612 Appendices. — England. Table III. Payments to (a) Deposit Contributors who have emigrated ; (6) Eepre- SENTATIVES OF DECEASED CONTRIBUTORS, AND (c) MaRRIED WoMEN SUS- PENDED FROM ORDINARY BENEFITS. Payment on Emigration. Payment at Death. Married Women's Special Benefit. ^ex. No. Amount. No. Amount. No. Payments from Contributions. State Grants. Total. Men Women ... 478 238 £ 8. d 186 18 9 68 4 9 223 58 £ s. d 89 10 6 15- 8 9 113 £ s. d 31 2 £ s. d 10 7 6 £ s. d 41 9 6 Totals ... 716 265 3 6 281 104 19 3 ll3 31 2 10 7 6 41 9 6 Table IV. General Summary of Benefit Payments to Deposit Contributors. Men. Women. Men and Women. Number of Pay- ments. Amount. Number of Pay- ments. Amount. Number of Pay- ments. Amount. Sickness Benefit ... Maternity Benefit ... Married Women's Special Benefit. 16,568 3,880 £ s. 7,757 6 4,171 11 d 4 7,744 287 113 £ s. d 3,178 1 218 5 10 41 9 6 24,312 4,167 113 £ s. d 10,935 6 5 4,389 16 10 41 9 6 Total 20,448 11,928 17 4 8,144 3,437 15 5 28,592 15,366 12 9 Payment on Emigra- tion Payment at Death ... 478 223 186 18 89 10 9 6 238 58 68 4 9 15 8 9 716 281 255 3 6 104 19 3 Total 701 276 9 3 296 83 13 6 997 360 2 9 Grand Total ... 21,149 12,205 6 7 8,440 3,521 8 11 29,589 15,726 15 6 Appendices. — England. 513 APPENDIX XIX. England. Particulars relating to the Issue of Certificates of Exemption. Table I. Statement showing the Number of Claims for Exemption under Section 2 OF the Act of 1911, and Section 5 of the Act of 1913, received AND dealt with FROM IST APRIL, 1913, TO 31ST MaRCH, 1914. {In continuation of Appendix XIX, page 626 of the last Report.) 1 No. of Claims ! No. of Certifi- No. of Claims . '• No. of received. cates granted. refused. 1 Claims in Month. hand at 1 1 1 1 1 end of ^^h. Total. 1 Month. Total. Per 1 Month. Total. : each Month. April, 1913 ... May 1,600 114,494 1,365 93,116 212 21,098 280 1,519 116,013 1,467 94,583 238 21,336 94 June ... 1,496 117,509 1,360 95,943 172 21,508 58 July 1,682 119,191 1,517 97,460 203 21,711 20 August 1,095 120,286 845 98,305 167 21,878 103 September ... 1,277 121,563 1,092 99.397 143 22,021 145 October 1,461 123,024 1,275 100,672 113 22,134 218 November 1,330 124,354 1,074 101,746 148 22,282 326 December 1,078 125,432 1,131 102,877 151 22,433 122 January, 1914 1,084 126,516 743 103,620 104 22,537 359 February 1,004 127,520 937 104,557 126 22,663 300 March 1 1,013 128,533 911 i 105,468 114 22,777 288 Table II. Statement showing the total Number of Certificates of Exemption granted from 15th July, 1912, to 31st March, 1914 :- («) Certificates granted from 15th July, 1912, to July, 1913 (6) Certificates granted from 14th July, 1913, to March, 1914 13th 31st 96,339 9,129 Total 105,468 Table III. Statement showing the total Number of Certificates of Exemption which were either cancelled or not renewed during the Period 15th July, 1912, to 31st March, 1914 :— (a) Certificates cancelled during the period 15th July, 1912, to 13th July, 1913, or not renewed at 13th July, 1913 (6) Certificates cancelled during the period 14th July, 1913, to 31st March, 1914 36,928 5,393 Total 42,321 Table IV. . Statement showing the total Number of Certificates of Exemption in FORCE ON 31sT March, 1914: — (a) Certificates of Exemption ren^tjoed b.^, from 14th July, 1913... 59,411 (6) Certificates granted between 14th July, 1913, and 31st March, 1914 9,129 (c) Less Certificates cancelled between 14th July, 1913, and 31st March, 1914 ... Total Number of Certificates current at 31st March, 1914 68,540 5,393 63,147 (B254— Gp. 5) 514 A'ppendices.— England. Table V. Statement setting out the Particular Ground on which the Certificates CURRENT ON 31ST MaRCH, 1914, WERE GRANTED :— (a) PeThsion or Income : — (a) Pension (mainly for Army, Navy and Police) ... 19,253 {h) Income ... .;. ... 20,708. (b) Dependence: — ■ (a) Married women dependent upon their husbands ... 13,029 (6) Apprentices, or young persons dependent upon parents or guardians ... ... 8,186 (c) Dependent persons other than those in (a) and (6)... 1,821 (c) Occupation ... ... ... ... ... ... ... 150 Total ... 63,147 Table VI. Statebibnt showing the Number of Exempt Persons entitled, to MedicaL AND Sanatorium Benefits. (a) Number of persons entitled to benefit on 12th January, 1914, by reason of 13 contributions having been paid in respect of them prior to sixth quarter in terms of paragraph 2 of Section 3 (2) of the Regulations relating to the Benefits of Exempt Persons ... ... ... 35,366 (6) Number of persons who became entitled to benefit after 12th January, 1914, by reason of 20 contributions having been paid in respect of them in accordance with the terms of Section 3 (1) of the Regulations relating to the Benefits of Exempt Persons 265 Total number of Exempt Persons in benefit on 31st March, 1914 ... 35,631 APPENDIX XX, England. List giving particulars of the Authorities, &c., to whom Cer- tificates of Exception have been granted under paragraphs (b) and (c) of Part II of the First Schedule to the Act of 1911, from 1st April, 1913, to 31st May, 1914, by the Joint Committee acting jointly with the Commission, and also the approximate number of persons to whose employment such Certificates apply. Name of Authority and approximate number of Date from which Certificate persons affected. is drawn to operate. Government Dupartments, Ac- Road Board, The (figures not available) 15th July, 1912. South Africa, The High Commissioner for the 6th May, 1913. Union Government of : male, 3 ; female, 1 ; ^ total, 4. County Councils (including Police Authorities) — Isleof Ely : male, 74... 6th May, 1913. Appendices. — England. 516 Date from which Certificate is drawn to operate. Name of Authority and approximate number of persons affected. Councils of County Boroughs — Birmingham : male, 14 Liverpool : male, 624 ; female, 1,069 ; total, 1,693 Southend-on-Sea (Police) : male, 100 Wallasey (Police) : male, 89 Councils of Non-County Boroughs — Doncaster : male, 43 Corporation of the City of London and Councils OF Metropolitan Boroughs — City of London Corporation : male, 5 ; female, 5 ; total 10 Hackney : male, 370 ; female, 16 ; total, 386 Guardians of the Poor — Blackburn Union : female, 1 Chichester Union : male, 1 Farnham Union : female, 1 Holbeck Union : male, 2 Leeds, Township of : male, 8 Lymington Union : male, 2 ; female, 4 ; total, 6... Sunderland Union : male, 3 Tam worth Union : male, 1 ; female, 1 ; total, 2 ... Winslow Union : female, 1 Asylums Authorities — Barnsley Hall Asylum Visiting Committee : male, 84 ; female, 59 ; total, 143. Cambridgeshire, Isle of Ely, and Borough of Cam- bridge Lunatic Asylum : male, 62 ; female, 46 ; total, 108. Devon County Lunatic Asylum Visiting Com- mittee : male, 142 ; female, 124 ; total, 266. Durham County Asylum Visiting Committee : male, 171 ; female, 104 ; total, 275. Gateshead Town Council Asylum Visiting Com- mittee : male, 41 ; female, 42 ; total, 83. Hampshire (County) Asylum Visiting Committee : male, 8 ; female, 4 ; total, 12. Hull City Asylum Visiting Committee : male, 55 ; female, 37 ; total, 92. Isle of Wight County Asylum Visiting Committee : male, 24 ; female, 32 ; total, 56. West Ham County Borough Asylum Visiting Committee : male, 3. Local and other Public Authorities (Unclas- sified) — Manchester, North : The Overseers of the Poor of 22nd April, 1913. the Township of : male, 2. Port of London Authority, The : male, 383 ... 28th May, 1913. Sheffield and Ecclesall, The Overseers of the Poor 1st October, 1913. of the Townships of : male, 28. 23rd July, 1913. 12th January, 1914. 1st April, 1914. 23rd August, 1913. 5th August, 1913. 26th May, 1914. 2nd May, 1913. 29th January, 1913. 28th April, 1914. 1st January, 1914. 23rd February, 1914. 21st April, 1914. 1st October, 1913. 2nd April, 1914. 4th November, 1912. nth April, 1913. 14th July, 1913. 27th May, 1913. 20th June, 1913. 12th June, 1913. 8th May, 1914. 27th November, 1913. 10th June, 1913. 12th August, 1913. 17th June, 1913. Ra-Ilway Companies and Joint Committees of two or more such Companies — Great Northern Railway Company : male, 1 23rd April, 1914. (B254— Gp. 5) R 2 516 Appendices. — England. APPENDIX XXI. England. List of Official Publications of the National Health Insurance Joint Committee and the National Health Insurance Com- mission (England) and of Publications of other Pepartments relating to National Health Insurance. [Revised to 1st June, 1914,] The following publications can be purchased, either directly or through any Bookseller, from the Government Sale Agents— Wyman and Sons. Ltd., Fetter Lane, London, E.G., 28, Abingdon Street, Westminster, London, S.W., and 54, St. Mary Street, Cardiff ; or the Clerk in charge. Publications Department, H.M. Stationery Office, 23, Forth Street, Edinburgh ; or E. Ponsonby, Ltd., 116, Grafton Street, Dublin. Application for any of the documents named should therefore be made to these Agents and not to the Offices of the Commission. The prices stated are for inland postap^e only. The publications in the List can be ordered in the British Colonies and Dependencies, the United States of America, the Continent of Europe and Abroad from the Agencies of T. Fisher Unwin. Documents marked with an asterisk (*) have been published since the date of the List published as App97idix XX to the Report for 1912-13. CLASSIFICATION. General Approved Societies Benefits ... Contributions ... Deposit Contributors Disputes and Decision of Ques- tions Exemptions and Exceptions Insurance Committees . . Investments Married Women Page 516 517 518 520 520 520 521 521 522 522 Mercantile Mai"ine Miscellaneous ... Naval and Military Forces, &c. Outworkers Panel, Pharmaceutical and Local Medical Committees . . . Special Customs, Sec. 47 Special Order Procedure Staff of the Commission, &c. ... Tables Voluntary Contributors Page 523 523 523 524 524 525 525 525 526 526 GENERAL. National Insurance Act, 1911. Price Qd. [By post, Sd], or is. 3d [By post, Is. 6d]. ■^^National Insurance Act, 1913. Price \^d. [By post, 2d], or 3d [By post 4d]. Index to the Health Insurance Provisions of the National Insurance Act, 1911 [Cd. 6468]. Price 3^d [By post, 4|d]. Joint Committee Regulations, dated 21st February, 1912, made under Section 83 of the National Insurance Act, 1911, by the Treasury [H.O. 46/1912]. Price Id [By post, \\d.\ *Joint Committee Amendment Regiilations, 1913, dated 7th August, 1913 {Provisional), made under Section 83 of the National Insurance Act, 1911, by the Treasury [H.C. 275/1913]. Price |d [By post, Id]. ^Incorporation of Joint Committee Regulations, 1913, dated 18th August, 1913 {Provisional), made by the Treasury. Price Id [By post, Ijd]. * Joint Committee Regulations, 1913, dated 9th October, 1913 {Provisional), made by the Treasury under Section 83 of the National Insurance Act, 1911. Price Id [By post, l^d]. Memorandum on the steps taken preliminary to the operation of Part I. of the National Insurance Act, 1911 [Cd. 6095], February, 1912. Price \\d. [By post, 2d]. Appendices. — England. 617 Interdepartmental Committee on Employment under the Crown as affected by Part I. of the National Insurance Act, 1911 : — First Report, May, 1912 [Cd. 6234]. Price 2^d. [By post, 3^.]- Second Report, June, 1912 [Cd. 6315]. Price Id. [By post, l^d.]. *Third Report, October, 1913 [Cd. 7176]. Price l^d. [By post, 2c/.]. t Report for 1912-13 on the Administration of the National Insurance Act, 1911. Part I. (Health Insurance) [Cd. 6907]. Price 2«. 9d. [By post, Ss. 2d.]. National Insurance Act, 1911, Amendment Bill :— ^Actuarial Report upon the Financial proposals of the BiU as introduced [Cd. 6898]. Price Id. [By post, IM.]. •^Memorandum upon the general objects of the Bill as introduced [Cd. 6914]. Price Id. [By post, l^d.]. ^Actuarial Report upon the Financial proposals of the Bill as amended by Standing Committee C [Cd. 6984]. Price Id. [By post, iM- *Note on Clause 8.— Calculation of Arrears [Cd. 6985]. Price 1^?. [By post, l^d.]. ^National' Insurance Act, 1913 (Dates of Commencement) Order, 1913, dated 23rd August, 1913 [Cd. 7074]. Price ^d. [By post, Id.]. *Expiring Orders Continuance Order, 1913, dated 31st December, 1913, made under Section 78 of the National Insurance Act, 1911 [Cd. 7216]. Price ^d. [By post. Id.]. APPROVED SOCIETIES. (a) Approval, <&c. "^List 14 (a). List of Societies Approved up to 31st December, 1913, by the National Health Insurance Joint Committee and by the Insurance Com- missioners for England, Scotland, Ireland and Wales. Price Qd. [By post, 11^0?.]. Constitution of Unregistered Societies Regulations, 1912, dated 17th April, 1912 [H.C. 95/1912]. Price \d. [By post, Id.]. Constitution of Sections Regulations, 1912, dated 6th June, 1912 [H.C. 151/1912]. Price \d. [By post, \d.]. Form A.S. 1. Approval of Societies, Preliminary Statement. "| Price ^. each Do. A.S. 2. Preliminary Statement, New Society. [By post, \d.\ Do. A.S. 3. (Revised.) Application for Approval of an I]x- 100 for 2«. Qd. isting Society. {Xot applicable to a Separate [By post, Section.) J>- A.S. 1, Do. A.S. 4. (Revised.) Application for Approval of a 2, 3, 4 & 19, Separate Section. 2«. lOd. ; Do. A.S. 7. Application for Membership of Society (Card). A.S. 7, Do. A.S. 19. Application for Approval of a new Society. j 3^. 2o?.]. ^Amalgamation and Transfer of Engagements Reg^ations, 1914. Draft dated 31st March, 1914. Price \\d. [By post, 2^.] *Dissolution of Societies Regulations, 1914. Draft dated 3rd April, 1914. Price Id. [By post, l\d.]. ^Withdrawal of Approval Regulations, 1914. Draft dated 3rd April, 1914. Price \d. [By post, \\d.]. (b) Model Rides. *Ameaidment of Rules Booklet, showing the amendments in the Model Rules necessary in consequence of the passing of the National Insurance Act, 1913. Price \d. [By post. Id.], or Is. M. per 100 [By post, \s. 1d.\ or 10^. per 1,000 [By rail, carriage forward]. Model Rules A and C (combined). For Male and Female Members. (To be appended as Part II. to the existing Rules of a Society seeking approval as a whole.) Price 1<:/. [By post, ifc?.]., or \s. for 12 [By post. Is. 4c?. J, or 6s. per 100 [By rail, carriage forward]. Model Rules B. (Revised). For a new Society or a Separate Section with Male Members only. Price \d. [By post, 2o?.], or \s. for 12 [By post, \s. 5o?.], or 6s. per 100 [By rail, carriage forward]. J This is now out of print. A reprint of those portions of the volume relating to the National Health Insurance Joint Committee and the National Health Insurance Commission (England) will shortly be available. (B254— Gp. 5) R 3 510 Appendices. — England. Model Rules D. For a Society with Women Members only. Price Id. [By post 2o?.], or Is. for 12 [By post Is. 5o?.], or 6s. per 100 [By rail, carriage forward]. Model RtQes E. For a new Centralized Society having a Delegate system and including both Men and Women Members. (A supplement to Model Rules A. and C.) Price ^d. [By post, Id J, or 6d. for 12 [By post, 8rf.], or 35. per 100 [By post, 3*. 7d]. Model Rules P. (Abstract.) (Revised.) A supplement to Model Rules A. and C, forming in conjunction with them a complete set of Rules for the conduct of business under the National Insurance Act, 1911. Price ^d. [By post, Id.l or 6d. for 12 [By post, 8o?.], or 3«. per 100 [By post, 3^. 7d]. (c) Fi7iance, <&c. Accounts of Approved Societies Regulations, 1912, dated 12th July, 1912 [H.C. 241/1912]. Price 2d. [By post, 2^d.]. Do. Do. Draft dated 31st Jan., 1913. Price 2d. [By post, 2id.l Initial Expenses Order, 1912, dated 2nd October, 1912, made under Section 78 of the National Insurance Act, 1911 [Cd. 6437]. Price ^d. [By post, lo?.]. Pajrments by Approved Societies to Insurance Committees Order, 1912, dated 14th October, 1912, made under Section 78 of the National Insurance Act, 1911 [Cd. 6456.] Price ^d. [By post, Id.] ^Transactions between Insurance Commissioners and Societies Regula- tions, 1913, dated 12th September, 1913. {Provisional and Draft). Price Id. [By post, l^d.]. '^Societies' Administration Expenses Regulations, 1913, dated 24th October, 1913 (Provisional and Draft). Price Ic^. [By post, l^d.]. ■^Preliminary Expenses Order, 1914, dated 19th January, 1914, made under Section 78 of the National Insurance Act, 1911 [Cd. 7259]. Price ^d. [By post, 1<^.]. ■^Subscriptions and Donations Regulations, 1914, dated 31st March, 1914 [H.C. 183/1914]. Price ^d. [By post, l^d.]. (d) Miscellaneous. *^m% for Joining an Approved Society Regulations, 1914, dated 24th March, 1914 [H.C. 168/1914]. Price \d. [By post, \\d.\ Place of Meeting of Approved Societies Regulations, 1913. Draft dated 7th March, 1913. Price \d. [By post, \\d.\ "^Membership of Approved Societies Order, 1913, dated 26th September, 1913, made under Section 78 of ihe National Insurance Act, 1911 [Cd. 7116]. Price \d. [By post, \d.\ See also under Disputes^ c&c. Insurance Committees, Naval and Military Forces, and Tables. BENEFITS. (a) Medical. Report of Sir William Plender to the Chancellor of the Exchequer on the result of his investigation into existing conditions in respect of medical attendance and remuneration in certain towns, July, 1912 [Cd. 6305]. Price \d. [By post, l^o?.]. Official Representations of the British Medical Association regarding the Administration of Medical Benefit and the reply of the Joint Committee thereto, July, 1912 [Cd. 6328]. Price l\d. [By jDost 2o?.]. Statements as to the Administration of Medical Benefit and Corre- spondence thereon between the Chancellor of the Exchequer and the British Medical Association, December, 1912 [Cd. 6520]. Price Z\d. [By J30St, 4^<^.]. anatory Statement as to Medical Benefit as affecting Medical " Practitioners, December, 1912, [Cd. 6542]. Price l\d. [By post, 2d.y Letter from the Chancellor of the Exchequer to the National Insurance Practitioners' Association, dated 18th December, 1912 [Cd. 6557]. Price \d. [By post. Id.]. Appendices. — England: 519 Memorandum explanatory of Medical Benefit under the German Sickness ■ Insurance Legislation, January, 1913 [Gd. 6581]. Price 4:^d. [By post, 5K]. ♦Conditions imposed by Section 15 (5) (iii) of the National Insurance Act, 1911, on the supply of Medicines to Insured Persons, Report of Departmental Committee, 9th June, 1913 :— Vol. I.— Report [Cd. 6853]. Price 2^d. [By post, 3c?.]. Vol. II. — Evidence and Appendices [Cd. 6854]. Price Is. 4:d. [By post. Is. 7d.]. ♦Medical Benefit Regulations, 1913, dated 10th January, 1914 [S. R. & 0., 1914, No. 5]. Price S^d. [By post, 4|i.]. (b) Sanatorium. Departmental Committee on Tuberculosis : — Interim Report, April, 1912 [Cd. 6164]. Price 3d. [By post, 4c?.]. Final Report, March, 1913 :— Vol. I.— Report [Cd. 6641]. Price 2^d. [By post, 3c?.]. Vol. II.— Appendix [Cd. 6654]. Price Is. l\d. [By post. Is. ll^d]. Order as to the Domiciliary Treatment of Tuberculosis dated 26th July, 1912, made by the Local Government Board under Section 16 (1) {b) of the National Insurance Act, 1911. [S. R. & O., 1912, No. 1038]. Price \d. [By_post, Ijc?.]. >lic Public Health (Tuberculosis) Regulations, 1912, dated 19th December, 1912, made by the Local Government Board. [S. R. & O., 1912, No. 1813]. Price \d. [By post, l^o?.]. Form Med. 1. Application to Insurance Committee for^ Price \d. each. Sanatorium Benefit. | [By post, Ic?.], Do. Med. 3. Form of letter to Tuberculosis Officer j- or* 2s. Qd. per referring Applicants for Sanatorium I 100 [By post. Benefit to him. J 2s. 10c?.]. Administration of Sanatorium Benefit. Memorandum dated 12th February, 1913, and Return, 15th July to 20th November, 1912 [Cd. 6625]. Price Id. [By post, \hd.\ * Administration of Sanatorium Benefit. Return, 15th July, 1912 to 30th April, 1913 [Cd. 6884]. Price \d. [By post, Id.]. ♦Administration of Sanatorium Benefit. Return, 15th July, 1912 to 11th January, 1914 [Cd. 7386]. Price Ic^. [By post, l^c^.]. ♦List of Sanatoria approved by the Local Government Board under the National Insurance Act, 1911, for England and Wales. 31st January, 1914; Price Ic?. [By post, l\d.\ (c) Miscellaneous. Behaviour during Disease Regulations, 1912, dated 25th June, 1912 [H.C. 174/1912]. Price \d. [By post, Ic^.]. Memorandum and Report on Substituted Benefits under Section 13 of the National Insurance Act, 1911, with Actuarial Memorandum. July, 1912 [Cd. 6292]. Price b\d. [By post, 7c?.]. Contributions to Superannuation Funds Regulations, 1913, dated 15th April, 1913 [H.C. 74/1913]. Price \d. [By post, ld.\ Handbook to the Administration of Sickness and Maternity Benefits by Approved Societies. Provisional Issue, 13th January to 14th July, 1913. Price 4c/. [By post, bd.\ N.B. — A revised edition is in course of preparation and will be issued shortly. ♦Rules as to Applications dealing with Benefits under the National Insurance Act, 1911, dated 2nd July, 1913, made by the Lord Chancellor under the Lunacy Acts [S. R. and O., 1913, No. 714]. Price Ic?. [By post, ♦Transition to Full Rate of Benefit Regulations, 1914, dated 28th May, 1914 [H.C. 282/1914]. Price \d. [By post, Ic/.]. ♦Payment of Benefits through the Post, Report of Interdepartmental Committee, 11th December, 1913 [Cd. 7245 J. Price l^d. [By post, 2c;.]. (B254— Gp. 5) R 4 520 Appendices. — England. ♦Reduced Rate of Sickness Benefit Regulations, il914, dated 26th May, 1914 [H.C. 262/1914]. Price ^d. [By post, Id.]. ^^^ See also under Tables, MarHed Women, \ Naval \\and Military Forces, Deposit Contributors and Mercantile Marine. CONTRIBUTIONS. ♦Collection of Contributions, Consolidated Regulations, 1914, dated 9th January, 1914 {Provisional and Draft). Price ^^d. [By post, 4^(i], Kegulations made by the Board of Trade under Section 99 of the National Insurance Act, 1911, as to Arrangements with Employers for Per- formance of their Duties by Labour Exchanges, dated 25th June, 1912 [H.C. 175/1912]. Price \d. [By post, If/.]. ♦Arrears 'Order, 1913, dated 11th October, 1913, made under Section 78 of the National Insurance Act, 1911 [Cd. 7124]. Price \d. [By post. Id]. ♦Arrears Regulations, 1914, dated 10th January, 1914 {Provisional and Draft). Price Id. [By post, \\d.\ ♦Arrears Regulations, 1914 (No. 2). Draft dated 8th May, 1914. Price Id. [By post, \\d.]. ♦Memorandum on the Arrears of Contributions of Employed Contributors, 29th May, 1914 [Cd. 7431]. Price Id. [By post, l^d.]. ♦Insurance Stamps Regulations, dated 6th February, 1914, made by the Commissioners of Inland Ee venue under Section 108 of the National Insurance Act, 1911 [H.C. 163/1914]. Price \d. [By post, Id.]. See also under Naval and Military Forces, ExemptioTis, Mercantile, Marine, Voluntary Contributors, and Investments. DEPOSIT CONTRIBUTORS. Transfer of Deposit Contributors Order, 1913, dated 12th February, 1913, made under Section 78 of the National Insurance Act, 1911 [Cd. 6630]. Price ^d. [By post, Id.]. ^-— — ♦Transfer of Deposit Contributors Order, 1913 (No. 2), dated' 2nd July, 1913, made under Section 78 of the National Insurance Act, 1911 [Cd. 6915]. Price \d. [By post Id]. ♦Transfer of Deposit Contributors Order, 1914, dated 27th April, 1914, made under Section 78 of the National Insurance Act, 1911 [Cd. 7389]. Price ^d. [By post, \d.\ ♦Deposit Contributors, Payments on Death Regulations, 1913, dated 26th September, 1913 [S. R. & O., 1913, No. 1036]. Price Id [By post, \\d.\ ♦Reasons why certain Insured Persons became Deposit Contributors. Report by the Chief Inspector to the National Health Insurance Commission (England) on an Enquiry, 23rd June, 1913 [Cd. 7039]. Price l^d [By post, 2d] ♦Deposit Contributors Benefits Order, 1913, dated 18th December, 1913, made under Section 78 of the National Insurance Act, 1911 [Cd. 7199]. Price \d. [By post. Id]. ♦Deposit Contributors Administration Expenses Regulations, 1914,_dated 13th May, 1914 [H.C. 233/1914]. Price ^d [By post. Id]. .^ :^ ♦Outstanding Reserve Values Order, 1914, dated 23rd January, 1914,'made under Section 78 of the National Insurance Act, 1911 [Cd. 7244]. Price \d. [By post. Id]. See also under Contributioiw, DISPUTES AND DECISION OF QUESTIONS. Rules of the Supreme Court as to Proceedings under Section 66 of the National Insurance Act, 1911, dated I5th May, 1912. [S. R. & O., 1912, No. 575.] Price Id [By post, l^d]. County Court Rules under Sections 66 and 68 of the National Insurance Act, 1911, made by the Rule Committee of the Supreme Court, dated 26th July, 1912. [S. R. & O., 1912, No. 1224]. Price Id [By post, l^d]. Decision of Cluestions Regulations, 1913, dated 19th March, 1913 [H.C. 23/1913]. Price Id [By post, l^d]. Appendices. — England. 621 ♦Decision of Guestions Regulations, 1913 (No. 2), dated 2nd December, 1913 {Pi'ovisional and Draft). Price \cl. [By post, \\d:'\. ♦Memoranda of Decisions given up to December 31st, 1913, under Section 66 of the National Insurance Act, 1911, and Section 27 (2) of the National Insurance Act, 1913 (with Index), Price Qd. [By post, 1\d.\ Appeals and Disputes Regulations, 1912, dated 2nd December, 1912 {Provi- sional) [H.C. 384/1912]. Price Id. [By post, \\d.]. Draft. Price Ic^. [By post, \\d.']. EXEMPTIONS AND EXCEPTIONS. ♦Claims for Exemption Regulations, 1914, dated 31st March, 1914 [H.C. 175/1914.]. Price \d. [By post, \d.\ ♦Exempt Persons Benefits Regulations, 1913, dated 20th December, 1913 {Provisional and Draft). Price \d. [By post, l^o?.]. Value of Contributions : Exempted Institutions Regulations, 1913, dated 25th January, 1913 [H.C. 467/1912.]. Price \d. [By post, \d.]. Value of Contributions : Teachers Regulations, 1912, D)-aft dated 17th September, 1912. Price \d. [By post, V^d.']. Share Fishermen— Penzance and St. Ives— Special Order, dated 19th March, 1913 [H.C. 22/1913.]. Price \d. [By post. Id.]. Subsidiary Employment, Provisional Special Orders:— No. 1, 1912, dated 13th July, 1912, [H.C. 244/1912]. Price ^. [By post, Irf.J. Various part time occupations. No. 2, 1912, dated 13th July, 1912 [H.C. 245/1912]. Price \d. .[By post, \d.\ Fruit Pickers, o&c, previously exempted. No. 3, 1912, dated 13th July, 1912 [H.C. 246/1912]. Price ^d. [By post, Id.']. Various part time occupations. No. 4, 1912, dated 30th December, 1912 [H.C. 415/1912]. Price \d. [By post, lm/jf. Price Id [By post, l^d.]. ^Transfer Values Regulations, 1914, dated 28th May, 1914. {Provisional), [H.C. 259/1914]. Price 2^d. [By post, 3d]. Draft. Price 2\d. [By post, 3d]. ^Tables showing the Transfer Value under Section 44, sub-section (1) of the National Insurance Act, 1911. See Married Women's Transfer Value Regulations^ 1914, on p. 523. (Form A.S. 34 is now obsolete.) VOLUNTARY CONTRIBUTORS. Transfer from Voluntary to Employed Rate Regulations, 1913, dated 28th March, 1913 [H.C. 39/1913]. Price \d. [By post. Id]. ^Voluntary Rate Regulations, 1914, dated 2nd June, 1914. Draft. Price Irf. [By post, l^d]. See also under Married Women, Appendices. — Scotland. 62,7 APPENDICES TO PART IV. NATIONAL HEALTH INSURANCE COMMISSION (SCOTLAND). PAGE. XXII. Number and classification of insured persons (based on first quarter cards) ... ... ... ... ... ... ... 528 XXIII. Particulars relating to the issue of certificates of exemption 528 XXIV. Questions submitted to the Commission for decision under Section 66 of the Act of 1911 531 XXV. Statement showing the classes of employment (other than in Government Departments) specified in Special Orders under subsection (1) of Section 47 of the Act of 1911, in respect of which employers have adopted the special provisions of the Section, and the number of employers who have given notice in respect of each such class ... ... ... ... 632 XXVI. Deposit contributors. — Table showing number of con- tributors who entered into insurance during each quarter 533 XXVII. Deposit contributors. — Table showing the number of in- sured persons, not members of Approved Societies, who surrendered cards for each quarter 533 XXVIII. Deposit contributors. — Particulars as to the number and amount of benefit payments in the year ended 11th January, 1914 534 XXIX. Claasification of Approved Societies ... 536 XXX. Table showing the approximate distribution of members of Approved Societies among the various types of Societies for the quarter ended 13th April, 1913 536 XXXI. Table showing the number of representatives of insured persons on each Insurance Committee ... ... ... 587 XXXII. Statement showing the number of doctors and chemists on the lists of Insurance Committees as at 12th January, 1914 538 XXXIII. Statement^of drug accounts — January, 1913 to January, 1914 640 XXXIV. Administration of sanatorium benefit for the period from 15th July, 1912 to 11th January, 1914 642 XXXV. Table showing the number of institutions approved in Scotland for the treatment of tuberculosis, the number of beds therein, and the number of approved dispensaries, in 1912, 1913, and 1914 .,. 543 XXXVI. Table showing the number of institutions in Scottish Civil Counties approved by the Local Government Board for Scotland for the treatment of tuberculosis as at 11th January, 1914, the number of beds therein, and the number of approved dispensaries 644 XXXVII. Table showing the number and classes of exempt persons who were entitled on the 12th January, 1914, to medical and sanatorium benefits, and the number and classes of exempt persons who have sent in declarations in connection with medical and sanatorium benefits under Section 9 of the Act of 1913, but who have Tiot yet the requisite number of contributions standing at their credit to qualify for benefit ... ... ... ... ... ... ... ,,. 545 XXXVIII. Table showing the sums paid over to Insurance Committees for medical and sanatorium benefits and administration expenses within the financial year from 12th January, 1913, to 11th January, 1914 546 XXXIX. Statement showing the distribution of the special grant for mileage for 1913 ... ... 547 XL. Statement showing receipts into and payments out of the Scottish National Health Insurance Fund from 15th July, 1912 to 11th January, 1914 648 528 Appendices.— Scotland. APPENDIX XXII. Scotland. Number and Classification of Insured Persons (Based on First Quarter Cards). Class of Insured Person. Men. Women. Total. (1) Employed Contributors ... f under 45 at entry . . . "Voluntary over 45 at entry ... Contri- ^ Special Married Wo- butors, 1 men Voluntary t Contributors 1,051,183 1,082 159 446,275 361 66 9 1,497,458 1,443 225 9 (2) Members of Approved Societies... Deposit Contri butors 1,023,910 28,514 431,710 15,001 1,455,620 43,515 (3)j British Subjects > Aliens r : ^ or (4) All Classes ... 1,047,845 4,579 446,169 542 1,494,014 5,121 1,052,424 446,711 1,499,135 ]Yote. — The number of Deposit Contributors transferred to Approved Societies (up to 11th January, 1914) was 8,226. APPENDIX XXIII. Scotland. Particulars relating to the Issue of Certificates of Exemption. Table I. Number of Claims for Exemption received since the Commencement OF the Act. Granted. Refused. Otherwise disposed of. Total. Claims received up to 31st March, 1913 ... Claims received between Ist April, 1913, and 11th January, 1914 ... 11,108 1,747 3,207 . 221 352 65 14,667 2,033 Total number of Claims received up to 11th January, 1914 ... .12,855 3,428 417 16,700 Appendices. — Scotland. 529 Table II. Analysis of Claims for Exemption received up to 11th January, 1914. Figures in Italics refer to Claims Received between \st September, 1912, and Wth January, 1914. Under 21 years of age. Over 21 and under 65 years of age. Over 65 years of age. Total. Number of Claims _ from men > ... 4,719 (^,6^5) 1 4,995 (i,j^<55) Number of Claims ' { from women, ...! 700 ((5^9)15,528(^^6) 587 (97) 171 {58) 10,301 {8,997) 6,399 {2,708) Number of ! Number of I Number of Applications \ Certificates ! Certificates Keceived. Issued. Refused. Claims under Section 2 (1) (a). Men:— Pensioners 1,661 {330) 1,647 {32Jt) 14 (^) Apprentices (Trade and Pro- fessional) ... 126 {60) 126 {60) — — Other Men 2,730 (679) 2,437 {586) 293 {93) Women 982 {378) 939 {361) 43 {17) Total numb«r of Claims under Section 2 (1) (a)... 5,499 {IMl) 5,149 {1,331) 350 {116) Claims under Section 2 (1) (b). Mm:^ Apprentices 4,285 {2,358) 1,110 {521) 3,433 {1,953) 858 {JtOS) Others ; 647 {mi) 463 {150) Single Women : — Apprentices 314 {16Jt) 231 {128) 83 (36) Others 1,019 (^9) 572 {300) 447 {139) Married Women: — Fish workers Other married women 1,723 {531) 2,191 {1,165) 1 2,919 (i,505) 995 {393) Total number of Claims under Section 2 (1) (b)... 10,642 {5,178) 7,802 (^055) 2,846 {1,123) Claims undei' Section 2 (1) (c). Section only operative from ■" . 1st September, 1913. Men ... ... ... 101 WoTnen ... 3/ 13 {13) 9 (9) 4. . w Miscellaneous Claims from per- sons entirely outwith'the Act, &c 546 {62) — — — — Total 16,700 {6,700) 12,960 {5,395) 3,200 {1,21(3) 6B0 Appendices. — Scotland. Table III. Statement showing the Number of Claims for Exemption received from CERTAIN Localities up to 11th January, 1914. Place. No. of Clairas. Glasgow .,. 3,400 Edinburgh Aberdeen Paisley Greenock Dundee Montrose Fraserburgh Peterhead Wick ... Perth ... Leith . . . Total 1,486 296 274 497 265 383 424 512 195 311 10,692 Table IV. Statement showing the Classes of Exempt Persons who held Certificates OF Exemption on the 11th January, 1914. Certificates under Section 2 (1) (a) : — Men : — Pensioners 1,121 Apprentices 66 Others ... 1,765 Women 677 Gertifixiates under Section 2 (1) (b) :- Men : — Apprentices Others Single Wotnen: — Apprentices Others Married Women: — Fish workers Dependent on husband Certifixiates wider Section 2 (1) (c) Total 1,821 432 85 257 963 739 3,629 4,297 9 Table V. Statement showing the Number or Certificates of Exemption subsequently cancelled and the Reasons for Cancellation. Claimants now insured: — Voluntarily ... Renewal of Certificate refused 2,202 359 Now over seventy years of age Ceased employment within the meaning of the Acts Left United Kingdom ..; Left Scotland and Certificate continued by another Commission Deceased ... "Gone away" — Claimant cannot be traced Certificates subsequently found to have been claimed in error... 2,561 81 1,473 200 30 118 308 152 Total 4,923 Appendices. — Scotland. 531 Table VI. Statement showing the Number of Exempt Persons who have voluntarily GIVEN UP their Certificates of Exemption and become Insured Persons. Under Section 2 (1) (a) : — Pensioners 226 Others 248 Under Section 2 (1) (b) :— Men and Single Women: — Apprentices 1,137 Others ,. 212 Married Women: — Fish workers... ... ... ... ... ... ... ... 112 Dependent on husband 238 Others 29 Total 2,202 APPENDIX XXIV. Scotland. Questions submitted to the Commission for Decision under Section 66 of the Act of 1911. (i) Period I5th Jvly, 1912— ll^A January, 1914: — Number of Questions received 2,01 2 Number of Questions disposed of : — Decisions issued 1,683 Cases dismissed ... ... .„ ... ... ... 174 Cases withdrawn 49 Cases transferred to other Commissions 2 1,908 Number of Questions in hand ... ... ... 104 {Hy Period \st April, 1913— ll^A January, 1914 :— Number of Questions received ... ... 266 Number of Questions disposed of : — Decisions issued... 273 Cases dismissed 43 Cases withdrawn 9 Cases transferred to other Commissions 2 327 532 Appendices. — Scotland. APPENDIX XXV. Scotland. Statement showing the Classes of Employment (other than in Government Departments) specified in Special Orders under subsection (1) of Section 47 of the Act of 1911, in respect of which Employers have adopted the Special Provisions of the Section, and the Number of Employers who have given Notice in respect of each such Class. Class of Employment. Clerks Farm Servants ..." Domestic Servants Shop Assistants Warehousemen ... • Foremen, Managers or Assistant Managers Commercial Travellers Porters, Messengers, Watchmen, &c. Journalists Teachers ... Resident Tutors or Governesses Number of Employers. 286 263 153 82 62 24 16 14 8 5 4 ' Total ... *917 * The actual number of individual employers concerned is 657, as a number of employers have adopted the provisions in respect of more than one class of employment. Appendices. — Scotland. 533 APPENDIX XXVI. Scotland. Deposit Contributors.— Table showing Number of Contributors who entered into Insurance during each Quarter. Men. Women. Men and Women. -A ; "^ ^ j "© m 'd Quarter ended 1.^1 .1 1 .-S -§ M hel sit ator 1 2 11 1 blis epo rib tab ^* U% 4l _j s zr^ o Esta as D Oont a o 13th October, 1912 ... 23,974 7,162 31,136 8,054 3,317 11,371 32,028 10,479 42,507 12th- January, 1913 ... 2,321 — 2,321 1,486 — 1,486 3,807 — 3,807 13th April, 1913 1,389 — 1,389 656 — 656 2,045 — 2,045 13th July, 1913 1,650 — 1,650 1,027 — 1,027 2,677 — 2,677 12th October, 1913 ... 849 — 849 426 — 426 1,275 — 1,275 11th January, 1914 ... 987 — 987 459 — 459 1,446 — 1,446 APPENDIX XXVII. Scotland. Deposit Contributors. — Table showing Number of Insured Persons, not Members of Approved Societies, who surren- dered Cards for each Quarter. Men and Women. Quarter ended III 1 1 o d 1 13th October, 1912 r2th January, 1913 13th April, 1913 13th July, 1913 12th October, 1913 11th January, 1914 32,974 31,287 24,465 22,022 19,755 17,649 10,479 4,733* 6,460* 6,660* 6,993* 3,131* 43,453 36,020 29,925 28,682 26,748 20,780 * These represent unassociated cards and may apply to established accounts or new entrants. i i Note. — (i) Established Deposit Contributors are those insured persons, not members of Approved Societies, who have taken formal steps to establish their status. (ii) Persons who surrendered cards in error at Post Offices are excluded from the above figures. 534 Appendices. — Scotland. ■a o I . ^ rH ^ 8 s g ,£3 3 00 »o o ooo I i I o o I PI "2 cftS'^S ta 3 a ■S S § s => a OCO N oo«oo ooo 8^^ 1 1 rH i-l »o o 5P O 3 C3 'O r-( ^ d 3 3 §02 02 •*3 4) O) mj< ■<*l t- ff 1 § ■e a » <£> t- aj =4 t*. ih lb ""I '"' t- 1 t- t- 1 "p a Ph>, cd ^ c? ^ ^ a ! "0 k ^ ^_^ ' ^ i EH r 00 ^ 1 ^ •* s ag s 1 ^•s^t •-V-' ^-v-' pi] M 3 5z; 3« Partia Payme (Accou exhaust CO s ^ ^ 1 ^^ — H _ fi i II g g 1 I g • • : : m 3 S : 05 : ' ■"• * * ^ ^ w 3 : "3 : '. m •-»^ • ^o. • s ^2 ^2 5 S--* 10 rH C-b rt >^ o5 fl s "o 1 !3 1 1^ II "0 1-1 H 19 H H 55 t, II li A » •a* ,2 fl .2 a tS oj 40 O) w^ pq Apprentices) 988 (c) Income — Apprentices : — i Trade 8 Professional 24 Total under Section 2 (1) {a) ...! 1,873 //. C&rtificates issued on the ground of ' '" dependence : — (a) Dependent Professional Apprentices (c) (d) ie) Trade Apprentices Married Women Married Fishworkers Others Total under Section 2 (1) (6) Grand Totals 646 391 118 1,155 3,028 2 280 282 8 35 313 222 121 699 981 ~\^- 4,009 120 108 1 1 2.30 448 678 48 1 49 203 112 10 — 193 — i 319 1.33 i 62 588 637 1,315 (B254— Gp. 5) 546 Appendices. — Scotland, APPENDIX^ XJCJCyill. Scotland. Table showing the sums paid over to Insurance Committees for Medical and Sanatorium Benefits and Administration Expenses within the financial year from 12th January, 1913, to 11th January, 1914. County Insurance Total Burgh Insurance Total Committee. Advances. Committee. , Advances. Aberdeen £ 16,521 Aberdeen £ 24,081 Argyll 7,718 Airdrie 3,750 Ayr 29,179 Arbroath 3,289 Banff 5,397 Ayr 4,668 Berwick 3,861 Clydebank 6,983 Bute 1,712 Coatbridge 6,585 Caithness 2,778 Dumbarton 3,135 Clackmannan 5,999 Dumfries and Maxwell- 3,460 Dumbarton 9,787 town. Dumfries ... 7,477 Dundee 26,452 Elgin and Nairn ... 5,221 Dunfermline 4,936 Fife 28,668 Edinburgh 44,478 Forfar 10,852 Falkirk 4,736 Haddington 5,875 Glasgow 163,200 Inverness 5,045 Greenock 11,618 Kincardine 2,777 Hamilton 5,857 Kirkcudbright 3,769 Inverness 2,474 Lanark 42,410 Kilmarnock 5,771 Linlithgow 9,677 Kirkcaldy 6,318 Midlothian , 16,259 Leith 12,042 Orkney 1,405 Motherwell 7,125 Peebles 2,605 Paisley 13,909 Perth 9,475 Perth 4,457 Renfrew 18,350 Rutherglen 3,883 Ross and Cromarty 3,824 Stirling 3,132 Roxburgh 8,020 Wishaw 3,879 Selkirk 4,634 Stirling 15,688 Sutherland 1,368 Wigtown 3,528 Zetland 2,444 Total Grand Total Total . £292,323 £380,218 £672,541 Appendices.^— Scotland. 547 APPENDIX XXXIX. Scotland. Statement showing the Distribution of the Special Grant for Mileage for 1913. HlGHLANDSfAND ISLANDS, — ToTAL GrANT, £10,000. Main Grant. Subsidiary Grant. Total. Argyll ... Caithness Inverness Orkney . . . North Perth Ross Sutherland Zetland... £ 1,940 250 2,310 170 800 1,560 490 700 £8,220 Seamen's National Insurance Society Total for Highlands and Islands £ 225 140 325 213 165 292 125 195 £1,680 £ 2,165 390 2,635 383 965 1,852 615 895 £9,900^ 100 £10,000< Lowlands. — Total Grant, £16,000. Main Subsidiary Tnfal Grant. Grant. £ £ £ Aberdeen 1,490 450 1,940 Ayr 685 135 820 Banff 525 160 685 Berwick ... 580 415 695 Bute 215 95 310 Clackmannan and Kinross 80 20 100 Dumfries 940 78 1,018 , Dumbarton 110 25 135 ' Elgin and Nairn 765 160 925 Fife 310 40 350 Forfar 1,075 270 1,345 Haddington 580 185 765 Kincardine 400 90 490 Kirkcudbright... ... 810 170 980 Lanark... ... ... ... ... 495 140 635 Linlithgow 40 16 56 Midlothian 410 110 520 Peebles 400 125 525 4: South Perth 710 200 910 Renfrew 75 20 95 : Roxburgh 870 96 966 Selkirk 385 190 575 Stirling ... 340 80 420 ■ Wigtown 410 100 510 £12,700 £3,070 £16,770 , Seamen s National Insurance Society ... 230- Total for Lowlands ... £16,000 Grand Total £26,000 (B254— Gp. 5) s 2 548 Appendices. — Scotland, ^ o I o » Is If o 3 o ri 0" w CO o w o -^r r-l o O 00 00 f-l o OJ CD 00 \0 r-l i-l (N (M I-l »o ©q 1— 1 O CO r-l pH o (M 00 l-H CO CO 00 oq crt 1-1 Tt »0 CO O r-4 O 03 -Tj • rt O c6 "Sill's • ^ : ?§ 03 o (1) Crt 72 50 :J§ •in o) a> 0) .Th J. ;_ o3 c6 ti Sh £3 S S "^ « : 3 2 i^* 03 fH : G 02 -, rt fl ?f5 S 2 '3-«+-i p.' .2 .2 > o o 03 « 03 >■ t^ o o Ph J3 P*J2 >_ *g o o ^ r ^^ o ^d n3 ro t3 Ph ^ d d'^ 2 o .2 o d 03 o ,9 03 d pqo ^^ »0 t^ O Tt< CO CO . 00 00 O »0 r-t CO CO Tj< (>l rj< c» CO O 00 o '^ J> CO'r-T O 00^ l-H of CO '"t Tj< 00 00 I-l 00 CO ■-« I> ^ CO a> CO CO Appendices. — Ireland. ' 549 APPENDICES TO PART V. NATIONAL HEALTH INSURANCE COMMISSION (IRELAND). Page XLI. Table showing the approximate distribution of members of Approved Societies among the various types of Approved Societies for the quarter ended 13th April, 1913 ... ... 550' XLII. Statement showing the number of firms, with the number of their employees, under the different methods of quarterly stamping, for certain periods 551. XLIII. Statement showing receipts into and payments out of the Irish National Health Insurance Fund from 15th July, 191 2, to 11th January, 1914 ... ... ... ... ... ... 552' XLIV. Deposit Contributors. — Table showing number of contributors who entered into insurance during each quarter 553^ XLV. Deposit Contributors. — Table showing number of insured persons, not members of Approved Societies, who surrendered cards for each quarter 553 XL VI. Deposit Contributors. — Particulars as to the number and amount of benefit payments in the year ended 11th January, 1914 554 XL VII. Statistics relating to exempt persons 556 XLVIII. Statement showing the number of certificates of exemption granted to Irish migratory labourers under Section 81 (3) of the Act of 1911 559 (B254— Gp. 0} s o 560 Appendices. — Ireland. APPENDIX XLI. Ireland. Table showing the Approximate Distribution of Members of Approved Societies among the various Types of Societies for the Quarter ended 13th April, 1913. Societies formed by Friendly Societies with Branches. Other Friendly Societies. Trade Unions. Industrial Assurance Companies and Collecting Societies. Employers' Provident Funds. Total for all Types of Societies. Societies approved by the Joint Com- mittee :— Men ..., Women 81,042 34,729 86,907 37,011 33,841 1,309 78,678 57,533 3 2 280,471 130,584 Total 115,771 123,91^ 35,150 136,211 5 411,056 .'Societies approved by the Irish Commission : — Men Women 6,129 3,230 163,372 88,365 20,520 6,714 9,125 2,607 5,224 187 204,370 101,103 Total 9,359 251,737 27,234 11,732 5,411 305,473 Total Membership of Approved Societies in Ireland :— Men Women 87,171 37,959 250,279 125,376 54,361 8,023 87,803 60,140 5,227 189 484,841 231,687 Total ... 125,130 375,655 62,384 147,943 5,416 716,528 Appendices. — Ireland. S^ APPENDIX XLII. Ireland. Statement showing the Number of Firms, with the number of their Employees, under the different Methods of Quarterly Stamping, for certain Periods. Third Quarter ending ISth April, 1913. Method. Number of Firms. Number of Employees. Men. Women. Total. 1 2 3 4 59 5 3 1 17,760 1,962 1,246 2,100 4,496 587 1,729 180 22,256 2,549 2,975 2,280 Total 68 ,23,068 6,992 30,060 Fourth Quarter ending l^th Jidy, 1913. Alethod. Number of Firms. Number of Employees. Men. Women. Total. 1 2 3 4 60 5 2 1 17,617 2,041 746 2,125 4,655 600 1,629 200 22,272 2,641 2,375 2,325 Total 68 22,529 7,084 29,613 Fifth Quarter ending \2th October, 1913. Method. Number of Firms. Number of Employees. Men. Women. Total. 1 2 3 4 60 6 3 1 16,774 5,082 761 2,125 4,200 626 1,691 200 20,974 5,708 2,452 2,325 Total • 70 24,742 6,717 31,459 Sixth Quarter ending l\th January, 1914. Method. Number of Firms. Number of Employees. Men. Women. Total. 1 2 3 4 «0 6 3 1 16,893 4,877 761 2,125 4,219 619 1,691 200 21,112 5,496 2,452 2,325 Total ... 70 24,656 6,729 31,385 (B254— Gp. 5) s4 552 Appendices. — Ireland. c^ rH o '■' o o 1— 1 ^ 1— 1 l-H CM ^ t- ^ . o i> CO CO r— 1 CD QO Oi (~, t- ro CO 00 o tr 00 CO I— < Tf t- CD !>. o CO 05 CO eo^ (M co" t^ co" r-^ CO CO 1— 1 CO ■£•« oS" »0 I-l un t- o •^ 00 rH l-H 00 oq 85 o CO O 00 CD l^ M +3 .05 • o : 5?Ph-s3 : ^ : 5 fl a o .JB S r K ^ "^ 3 ® =8 r- O d (X) r^ d - 1^ 2^ ^^ nil 5 ce d ^^ I o a a * 2 ^ "^-" (S «j o iZ n'^ «i o^ « F _S d d is I o o o o IWHHH 02 "b d w . Appendices. — Ireland. 553 APPENDIX XLIV. Ireland. Deposit Contributors. — Table showing Number of Contributors who entered into Insurance during each Quarter. Men. Women. Men and Women. Quarter ended. i i tn id 3 o 0) .a .2 1 1 3 I'll CO 2 r") 1 a i 13th October, 1912 r2th January, 1913 13th April, 1913 13th July, 1913 12th October, 1913 11th January, 1914 6.874 986 132 90 204 246 2,728 1,612 1,340 1,500 1,513 1,200 9,602 2,498 1,472 1,590 1,717 1,446 3,922 1,684 538 ' 780 118 ! 663 71 i 698 192 I 578 112 600 6,60 1 1,318 781 769 770 712 10,796 4,412 1,524 2,292 250 2,003 161 ' 2,198 396 ! 2,091 358 i 1,800 i 15,208 3,816 2,253 2,359 2,487 2,158 APPENDIX XLV. Ireland. Deposit Contributors. — Table showing Number of Insured Persons, not Members of Approved Societies, who sur- rendered Cards for each Quarter. Men. Women. Men and Women, ^ '6 aa 'd 03 t3 Quarter ended CO |.t5 2 00 'S-"t5 -2 GO lablish Depos antribu 1 S ^ d. in 3 il s ^ tablish Depos 3ntribu 3 GQ -£1 ^So t3 H ^^6 iD H l^^o a o 13th October, 1912 6,874 2.728 9,602 3,922 1,684 5,606 10,796 4,412 15,208 12th January, 1913 6,300 2,178 8,478 3,800 1,235 i 5,035 10,100 3,413 13,513 13th April, 1913 4,984 1,986 6,970 3,204 1,016 4,220 8,188 3,002 11,190 13th July, 1913 4,116 1,849 , 5,964 2,605 880 3,485 6,720 2,729 9,449 12th October, 1913 3,208 1,600 4,808 2,196 809 3,005 6,404 2,409 7,813 11th January, 1914 3,124 j 1,548 4,672 2,124 763 1 2,877 1 5,248 2,301 7,549 Note. — (i) Established deposit contributors are those insured persons, not members of Approved Societies, who liave taken formal steps to establish their status. (ii) Persons who surrendered cards in error at Post Offices are excluded from th* above figures. 554 Appendices. — Ireland, be S.aS'f h Jcc^o ^ ^ ^ t- CO ho ^.«t j-^. t- OS OS CO 1 |«Blo • Jcooo §^l5 ^ JOOO O o ' o o o UrHrH rH o ' o rH <1B^|| < ^02 * «o 0> ■§ r-i 1 '"' rH -^ -^ '^ Sh H . «i"2 s g? s rH i CD ^ ^s" o ^ ' 50 s 1 i 1 1 1 « OS ISr-( J-j o OS CO OS CO a> CD IS" 00 TO CO o C• ^ < o 1 «Tt.^ ■^ XI Td ff 0.2 .iJOrnt^ kO 00 iS> CO 00 o ° .Jt^tO ■_Y— ' o *^ a « g s g g li CO CO s s g i 1 1 i ^ ^ ^ ^ •^ 1 o 1 00 00 00 00 53 APPENDIX XLVI. Ireland. Number and Amount 11th January, 1914. ^ S ^ ^ 9 to i 3 a ^1 i P 00 CM CM 00 1 i^« 1 I-H 1 i o gc. 1 * 1 1 00 o o 1 1 B 3 lilt ^-v-' 2 s 1 ^ nil 2 5g - - 8 o ^^S-^ ^ "^fS^Sg M (U ^ a> O ! 4J "a 6 3 5 g 2 g g g S OS •-' "-• 8 ta >, f^ >s 1 o ca -* ^ fin / — " — > Ph ,— ^-^ r-"—^ 03 : : : : ^rr-. : : : : : : : : OS M (M CM S xn S • • • ov • : • S '■ '' S : : : »^ e3 3 "9 :^ : "S :^ : 1 "3 : : ^ (0 o "'wg ■ ^^£ • *^2 * 6 ^S IS . 2 q8 iti ■■ O 3 § 1 S '«'^ tC CD ta CD gi-s „ iOHT, CD CD 1. (0 c3 s ill 1 O 3 |i 1 ta 3 1 1 £1 to m ^ 1— 1 ^ tJ H Is Is ^ .s.- 41 Sh lis IP II rfl en ro ^Ss •^•o -3 CD o •5S .2 C li 'SS : i : : Q A 5 >< « P s ^ 1 ^ v M g 1 S ^ S ^ 1 Appendices — Ireland. 55<^ Table III. Payments to (a) Deposit Contributors who have emigrated ; (b) Repre- sentatives OF Deceased Contributors, and (c) Married Women sus- pended FROM ORDINARY BENEFITS. Payment on Emigration. Payment at Death. Married Women's Special Benefit. Sex. No. Amount. No. Amount. No. Payments from Contributions. State Grants. Total. Men... ... Women ... 2 4 £ s. d 10 5 13 4 2. £ *. d. 14 9 2 £ s. d 6 10 £ s. d 2 4 £ 6. d 9 2 Totals ... 6 1 13 9 2 14 9 2 6 10 2 4 9 2 Table IV. General Summary of Benefit Payments to Deposit Contributors. Men. Women. Men and Women. Number of Pay- ments. Amount. Number of Pay- ments. Amount. Number of Pay- ments. Amount. Sickness Benefit Maternity Benefit ... Married Women's Special Benefit 248 102 £ s. 158 10 110 2 d 192 8 2. £ s. Ill 7 6 14 9 d 4 I' 440 110 2 £ s. d. 269 17 6i 116 16 6i 9 2 Tt)tal 350 268 12 8J 202 118 10 H 652 387 3 3 Payment on Emigra- tion Payment at Death ... 2 2 10 14 5 9 4 1 3 4 6 2 1 13 9 14 9 Total 4 1 5 2 4. 1 3 4 8 2 8 6 Grand Total ... 354 269 17 lOJ 206 119 13 lOJ 560 389 11 9 656 Appendices. — Ireland. APPENDIX XLVII. Ireland. Statistics relating to Exempt Persons. Table I. Table showing the Number of Certificates of Exemption issued FROM 15th July, 1912, to 31st March, 1914. 15th July, 1912, to 13th July, 1913. 14th July, 1913, to 31st March, 1914. Total. Certificates granted on ground of — A. Pension or Income : — (a) Pension {h) Income 2,274 930 200 41 2,474 971 B. Dependence: — 3,204 241 3,445 {a) Married women (depen- dent on husbands) ih) Apprentices or young people (dependent on parents or guardians) ... (c) Other dependants 61 322 34 7 76 5 68 398 39 -O. Section b of Act of \^\2 :— 417 88 505 Persons dependent on some other occupation — 7 7 D. Persons aged 65 (not previously employed) 1 1 2 Totals 3,622 337 3,959 Number of 1912-13 Certificates renewed 2,431 Number of fresh claims rejected... Number of renewal claims — 66 — rejected ... — 21 — Total number of Certificates issued up to 31st March, 1914 ... 3,959 Total number of Certificates cancelled 1,467 Number of exempt persons on 31st March, 1914 2,492 Appendices. — Ireland. 657 Table II. Statement showing Number of Certificates of Exemption cancelled PROM 15th July, 1912, to 31st March, 1914 Reason, Become insured Entered an excepted employment Gone abroad Moved to Great Britain No longer employed Age 70 Deceased Certificates not renewed Total... Number. 585 yment 240 . ... ... . 21 . 39 250 14 53 265 ... ..• . 1,467 ■;. .: ' Table III. Statement showing Number of Exempt Persons in respect of whom Contributions have been received for each Quarter — iBtQ uarter ... 2nd » •.• ' . 3rd »» ••• 4th }, ..• . 5tli „ ... eth >i ••• £ s. d. 2,385 (representing) 318 9^ 2,530 1) 338 16 7 2,560 2,510 2,345 2,190 Note. — The amounts for the third and subsequent quarters have not yet been calculated as the return of cards is not yet complete — a number of cases being still under investigation. 558 Appendices. -^Ireland. Table IV. Table showing thb Ndubkr of Exempt Persons untitled to Benefits. Number of Exempt Persons entitled to Sanatorium Benefit on 12th January, 1914. Number of Exempt Persona entitled to Full Benefits on Ist April, 1914. Counties. Antrim ... Armagh ... Carlow Cavan Clare Cork Donegal Down Dublin Fermanagh ... Galway ... Kerry Kildare Kilkenny.;. ... King's County ... Leitrim ... Limerick Londonderry Longford Louth Mayo Meath Monaghan Queen's County ... Roscommon Sligo Tipperary North „ South Tyrone Waterford Westmeath Wexford ... Wicklow ... Total ... County Boroughs. Belfast ... Cork Dublin ... Limerick ... Londonderry Waterford Total ... Counties Grand Total 71 27 9 9 15 119 22 85 196 19 33 34 33 13 22 6 15 16 1 45 17 11 5 16 6 11 18 36 23 24 28 26 26 1,031 414 138 337 56 30 44 1,018 1,031 2,049 69 30 11 9 16 114 25 89 193 19 34 34 32 16 28 5 14 14 1 45 18 12 4 19 9 13 11 35 20 28 89 27 1,046 431 141 367 66 31 39 1,054 1,046 2,100 Appendices. — Ireland. 559 APPENDIX XLVIII. Ireland. Statement showing the Number of Certificates of Exemption granted to Irish Migratory Labourers under Section 81(3) of the Act of 1911. 1st Year (15th July, 1912, to 23rd February, 1913). Total number of Claims for exemption received 6,495 Number of Certificates granted 6,765 Number of Claims rejected 730 2nd Year (23rd February, 1913, to 13th January, 1914). Total number of Renewal Claims received 3,905 Number of Renewal Certificates granted ... ... ... ... 3,860 Number of Renewal Claims rejected ... ,., 45 Total number of fresh Applications received ... ... ... ... 3,143 Number of Certificates granted 3,039 Number of Claims rejected 104 Total number of Persons exempted 6,899 3rd Year (commencing 13th January, 1914). Total number of Renewal Claimu received 3,963 Number of Renewal Certificate* granted 3,914 Number of Renewal Claims rejected 49 Total number of fresh Applications received 110 Number of Certificates granted 100 Number of Claims rejected 10 V Appendices. — Wales. 661 APPENDICES TO PART VI. NATIONAL HEALTH LVSURANCE COMMISSION (WALES). Page XLIX. Table showing number of Approved Societies operating in Wales arranged according to class and Welsh membership 56^ L. Statement showing particulars relating to security given by Approved Societies under Section 26 of the Act of 1911 ... 563- LI. Analysis of members of Approved Societies in Wales for the quarter ended 12th January, 1913 564 LII. Table showing the approximate distribution of members of Approved Societies among the various types of Societies for the quarter ended 13th April, 1913 565 LIII. Quarterly stamping. — Statistics for the year ended 11th January, 1914 565 LIV. Statement showing receipts into and payments out of the Welsh National Health Insurance Fund from 15th July, 1912, to 11th January, 1914 566 LV. Stamping during week after payment of wages. — Statistics for the year ended 11th January, 1914 567 LVI. Statement showing the number of members of each Insurance Committee ... ... ... ... ... ... ... ... 56T LVII. Summary of scheme of the King Edward VII Welsh National Memorial Association 56S LVIII. Extract from agreement between County and County Borough Councils and the King Edward VII Welsh National Memorial Association 571 LIX. Statement showing the number of non-insured persons (other than dependants of insured persons) being treated by the King Edward VII Welsh National Memorial Association in resi- dential institutions, or who have been treated therein, during the period from 15th July, 1913, to Uth January, 1914 ... 571 LX. Systems and institutions for which approval has been granted under Section 15 (4) of the Act of 1911 572 LXI. Statement, compiled from the index registers, showing the number of insured persons (members of Approved Societies and deposit contributors) in Insurance Committee areas as on 12th January, 1914 573 LXII. Statement showing the number of doctors and chemists on the panels for each Insurance Committee area on 1 2th Jajiuary, 1914 574 562 Appendices. — Wales. Page LXIII. Deposit Contributors. — Table showing contributions paid and charges made against deposit contributors' accounts for each of the first four quarters ... ... ... 574 LXIV. Deposit Contributors. — ^Table showing number of contributors who entered into insurance during each quarter 575 LXV. Deposit Contributors. — Table showing number of insured persons, not members of Approved Societies, who surrendered cards for each quarter ... 575 LXVl. Deposit Contributors. — Particulars as to the number and amount of benefit payments in the year ended 11th January, 1914 576 LXVII. Analysis of replies obtained by officers of the Outdoor Staff" from a representative group of deposit contributors ... ... 578 LXVIII. Statement showing the ages and occupations of a representative group of deposit contributors 579 LXIX. Statistics as to exemption certificates ... ..."580 LXX. Statement as to payment of contributions in respect of exempt persons ... ... ... ... ... ... ... ... 580 LXXI. List giving particulars of the Authorities, &c., to whom certifi- cates of exception have been granted under paragraphs (b) and (c) of Part II of the First Schedule to the Act of 1911, by the Joint Committee acting jointly with the Commission, and also the approximate number of persons to whose employment such certificates apply 581 Appendices. — Wales. 563 APPENDIX XLIX. Wales. Table showing Number of Approved Societies operating in Wales arranged according to Class and Welsh Membership. [mi. aa^ (V X *^' 1 ^ 2 1 r Indus »mpanie 8 thereo I r-3 x> s h °r^ 9 d d — H> O 03^ P ^ I a •s I i , tooio ao-^«iret- o 11 || w«S eo^Sc^^ & ^ !? S^S ^ ^"=52 > 1 'c U5CC OH 1—1 rl x> |gg S^iss, ,s iM '^u^ 1 S .., t a'" s - ■" 's "'1 1 (N III 1 1 1 1 ! 1 1 1 1 1 1 §1 » 3 •"§§s ;5 1^ 1 1 1 12 SS g 0» (M Mi 1 1 1 1 i 1 1 1 1 1 1 1 ^1 s •^^s s n 1 1 1^ ;:^S eo i ^5g5 S 1^'^"' l"^ ^2 ^ 'i hi » III 1 1 1 1 I 1 1 1 1 1 >2 o i« III 1 1 II 1 1 1 1 1 1 u g a H ' .D Tj! III 1 1 1 1 1 1 1 1 1 1 1 o ti P£1 1 P£| "S^ Vil^]'^ 1 IS ^i 1 (N 1 eCrH OS 1 !0 1 w 1 1 "^ 1-H 00 05 "ft » *;:;j£^ ^2S2I£ ^, 50 ON (N s ^^ P£; pq 1-4 • g«0O ^gO^HSD M IS ^s in ifil •^jT^DGr of aOiSiCi :a 8| H S ^ 4 1^1 MM! 1 1 1 1^ CM 1 II »»j«eo Oi 1 eo?«-* 1 1 «o §1 1 ^11 1 1^*^55 li r^^ --< 1 coS S o o '-' ^ m -§^ Jo IS 1^ 1^ IS 2g t- « «5 1 ■* 1 1 1 1 1 w 1 1 1 1 1 '"' t- s ■ O . -* £i 1 1 1 1 I^J 1 1 1 r^. '^> n •E "g'^ ^^s^^§ '£> •oco S •<*< c ■, CO 1 1 S '^ o ft a < (?f .-HCO Tjt ci I ■* sg IM H ^ r-l i-H CO s O; rH -XI CO ^ r-J O CO ^ ■* a> CO 00 ,_( 1 '^ t- 3 . to +s *"< (3 C 5 CO 05 >>« S "Sis bCeS CO (»•« o CO g o B -'a a i?i^ Vim 03 03 u '3 0) >5ji'0 to -5 * pq j (M ,-H (M I 3 I C ,_, (M CO iC Q, .H rH JM e« I I Appendices. — Wales. 566 APPENDIX LII. Wales. Table showing the Approximate Distribution of Members of Approved Societies among the Various Types of Societies for the Quarter ended 13th April, 1913. Societies formed by- Friendly I Societies with i Branches. Other Friendly Societies Trade Unions. Industrial Assurance Companies and Collecting Societies. Employers' Provident Funds. Total for all Types of Societies. Societies approved by the Joint Com- mittee :— Men Women 144,995 22,053 100,623 17,068 84,885 5,685 153,945 59,685 666 45 485,114 104,536 Total ... 167,048 117,691 90,570 213,630 711 589,650 Societies approved by the Welsh Commission : — Men Women 14,799 493 68,272 4,719 5,093 145 388 10 ~ 88,552 5,367 Total ... 15,292 72,991 5,238 398 93,919 Total Membership of Approved Societies in Wales : — Men Women 159,794 22,546 168,895 21,787 89,978 5,830 154,333 59,695 666 45 573,666 109,903 Total ... 182,340 190,682 95,808 214,028 711 683,569 APPENDIX LIII. Walks. Quarterly Stamping. — Statistics for the Year ended 11th January, 1914. Period. No. of Employers. No. of Employees aflFected. Men. Women. Total Value of Stamps supplied. Third Quarter Fourth „ Fifth „ Sixth 105 100 100 101 145,653 144,490 148,025 158,738 5,362 5,246 4,831 5,129 151,015 149,736 152,856 163,867 55,586 18 54,197 15 2 54,435 6 6 61,298 9 9 Total ... 225,518 9 5 566 Appendices. — Wales. CO o § 03 « «rt =« si i e*?oo I— 1 CO CM ec CO t- e*3 00 t- CO Jt- W 00 l-H O 1i 02 -♦-' i a :'n : dll , c8 02 s§ 02 O CC3 -5 oW a.-§ §-3 S,"5«'S ^ o CO 2 Tf 05 I— t CO CO !>• I— I 1— I T*< - lO 05 "<# 0> CO CO ■is frw : S 08 M DO o : l5.s|o| ,, >^ (D £^ ^§ o a> W o w X '-' '*' ' ' 53 <=> (11 "^ -4-3 U^ .S ^l-S CO CO CM fM CO kC (M CO^OD irTco" 05 1 Pi 2 "^ U5 1 00 x X £ s. d. 99 5 6 2 OS o 05 o CO 1 il £ s. d. 353 4 11 94 8 2 5 ■* •* ^ x> a > o 3 O a < 3 291 4 6 5 6 3 o ^1 £ s. d. 63 7 10 1 6 6 tX •* s a 2 2-E 227 16 8 3 19 9 eo i a e >> t o s (2: 3l §5 s 1 J I- 1 1 S 00 i Partial Payment (Account exhausted). IM 00 i EH '1 1 1 § 5 British Subjects under 65 on 15th July, 1912 ... Aliens under 65 on 15th July, 1912 Over 65 (British Subjects and Aliens) British Subjects under 65 on 15th July, 1912 ... Aliens under 65 on 1 5th July, 1912 ..." Totals of all Classes § 1 1 Appendices. — Wales. 577 Table III. Payments to (a) Deposit Contributors who have emigrated ; (6) Repre- sentatives OF Deceased Contributors, and (c) Married Women sus- pended FROM ordinary BENEFITS. Payment on Emigration. Payment at Death. "Married Women's Special Benefit. Sex. No. Amount. No. A mount. No. Payments from Contributions. State Grants. Total. Men Women 18 5 £ s. d. 5 17 1 1 12 3 9 £ 5. d. 3 16 4 3 £ s. d. 16 7 £ s. d. 5 7 £ s. d. 1 2 2 Totals ... 23 7 9 4 9 3 16 4 3 16 7 5 7 1 2 2 Table IV. General Summary of Benefit Payments to Deposit Contributors. Men. Number of Pay- ments. Amount. Women. Number of Pay- ments. Amount. Men and Women. Number of Pay- ments. Amount. Sickness Benefit .. Maternity Benefit .. Married Women's Special Benefit Total Payment on Emigra- tion Payment at Death .. Total Grand Total .. 1,045 272 1,317 1,344 £ s. d. 547 7 291 4 6 5 17 1 3 16 4 9 13 5 847 18 6 298 8 3 £ s. d. 129 5 1 5 6 3 1 2 2 309 5 135 13 6 1 12 3 1 12 3 314 137 6 9 1,343 280 1,626 32 1,668 £ s. d. 676 5 8 296 10 9 1 2 2 973 18 7 7 9 3 16 4 4 11 5 8 985 4 3 (B2 54— Gp. 5) 678 Appendices. — Wales. APPENDIX LXVII. Wales. Analysis of Replies obtained by Officers of the Outdoor Staff from a Representative Group of Deposit Contributors. Answer. Men. Women. Total Question. i i i 4 No. ^1 No. U 1 No. S fl 5 fl S fl 1^8 Ph8 Has the deposit con- Yes 108 18-8 17 9-7 125 16-7 tributor ever ap- No ... 465 81-2 156 89-7 621 83-1 plied to become a No information — — 1 0-6 1 0-2 member of an Ap- proved Society ? If rejected, on what 111 health 10^ n 111 grounds ? Physical deformity ... 3 — 3 Intermittent employ- 1 - 4-9 — >■ 1-1 1^ 4-0 ment. i Not disclosed 14 1 1 isj Number accepted 80 13-9 15 8-6 95 12-7 If no application 1. Ignorance ... 68 14-6 41 26-2 109 17-6 made, the reason 2. Indifference 217 46-7 53 34 270 43-5 why? 3. Intermittent em- ployment. 41 8-8 4 2-6 45 7-2 4. Hostility to Act ... 26 5-6 7 4-5 33 5-3 6. Disinclination 54 11-6 17 10 -9 71 11-4 6. Ill health 10 2-2 - ! - 10 1-6 7. Misapprehension as 17 3-6 6 3-8 23 3-7 to position of 1 Approved Society i member. 8. Deliberate choice ... 17 3-6 19 12-2 36 5-8 9. Uncertainty in 10 2-2 4 2-6 14 2-3 choice of Ap- proved Society. 10. Arrears on private side. 11. Supposed wish of 4 0-9 — — ^ 0-6 1 0-2 5 3-2 6 1-0 employer. Does the deposit con- Yes 385 78-1 109 69-4 4941 76-0 tributor appreciate No 99 20-1 48 30-6 147^ 22-6 the relative advant- No information 9 1-8 — — 9j 1-4 age of the two systems ? Has any agent tried Yes 113 23-1 35 22-1 148 22-8 to induce the de- No 367 74-9 118 74-7 485 74-8 posit contributor to No information 10 2-0 5 3-2 15 2-4 join an Approved Society ? Has the deposit con- Yes 296 60-0 77 48-4 373 57-2 tributor any inten- No 142 28-8 71 44-7 213 32-7 tion of joining an Undecided 16 3-2 6 3-8 22 3-4 Approved Society 1 No information 39 8-0 5 3 1 44 6-7 Number of deposit contributors questioned . . . 573 174 747 Appendices. — Wales. 679 APPENDIX LXVIII. Wales. Statement showing the Ages and Occupations of a Repre- sentative Group of Deposit Contributors. Ages. Men. I Women. 16—21 66 33 21—25 35 21 25—30 54 17 30 35 53 6 35—40 53 6 40—45 31 15 45—50 40 6 50—55 33 6 55—60 30 18 60—65 38 11 65—70 14 4 Grand Total ... 447 145 Occupations. Men. 1 Women. Labourers . 126 Domestics ... 77 Craftsmen . . 58 Charwomen 26 Colliery-workers . 54 Shop-workers .. 12 Office-workers ... . 38 Hotel-workers 6 Shop-workers . 31 • School-teachers 5 Farm-workers ... . . 30 Office-workers .. 5 Estate-workers ... . . 18 Nurses 5 Mechanics . 15 1 Dressmakers 4 Metal-workers ... . 13 Farm-workers 3 Railway-workers . 12 ' Post Office employees 2 Hotel- workers ... . . 10 i Seamen ... 9 Gardeners 8 Auxiliary postmen . 5 Commercial-travellers . . 5 Printers ... . 4 Tailors 3 School-teachers ... 2 Chauffeurs .. 2 Musicians 2 Road-surveyor ... . 1 i Professional golfer • 1 447 145 580 Appendices. — Wales. APPENDIX LXIX. Wales. Statistics as to Exemption Certificates. Certificates valid up to ISth July, 1913 Certificates renewed up to 12th July, 1914 ... Certificates surrendered on 13ch July, 1913 ... Certificates for which no application for renewal was received Certificates refused renewal No. of fresh claims received since 13th July, 1913 No. of fresh Certificates issued ... No. of 1913-14 Certificates issued No. of 1913-14 Certificates cancelled as at 3l8t March, 1914 No. of exempt persons in benefit as at 31st March, 1914 ... No. of exempt persons who have sufficient contributions to credit but who have not returned the form as to age, &c., 31st March, 1914 No. of persons who state that they do not want benefit, 31st March, 1914 No. of exempt persons with less than 13 contributions to credit, as at 31st March, 1914 ... 2,027 ... 1,599 ... 308 ... 84 ... 36 ... 302 ... 276 1,875 ... 118 ... 1,129 their as at 176 as at 11 their ... 441 APPENDIX LXX. Wales. Statement as to Payment of Contributions in respect of Exempt Persons. -(J '^ Td rd ,d rd ^ . d • U . ■*-* .• -p . ■►^ -• F— ( ^ 0) (S z W ^ -t' fe ^ ^ ^ ^ bo-g bo-g tat bDt tct a ^ .s ^ a ^ ■B ^ S ^ •^ ^ *S !^ •s ^ 'S ^ 'u ^ 'u ^ isO* SO* p.* v«ir r '