Under the National Insurance Act medical domiciliary assistance,—but only to the extent which is within the competence of a medical practitioner of average ability,—is provided under contract for one-third of the total population; and evidently this implies an immense abstraction from ordinary private medical practice. There is no provision, hitherto, for consultant and expert facilities when required (except for tuberculosis), for the nursing of patients, or for institutional treatment of any disease, except tuberculosis; and no funds are generally available for these purposes except such as belong to the community at large. In view of the preceding facts and of other considerations which I have not mentioned, reconstruction of the English Insurance scheme is obviously required. The scheme cannot persist in its present form. The already accomplished amalgamation of the Local Government Board and National Insurance Commission, should make radical changes easier; an equally important step would be the transfer of the medical functions of the Local Insurance Committees to Public Health Authorities. The creation of these independent committees was one of the greatest blunders of the National Insurance Act, which was conceived ill-advisedly, had too short a gestation, and suffered a premature and forced delivery; and we may hope that ere long, it may be replaced entirely, on its medical and hygienic side, by a rapid extension of the medical activities of the public health service which will conduce to the welfare of the whole nation. It is impossible to justify the continuance of state subsidisation of benefits for a favoured portion of the wage-earning classes, when poorer persons who do not come within the category of employed persons or who fall out of employment, and when clerks and others on limited salaries who are unable to provide adequately for sickness, are left unprovided for. _A National Medical Service_ What is most urgently needed is a national medical service which will give for all who cannot afford them hospital treatment and the services of consultants and of scientific aids to diagnosis and treatment whenever required; and which will provide nurses during illness treated at home, when this is asked for by the doctor in attendance. Outside the operation of the National Insurance Act, these services have been provided to a steadily increasing extent, but in a characteristically British fashion. They have grown largely under voluntary management, and as exemplifications of Christian philanthropy; though official has rapidly overtaken the voluntary provision of hospitals and nursing, the two working side by side, each in their respective spheres, and on the whole with cordial coöperation. The extent to which institutional treatment with its more satisfactory arrangements is replacing the domiciliary treatment of disease may be gathered from the following striking facts: In England and Wales