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Whither child welfare?
W H I T H E R CHILD W E L F A R E ? * By
DOROTHY
F.
EGAN,
M.R.C.S., L.R.C.P.,
D.P.H.
Principal Medical Officer, Maternity and Child Welfare, London County Council President, The Society of Medical Officers of tIeatth, 1964-1965. IN Kensington Square just round the corner from where I live stands a house bearing a blue plaque which reads "Sir John Simon 1816-1904 Pioneer of Public Health lived here". M y erstwhile neighbour, who was President of the Society for the first five years of its history could never have foreseen that one day that high office would be filled by a woma n. This distinction was conferred on Dr Jean M a c k i n t o s h in 1954 and on D r N o r a Wattie in t961. It is an h o n o u r to be third w o m a n President of the Society a n d a very great privilege. But I feel this is not so m u c h a tribute to me as a w o m a n as the recognition by the Society of the achievements of the maternity a n d child welfare services and an expression of confidence that a period of expansion a n d d e v e l o p m e n t lies ahead. One o f the achievem~,,zts of the past decade has been the progress m a d e towards better integration with the hospital and general practitioner services. I n the maternity services, liaison committees have forged a link between ~onsultant obstetricians, general practitioner obstetricians a nd the medical officer o f health by providing a f or um where the problems of each could be discussed. The introduction of planned 48-hour discharge schemes for example, has required the closest co-operation between all three branches o f the service a n d these arrangements are being kept under constant review. In the domiciliary field the midwife has been persuaded to forget her early fears of Ioss of status a n d actively to encourage mothers to book a doctor for maternity medical services. T h u s there has been a dramatic r i s e - - a l m o s t to 100 per cent., in the n u m b e r of h o m e confinements booked with a doctor as well as the midwife. In m a n y areas the general practitioner obstetrician has replaced the clinic d o c t o r in the local authority ante-natal clinic, a nd his personal contact there with the local authority team has helped to build a good relationship between general practitioners and the public health services. F u l l integration has been attempted in some areas by the a~tachment o f health visitors as well as other local authority staffs to general practitioners w o r k i n g in groups. The extent to which this has been carried out has been limited by the structure of general practice. Thus in 1963 although there h a d been a substantial reduction in the n u m b e r of single practices in the country a s a whole, almost one h a l f o f the total practices were still single h a n d e d a n d *Presidential address delivered at an o r d i n a r y meeting o f the Society on September 25th, 1964. 13
14
PUBLIC
HEALTH
VOL.
LXXIX
NO.
1
very largely without an assistant. Four fifths of the remaining partnership practices had only two principles. There has been perhaps less advance in establishment of group practices in the large urban areas, where the lock-up surgery still flourishes and commercial night call services have made their appearance. Under these conditions progress towards the full scale attachment of health visitors has necessarily been very slow. But in spite of these difficulties medical officers of health have encouraged their health visitors to make personal contact with doctors practising in their districts, to seek the general practitioner's advice in difficult family situations and to offer social services which the doctor m a y need for his patients. A study was recently carried out in Leeds (Akester and MacPhail, 1964) to try to measure the change in volume and content of the health visitor's work which would follow their attachment to general practices in the city. The authors reported that the discursive nature of general practice and its frequent duplication in the same household made attachment extremely difficult. Nevertheless in some two thousand home visits made by health vMtors in one week no fewer than two hundred referrals were made by them t :eneral practitioners. This kind of co-operation, which is being built up in the majority of local authority areas, is perhaps a better measure of the integration which has been achieved than can be deduced from the sum total o f experiments in the full scale attachment o f health visitors. It has frequently been said during the past decade that the local authority child welfare clinic will no longer be needed as all child welfare work will be taken over by general practitioners. Attendances however, have shown a steady rise in the past three years. In my own authority some 90 per cent. of mothers make a first attendance at the child welfare clinic and these figures have varied very little in the last 10 years. It seems, therefore, that there is a large group of mothers in the comnmnity who seek the general practitioner's advice only when there is illness in the family and who still require the counselling and supportive services given at present by the clinic doctor and health visitors at child welfare clinics. In the large urban areas where community life has virtually ceased to exist, the child welfare clinic has become possibly the only focal point in the community which is recognised by a large group of mothers as a place where they could seek advice and help on a wide variety of health problems. This situation has been the result of half a century of patient work and is perhaps too valuable an asset to be lightly cast away. It is noteworthy in this connection that in a recent circular (Home Office, 1963) to local authorities on the new powers conferred on children's departments, under section I of the Children and Young Person's Act 1963 (to prevent children being taken into care) the Home Office placed great emphasis on the need for centres which might become such a point of reference. The child welfare centre undoubtedly provides an ideal setting for work with well babies, and at no time could it be considered a good arrangement to combine this work with the diagnosis of ailments or illnesses in young
WHITHER
CHILD
WELFARE?
15
children. But there is likely to be a great advantage in both functions being carried out by the same doctor. In any future community health service which we hope to built, it will be essential for the general practitioner and child welfare services to be united. But we must see to it that we do not lose the dynamic force of the service by scattering it, without careful planning, among general practitioners of widely differing standards, subjected to unpredictable and even to overwhelming pressures of c l i n i c a l w o r k and restricted in their approach to preventive work by insufficient administrative and clerical help. This is all the more important at the present time when new trends are being developed in child welfare. The emphasis now is on developmental examinations, and the Society has taken the lead in designing a new form of medical card for recording the observations of the doctor on the mental, physical and emotional development of the child. The card is at present being tried out in several pilot experiments and it is hoped that ultimately it will be brought into use on a national scale. A start too has been made in screening whole infant populations for phenylketonuria; it seems likely that with new knowledge o f metabolic di sorders this m a y well be only a beginning. Doctors and health visitors are being given the opportunity to study the psychology of childhood and preventive psychiatry at case conferences held in child welfare centres with consultant psychiatrists and psychiatric social workers from local child guidance clinics. An outstanding contribution is being made in the early diagnosis of congenital abnormalities and the co-ordination of medical care and supportive services for children suffering from handicapping conditions of all kinds. Local authorities have shown the importance attached by them to the development of these new trends in their response to the Society's course in Child Health which starts next week under the directorship of Dr M a r y Sheridan, which was over-subscribed nearly two months ago. The need for such a course of training for doctors was urged by Dr N o r a Wattie in her presidential year. The six-week course has been designed to give a comprehensive training in developmental p~ediatrics to doctors experienced in the maternity and child welfare and school health services. This new venture which is likely to be the first of a number of such courses indicates that clinic doctors are seriously preparing to meet the new challenge. I f general practitioners are ultimately to replace the clinic doctor, they too must seek training in screening techniques and developmental diagnosis, and must study the ever-growing knowledge of the causes of congenital abnormalities. It is sometimes said that if the doctor in practice has a special interest he can find time to do it, but this is only partly true--fundamentally, re-organisation of general practitioners into groups is of the first importance. Does not the solution to these difficulties lie in the concept of the health centre? Should we not forge ahead, as has been done already in some areas with schemes to bring the general practitioner with an interest in clinical and
16
PUBLIC
HEALTH
VOL.
LXXIX
NO.
1
preventive p~ediatrics into the existing child welfare service, so t h a t his preventive w o r k is a d m i n i s t e r e d by the local a u t h o r i t y a n d p a i d for by them, w h e t h e r the w o r k is carried o u t in local a u t h o r i t y buildings or in the d o c t o r ' s surgery? A t field level the general p r a c t i t i o n e r will ultimately b e c o m e the clinical leader o f the local health a u t h o r i t y team, but the direction o f the service m u s t r e m a i n with the medical officer o f health. H e is in a p o s i t i o n to compile registers o f h a n d i c a p p e d children a n d o f children in danger o f developing a handicap. He can observe any unusual c o n c e n t r a t i o n o f congenital a b n o r m a l i t i e s requiring epidemiological investigation a n d can plan a h e a d the facilities r e q u i r e d to meet individual needs. The transfer of records between local health authorities is c o m m o n practice a n d constitutes an i m p o r t a n t f a c t o r in follow-up, particularly in u r b a n areas where there is a c o n t i n u a l shift o f p o p u l a t i o n . The a t t a c h m e n t o f clinic d o c t o r s to hospital p,-ediatric d e p a r t m e n t s on an exchange basis h a s n o t proved entirely successful in the past p r o b a b l y because the clinic d o c t o r h a s been expected to become a clinician rather t h a n to contribute his knowledge o f social p~ediatrics to lhe hospital. O n the other h a n d the hospital registrar might m o r e profitably have been given better opportunities to see s o m e t h i n g o f the services o f local authorities for the follow-up a n d care o f the h a n d i c a p p e d child. W h e n the plans f o r the establishment o f assessment centres within the hospital service have been implemented, it w o u l d be a p p r o priate if senior medical officers o f local health authorities w h o regularly review the registers o f h a n d i c a p p e d children were a t t a c h e d part-time to the hospital units to advise o n the social services and educational facilities to suit individual needs. It will be interesting to see w h a t action will be taken by the Ministry of H e a l t h on the p r o p o s a l s o f the C o h e n C o m m i t t e e (1964) to set up a new central b o d y to organise health e d u c a t i o n activities on a national level a n d to evaluate the results o f such c a m p a i g n s . I t is suggested t h a t the n e w b o d y w o u l d give a d v i c e a n d assistance to local agencies a n d w o u l d p r o m o t e training f o r all personnel c o n c e r n e d in health education. It will be generally agreed t h a t n e w m e a s u r e s with increased financial b a c k i n g will be essential if progress is to be m a d e in changing the habits o f adults a n d in a w a k e n i n g in t h e m a sense o f responsibility a b o u t the effect o f their example on children. T h e C e n t r a l C o u n c i l o f H e a l t h E d u c a t i o n has served the local authorities well in the past. I t is h o p e d t h a t their experience a n d skill particularly in the a r r a n g e m e n t o f training p r o g r a m m e s will be s o u g h t by the new body. H e a l t h e d u c a t i o n is n o longer the sole concern o f a n y one discipline, but it has long been, a n d will r e m a i n , a special task f o r public h e a l t h d e p a r t m e n t s . Local authorities m u s t see to it that they will h a v e direct r e p r e s e n t a t i o n on the new B o a r d . A K E s a- E R, J o v C ~. M . & M A c P n A I L, A . W . H e a l t h V i s i t i n g a n d G e n e r a l P r a c t i c e . The Lancet. 2 2 . 8 . 6 4 . H O M E O F F I C E C I R C U L A R NO. 204/1963. I I E A L T H E D U C A T I O N. "'Report o f a Joint Committee of the Central and Scottish H e a l t h S e r v i c e s C o u n c i l s . 1964.
DOROTHY
F.
EGAN,
M.R.C.S., L.R.C.P.,
D.P.H.
Principal Medical Officer, Maternity and Child Welfare, London County Council President, The Society of Medical Officers of tIeatth, 1964-1965. IN Kensington Square just round the corner from where I live stands a house bearing a blue plaque which reads "Sir John Simon 1816-1904 Pioneer of Public Health lived here". M y erstwhile neighbour, who was President of the Society for the first five years of its history could never have foreseen that one day that high office would be filled by a woma n. This distinction was conferred on Dr Jean M a c k i n t o s h in 1954 and on D r N o r a Wattie in t961. It is an h o n o u r to be third w o m a n President of the Society a n d a very great privilege. But I feel this is not so m u c h a tribute to me as a w o m a n as the recognition by the Society of the achievements of the maternity a n d child welfare services and an expression of confidence that a period of expansion a n d d e v e l o p m e n t lies ahead. One o f the achievem~,,zts of the past decade has been the progress m a d e towards better integration with the hospital and general practitioner services. I n the maternity services, liaison committees have forged a link between ~onsultant obstetricians, general practitioner obstetricians a nd the medical officer o f health by providing a f or um where the problems of each could be discussed. The introduction of planned 48-hour discharge schemes for example, has required the closest co-operation between all three branches o f the service a n d these arrangements are being kept under constant review. In the domiciliary field the midwife has been persuaded to forget her early fears of Ioss of status a n d actively to encourage mothers to book a doctor for maternity medical services. T h u s there has been a dramatic r i s e - - a l m o s t to 100 per cent., in the n u m b e r of h o m e confinements booked with a doctor as well as the midwife. In m a n y areas the general practitioner obstetrician has replaced the clinic d o c t o r in the local authority ante-natal clinic, a nd his personal contact there with the local authority team has helped to build a good relationship between general practitioners and the public health services. F u l l integration has been attempted in some areas by the a~tachment o f health visitors as well as other local authority staffs to general practitioners w o r k i n g in groups. The extent to which this has been carried out has been limited by the structure of general practice. Thus in 1963 although there h a d been a substantial reduction in the n u m b e r of single practices in the country a s a whole, almost one h a l f o f the total practices were still single h a n d e d a n d *Presidential address delivered at an o r d i n a r y meeting o f the Society on September 25th, 1964. 13
14
PUBLIC
HEALTH
VOL.
LXXIX
NO.
1
very largely without an assistant. Four fifths of the remaining partnership practices had only two principles. There has been perhaps less advance in establishment of group practices in the large urban areas, where the lock-up surgery still flourishes and commercial night call services have made their appearance. Under these conditions progress towards the full scale attachment of health visitors has necessarily been very slow. But in spite of these difficulties medical officers of health have encouraged their health visitors to make personal contact with doctors practising in their districts, to seek the general practitioner's advice in difficult family situations and to offer social services which the doctor m a y need for his patients. A study was recently carried out in Leeds (Akester and MacPhail, 1964) to try to measure the change in volume and content of the health visitor's work which would follow their attachment to general practices in the city. The authors reported that the discursive nature of general practice and its frequent duplication in the same household made attachment extremely difficult. Nevertheless in some two thousand home visits made by health vMtors in one week no fewer than two hundred referrals were made by them t :eneral practitioners. This kind of co-operation, which is being built up in the majority of local authority areas, is perhaps a better measure of the integration which has been achieved than can be deduced from the sum total o f experiments in the full scale attachment o f health visitors. It has frequently been said during the past decade that the local authority child welfare clinic will no longer be needed as all child welfare work will be taken over by general practitioners. Attendances however, have shown a steady rise in the past three years. In my own authority some 90 per cent. of mothers make a first attendance at the child welfare clinic and these figures have varied very little in the last 10 years. It seems, therefore, that there is a large group of mothers in the comnmnity who seek the general practitioner's advice only when there is illness in the family and who still require the counselling and supportive services given at present by the clinic doctor and health visitors at child welfare clinics. In the large urban areas where community life has virtually ceased to exist, the child welfare clinic has become possibly the only focal point in the community which is recognised by a large group of mothers as a place where they could seek advice and help on a wide variety of health problems. This situation has been the result of half a century of patient work and is perhaps too valuable an asset to be lightly cast away. It is noteworthy in this connection that in a recent circular (Home Office, 1963) to local authorities on the new powers conferred on children's departments, under section I of the Children and Young Person's Act 1963 (to prevent children being taken into care) the Home Office placed great emphasis on the need for centres which might become such a point of reference. The child welfare centre undoubtedly provides an ideal setting for work with well babies, and at no time could it be considered a good arrangement to combine this work with the diagnosis of ailments or illnesses in young
WHITHER
CHILD
WELFARE?
15
children. But there is likely to be a great advantage in both functions being carried out by the same doctor. In any future community health service which we hope to built, it will be essential for the general practitioner and child welfare services to be united. But we must see to it that we do not lose the dynamic force of the service by scattering it, without careful planning, among general practitioners of widely differing standards, subjected to unpredictable and even to overwhelming pressures of c l i n i c a l w o r k and restricted in their approach to preventive work by insufficient administrative and clerical help. This is all the more important at the present time when new trends are being developed in child welfare. The emphasis now is on developmental examinations, and the Society has taken the lead in designing a new form of medical card for recording the observations of the doctor on the mental, physical and emotional development of the child. The card is at present being tried out in several pilot experiments and it is hoped that ultimately it will be brought into use on a national scale. A start too has been made in screening whole infant populations for phenylketonuria; it seems likely that with new knowledge o f metabolic di sorders this m a y well be only a beginning. Doctors and health visitors are being given the opportunity to study the psychology of childhood and preventive psychiatry at case conferences held in child welfare centres with consultant psychiatrists and psychiatric social workers from local child guidance clinics. An outstanding contribution is being made in the early diagnosis of congenital abnormalities and the co-ordination of medical care and supportive services for children suffering from handicapping conditions of all kinds. Local authorities have shown the importance attached by them to the development of these new trends in their response to the Society's course in Child Health which starts next week under the directorship of Dr M a r y Sheridan, which was over-subscribed nearly two months ago. The need for such a course of training for doctors was urged by Dr N o r a Wattie in her presidential year. The six-week course has been designed to give a comprehensive training in developmental p~ediatrics to doctors experienced in the maternity and child welfare and school health services. This new venture which is likely to be the first of a number of such courses indicates that clinic doctors are seriously preparing to meet the new challenge. I f general practitioners are ultimately to replace the clinic doctor, they too must seek training in screening techniques and developmental diagnosis, and must study the ever-growing knowledge of the causes of congenital abnormalities. It is sometimes said that if the doctor in practice has a special interest he can find time to do it, but this is only partly true--fundamentally, re-organisation of general practitioners into groups is of the first importance. Does not the solution to these difficulties lie in the concept of the health centre? Should we not forge ahead, as has been done already in some areas with schemes to bring the general practitioner with an interest in clinical and
16
PUBLIC
HEALTH
VOL.
LXXIX
NO.
1
preventive p~ediatrics into the existing child welfare service, so t h a t his preventive w o r k is a d m i n i s t e r e d by the local a u t h o r i t y a n d p a i d for by them, w h e t h e r the w o r k is carried o u t in local a u t h o r i t y buildings or in the d o c t o r ' s surgery? A t field level the general p r a c t i t i o n e r will ultimately b e c o m e the clinical leader o f the local health a u t h o r i t y team, but the direction o f the service m u s t r e m a i n with the medical officer o f health. H e is in a p o s i t i o n to compile registers o f h a n d i c a p p e d children a n d o f children in danger o f developing a handicap. He can observe any unusual c o n c e n t r a t i o n o f congenital a b n o r m a l i t i e s requiring epidemiological investigation a n d can plan a h e a d the facilities r e q u i r e d to meet individual needs. The transfer of records between local health authorities is c o m m o n practice a n d constitutes an i m p o r t a n t f a c t o r in follow-up, particularly in u r b a n areas where there is a c o n t i n u a l shift o f p o p u l a t i o n . The a t t a c h m e n t o f clinic d o c t o r s to hospital p,-ediatric d e p a r t m e n t s on an exchange basis h a s n o t proved entirely successful in the past p r o b a b l y because the clinic d o c t o r h a s been expected to become a clinician rather t h a n to contribute his knowledge o f social p~ediatrics to lhe hospital. O n the other h a n d the hospital registrar might m o r e profitably have been given better opportunities to see s o m e t h i n g o f the services o f local authorities for the follow-up a n d care o f the h a n d i c a p p e d child. W h e n the plans f o r the establishment o f assessment centres within the hospital service have been implemented, it w o u l d be a p p r o priate if senior medical officers o f local health authorities w h o regularly review the registers o f h a n d i c a p p e d children were a t t a c h e d part-time to the hospital units to advise o n the social services and educational facilities to suit individual needs. It will be interesting to see w h a t action will be taken by the Ministry of H e a l t h on the p r o p o s a l s o f the C o h e n C o m m i t t e e (1964) to set up a new central b o d y to organise health e d u c a t i o n activities on a national level a n d to evaluate the results o f such c a m p a i g n s . I t is suggested t h a t the n e w b o d y w o u l d give a d v i c e a n d assistance to local agencies a n d w o u l d p r o m o t e training f o r all personnel c o n c e r n e d in health education. It will be generally agreed t h a t n e w m e a s u r e s with increased financial b a c k i n g will be essential if progress is to be m a d e in changing the habits o f adults a n d in a w a k e n i n g in t h e m a sense o f responsibility a b o u t the effect o f their example on children. T h e C e n t r a l C o u n c i l o f H e a l t h E d u c a t i o n has served the local authorities well in the past. I t is h o p e d t h a t their experience a n d skill particularly in the a r r a n g e m e n t o f training p r o g r a m m e s will be s o u g h t by the new body. H e a l t h e d u c a t i o n is n o longer the sole concern o f a n y one discipline, but it has long been, a n d will r e m a i n , a special task f o r public h e a l t h d e p a r t m e n t s . Local authorities m u s t see to it that they will h a v e direct r e p r e s e n t a t i o n on the new B o a r d . A K E s a- E R, J o v C ~. M . & M A c P n A I L, A . W . H e a l t h V i s i t i n g a n d G e n e r a l P r a c t i c e . The Lancet. 2 2 . 8 . 6 4 . H O M E O F F I C E C I R C U L A R NO. 204/1963. I I E A L T H E D U C A T I O N. "'Report o f a Joint Committee of the Central and Scottish H e a l t h S e r v i c e s C o u n c i l s . 1964.