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Dental care of the child under the national health service act
PUBLIC HEALTH,~February, 1948
D E N T A L CARE OF T H E CHILD U N D E R T H E NATIONAL H E A L T H SERVICE ACT* By D. E. MASON, L.D.S., Chief Dental Officer, Nottinghamshire My duty this afternoon is to place before you, for your consideration and criticisms, my views as to what I, as a public dental officer, consider will be efficient methods of providing routine and (where necessary) special dental treatment for school children when the N.H.S. Act comes into operation in July, 1948. With the introduction of the National Health Service Act, children attending maintained schools will have at their disposal two agencies through which they will be able to obtain, without the payment of any fees, all necessary dental treatment. One agency will be the School Dental Service within the School Health Service of the local education authority in whose area the school is situated, and the other agency will be the general dental services scheme set up by local executive councils under Section 40 of the N.H.S. Act. You will see, therefore, that as matters stand at present, there w~ll be two separately administered and unco-ordinated official dental treatment schemes for the school child, one being sponsored by the Ministry of Health under the N.H.S. Act and the other being sponsored by the Ministry of Education under the Education Act. Such an arrangement must result in division of responsibility with consequential inefficiency, overlapping and omissions, and with the unfortunate child falling between the two administrative stools. I n the absence of any specific ruling to the contrary it is logical to assume that payment in respect of children treated through the general dental services scheme will be made by the Ministry of Health and that local education authorities will not be called upon to pay anything f o r such cases. In other words, a local education authority will be saved considerable expenditure by failing to provide a complete school dental service, and by adopting a policy of encouraging school children to obtain their dental treatment through the general dental services of the N.H.S. Act. If what I have said is a logical interpretation of how the position stands at present, then is it likely, in such circumstances, that all L.E.A.s will make serious attempts to provide complete dental services themselves ? I think, then, that you will agree with me when I say that divided responsibility for the provision of this service is undesirable a n d that it is the duty of the dental profession as a whole, mid of specialised Groups like this in particular, to produce helpful and constructive proposals which will be of assistance to the Government in formulating the working details of a scheme which wilt be to the benefit of the children concerned and which will obviate inefficiency and cut down overlapping to the lowest possible level. T h e primary concern must be the welfare of the children, but almost of equal importance is the need for the most careful and economic use of dental man-power bearing in mind the existing low n u m b e r of dental practitioners in Great Britain. For the Government to introduce a Regulation which totally excludes school children from participating in the general dental service, would, I think, be a wrong procedure because it would eliminate healthy competition by giving a monopoly to local education authorities, some of which have not in the past shown themselves to be particularly anxious to provide complete and comprehensive dental services for the children under their care. On the other hand, it would, I consider, be a mistake of even greater magnitude for the Government to abolish, as a treatment service, the existing school dental service on the grounds that all necessary dental treatment can, in future, be provided through the agency of the general dental service under the N.H.S. Act, and that the majority of the dental officers at present employed within the school dental service would have no difficulty in obtaining full time employment within the general dental service, the remaining few being retained as inspecting officers. * Paper and discussion at a meeting of the Dental Officers' Group, Society of M.O. I-I., on Oct. 4th, 1947.
89 If you accept my contention that neither of the foregoing would be a satisfactory solution, then we are left with a third possibility which is that the school dental service should continue to" function as a progressive inspection and treatmenm service and that children in attendance at maintained schools should be encouraged to make use of it and yet at the same time some provision should exist for treatment through the general dental services scheme for those children whose parents possess a preference for this procedure. In speaking in favour of this third possibility, it w o u l d appear that I am now advocating the very scheme which I have just been deprecating, but the following safeguards put a different COl~plexion on matters. T h e Ministry of Health will, presumably, be credited with all the contributions paid by the population in respect of the National Health Service. This being the case, it is logical to suggest that the costs of the service (including the dental treatment of school children) should ultimately be borne by the Ministry of Health. As the person who pays the piper is the one who is entitled to name the tune to be played, then what I have suggested would justify the Ministry of Health in assuming ultimate responsibility for the school dental service and its efficiency and as far as I can see there is nothing in this suggestion which is in any way at variance with the text of the N.H.S. Act. For convenience, however, I suggest that the Ministry of Education should continue to act, as at present, somewhat in the capacity of an agent for the Ministry of Health, by making arrangements through local education authorities for the provision of a satisfactory school dental service. This suggestion seems to be in accordance with Section 48 of the Education Act which, we should bear in mind, is now a law actually in operation and which is not, therefore, likely to be changed unless time proves it to be ineffective. My next suggestion may surprise you because it is to the effect that every dental officer employed by a local authority should be required to register under the general dental services scheme outlined under Section 40 of the N.H.S. Act and that he should make the appropriate claim to the Dental Estimates Board for payment to his local authority (not to himself because he wilt be receiving a fixed salary) in respect of all dental treatment which he carries out for his local authority. T h e advantages of a procedure of this sort include : - 1. T h e cost of treatment (but not of capital expenditure such as the building of clinics) would fall on the Ministry of Health and not on local education authorities with the result that local authorities would be more likely to provide a more complete dental service. 2. T h e fees obtained by local authorities from the Ministry of Health for treatment carried out, could be compared with the running costs involved in providing the treatment and any appreciable variation, either way, from a balance would call for an investigation and explanation. 3. T h e machinery of the Ministry of Health for securing that dental treatment carried out under the N.H.S. A c t is being performed in an efficient manner and under suitable conditions could be applied with equal force to the dental officers employed by local authorities as it will be to the other practitioners working under the scheme. (I very much doubt if some of the treatment premises which school dental officers are at present using would be passed as satisfactory premises under the N.H.S. scheme.) 4. T h e patients of local authority dental officers would be u n d e r precisely the same Regulations, in regard to dental treatment, as the patients of other practitioners and there would, of course, ~e the same machinery for dealing with complaints of a professional nature. 5. T h e Local Dental Practitioners' Committee and the local executive council, established under the N.H.S. Act, would be in a position to take an active interest in the local authorities school dental service. At present these bodies would appear to have no locus standi at all in this matter, but I suggest to you that these two bodies, because of their composition and duties ought to play a part in every branch of the dental services in their area.
90 6. I t would place the local authority dental officer on the same professional plane and on a comparable professional basis w i t h his colleague performing similar duties outside t h e local authority's ambit, thereby giving h i m a justifiable claim for comparable remuneration which he certainly doesn't receive u n d e r present conditions. 7. I t would bring to the notice of local authorities the cash value o f the treatment carried out per a n n u m by an industrious and efficient dental officer. A t present the value of this treatm e n t (which includes the taking and processing of x-ray films, orthodontia, the provision of artificial dentures, crowns and cleft p a l a t e appliances and the administration of general anaesthetics in addition to routine fillings and extractions) seems to be very m u c h underestimated j u d g i n g by present remuneration standards. I c o m m e n d these administrative points to you for your consideration and criticisms not because I think they are in a n y w a y ideal b u t because I cannot think of any better m e t h o d which will at one and the same time combine the qualities of continuing t h e existing clinical aspect of the service ; of providing an incentive to local authorities to make progress with their dental s c h e m e s ; of placing ultimate responsibility for the service in the hands of only one M i n i s t r y ; of unifying treatm e n t procedure regardless of the agency t h r o u g h which treatm e n t is obtained and of conforming to the general r e q u i r e m e n t s of b o t h the Education A c t and the N . H . S . A c t : I n advocating that the e x i s t i n g school dental service should not only be continued but greatly expanded, and that school children should be given every possible e n c o u r a g e m e n t to obtain their necessary dental t r e a t m e n t t h r o u g h it, I feel that I need n o t make e i t h e r excuse or apology to this or any o t h e r meeting. T h e school dental service is staffed by m e n and w o m e n w h o have selected this aspect of dentistry because they like dealing w i t h children and, after having s p e n t 25 years in this service, I can say w i t h o u t hesitation that the efficient results w h i c h are being obtained by experienced and conscientious officers have to be seen to be fully appreciated. It is true to say that some private dental practitioners are v e r y successful in their dental t r e a t m e n t of children, b u t it is equally true to say that there are m a n y private dentists who openly admit t h a t they have little or no patience w i t h children (particularly nervous y o u n g children) and that t h e y heartily dislike having to treat them. Based on experience, I t h i n k I can say that the dental t r e a t m e n t of children necessitates its o w n specialised training and that the dentist w h o has had this training and has a flair for the w o r k will accomplish a greater a m o u n t of treatment with a greater a m o u n t of success, in a given time, than the dentist w h o deals w i t h children only as a side-line. T h i s is a most i m p o r t a n t point w h e n it is realised that approximately 6,000,000 children attend maintained schools and that a m i n i m u m of 2,000 experienced whole-time dental officers are needed (at prevailing acceptance rates), to p u t and maintain their teeth in a sound condition. F r o m an administrative point of view, it seems to me to be the obviously desirable procedure for these c h i l d r e n to continue to have their teeth inspected at regular intervals at school and for those with defects to be encouraged to have their treatment, carried out in a dental cIinic situated near to the school rather than to seek treatment f r o m an unspecified private practitioner whose rooms m a y be several miles away, T h e existing school dental service, although admittedly far f r o m perfect and far f r o m complete, has been built up on the trial and error method, and can now be regarded as a well-organised smacture based on the solid foundation of useful experience and because it is organised, it produces a larger proportion of dentally treated cases per thousand of the population than w o u l d be achieved if children were left to seek der~tal treatment on their own account through the private or quasi-private practitioner of their choice. I venture to suggest that at the present t i m e - - i n the p r o v i n c e s - - a t least 90% of the routine dental t r e a t m e n t w h i c h is given to children attending maintained schools is given t h r o u g h the school dental service and, in view of the fact that teachers, parents and children are n o w so familiar with this service, and generally speaking have such confidence in it, I think it would be a big mistake to interfere with its present comprehensive t r e a t m e n t policy j and it would, in m y
PUBLIC HEALTH, February, 1948 opinion, be a retrogressive step a m o u n t i n g to a tragedy to attempt to reduce it to a m e r e inspectorial service "with the children left to make their own arrangements in regard to obtaining treatment. O r t h o d o n t i c treatment is also b e i n g m o s t successfully undertaken by school dental officers w i t h the aid and assistance, where necessary, of consultant orthodontists, and I can see no justifiable reason w h y school children in n e e d of this specialised t r e a t m e n t should not continue to be encouraged to obtain it t h r o u g h the school dental service. I will conclude m y remarks by saying that, although I was invited to deal only w i t h the " Dental Care of the School Child u n d e r the N . H . S . A c t , " I feel I m u s t say one sentence in connection w i t h the dental care of the expectant m o t h e r and pre-school child because these two groups, a l o n g w i t h school children, fall w i t h i n the priority classes to be p r o vided for by local authorities. T h e administrative points which I have put f o r w a r d in respect of the school child apply with equal force to the expectant m o t h e r and pre-school child except for the fact that in these cases the t e r m " H e a l t h Authority " should be substituted for " E d u c a t i o n A u t h o r i t y . " DISCUSSION Mr. J. E. H. DUCKWORTH,who opened the discussion, said he was speaking as a private practitioner and private practice was, he considered, the finest service in the country. -Any remarks he would make would be on the assumption that the N.H.S. Act would provide a service which the profession would approve. In principle he was in entire agreement with Mr. Mason. There were some points, however, on which he would like to comment. There were private practitioners who did like attending children and some who did not, but in spite of that there was a colossal number iv_ the profession who, nevertheless, did attend children. He thought private practitioners were at a disadvantage in this respedt. They did not keep statistics and he could not quote the number of patients he had in a year, but he had attended 530 children, 180 of whom were entitled to free treatment, but whose parents, nevertheless, brought them to h lm. . . . There. were thousands more like him. What he pleaded for again and again was "integration." If we were to have a child health service, and there was no dentist in the country who did not want it, it could not be done if the two services were to be segregated. Our efforts towards integration should begin now. He did not think it was good for the public dental officer to exist for 25 years in the rarefied atmosphere of school dentistry and he did not think the school dentist gave any better treatment to the child than the private practitioner. The two should be brought together under the N.H.S. Act. There were perhaps some things which were better done within the service, and orthodontics was one, It would be a great help to the private practitioner if orthodorttic clinics were set up. tie did not think the children should be herded into clinics, after all the average clinic was not a very pleasant place. He believed that parents should have the right to choose. He believed in family dentistry, the kind that was carried out in some 14,000 dentists' surgeries in the country. DR. N~WTH said he had heard the same arguments over and over again. The same points had been brought before his Society and rejected. A public dental officer would probably treat 2,000 children in a year compared with Mr. Duckworth's 530. Surely there was something in treating a large number of children. Was not child dentistry a specialised job ? He did not think a clinic was an undesirable place and said that in a clinic you did get the personal touch. He sympathised with Mr. Duckworth's remarks about the family dentist, but in the health service they often found it impossible to find out even who the family' doctor was, and he imagined it would be the same with the dentist. MISS HnRmSoN found herself agreeing with Mr. Duckworth. There was one point, "however. No records were kept of the people who said " I want to go to a clinic." MR. McCLELLANDpleaded for more dental propaganda, not only for children but also for adolescents and expectant and nursing mothers. He thought we lacked good dental propaganda films and he mentioned ass American Navy film on " H o w to clean the teeth." He knew 6f no film like it in this country. He knew many children .who got out of seeing the public dental officer by saying they were going to their own private dentist. MR. J; W. GILBERTsaid there must be reasonableness. Mr. Mason and Mr. Duckworth both disliked being milled irlto a Clinic. Children attending a private practitioner were at a disadvantage. They shoufd be entitled-to the same marks and privileges as the child who attended the public dental officer. He thought that instead of receiving a salary cheque from the local authority the public dental officer should be paid for the work done by the general health service. MR. A. G. LUNT stressed that everyone in the dental profession
PUBLIC H E A L T H , F e b r u a r y , 1948 MR. K. BATTEN d i d n o t agree w i t h M r . M a s o n ' s s u g g e s t i o n as t o p a y m e n t . It w o u l d a d d complications a n d there w o u l d be too m u c h control. T h e local a u t h o r i t y should provide a dental service f r o m zero to m o t h e r h o o d . He t h o u g h t t h e private d e n t i s t could e x a m i n e the child a n d reciprocate b y stating t h e r e was t r e a t m e n t n e e d e d a n d send h i m to a school clinic. He failed to see h o w there could be co-operation b e t w e e n t h e private practitioner a n d t h e local a u t h o r i t y as long as t h e patient h a d the o p t i o n of g o i n g to w h o m s o e v e r h e p/eased. MR. PEACOCK said t h a t after e x a m i n i n g a child t h e dental officer could advise that a private practitioner be visited or alternatively t h a t advantage could be taken of t h e facilities provided by t h e school dental service. Local authorities as a whole were quite willing to provide a very good service indeed, b u t t h e r e were two things s t o p p i n g t h e m , buildings a n d personnel. MR. GOODEN said there were still a n u m b e r of local authorities w h o d i d n o t appreciate t h e necessity for a full dental service. So far as t h e private practitioner was c o n c e r n e d t h e position was still dubious. U n d e r t h e N . H . S . Act t h e r e were certain stipulations a n d conditions to w h i c h t h e y could not agree. H e asked w h a t was there a b o u t child d e n t i s t r y that m a d e it a speciality ? O r t h o d o n t i c treatm e n t : yes ; b u t d a y - t o - d a y t r e a t m e n t : n o 1 T h e s a m e c o n t i n u o u s t r e a t m e n t week in arid week out m u s t be a d r a i n o n anyone. T h e scope of the public dental officer s h o u l d be w i d e n e d . MR. W . RITCHIE YOUNO was s u r p r i s e d at t h e attitude o f s o m e at t h e m e e t i n g . He h a d always t h o u g h t t h a t we were all o n e h a p p y breed. Surely t h e w o r k was the same. T h e r e were o n l y five services t h a t could be given, to clean, to remove, to scale, to fill a n d to replace. Everyone had d i s c u s s e d ' t h e p r o b l e m f r o m t h e p o i n t of view of t h e dentist, b u t t h e y s h o u l d also consider t h e p o i n t of view of t h e patient. MR. W. G. SENIOR congratulated t h e G r o u p on a very i n t e r e s t i n g m e e t i n g . M r . M a s o n h a d s u g g e s t e d ~ ingenious m e t h o d for t h e public dental service. O n t h e other h a n d , M r . D u c k w o r t h h a d p u t forward a s t r o n g claim for the p r i v a t e practitioner. T h e y m u s t r e m e m b e r t h a t it was a private practitioner w h o first started school dentistry. I n his view the Beveridge R e p o r t was responsible for t h e idea t h a t t h e r e was a shortage of d e n t i s t s . T h e r e was no shortage of dentists now. T h e r e were sufficient to m e e t t h e d e m a n d s . I n regard to p r o p a g a n d a it was n o t n e c e s s a r y to go to t h e U.S.A. for films. W e h a d o u r o w n first-rate films on t h e care of t h e teeth. H e t h o u g h t u l t i m a t e l y t h e solution w o u l d be co-operation f r o m t h e local dental c o m m i t t e e s . MR. A. T . WYNNE t h o u g h t there w a s one p o i n t that was overlooked. T a k i n g t h e c o u n t r y as a whole and looking into t h e f u t u r e t h e shortage of p r e m i s e s a n d m a n p o w e r was very severe. It was easy e n o u g h to decide w h a t y o u w a n t e d to be done, b u t n o t so easy to p u t it into practice. Since t h e war local a u t h o r i t i e s h a d s h o w n m u c h m o r e willingness to i m p r o v e public dentistry. MR. J. C. CROSSLEY t h o u g h t Mr. M a s o n was r i g h t in s u g g e s t i n g t h a t public dental officers should register a n d that t h e local executive c o m m i t t e e s h o u l d p a y for t h e work t h e y were doing. T h i s should help to provide a really efficient service. MR. MASON, in h i s reply, took up M r . Senior's r e m a r k s o n staffing problems. T h e M i n i s t r y of E d u c a t i o n h a d p r o v i d e d t h e following figures. T h e r e were 725 dental officers e m p l o y e d - - 4 0 8 p a r t - t i m e a n d 317 full-time. T h e actual n u m b e r required for m e e t i n g t h e n e e d was 3,000. H e t h o u g h t that s o m e speakers h a d overlooked t h e fact that to have t h e i r s c h e m e s we m u s t have an Act of Parliament passed. MR. DUCKWORTH, t a k i n g u p Dr. N e w t h ' s point, said he was trying to refute the claim t h a t school d e n t i s t r y was a specialised job, a t o o t h filled by a public dental officer in a clinic a n d that filled by a private practitioner were equally t h e same t h i n g . A c c o r d i n g to W h i t a k e r s ' there were 10½ m i l l i o n children to be looked after. Public dental officers in 1945 e x a m i n e d 2~ million o f t h e m . H e w o u l d leave t h e m w i t h t h e idea t h a t n e i t h e r t h e public dental officer n o r t h e private practitioner could h a n d l e this m a t t e r . T h e m o r e strain y o u p u t on the public dental officer or t h e m o r e y o u p u t on t h e private practitioner, t h e m o r e difficult y o u were g o i n g to m a k e it. Votes of t h a n k s to M e s s r s . M a s o n a n d D u c k w o r t h were p r o p o s e d b y M r . Batten, s e c o n d e d by M r . Crossley, a n d carried by acclamation.
T h e British Standards Institution h a s now p u b l i s h e d B.S. 1425/1948, " Cleanliness of Fillings a n d Stuffings for Bedding, etc.," w h i c h will be of interest to M.O.H,s in areas where t h e r a g flock i n d u s t r y operates. Obtainable from t h e B.S.L, 24/28, Victoria Street, London, S.W.I, price 3s. post free. Citizen, the j o u r n a l of civic affairs, reappears in its second year in a new f o r m a t a n d will henceforward b e p u b l i s h e d every two m o n t h s in order to conserve paper a n d increase its circulation. It is well got u p a n d i_ts articles s h o u l d be of interest to aI1 intelligent readers concerned with local g o v e r n m e n t matters. P u b l i s h e d by W a l t e r K i n g , Ltd., 11, Bolt Court, Fleet Street, E.C.4. A n n u a l subscription 9s. 6d. (post free).
91 CORRESPONDENCE " DYING ENGLAND " OR " THE BIRTH OF A NATION " ? To the Editor o f PUBLIC HEALTH S I R , - - I s u s p e c t that D r . J o h n s o n w o u l d have fallen into t h e small class o f overfeds a b o u t w h i c h o u r colleagues o v e r t h e water are concerned, a n d to w h i c h y o u referred last m o n t h , a n d that he would have lived a longer a n d a healthier life on the diet of m o d e r n Britain ; as to w h e t h e r this w o u l d have m a d e his J o h n s o n e s e better or worse I a m n o t prepared to hazard a guess. N o r d o I propose to a d d r e s s m y s e l f to the question as to w h e t h e r Britain t o - d a y is being p r o p e r l y fed except to say in p a s s i n g t h a t " S e a r c h e r after T r u t h " s e e m s to m e to have d e m o n s t r a t e d clearly t h e logic of feeding t h e nation according to biological needs, a n d particularly of i m p r o v i n g the lot of the " priority classes." W h a t I a m c o n c e r n e d to b r i n g out, as one small part o f a very complicated issue, is t h e need for convincing evidence before a n y definite s t a t e m e n t is m a d e on t h e e x t e n t of t h e advantages or disadvantages of s u c h procedure. T h e search for s u c h evidence as it concerns t h e nation, r a t h e r t h a n the individual, n e e d s to be m o r e exacting before p r o n o u n c i n g o n cause mad effect. As " Searcher after T r u t h " has vividly s h o w n , food is n o w distributed m o r e in accordance w i t h biological n e e d s t h a n ever before /it this c o u n t r y , or a n y o t h e r p r e s e n t or past, a n d as h e h a s stated the d e a t h s o f m o t h e r s , o f babies before a n d after birth, o f children, mid o f t h e t u b e r c u l o u s a n d aged h a s declined ; in t h e case of t h e m o t h e r s , d y i n g as a result of c h i l d b i r t h , a n d o f c h i l d r e n b e t w e e n one a n d five years o f age, the decline h a s b e e n so r a p i d as to be dramatic (Table I). P u t t i n g o n one side the foolish suggestion that E n g l a n d is d y i n g on h e r feet, w h i c h is obviously u n t r u e , we m u s t resist t h e t e m p t a t i o n to r u s h to o t h e r e x t r e m e s a n d see in these declining mortalitles sure p r o o f of the beneficent effects o f the food policy of recent years. Physically at least, E n g l a n d is not " d y i n g " but, as he indicates, " r e s u r g e n t " : is this effect due to food ? T h e facts of the redistribution of food, particularly milk, c a n n o t be denied, n o r can t h e figures of the R e g i s t r a r General ; has t h e food caused t h e figures ? I a m n o t suggesting that this is n o t a case of cause a n d effect b u t I do say that a good deal m o r e study is n e e d e d before t h e r e can be a n y certainty of s u c h a connection. F o o d has n o t been t h e o n l y variable in t h e last decade o f our history. A cynic m i g h t say, w i t h o u t fear o f absolute contradiction o n t h e facts ffs n o w known, t h a t t h e m o r t a l i t y figures would have b e e n worse if left alone to t h e operation o f t h e variation in food c o n s u m p t i o n a n d d i s t r i b u t i o n a n d t h a t o t h e r variables have been so s t r i k i n g in their effects as to m a s k s u p p o s e d l y adverse effects of food. T h i s interpretation w o u l d be highly improbable in face of certain k n o w n facts w h i c h " Searcher after T r u t h " e m phasised, namely, t h e i m p r o v i n g stature o f children a n d the disappearance o f deficiency d i s e a s e s ; f u r t h e r m o r e , s u c h a n interpretation w o u l d n o t be in accord w i t h the evidence of physiological needs of p r o t e i n in pregmancy a n d t h e probable inference that t h e higher intake of milk protein has r e d u c e d the incidence of liver atrophies a n d eclampsias w h i c h have c o n t r i b u t e d to m a t e r n a l mortality in t h e past. Nevertheless, " Searcher after T r u t h " d i d not m e n t i o n certain puzzling findings recently m a d e k n o w n , that the r e d u c t i o n o f stillbirths in Scotland h a s been m o s t m a r k e d in social classes 1, 9. a n d 3, in w h i c h it s e e m s unlikely t h a t diet has improved d u r i n g the war, a n y w a y to the extent of t h a t in classes 4 and 5. Are the better-to-do m o t h e r s , b y reason o f a greater intelligence, " taking u p " t h e v i t a m i n foods m o r e readily or cons u m i n g t h e i r allotted portion of m i l k t h r o u g h a better u n d e r s t a n d i n g of the value of these protective m e a s u r e s ? N o r did he m e n t i o n the runaours that have b e e n circulating a n d w h i c h are m e n t i o n e d by Sir Jack D r u m m o n d in t h e J a n u a r y Practitioner, t h a t t h e g r o w t h of adolescents has b e g u n to decline. I n short, t h e s t a t e m e n t that " t h e remarkable changes in vital statistics, particularly of o u r m o t h e r s ' a n d children, m u s t be largely ascribed to t h e success of this great biological e x p e r i m e n t , " a l t h o u g h it m a y be wholly or partially true, cannot be said to have been proved. A d e e p e r search is required. I n an a t t e m p t to take this intricate p r o b l e m one stage further, I a m including below a n analysis of deaths o f children aged o n e to five in t h e W e s t R i d i n g of Y o r k s h i r e (Table II). T h e m o r t a l i t y figures for t h e various g r o u p s referred to b y " S e a r c h e r after T r u t h " have for p u r p o s e s o f reference also been set o u t in Table I : t h e y s h o w how t r u l y remarkable has been t h e i m p r o v e m e a t in t h e past decade. T h e n u m b e r of children in the W e s t R i d i n g has c h a n g e d little in the last decade a n d the n u m b e r s of d e a t h s can, therefore, be taken as r o u g h l y comparable. W h e n arranged in six g r o u p s of broadly similar pathological processes it is seen t h a t three g r o u p s (4, 5 a n d 6) have c o n t r i b u t e d little to t h e general r e d u c t i o n in c o m p a r i s o n with t h e o t h e r three (I, x2 a n d 3) ; o f t h e total decline o f 302 deaths, n o less t h a n 238 have occurred in g r o u p s 1, 2 a n d 3. W e m u s t accept t h e general u n c e r t a i n t y of diagnosis as recorded o n d e a t h certificates, in t h e absence of a pathologist's post-mortem corroshould b e u n i t e d in t h e i r efforts to provide t r e a t m e n t f r o m t h e cradle to the grave.
D E N T A L CARE OF T H E CHILD U N D E R T H E NATIONAL H E A L T H SERVICE ACT* By D. E. MASON, L.D.S., Chief Dental Officer, Nottinghamshire My duty this afternoon is to place before you, for your consideration and criticisms, my views as to what I, as a public dental officer, consider will be efficient methods of providing routine and (where necessary) special dental treatment for school children when the N.H.S. Act comes into operation in July, 1948. With the introduction of the National Health Service Act, children attending maintained schools will have at their disposal two agencies through which they will be able to obtain, without the payment of any fees, all necessary dental treatment. One agency will be the School Dental Service within the School Health Service of the local education authority in whose area the school is situated, and the other agency will be the general dental services scheme set up by local executive councils under Section 40 of the N.H.S. Act. You will see, therefore, that as matters stand at present, there w~ll be two separately administered and unco-ordinated official dental treatment schemes for the school child, one being sponsored by the Ministry of Health under the N.H.S. Act and the other being sponsored by the Ministry of Education under the Education Act. Such an arrangement must result in division of responsibility with consequential inefficiency, overlapping and omissions, and with the unfortunate child falling between the two administrative stools. I n the absence of any specific ruling to the contrary it is logical to assume that payment in respect of children treated through the general dental services scheme will be made by the Ministry of Health and that local education authorities will not be called upon to pay anything f o r such cases. In other words, a local education authority will be saved considerable expenditure by failing to provide a complete school dental service, and by adopting a policy of encouraging school children to obtain their dental treatment through the general dental services of the N.H.S. Act. If what I have said is a logical interpretation of how the position stands at present, then is it likely, in such circumstances, that all L.E.A.s will make serious attempts to provide complete dental services themselves ? I think, then, that you will agree with me when I say that divided responsibility for the provision of this service is undesirable a n d that it is the duty of the dental profession as a whole, mid of specialised Groups like this in particular, to produce helpful and constructive proposals which will be of assistance to the Government in formulating the working details of a scheme which wilt be to the benefit of the children concerned and which will obviate inefficiency and cut down overlapping to the lowest possible level. T h e primary concern must be the welfare of the children, but almost of equal importance is the need for the most careful and economic use of dental man-power bearing in mind the existing low n u m b e r of dental practitioners in Great Britain. For the Government to introduce a Regulation which totally excludes school children from participating in the general dental service, would, I think, be a wrong procedure because it would eliminate healthy competition by giving a monopoly to local education authorities, some of which have not in the past shown themselves to be particularly anxious to provide complete and comprehensive dental services for the children under their care. On the other hand, it would, I consider, be a mistake of even greater magnitude for the Government to abolish, as a treatment service, the existing school dental service on the grounds that all necessary dental treatment can, in future, be provided through the agency of the general dental service under the N.H.S. Act, and that the majority of the dental officers at present employed within the school dental service would have no difficulty in obtaining full time employment within the general dental service, the remaining few being retained as inspecting officers. * Paper and discussion at a meeting of the Dental Officers' Group, Society of M.O. I-I., on Oct. 4th, 1947.
89 If you accept my contention that neither of the foregoing would be a satisfactory solution, then we are left with a third possibility which is that the school dental service should continue to" function as a progressive inspection and treatmenm service and that children in attendance at maintained schools should be encouraged to make use of it and yet at the same time some provision should exist for treatment through the general dental services scheme for those children whose parents possess a preference for this procedure. In speaking in favour of this third possibility, it w o u l d appear that I am now advocating the very scheme which I have just been deprecating, but the following safeguards put a different COl~plexion on matters. T h e Ministry of Health will, presumably, be credited with all the contributions paid by the population in respect of the National Health Service. This being the case, it is logical to suggest that the costs of the service (including the dental treatment of school children) should ultimately be borne by the Ministry of Health. As the person who pays the piper is the one who is entitled to name the tune to be played, then what I have suggested would justify the Ministry of Health in assuming ultimate responsibility for the school dental service and its efficiency and as far as I can see there is nothing in this suggestion which is in any way at variance with the text of the N.H.S. Act. For convenience, however, I suggest that the Ministry of Education should continue to act, as at present, somewhat in the capacity of an agent for the Ministry of Health, by making arrangements through local education authorities for the provision of a satisfactory school dental service. This suggestion seems to be in accordance with Section 48 of the Education Act which, we should bear in mind, is now a law actually in operation and which is not, therefore, likely to be changed unless time proves it to be ineffective. My next suggestion may surprise you because it is to the effect that every dental officer employed by a local authority should be required to register under the general dental services scheme outlined under Section 40 of the N.H.S. Act and that he should make the appropriate claim to the Dental Estimates Board for payment to his local authority (not to himself because he wilt be receiving a fixed salary) in respect of all dental treatment which he carries out for his local authority. T h e advantages of a procedure of this sort include : - 1. T h e cost of treatment (but not of capital expenditure such as the building of clinics) would fall on the Ministry of Health and not on local education authorities with the result that local authorities would be more likely to provide a more complete dental service. 2. T h e fees obtained by local authorities from the Ministry of Health for treatment carried out, could be compared with the running costs involved in providing the treatment and any appreciable variation, either way, from a balance would call for an investigation and explanation. 3. T h e machinery of the Ministry of Health for securing that dental treatment carried out under the N.H.S. A c t is being performed in an efficient manner and under suitable conditions could be applied with equal force to the dental officers employed by local authorities as it will be to the other practitioners working under the scheme. (I very much doubt if some of the treatment premises which school dental officers are at present using would be passed as satisfactory premises under the N.H.S. scheme.) 4. T h e patients of local authority dental officers would be u n d e r precisely the same Regulations, in regard to dental treatment, as the patients of other practitioners and there would, of course, ~e the same machinery for dealing with complaints of a professional nature. 5. T h e Local Dental Practitioners' Committee and the local executive council, established under the N.H.S. Act, would be in a position to take an active interest in the local authorities school dental service. At present these bodies would appear to have no locus standi at all in this matter, but I suggest to you that these two bodies, because of their composition and duties ought to play a part in every branch of the dental services in their area.
90 6. I t would place the local authority dental officer on the same professional plane and on a comparable professional basis w i t h his colleague performing similar duties outside t h e local authority's ambit, thereby giving h i m a justifiable claim for comparable remuneration which he certainly doesn't receive u n d e r present conditions. 7. I t would bring to the notice of local authorities the cash value o f the treatment carried out per a n n u m by an industrious and efficient dental officer. A t present the value of this treatm e n t (which includes the taking and processing of x-ray films, orthodontia, the provision of artificial dentures, crowns and cleft p a l a t e appliances and the administration of general anaesthetics in addition to routine fillings and extractions) seems to be very m u c h underestimated j u d g i n g by present remuneration standards. I c o m m e n d these administrative points to you for your consideration and criticisms not because I think they are in a n y w a y ideal b u t because I cannot think of any better m e t h o d which will at one and the same time combine the qualities of continuing t h e existing clinical aspect of the service ; of providing an incentive to local authorities to make progress with their dental s c h e m e s ; of placing ultimate responsibility for the service in the hands of only one M i n i s t r y ; of unifying treatm e n t procedure regardless of the agency t h r o u g h which treatm e n t is obtained and of conforming to the general r e q u i r e m e n t s of b o t h the Education A c t and the N . H . S . A c t : I n advocating that the e x i s t i n g school dental service should not only be continued but greatly expanded, and that school children should be given every possible e n c o u r a g e m e n t to obtain their necessary dental t r e a t m e n t t h r o u g h it, I feel that I need n o t make e i t h e r excuse or apology to this or any o t h e r meeting. T h e school dental service is staffed by m e n and w o m e n w h o have selected this aspect of dentistry because they like dealing w i t h children and, after having s p e n t 25 years in this service, I can say w i t h o u t hesitation that the efficient results w h i c h are being obtained by experienced and conscientious officers have to be seen to be fully appreciated. It is true to say that some private dental practitioners are v e r y successful in their dental t r e a t m e n t of children, b u t it is equally true to say that there are m a n y private dentists who openly admit t h a t they have little or no patience w i t h children (particularly nervous y o u n g children) and that t h e y heartily dislike having to treat them. Based on experience, I t h i n k I can say that the dental t r e a t m e n t of children necessitates its o w n specialised training and that the dentist w h o has had this training and has a flair for the w o r k will accomplish a greater a m o u n t of treatment with a greater a m o u n t of success, in a given time, than the dentist w h o deals w i t h children only as a side-line. T h i s is a most i m p o r t a n t point w h e n it is realised that approximately 6,000,000 children attend maintained schools and that a m i n i m u m of 2,000 experienced whole-time dental officers are needed (at prevailing acceptance rates), to p u t and maintain their teeth in a sound condition. F r o m an administrative point of view, it seems to me to be the obviously desirable procedure for these c h i l d r e n to continue to have their teeth inspected at regular intervals at school and for those with defects to be encouraged to have their treatment, carried out in a dental cIinic situated near to the school rather than to seek treatment f r o m an unspecified private practitioner whose rooms m a y be several miles away, T h e existing school dental service, although admittedly far f r o m perfect and far f r o m complete, has been built up on the trial and error method, and can now be regarded as a well-organised smacture based on the solid foundation of useful experience and because it is organised, it produces a larger proportion of dentally treated cases per thousand of the population than w o u l d be achieved if children were left to seek der~tal treatment on their own account through the private or quasi-private practitioner of their choice. I venture to suggest that at the present t i m e - - i n the p r o v i n c e s - - a t least 90% of the routine dental t r e a t m e n t w h i c h is given to children attending maintained schools is given t h r o u g h the school dental service and, in view of the fact that teachers, parents and children are n o w so familiar with this service, and generally speaking have such confidence in it, I think it would be a big mistake to interfere with its present comprehensive t r e a t m e n t policy j and it would, in m y
PUBLIC HEALTH, February, 1948 opinion, be a retrogressive step a m o u n t i n g to a tragedy to attempt to reduce it to a m e r e inspectorial service "with the children left to make their own arrangements in regard to obtaining treatment. O r t h o d o n t i c treatment is also b e i n g m o s t successfully undertaken by school dental officers w i t h the aid and assistance, where necessary, of consultant orthodontists, and I can see no justifiable reason w h y school children in n e e d of this specialised t r e a t m e n t should not continue to be encouraged to obtain it t h r o u g h the school dental service. I will conclude m y remarks by saying that, although I was invited to deal only w i t h the " Dental Care of the School Child u n d e r the N . H . S . A c t , " I feel I m u s t say one sentence in connection w i t h the dental care of the expectant m o t h e r and pre-school child because these two groups, a l o n g w i t h school children, fall w i t h i n the priority classes to be p r o vided for by local authorities. T h e administrative points which I have put f o r w a r d in respect of the school child apply with equal force to the expectant m o t h e r and pre-school child except for the fact that in these cases the t e r m " H e a l t h Authority " should be substituted for " E d u c a t i o n A u t h o r i t y . " DISCUSSION Mr. J. E. H. DUCKWORTH,who opened the discussion, said he was speaking as a private practitioner and private practice was, he considered, the finest service in the country. -Any remarks he would make would be on the assumption that the N.H.S. Act would provide a service which the profession would approve. In principle he was in entire agreement with Mr. Mason. There were some points, however, on which he would like to comment. There were private practitioners who did like attending children and some who did not, but in spite of that there was a colossal number iv_ the profession who, nevertheless, did attend children. He thought private practitioners were at a disadvantage in this respedt. They did not keep statistics and he could not quote the number of patients he had in a year, but he had attended 530 children, 180 of whom were entitled to free treatment, but whose parents, nevertheless, brought them to h lm. . . . There. were thousands more like him. What he pleaded for again and again was "integration." If we were to have a child health service, and there was no dentist in the country who did not want it, it could not be done if the two services were to be segregated. Our efforts towards integration should begin now. He did not think it was good for the public dental officer to exist for 25 years in the rarefied atmosphere of school dentistry and he did not think the school dentist gave any better treatment to the child than the private practitioner. The two should be brought together under the N.H.S. Act. There were perhaps some things which were better done within the service, and orthodontics was one, It would be a great help to the private practitioner if orthodorttic clinics were set up. tie did not think the children should be herded into clinics, after all the average clinic was not a very pleasant place. He believed that parents should have the right to choose. He believed in family dentistry, the kind that was carried out in some 14,000 dentists' surgeries in the country. DR. N~WTH said he had heard the same arguments over and over again. The same points had been brought before his Society and rejected. A public dental officer would probably treat 2,000 children in a year compared with Mr. Duckworth's 530. Surely there was something in treating a large number of children. Was not child dentistry a specialised job ? He did not think a clinic was an undesirable place and said that in a clinic you did get the personal touch. He sympathised with Mr. Duckworth's remarks about the family dentist, but in the health service they often found it impossible to find out even who the family' doctor was, and he imagined it would be the same with the dentist. MISS HnRmSoN found herself agreeing with Mr. Duckworth. There was one point, "however. No records were kept of the people who said " I want to go to a clinic." MR. McCLELLANDpleaded for more dental propaganda, not only for children but also for adolescents and expectant and nursing mothers. He thought we lacked good dental propaganda films and he mentioned ass American Navy film on " H o w to clean the teeth." He knew 6f no film like it in this country. He knew many children .who got out of seeing the public dental officer by saying they were going to their own private dentist. MR. J; W. GILBERTsaid there must be reasonableness. Mr. Mason and Mr. Duckworth both disliked being milled irlto a Clinic. Children attending a private practitioner were at a disadvantage. They shoufd be entitled-to the same marks and privileges as the child who attended the public dental officer. He thought that instead of receiving a salary cheque from the local authority the public dental officer should be paid for the work done by the general health service. MR. A. G. LUNT stressed that everyone in the dental profession
PUBLIC H E A L T H , F e b r u a r y , 1948 MR. K. BATTEN d i d n o t agree w i t h M r . M a s o n ' s s u g g e s t i o n as t o p a y m e n t . It w o u l d a d d complications a n d there w o u l d be too m u c h control. T h e local a u t h o r i t y should provide a dental service f r o m zero to m o t h e r h o o d . He t h o u g h t t h e private d e n t i s t could e x a m i n e the child a n d reciprocate b y stating t h e r e was t r e a t m e n t n e e d e d a n d send h i m to a school clinic. He failed to see h o w there could be co-operation b e t w e e n t h e private practitioner a n d t h e local a u t h o r i t y as long as t h e patient h a d the o p t i o n of g o i n g to w h o m s o e v e r h e p/eased. MR. PEACOCK said t h a t after e x a m i n i n g a child t h e dental officer could advise that a private practitioner be visited or alternatively t h a t advantage could be taken of t h e facilities provided by t h e school dental service. Local authorities as a whole were quite willing to provide a very good service indeed, b u t t h e r e were two things s t o p p i n g t h e m , buildings a n d personnel. MR. GOODEN said there were still a n u m b e r of local authorities w h o d i d n o t appreciate t h e necessity for a full dental service. So far as t h e private practitioner was c o n c e r n e d t h e position was still dubious. U n d e r t h e N . H . S . Act t h e r e were certain stipulations a n d conditions to w h i c h t h e y could not agree. H e asked w h a t was there a b o u t child d e n t i s t r y that m a d e it a speciality ? O r t h o d o n t i c treatm e n t : yes ; b u t d a y - t o - d a y t r e a t m e n t : n o 1 T h e s a m e c o n t i n u o u s t r e a t m e n t week in arid week out m u s t be a d r a i n o n anyone. T h e scope of the public dental officer s h o u l d be w i d e n e d . MR. W . RITCHIE YOUNO was s u r p r i s e d at t h e attitude o f s o m e at t h e m e e t i n g . He h a d always t h o u g h t t h a t we were all o n e h a p p y breed. Surely t h e w o r k was the same. T h e r e were o n l y five services t h a t could be given, to clean, to remove, to scale, to fill a n d to replace. Everyone had d i s c u s s e d ' t h e p r o b l e m f r o m t h e p o i n t of view of t h e dentist, b u t t h e y s h o u l d also consider t h e p o i n t of view of t h e patient. MR. W. G. SENIOR congratulated t h e G r o u p on a very i n t e r e s t i n g m e e t i n g . M r . M a s o n h a d s u g g e s t e d ~ ingenious m e t h o d for t h e public dental service. O n t h e other h a n d , M r . D u c k w o r t h h a d p u t forward a s t r o n g claim for the p r i v a t e practitioner. T h e y m u s t r e m e m b e r t h a t it was a private practitioner w h o first started school dentistry. I n his view the Beveridge R e p o r t was responsible for t h e idea t h a t t h e r e was a shortage of d e n t i s t s . T h e r e was no shortage of dentists now. T h e r e were sufficient to m e e t t h e d e m a n d s . I n regard to p r o p a g a n d a it was n o t n e c e s s a r y to go to t h e U.S.A. for films. W e h a d o u r o w n first-rate films on t h e care of t h e teeth. H e t h o u g h t u l t i m a t e l y t h e solution w o u l d be co-operation f r o m t h e local dental c o m m i t t e e s . MR. A. T . WYNNE t h o u g h t there w a s one p o i n t that was overlooked. T a k i n g t h e c o u n t r y as a whole and looking into t h e f u t u r e t h e shortage of p r e m i s e s a n d m a n p o w e r was very severe. It was easy e n o u g h to decide w h a t y o u w a n t e d to be done, b u t n o t so easy to p u t it into practice. Since t h e war local a u t h o r i t i e s h a d s h o w n m u c h m o r e willingness to i m p r o v e public dentistry. MR. J. C. CROSSLEY t h o u g h t Mr. M a s o n was r i g h t in s u g g e s t i n g t h a t public dental officers should register a n d that t h e local executive c o m m i t t e e s h o u l d p a y for t h e work t h e y were doing. T h i s should help to provide a really efficient service. MR. MASON, in h i s reply, took up M r . Senior's r e m a r k s o n staffing problems. T h e M i n i s t r y of E d u c a t i o n h a d p r o v i d e d t h e following figures. T h e r e were 725 dental officers e m p l o y e d - - 4 0 8 p a r t - t i m e a n d 317 full-time. T h e actual n u m b e r required for m e e t i n g t h e n e e d was 3,000. H e t h o u g h t that s o m e speakers h a d overlooked t h e fact that to have t h e i r s c h e m e s we m u s t have an Act of Parliament passed. MR. DUCKWORTH, t a k i n g u p Dr. N e w t h ' s point, said he was trying to refute the claim t h a t school d e n t i s t r y was a specialised job, a t o o t h filled by a public dental officer in a clinic a n d that filled by a private practitioner were equally t h e same t h i n g . A c c o r d i n g to W h i t a k e r s ' there were 10½ m i l l i o n children to be looked after. Public dental officers in 1945 e x a m i n e d 2~ million o f t h e m . H e w o u l d leave t h e m w i t h t h e idea t h a t n e i t h e r t h e public dental officer n o r t h e private practitioner could h a n d l e this m a t t e r . T h e m o r e strain y o u p u t on the public dental officer or t h e m o r e y o u p u t on t h e private practitioner, t h e m o r e difficult y o u were g o i n g to m a k e it. Votes of t h a n k s to M e s s r s . M a s o n a n d D u c k w o r t h were p r o p o s e d b y M r . Batten, s e c o n d e d by M r . Crossley, a n d carried by acclamation.
T h e British Standards Institution h a s now p u b l i s h e d B.S. 1425/1948, " Cleanliness of Fillings a n d Stuffings for Bedding, etc.," w h i c h will be of interest to M.O.H,s in areas where t h e r a g flock i n d u s t r y operates. Obtainable from t h e B.S.L, 24/28, Victoria Street, London, S.W.I, price 3s. post free. Citizen, the j o u r n a l of civic affairs, reappears in its second year in a new f o r m a t a n d will henceforward b e p u b l i s h e d every two m o n t h s in order to conserve paper a n d increase its circulation. It is well got u p a n d i_ts articles s h o u l d be of interest to aI1 intelligent readers concerned with local g o v e r n m e n t matters. P u b l i s h e d by W a l t e r K i n g , Ltd., 11, Bolt Court, Fleet Street, E.C.4. A n n u a l subscription 9s. 6d. (post free).
91 CORRESPONDENCE " DYING ENGLAND " OR " THE BIRTH OF A NATION " ? To the Editor o f PUBLIC HEALTH S I R , - - I s u s p e c t that D r . J o h n s o n w o u l d have fallen into t h e small class o f overfeds a b o u t w h i c h o u r colleagues o v e r t h e water are concerned, a n d to w h i c h y o u referred last m o n t h , a n d that he would have lived a longer a n d a healthier life on the diet of m o d e r n Britain ; as to w h e t h e r this w o u l d have m a d e his J o h n s o n e s e better or worse I a m n o t prepared to hazard a guess. N o r d o I propose to a d d r e s s m y s e l f to the question as to w h e t h e r Britain t o - d a y is being p r o p e r l y fed except to say in p a s s i n g t h a t " S e a r c h e r after T r u t h " s e e m s to m e to have d e m o n s t r a t e d clearly t h e logic of feeding t h e nation according to biological needs, a n d particularly of i m p r o v i n g the lot of the " priority classes." W h a t I a m c o n c e r n e d to b r i n g out, as one small part o f a very complicated issue, is t h e need for convincing evidence before a n y definite s t a t e m e n t is m a d e on t h e e x t e n t of t h e advantages or disadvantages of s u c h procedure. T h e search for s u c h evidence as it concerns t h e nation, r a t h e r t h a n the individual, n e e d s to be m o r e exacting before p r o n o u n c i n g o n cause mad effect. As " Searcher after T r u t h " has vividly s h o w n , food is n o w distributed m o r e in accordance w i t h biological n e e d s t h a n ever before /it this c o u n t r y , or a n y o t h e r p r e s e n t or past, a n d as h e h a s stated the d e a t h s o f m o t h e r s , o f babies before a n d after birth, o f children, mid o f t h e t u b e r c u l o u s a n d aged h a s declined ; in t h e case of t h e m o t h e r s , d y i n g as a result of c h i l d b i r t h , a n d o f c h i l d r e n b e t w e e n one a n d five years o f age, the decline h a s b e e n so r a p i d as to be dramatic (Table I). P u t t i n g o n one side the foolish suggestion that E n g l a n d is d y i n g on h e r feet, w h i c h is obviously u n t r u e , we m u s t resist t h e t e m p t a t i o n to r u s h to o t h e r e x t r e m e s a n d see in these declining mortalitles sure p r o o f of the beneficent effects o f the food policy of recent years. Physically at least, E n g l a n d is not " d y i n g " but, as he indicates, " r e s u r g e n t " : is this effect due to food ? T h e facts of the redistribution of food, particularly milk, c a n n o t be denied, n o r can t h e figures of the R e g i s t r a r General ; has t h e food caused t h e figures ? I a m n o t suggesting that this is n o t a case of cause a n d effect b u t I do say that a good deal m o r e study is n e e d e d before t h e r e can be a n y certainty of s u c h a connection. F o o d has n o t been t h e o n l y variable in t h e last decade o f our history. A cynic m i g h t say, w i t h o u t fear o f absolute contradiction o n t h e facts ffs n o w known, t h a t t h e m o r t a l i t y figures would have b e e n worse if left alone to t h e operation o f t h e variation in food c o n s u m p t i o n a n d d i s t r i b u t i o n a n d t h a t o t h e r variables have been so s t r i k i n g in their effects as to m a s k s u p p o s e d l y adverse effects of food. T h i s interpretation w o u l d be highly improbable in face of certain k n o w n facts w h i c h " Searcher after T r u t h " e m phasised, namely, t h e i m p r o v i n g stature o f children a n d the disappearance o f deficiency d i s e a s e s ; f u r t h e r m o r e , s u c h a n interpretation w o u l d n o t be in accord w i t h the evidence of physiological needs of p r o t e i n in pregmancy a n d t h e probable inference that t h e higher intake of milk protein has r e d u c e d the incidence of liver atrophies a n d eclampsias w h i c h have c o n t r i b u t e d to m a t e r n a l mortality in t h e past. Nevertheless, " Searcher after T r u t h " d i d not m e n t i o n certain puzzling findings recently m a d e k n o w n , that the r e d u c t i o n o f stillbirths in Scotland h a s been m o s t m a r k e d in social classes 1, 9. a n d 3, in w h i c h it s e e m s unlikely t h a t diet has improved d u r i n g the war, a n y w a y to the extent of t h a t in classes 4 and 5. Are the better-to-do m o t h e r s , b y reason o f a greater intelligence, " taking u p " t h e v i t a m i n foods m o r e readily or cons u m i n g t h e i r allotted portion of m i l k t h r o u g h a better u n d e r s t a n d i n g of the value of these protective m e a s u r e s ? N o r did he m e n t i o n the runaours that have b e e n circulating a n d w h i c h are m e n t i o n e d by Sir Jack D r u m m o n d in t h e J a n u a r y Practitioner, t h a t t h e g r o w t h of adolescents has b e g u n to decline. I n short, t h e s t a t e m e n t that " t h e remarkable changes in vital statistics, particularly of o u r m o t h e r s ' a n d children, m u s t be largely ascribed to t h e success of this great biological e x p e r i m e n t , " a l t h o u g h it m a y be wholly or partially true, cannot be said to have been proved. A d e e p e r search is required. I n an a t t e m p t to take this intricate p r o b l e m one stage further, I a m including below a n analysis of deaths o f children aged o n e to five in t h e W e s t R i d i n g of Y o r k s h i r e (Table II). T h e m o r t a l i t y figures for t h e various g r o u p s referred to b y " S e a r c h e r after T r u t h " have for p u r p o s e s o f reference also been set o u t in Table I : t h e y s h o w how t r u l y remarkable has been t h e i m p r o v e m e a t in t h e past decade. T h e n u m b e r of children in the W e s t R i d i n g has c h a n g e d little in the last decade a n d the n u m b e r s of d e a t h s can, therefore, be taken as r o u g h l y comparable. W h e n arranged in six g r o u p s of broadly similar pathological processes it is seen t h a t three g r o u p s (4, 5 a n d 6) have c o n t r i b u t e d little to t h e general r e d u c t i o n in c o m p a r i s o n with t h e o t h e r three (I, x2 a n d 3) ; o f t h e total decline o f 302 deaths, n o less t h a n 238 have occurred in g r o u p s 1, 2 a n d 3. W e m u s t accept t h e general u n c e r t a i n t y of diagnosis as recorded o n d e a t h certificates, in t h e absence of a pathologist's post-mortem corroshould b e u n i t e d in t h e i r efforts to provide t r e a t m e n t f r o m t h e cradle to the grave.