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Family health
FAMILY HEALTH By J E A N
M. M A C K I N T O S H ,
C.B.E., M.D., D.P.H.
Senior Fellow, Department of Social Medicine, Birmingham University IN the first instance there are two very obvious points one might make. The first is that family health is not the exclusive responsibility of one person or group of persons but is a subject, the responsibility for which must inevitably be shared by a number of persons, but not necessarily a large number. The second point is that the people who are primarily responsible for family health are the members of the family themselves and that any arrangements which other persons outside the family may try to make for its well-being should always make allowance for that fact. In other words, our schemes of care should always, as far as possible, be designed to help people to help themselves and not necessarily to do things for them. Until fairly recently, although some general practitioners had the time to be interested in their families as people rather than as sick persons, the majority were so weighed down with the task of caring for the sick that they had little or no time to think of the wider issues involved in family care. The phenomenal growth of the personal health services of the local authorities over the past 50 years illustrates my point. In considering family care in detail it is usual to start with the expectant mother. For many years a large part of the responsibility for the care of the expectant mother fell on the medical and nursing staff of the local authority. We live in times of change, however. An increasing proportion of this work is now the responsibility of the hospitals, and to a lesser extent, of the general practitioner. The responsibility of local authority medical officers at least for the physical examination of the mothers is becoming less and less. This has been a matter of regret to many of us but we realise that with the development of the medical services it is inevitable. What we really care about is that the work we did should be replaced by something at least as good, if not better. This does not happen automatically--it has to be worked for. In the recommendations of the Cranbrook Committee I see a wonderful opportunity for the general practitioner interested in midwifery if he will only seize it. Here I would say to my general practitioner colleagues that the College has a job to do. What you have to guard against, particularly in the midwifery service, is the tendency of diehards and brash youngsters to take themselves too seriously and to overstate their case--in fact to envelope the phrase "family doctor" with a mystique which can only make it ridiculous. This tendency to overstate one's case is not peculiar to general practitioners--members of the public health service can suffer from it, too. To be aware of the danger is to go more than halfway to overcoming it. Whatever may be said in the intervening period I am sure that the logic of events will lead to a situation where the bulk of normal midwifery practice, whether home or in hospital, will be undertaken 56
FAMILY
HEALTH
57
by a corps of general practitioner obstetricians consisting of something between one-third or one-half of the general practitioners in practice at any one time. To acknowledge the logic of this situation does not, in my view, diminish the dignity or importance of the general practitioner, far otherwise. The antenatal care of the mother includes not only her physical examination but also her education to enable her to attain and maintain optimum mental and physical health during her pregnancy. She needs help with domestic difficulties such as housing or financial problems, not to mention the psychological strains which may develop in the family. This teaching takes time, which, in present circumstances, is not always at the disposal of the general practitioner. Even if he had the time the mother can often best work through her problem--indirectly as it w e r e ~ i n general discussion in a small group of other expectant mothers with very similar problems. Here the health education services provided by the local health authority, either at the clinic or the surgery, can be of immense help to the general practitioner and his patient. Local authority medical officers, midwives and health visitors, whose training and experience have such a strong bias towards health education, have much to contribute in this way and their services should be freely available to and welcomed by their general practitioner colleagues. When we come to the care of the child the situation is different. Because the well-run child welfare clinic is primarily an educational exercise some general practitioners are not interested while others find themselves at sea in a situation where they are not called on to give treatment for a specific ailment and give up the attempt. Some are unaware of their ineffectiveness and carry on. Those G.P's. who are happy in work of this nature do it well but may be up against the difficulty of a general practitioner in my own area who told me he would have to abandon the child welfare clinic for his own patients, which he had held at one of our welfare centres, because it was--I use his own w o r d s - "degenerating into another surgery". For these reasons I think the local authority child welfare clinic is likely to remain with us for a long time yet, although not necessarily in its present form. If you ask me how I think it is likely to develop, I have difficulty in answering, except in the most tentative way. Health centres have not developed in the way envisaged by the National Health Service Act. I think there is a case to be argued for using existing local authority clinics as focal points in the area, to which all those working in the domiciliary medical and social services in the area would naturally gravitate. The local authority medical and nursing staff would be based there with the local authority medical officer taking his proper place as social physician in the area. One of the things which has made for difficulty in the past, and indeed in the present, is that mothers attending clinics have from time to time received conflicting advice by general practitioners on the one hand and local authority staff on the other. I do not think we will ever arrive at the state when we will all think alike on every subject but I do think that by meeting
58
PUBLIC
HEALTH
VOL.
LXXIV
NO.
2
regularly, in small local groups formally and informally, many of our difficulties could be hammered out. Many general practitioners are increasingly realising the value of the health visitor, but though most public health doctors sympathise, the administrative difficulties in the way of assigning health visitors to general practitioners' surgeries or amalgamating the health visiting and district nursing services are considerable. The use of the local authority clinic as the focal point for all the services would help to provide the right sort of liaison. I doubt very much whether, even were all general practitioners working in health centres with nurses in attendance, whether we would think it desirable to alter the present arrangements. As for the routine and special examination of school children and the ascertainment and provision for the handicapped to be effective, the coverage must be as near 100~ as we can make it. Whatever may be the arguments for or against routine medical inspection as understood at present in this country there can be no argument about the importance of a regular survey of the health of individual children. This, general practitioners would find difficult, if not impossible, to do. The same arguments might also apply to immunisation for diphtheria, poliomyelitis, vaccination, etc., if 1 0 0 ~ coverage is wanted, whatever be the age group, there is much to be said for the health department rather than the general practitioner being responsible for this work but the general practitioner should be kept informed as to what is happening to his patient. The contribution which the health department can make to the care of the aged is so well known that I need not elaborate the theme. One remark I would like to make is that when we talk about the chronic sick we think too often only in terms of the aged chronic sick. There is a job to be done by us both in relation to the young chronic sick and the care and aftercare ofi3atients discharged from hospital. General practitioners are sometimes very cagey on this latter subject and are most unwilling that medical officers of health should be informed about the discharge of their patients. By this attitude o f mind they are doing their patients great disservice and often delay the provision of the ancillary services which their patients require. Finally, we have to apply our minds to the question of whether too many patients are admitted to hospital who could equally well, or even more suitably, be treated at home with the assistance of the personal health services o f the local authority. This is a subject which is receiving active attention at the present time in the Department which I am at present working and is one on which our information is at present scanty. We must ask ourselves are the local authority services inadequate and so make hospital admission inevitable or is it the general practitioner who is not prepared to accept responsibility 9. I think you will see from what I have said that far from the importance of the general practitioners and health department staffs diminishing, if they will work together in mutual trust, the field of work opening out before them is vast and will extend them to their fullest capacity.
M. M A C K I N T O S H ,
C.B.E., M.D., D.P.H.
Senior Fellow, Department of Social Medicine, Birmingham University IN the first instance there are two very obvious points one might make. The first is that family health is not the exclusive responsibility of one person or group of persons but is a subject, the responsibility for which must inevitably be shared by a number of persons, but not necessarily a large number. The second point is that the people who are primarily responsible for family health are the members of the family themselves and that any arrangements which other persons outside the family may try to make for its well-being should always make allowance for that fact. In other words, our schemes of care should always, as far as possible, be designed to help people to help themselves and not necessarily to do things for them. Until fairly recently, although some general practitioners had the time to be interested in their families as people rather than as sick persons, the majority were so weighed down with the task of caring for the sick that they had little or no time to think of the wider issues involved in family care. The phenomenal growth of the personal health services of the local authorities over the past 50 years illustrates my point. In considering family care in detail it is usual to start with the expectant mother. For many years a large part of the responsibility for the care of the expectant mother fell on the medical and nursing staff of the local authority. We live in times of change, however. An increasing proportion of this work is now the responsibility of the hospitals, and to a lesser extent, of the general practitioner. The responsibility of local authority medical officers at least for the physical examination of the mothers is becoming less and less. This has been a matter of regret to many of us but we realise that with the development of the medical services it is inevitable. What we really care about is that the work we did should be replaced by something at least as good, if not better. This does not happen automatically--it has to be worked for. In the recommendations of the Cranbrook Committee I see a wonderful opportunity for the general practitioner interested in midwifery if he will only seize it. Here I would say to my general practitioner colleagues that the College has a job to do. What you have to guard against, particularly in the midwifery service, is the tendency of diehards and brash youngsters to take themselves too seriously and to overstate their case--in fact to envelope the phrase "family doctor" with a mystique which can only make it ridiculous. This tendency to overstate one's case is not peculiar to general practitioners--members of the public health service can suffer from it, too. To be aware of the danger is to go more than halfway to overcoming it. Whatever may be said in the intervening period I am sure that the logic of events will lead to a situation where the bulk of normal midwifery practice, whether home or in hospital, will be undertaken 56
FAMILY
HEALTH
57
by a corps of general practitioner obstetricians consisting of something between one-third or one-half of the general practitioners in practice at any one time. To acknowledge the logic of this situation does not, in my view, diminish the dignity or importance of the general practitioner, far otherwise. The antenatal care of the mother includes not only her physical examination but also her education to enable her to attain and maintain optimum mental and physical health during her pregnancy. She needs help with domestic difficulties such as housing or financial problems, not to mention the psychological strains which may develop in the family. This teaching takes time, which, in present circumstances, is not always at the disposal of the general practitioner. Even if he had the time the mother can often best work through her problem--indirectly as it w e r e ~ i n general discussion in a small group of other expectant mothers with very similar problems. Here the health education services provided by the local health authority, either at the clinic or the surgery, can be of immense help to the general practitioner and his patient. Local authority medical officers, midwives and health visitors, whose training and experience have such a strong bias towards health education, have much to contribute in this way and their services should be freely available to and welcomed by their general practitioner colleagues. When we come to the care of the child the situation is different. Because the well-run child welfare clinic is primarily an educational exercise some general practitioners are not interested while others find themselves at sea in a situation where they are not called on to give treatment for a specific ailment and give up the attempt. Some are unaware of their ineffectiveness and carry on. Those G.P's. who are happy in work of this nature do it well but may be up against the difficulty of a general practitioner in my own area who told me he would have to abandon the child welfare clinic for his own patients, which he had held at one of our welfare centres, because it was--I use his own w o r d s - "degenerating into another surgery". For these reasons I think the local authority child welfare clinic is likely to remain with us for a long time yet, although not necessarily in its present form. If you ask me how I think it is likely to develop, I have difficulty in answering, except in the most tentative way. Health centres have not developed in the way envisaged by the National Health Service Act. I think there is a case to be argued for using existing local authority clinics as focal points in the area, to which all those working in the domiciliary medical and social services in the area would naturally gravitate. The local authority medical and nursing staff would be based there with the local authority medical officer taking his proper place as social physician in the area. One of the things which has made for difficulty in the past, and indeed in the present, is that mothers attending clinics have from time to time received conflicting advice by general practitioners on the one hand and local authority staff on the other. I do not think we will ever arrive at the state when we will all think alike on every subject but I do think that by meeting
58
PUBLIC
HEALTH
VOL.
LXXIV
NO.
2
regularly, in small local groups formally and informally, many of our difficulties could be hammered out. Many general practitioners are increasingly realising the value of the health visitor, but though most public health doctors sympathise, the administrative difficulties in the way of assigning health visitors to general practitioners' surgeries or amalgamating the health visiting and district nursing services are considerable. The use of the local authority clinic as the focal point for all the services would help to provide the right sort of liaison. I doubt very much whether, even were all general practitioners working in health centres with nurses in attendance, whether we would think it desirable to alter the present arrangements. As for the routine and special examination of school children and the ascertainment and provision for the handicapped to be effective, the coverage must be as near 100~ as we can make it. Whatever may be the arguments for or against routine medical inspection as understood at present in this country there can be no argument about the importance of a regular survey of the health of individual children. This, general practitioners would find difficult, if not impossible, to do. The same arguments might also apply to immunisation for diphtheria, poliomyelitis, vaccination, etc., if 1 0 0 ~ coverage is wanted, whatever be the age group, there is much to be said for the health department rather than the general practitioner being responsible for this work but the general practitioner should be kept informed as to what is happening to his patient. The contribution which the health department can make to the care of the aged is so well known that I need not elaborate the theme. One remark I would like to make is that when we talk about the chronic sick we think too often only in terms of the aged chronic sick. There is a job to be done by us both in relation to the young chronic sick and the care and aftercare ofi3atients discharged from hospital. General practitioners are sometimes very cagey on this latter subject and are most unwilling that medical officers of health should be informed about the discharge of their patients. By this attitude o f mind they are doing their patients great disservice and often delay the provision of the ancillary services which their patients require. Finally, we have to apply our minds to the question of whether too many patients are admitted to hospital who could equally well, or even more suitably, be treated at home with the assistance of the personal health services o f the local authority. This is a subject which is receiving active attention at the present time in the Department which I am at present working and is one on which our information is at present scanty. We must ask ourselves are the local authority services inadequate and so make hospital admission inevitable or is it the general practitioner who is not prepared to accept responsibility 9. I think you will see from what I have said that far from the importance of the general practitioners and health department staffs diminishing, if they will work together in mutual trust, the field of work opening out before them is vast and will extend them to their fullest capacity.