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Selective school medical inspection in Hampshire
SELECTIVE SCHOOL MEDICAL INSPECTION 1N HAMPSHIRE By L I O N E L
BACON,
M.D., D.P.It.
Deputy County Medical Offices" and Deputy Principal School Medical Officer THE School Health Service and Handicapped Pupils Regulations of 1953 permitred local education authorities to experiment in their methods of school medical inspection, and since then there has developed an increasing interest in the possible advantages of examining children selected on some other basis than age. The chief medical officer of the Ministry of Education has commented on a number of experiments in selective inspection in "The Health of the School Child" (1958-9) and I believe that several other authorities are now developing schemes. It may therefore be of some interest to record our impressions of the first two years of selective inspection in Hampshire. The school population has increased by almost 5 ~ per annum during the past 10 years. Consequently we have always been short of medical and nursing staff, and it was with a view to using our limited resources as economically as possible tha~ we first toyed with the idea of selective inspection. Further, in asking for more doctors and nurses we felt that we must be prepared for the criticism that school medical inspection had become redundant now that any child could be taken, free of charge, to his family doctor. We knew of course that we were recording vast numbers of defects at periodic medical inspection, but we could not say how many of these defects were already being treated through the general practitioner and hospital services. A OEVECT S U R V E Y So we conducted a special survey, designed to inform us on these two points --was our periodic medical inspection in fact bringing to light for the first time defects of significance? and if so, could we have found these by any procedure more efficient and economical than the medical examination of children in specified age-groups ? Some account of this "defect survey" will be published in The Royal Society of Health Journal (Dec., 1961). Here it must suffice to say that in the cxamination of 8,189 successive children at periodic medical inspection in three age groups, 3,387 defects were recorded which had not previously been noted at any previous school medical inspection. Of these, 2,061 (61 ~ ) were either unknown to the parents or, if known, had not been brought under treatment which in the opinion of the school medical officer was required: the 339
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rate among entrants was 53 ~ and among the older children it was 67~o. Detailed and critical study of the 2,061 defects (grouped under 215 diagnoses) satisfied us that with a few exceptions, of which defective vision and certain congenital conditions were the most important, they could have been suspected without recourse to medical examination. QUESTIONNAIRE
TO
PARENTS
This study brought out the importance of obtaining a full medical history from the parents. Hitherto we had used a brief form of letter prior to medical inspection, seeking little information other than the child's history in respect of certain infectious diseases and immunisation procedures. We have now adopted a far more comprehensive questionnaire (Appendix 1) which covers the symptoms of most of the conditions found in our defect survey. Ideally this would be used at least once a year: in practice it would be lmreasonable to ask parents to complete it, 0i" heads to distribute it, so often, and as a compromise it is used prior to the entrant and leavers' inspections and at ages 8 and 12. As originally devised it sought information as to the occurrence of all the symptoms listed during the preceding three-year period; but we found that, with the exception of a few conditions now separately listed, it was preferable to relate the inquiry to the preceding year. The questionnaire is accompanied by an explanatory letter to parents, and the letter which is sent prior to the entrants' inspection gives a brief account of the medical inspection system as it applies throughout the child's school life. THE
NEW
SCHOOL
MEDICAL INSPECTION IN HAMPSHIRE
SYSTEM
Following the defect survey, and starting in September, 1959, we modified our system of medical inspection considerably. The entrants' inspection is retained, and has become of even greater importance than before because it is the only school medical examination which every child now receives. Twelve children are called per session, giving an average attendance of 10 in the two and a half hours. It is of course essential that no congenital or other defects should be overlooked at this stage. Another change that has been made is that each school is intended to be visited every term, instead of only once a year (for periodic inspection) as formerly; this enables us to examine all entrants in their second term, or in their first term exceptionally at the head teacher's request. Every child's vision is tested annually by the school nurse. The intermediate inspection has been totaLly discontinued. The leavers" inspection has been retained in a modified form. It is an interview, at which the child's health during school life is briefly reviewed, inquiry is made as to his proposed occupation in relation to any disability he may have, he is given the opportunity to voice any worries about his health,
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and he is medically examined only if and to the extent that there appears any need to do so. This is, on average, a rapid procedure, timed at 12 to the hour. It is not regarded as an occasion for finding defects: this should be done earlier, as the defects arise, not when the child is about to leave schoo/. It is carried out in the child's penultimate term. Throughout the whole of his school life a child is liable to be selected for medical inspection. Of course, this always was so: the previous system, in Hampshire as elsewhere, provided for "specials" to be brought forward by the head teacher, parent, or nurse at any medical inspection--but there was no organised search for children who ought to be examined, and the number of "specials" was relatively small. THE
SELECTION
VISIT
Our present procedure provides for a termly "selection visit" for the specific purpose of deciding which children shall be medically examined: it is an interview with the head teacher by appointment. When, in September, 1959, the system was first introduced, no attempt was made to guide medical officers, except in a very wide sense, as to how to conduct their selection visits. It was felt that conditions in schools varied so widely, as did the personalities and relationships of the doctors, nurses, and heads, that they should be given a completely free hand--the only requirement was to satisfy themselves so far as they could that they did not miss children who might have significant defects. During the second year the writer was present throughout selection visits conducted by 25 medical officers and was able to observe the varying forms that. these visits took, and as a result to prepare a suggested pattern of procedure (see Appendix II). The principal ingredients of the selection procedure are: .... (1) the questionnaire completed by the parents (Appendix I). (2) the information provided by the head teacher. (3) the information provided by the nurse. (4) direct observation of the children at physical education or play. The questionnaire relates only to 8- and 12-year-old children (also to entrants and leavers, but these are not considered for selection). We have found that surprisingly few are not returned, and the great majority appear to have been completed with care and understanding. The questionnaire may of itself give clear and sufficient grounds for selecting a child; more frequently it indicates that the child has had symptoms (headache, cough, etc.) which could be either trivial or significant, and in this case the medical officer makes his decision after discussion with the nurse, who may have knowledge of the parents and the home, and with the head as to school attendance and the occurrence of the symptom at school. Medical .officers are now asked (at first they were not) to review rapidly with the head all the children to whom the questionnaire relates, even though it gives the child a clean bill of health;
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thus ensuring that at age 8 and 12 each child is considered individually and by name. Apart from its direct value in selection, tile questionnaire discussed in this way between doctors and heads serves to inform the latter as to the meaning and importance to the doctor of the various symptoms as they turn up--it is all part of the vital process of assisting heads to know what the doctors are looking for. The head teacher's contribution is of value in proportion to the trouble he has taken and to his knowledge of what we are looking for. Nearly all heads have proved most interested and co-operative, and the value of the information they give has increased tremendously after one or two selection visits. In small schools they know all the children individually: in large schools they cannot be expected to do so, and the worth of their contribution depends upon the effectiveness of their consultation with their class teachers. Many of the heads use simple referral slips (which we provide) held by the class teachers, so that they can refer children at any time--not just before a selection visit. The whole procedure is greatly enhanced in value if the class teachers develop an interest in, and awareness of, the health of the children. The school medical officer is asked to try to satisfy himself, either that the head has personal knowledge of the children or that he has really gone to trouble to get the requisite information from the class teachers; and it is not in practice at all difficult to tell if the head is not well informed. Frequently the head invites the medical officer to meet this or that class teacher, perhaps to have a first-hand report on a particular child, and this we welcome; especially is it of value to meet the teachers of backward children and of physical education. The school nurse's contribution, in terms of additional names brought forward, tends to be small: usually the head already knows of those children about whom she is concerned, and they appear on his list. But her knowledge of the homes and parents can be of great value, particularly in assessing and interpreting the questionnaire. In the primary schools there is no doubt that her presenceat the selection visit is important. In the secondary schools this is open to question, since the children are drawn from an area far wider than her own. Nevertheless, we feel that even in these schools her attendance is of value, and her status as nurse to the school would be prejudiced if she did not attend the selection visit. Tile fourth ingredient of the selection visit--direct observation of the children--was the most controversial in planning the procedure, is the most questionable in value, and the most variable in practice. It ranges from nil, through observation from the window of the children at play, to a full parade of all the pupils round their classrooms. Obviously the last is practicable only in a small school and with-a willing head teacher (it is firmly written into our scheme that school medical officers do not enter classrooms as o f right), and its value perhaps lies in the contact it promotes with the class teacher and the opportunity to observe footwear, rather than observation of the children them-
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selves. Apart from very small schools, observation can only be on a sampling basis anyway; but even so it is of value if it leads to an enhanced appreciation by the head, or better still by the teacher of physical education, of the types of posture and foot faults that we are looking for. Observation of one or two classes engaged in bare-foot physical education is indeed the best means of securing the very necessary contact with the physical education teacher, and in secondary schools is well worth going for. In primary, and particularly infant, schools, there is rarely a specialist teacher of physical education in Hampshire: at this age foot and posture faults are fewer, but by watching the children in the playground one may observe the obese, the lethargic, the clumsy, the timid, and the unhappy. Direct observation of the children aims primarily, though not wholly, at detecting "orthopaedic" defects, and there is evidence (vide infra) that these are recorded less frequently than by periodic inspection. IMPROVED
LIAISON
BETWEEN
DOCTORS
AND
TEACHERS
Looking back to the planning of our scheme, and reviewing the first two years of its working, one thing stands out clearly. We set out to devise an improved defect-finding procedure; what has emerged is an opportunity for vastly improved doctor-teacher relationships--so much so that if, at any future time, we were to decide that any form of intermediate inspection must be re-introduced, I am certain that we would wish also to retain the selection visit in addition. It would be wrong to convey that in our old procedure we were at loggerheads with the teachers; on the contrary most of our doctors and heads got along very wellwbut it was in many cases that polite friendliness which thrives on brief and infrequent contact! Certainly our selection procedure was viewed with deep distrust by the head teachers' representatives in the discussion stage. They had a good deal to say about encroachments upon school time; they resisted any suggestion that the school medical officers should have a right to see children in the classroom, including the physical education class; and they reacted strongly against a suggestion that in large schools someone, for instance the physical education teacher, might act on the head teacher's behalf as a sort of "health spotter" with a special interest in the children's health. But in spite of these difficulties the scheme, supported by a clearsighted county education officer, was agreed substantially as proposed; and, once accepted, it has received loyal and consistent support from the heads' representatives. The closer contact which the selection visit provides is doubly beneficial: not only do the heads learn what the school medical officers are looking for and aiming to do, but also the doctors have a fuller opportunity to learn of the practical problems, both for the head and for the class teacher, of providing special educational treatment, or of making any sort of special provision for individual children. Of course we in the School Health Service
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must make such recommendations, and do all we can for the "lame duck" in the ordinary school, but if our recommendations are to be respected they must be made with a clear knowledge of just what they entail for the staff and the rest of the children. The selection visit provides a suitable occasion for the school medical officer to discuss with the head teacher children who are backward and may require ascertainment as educationally subnormal. The value of the "2 H.P. examination" is enormously enhanced (whatever the findings and recommendation) if it includes, preferably before the recommendation is finally made, a discussion between the head teacher and the doctor: this is now greatly facilitated. This improved liaison is the dearest result of the selection visit; but it is also due to the more frequent contacts now provided. The objective of a termly visit has not been achieved (vide infi'a) but even so our visits are far more frequent than formerly, particularly in the primary schools, and this of itself obviously makes for closer liaison. DEFECT-FINDING
BY
SELECTIVE
INSPECTION
The results of selective inspection, in terms of defects found, are very difficult to assess. The figures are not comparable with those relating to periodic inspection. The latter related to all defects found among all children of a particular age, including those already under treatment, and without regard to the duration of the defect. This cross-section effect no doubt has an interest and a value, but it gives a somewhat misleading picture of the health of school children as a whole. The defects which we are now recording (apart from those in entrants and part of those in leavers) are, or should be, for the most part newly arisen, and related to all age groups. It has in fact proved quite impossible to draw any valid conclusion from the defect statistics as to the effectiveness of selection. The test of this will be the discovery, by school medical inspection or otherwise, of defects which appear to be of long standing, and we are watching closely for these: but only over years can information of this sort accumulate, and even then it will have to be weighed against the disadvantages of age group inspection which by its very nature fails to find most newly-arisen defects. Although there is no direct statistical comparability, something may be learned by studying the relative frequency of different types of defect recorded under the old method and the new. Up to the present we have discerned two clear trends--one is towards a reduction in the number of children found with "orthopaedic" defects; the other is an increase in those with "psychological" difficulties. ORTHOPAEDIC
DEFECTS
"Rox:~nd backs" and "flat feet" constituted about one-third of the defects rec~',rcjed ~ our previous intermediate and leavers' inspections, half of these
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being referred for observation only. In 1960---our first full calendar year of selective inspection only one-fifth of the defects recorded among leavers were "orthopaedic" (of which three-quarters were referred for observation); while among "specials", which of course includes many more younger children, only one-ninth of all defects recorded were "orthopaedic". (The number and proportion of "orthopaedic" defects among entrants is practically unchanged). Naturally we ask ourselves if this represents a failure of the selection procedure --are we missing real defects that ought to be found and treated ? This must be, to some extent, a matter of personal opinion. The wide variation as between medical officers in the number and type of "orthopaedic" defects found by them, under either system, is itself evidence of this. The foot-faults found mostly fell into two groups--"flat feet" (pes planus, or valgus ankles, with or without "knock knees") and "shoe-pressure defects" (hallux valgus, hammer toes, crowded or overlapping toes, etc.). The former were much the more numerous, and it seems likely that few of them were accompanied by any functional inefficiency: our selection procedure we hope and believe should pick out the child whose feet are in any way incompetent. The less numerous "shoe pressure" faults are important: the earlier we can detect them the better--all we feel justified in claiming at the moment is that the selection visit provides some, if limited, opportunities for observing both feet and footwear term after term, whereas our intermediate inspection provided no such facilities between age 6 and age 11 or 12. Similar considerations apply to "round backs". A child may slump at medical inspection, though mobile, active and straight in the playground or gym.; and our present methods seem to offer the best hope of picking out, with the help of the physical education teachers, those whose posture is bad when they are in action and at ease. Nevertheless, it is, as 1 have said, in relation to "orthopaedic" defects more than any other: that we feel the need for critical and constant appraisal of the selection visits.. P S Y C H O L O G I C A L PROBLEMS The number of children reported as requiring treatment or obs~,:~'a|i~iti ~ d e r the heading "psychological--stability" has increased by abov.jt ~)i!g-third (excluding entrants). This might mean no more than that a great many more children have come under review: as emotional troubles tend to be transient the majority would have passed unrecorded under a system of periodic inspection. But I think there is a little more to it than this: our medical officers are making special inquiry as to children whose happiness or whose education may be suffering as a result of undue emotional stresses, and many heads have welcomed and responded to this type of inquiry. Selective inspection provides valuable opportunities to learn more about the age of onset of various disabilities. Statistics based upon age group inspections are notoriously fallacious in this respect. It is not, however, to be supposed that this information is automatically provided by the system. The office
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procedure of itself provides information as to new defects arising at all ages, but those ages ~re not recorded in preparing the stalislics required by the Ministry (except in respect of defective vision), and to do this in respect of all defects would place a greater burden upon the office slaff than they could carry. But nevertheless the system permils of it and il will be easy enough to make this sort of inquiry in respecl of one or two sclccled defects in each year. ADMINISTRATION ANt) STAFFING Tile introduction of the new system imposed a heavy strain upon the office
staff in the School Health Section, This was not because the administration it more complex or time-consuming than wilh the old system: but of course it had all to be learned and applied by the entire staff" at once, whereas the other had grown gradually dlrough ~he years. No addilional clerical slaff were employed, but it must be admilled tha! the goirJg was heavy for the first year. Nor were additional medical or nursing staff appointed, excepl that the equivalent of one whole-time school nurse was added 1o lhe establishment to meet the additional demands of annual vision testing: the actual work is of course spread equally among all the healfll visitor/school nurses. 11 was not possible to calculate exactly whether any additional medical staff would be required. In tile complex equation between longer entrant examinations, termly selection visits, and additional "special examinatio~ls °' on the one hand, and shorter leavers' examinations and abolished intermediate examinations on the olher, the big unknown was the number of children who would be selected for inspection. We thought we mighl '~break even", and proceeded on this assumption. We are in fact badly behindhand and in 1960 averaged only about one and a half seiections visils and one and a half inspcclions per school, instead of the intended lhree of each. This does not mean that the new procedure requires twice as much medical (and nursing) time as the old: possibly it needs no more at all. Deficiency on our eslablishmenI, our rapidly growing school population, and the demands of immunisation and vaccination have accumulated to embarrass the work : it is notorious that when doctors are short school medical inspection is the first thing to go, because it does not work by fixed sessions. Also there is no doubt~il is already apparent~ thal in tile initial stages of the scheme the selection visils look longer, and the number of children selecled for examination was greater: the "law of diminishing returns" applies. Tile origi~al intention was to average two selection visits per session. This has proved impracticable, not for lack of time but because of the difficulties in relaling lhe selection visits to the subsequent medical inspections--so that medical time has undoubtedly been wasted by unfilled sessions, lit has now been decided that school medical officers shall proceed after the selection visit to examine any children due for re-examination whose parents are not required to be present. In spite of our failure to carry out our
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intended termly visits, we are in fact averaging )m))-e visits per school per year lhan under the old system. Our selcclive inspection procedure is now a going concern. Such few qlties as lhcre were occt)rrcd in lhc fitsl tcrnl and were due almost entirely ~durc to understand the scheme, It is of course subject Io continuous ~t:~Jew, and lo ailcr~tion if necess,ary; but it has been going long enough Io show lhal it is pcrfeclly workable ~nd theft it Ires some very teal advantages over our previous syslcm. 1 am indcbled 1o Dr, I, A, MacDaugall, County Medical Oltlcer and Principal School Medical Otticcr fi)r llampshirc, for permission Io publish
lhls account of a service for which he is responsible, Mu~h of the infi~rm~lion conlaincd in lhis p~tper was included in a paper presenled at the Hc~llh Congress of lhe Royal Socicly of ticalth in April, 1961, and is here reproduced wilh (he Socicly's permission. A t' p ~ 1',1l) I x I ttAMI)SItlRE SC)IOOI,
(Form S H S 21) COUNTY MIT. 1) I C A L
COUNCIl,
INSPECTION
This form should be compleled and relurned to the ltend Teacher as soon as possible. Child's Name Date of (in full) ............................................................... B i r l h ....................................... School ......................................... Class o r F o r m .......... T h e f o l l o w i n g i v ) f o r l n a t i o n w i l l be a~ked f o r f o u r l i m e s in n child',~ s c h o o l life
--al ages 5, 8, 12 and 14 or older approximately ; ~ If your child is age 5, please give information as from 8, ,, ,, ,, 12, ,, ,, ,, 14 or older, ,, ,, ,, It
91
)P
birth, age 5, ,, 8, ,, 12.
ln.&cttous Illness
ltiTmunt,~at to~ts
If your child ha~ had 'lay of the following illnesses, please stale when lhey occurred :--
ttas your child been vaccinated or immunised ag~ains! any of the fi)llowing illnesses ? If so, please ~l,'tte when : ~
Year or Age
Whooping Cough .................. Measles . . . . . . . . . . . . . . . . . . . . . . . Scarlet Fever . . . . . . . . . . . . . Mumps ........................ Chicken Pox . . . . . . . . . . . . . . . . German Measles .............. Olher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year or Age
(a) Smallpox (this is the ordinary vaccination of babies) ,,. (b) Diphtheria ...... (c) Whooping Cough ,., (d) Tetanus . . . . . . . . . (e) Tubercl loses (vaccination with "B.C.G.") . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................ ( f ) Poliomyelitis (g) Any other disease ,
.
,1[
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other illness (please state illness and year or age)
Year or Age
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Operations (please state operation and year or age) Serious Accident or Injury (please state nature of accident or injury and year or age) iias Yourch~"[d~fferedin tie"PasiTH'REEYEARs fro;lan); ofthe foliowing sympioms or conch'tions ? I f so, please underline. Difficulty in ~earing Earache, or discharge from the ears Asthma
Rheumatism or joint pains Fits or fainting attacks
Has your child suffered in the PAST YEAR from an), of the following symptoms or conditions ? 1.]"so,please underline. Skin rash or sores Boils, abscesses Chilblains Difficulty in seeing Sore eyes Headaches Sore throats Catarrh Hay fever Difficulty with speech Enlarged glands Shortness of breath Chronic or frequent cough
Weakness or pain in arms, legs, hands or feet Backache Bedwetting Nervousness Difficult or abnormal behaviour Sleeplessness, nightmares or sleepwalking Stomach pains Poor appetite Sickness Constipation Nose-bleeds Travel-sickness Pain or difficulty in passing water Excessive or painful monthly periods.
Is there an), particular matter upon which you wouM like tile Doctor's advice ? To Parents of Entrants (usually 5-year-olds) and Leavers (14 years or older), you will be very welcome at the examination. Will you be present ?............................................................ Please give the name of your Family Doctor .......................................................................................... Date ................................................................ Signed .......................................................................................... (Parent or Guardian) Present Address ...................................................................................................................................................... APPENDIX
THE
II
SELECTION
VISIT--A
SUGGESTED
PATTERN
(1) Inquire as to physical activities (physical education, dancing, games, play) that (2)
(3)
will be taking place during the probable period of the visit, with a view to breaking off and watching the children at the appropriate times. Go through the SHS 21's (if any) with the school nurse, separating out those already down for re-examination, and dividing the rest into those clearly to be selected, those not and those doubtful (depending on information to be sought from head teacher). Go through the SHS 21's with the head teacher, informing him which children you would like to select (and why), consulting with him as to the "doubtfuls," and giving him the opportunity to comment also on the ones you
SELECTIVE SCHOOL MEDICAL INSPECTION
(4)
(5) (6) (7) (8)
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have not selected : i.e. go throus;~ all the S H S 21"s with the Head Teacher mthus ensuring that every child is individually considered, however briefly, at age 8 and 12. Also inquire as ~o any S H S 2 r s not retur~:~' ~md consider, on information given by the school nurse and the he~d teacher, whether they should be "selected" ; or possibly home-visited by the school nurse. Ask the Head Teacher for names ofchiidren he wishes to recommend for examination. Endeavour to satisfy yourself : w (a) either that the head teacher has an adequate personal knowledge of all tile children, or that his list has been compiled after adequate consultation with the class teachers : it is preferable that there should be provision for referral by class teachers at any time, and not only a " w h i p r o u n d " before the selection visit. Referral slips (to txi held by class teachers) are available to head teachers who want them. (b) that head teacher is fully informed of all the kinds of child we are interested in. It may be necessary to ask leading questions to ensure this, and it is suggested that these should include :-(i) non-progressing (as well as backward) children. Meet the teacher of the backward class (if any) if possible. (it) speech-defective children. (iii) those with possible hearing-loss (bearing in mind particularly high-frequency loss). (iv) those with any evidence of emotional disturbance (the" unhappy" as well as the nuisances). (v) knicker-wetters. (vi) those who avoid, or are bad at, games or physical education. Meet the teacher of physical education (if any) if possible. (vii) those ,with abnormal home backgrounds. Inquire re absentees and if thought necessary and advisable go through the attendance registers with the head teacher. Ask the School Nurse for names of any additional children known to her who may warrant selection, on account of home conditions or otherwise. In Infants' Schools ask the head teacher if there are any new entrants she wishes seen as " specials " rather than waiting for the normal " E n t r a n t s " inspection in their second term. Go through any 2 H.P.'s with the head teacher (Check typed list with Head Teacher for any children who have left.) (inquire as to next term's leavers.) (Discuss with Head Teacher the children already down for re-examination.) (Inquire, and if necessary inspect, as to hygienic conditions in the school.)
BACON,
M.D., D.P.It.
Deputy County Medical Offices" and Deputy Principal School Medical Officer THE School Health Service and Handicapped Pupils Regulations of 1953 permitred local education authorities to experiment in their methods of school medical inspection, and since then there has developed an increasing interest in the possible advantages of examining children selected on some other basis than age. The chief medical officer of the Ministry of Education has commented on a number of experiments in selective inspection in "The Health of the School Child" (1958-9) and I believe that several other authorities are now developing schemes. It may therefore be of some interest to record our impressions of the first two years of selective inspection in Hampshire. The school population has increased by almost 5 ~ per annum during the past 10 years. Consequently we have always been short of medical and nursing staff, and it was with a view to using our limited resources as economically as possible tha~ we first toyed with the idea of selective inspection. Further, in asking for more doctors and nurses we felt that we must be prepared for the criticism that school medical inspection had become redundant now that any child could be taken, free of charge, to his family doctor. We knew of course that we were recording vast numbers of defects at periodic medical inspection, but we could not say how many of these defects were already being treated through the general practitioner and hospital services. A OEVECT S U R V E Y So we conducted a special survey, designed to inform us on these two points --was our periodic medical inspection in fact bringing to light for the first time defects of significance? and if so, could we have found these by any procedure more efficient and economical than the medical examination of children in specified age-groups ? Some account of this "defect survey" will be published in The Royal Society of Health Journal (Dec., 1961). Here it must suffice to say that in the cxamination of 8,189 successive children at periodic medical inspection in three age groups, 3,387 defects were recorded which had not previously been noted at any previous school medical inspection. Of these, 2,061 (61 ~ ) were either unknown to the parents or, if known, had not been brought under treatment which in the opinion of the school medical officer was required: the 339
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rate among entrants was 53 ~ and among the older children it was 67~o. Detailed and critical study of the 2,061 defects (grouped under 215 diagnoses) satisfied us that with a few exceptions, of which defective vision and certain congenital conditions were the most important, they could have been suspected without recourse to medical examination. QUESTIONNAIRE
TO
PARENTS
This study brought out the importance of obtaining a full medical history from the parents. Hitherto we had used a brief form of letter prior to medical inspection, seeking little information other than the child's history in respect of certain infectious diseases and immunisation procedures. We have now adopted a far more comprehensive questionnaire (Appendix 1) which covers the symptoms of most of the conditions found in our defect survey. Ideally this would be used at least once a year: in practice it would be lmreasonable to ask parents to complete it, 0i" heads to distribute it, so often, and as a compromise it is used prior to the entrant and leavers' inspections and at ages 8 and 12. As originally devised it sought information as to the occurrence of all the symptoms listed during the preceding three-year period; but we found that, with the exception of a few conditions now separately listed, it was preferable to relate the inquiry to the preceding year. The questionnaire is accompanied by an explanatory letter to parents, and the letter which is sent prior to the entrants' inspection gives a brief account of the medical inspection system as it applies throughout the child's school life. THE
NEW
SCHOOL
MEDICAL INSPECTION IN HAMPSHIRE
SYSTEM
Following the defect survey, and starting in September, 1959, we modified our system of medical inspection considerably. The entrants' inspection is retained, and has become of even greater importance than before because it is the only school medical examination which every child now receives. Twelve children are called per session, giving an average attendance of 10 in the two and a half hours. It is of course essential that no congenital or other defects should be overlooked at this stage. Another change that has been made is that each school is intended to be visited every term, instead of only once a year (for periodic inspection) as formerly; this enables us to examine all entrants in their second term, or in their first term exceptionally at the head teacher's request. Every child's vision is tested annually by the school nurse. The intermediate inspection has been totaLly discontinued. The leavers" inspection has been retained in a modified form. It is an interview, at which the child's health during school life is briefly reviewed, inquiry is made as to his proposed occupation in relation to any disability he may have, he is given the opportunity to voice any worries about his health,
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and he is medically examined only if and to the extent that there appears any need to do so. This is, on average, a rapid procedure, timed at 12 to the hour. It is not regarded as an occasion for finding defects: this should be done earlier, as the defects arise, not when the child is about to leave schoo/. It is carried out in the child's penultimate term. Throughout the whole of his school life a child is liable to be selected for medical inspection. Of course, this always was so: the previous system, in Hampshire as elsewhere, provided for "specials" to be brought forward by the head teacher, parent, or nurse at any medical inspection--but there was no organised search for children who ought to be examined, and the number of "specials" was relatively small. THE
SELECTION
VISIT
Our present procedure provides for a termly "selection visit" for the specific purpose of deciding which children shall be medically examined: it is an interview with the head teacher by appointment. When, in September, 1959, the system was first introduced, no attempt was made to guide medical officers, except in a very wide sense, as to how to conduct their selection visits. It was felt that conditions in schools varied so widely, as did the personalities and relationships of the doctors, nurses, and heads, that they should be given a completely free hand--the only requirement was to satisfy themselves so far as they could that they did not miss children who might have significant defects. During the second year the writer was present throughout selection visits conducted by 25 medical officers and was able to observe the varying forms that. these visits took, and as a result to prepare a suggested pattern of procedure (see Appendix II). The principal ingredients of the selection procedure are: .... (1) the questionnaire completed by the parents (Appendix I). (2) the information provided by the head teacher. (3) the information provided by the nurse. (4) direct observation of the children at physical education or play. The questionnaire relates only to 8- and 12-year-old children (also to entrants and leavers, but these are not considered for selection). We have found that surprisingly few are not returned, and the great majority appear to have been completed with care and understanding. The questionnaire may of itself give clear and sufficient grounds for selecting a child; more frequently it indicates that the child has had symptoms (headache, cough, etc.) which could be either trivial or significant, and in this case the medical officer makes his decision after discussion with the nurse, who may have knowledge of the parents and the home, and with the head as to school attendance and the occurrence of the symptom at school. Medical .officers are now asked (at first they were not) to review rapidly with the head all the children to whom the questionnaire relates, even though it gives the child a clean bill of health;
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thus ensuring that at age 8 and 12 each child is considered individually and by name. Apart from its direct value in selection, tile questionnaire discussed in this way between doctors and heads serves to inform the latter as to the meaning and importance to the doctor of the various symptoms as they turn up--it is all part of the vital process of assisting heads to know what the doctors are looking for. The head teacher's contribution is of value in proportion to the trouble he has taken and to his knowledge of what we are looking for. Nearly all heads have proved most interested and co-operative, and the value of the information they give has increased tremendously after one or two selection visits. In small schools they know all the children individually: in large schools they cannot be expected to do so, and the worth of their contribution depends upon the effectiveness of their consultation with their class teachers. Many of the heads use simple referral slips (which we provide) held by the class teachers, so that they can refer children at any time--not just before a selection visit. The whole procedure is greatly enhanced in value if the class teachers develop an interest in, and awareness of, the health of the children. The school medical officer is asked to try to satisfy himself, either that the head has personal knowledge of the children or that he has really gone to trouble to get the requisite information from the class teachers; and it is not in practice at all difficult to tell if the head is not well informed. Frequently the head invites the medical officer to meet this or that class teacher, perhaps to have a first-hand report on a particular child, and this we welcome; especially is it of value to meet the teachers of backward children and of physical education. The school nurse's contribution, in terms of additional names brought forward, tends to be small: usually the head already knows of those children about whom she is concerned, and they appear on his list. But her knowledge of the homes and parents can be of great value, particularly in assessing and interpreting the questionnaire. In the primary schools there is no doubt that her presenceat the selection visit is important. In the secondary schools this is open to question, since the children are drawn from an area far wider than her own. Nevertheless, we feel that even in these schools her attendance is of value, and her status as nurse to the school would be prejudiced if she did not attend the selection visit. Tile fourth ingredient of the selection visit--direct observation of the children--was the most controversial in planning the procedure, is the most questionable in value, and the most variable in practice. It ranges from nil, through observation from the window of the children at play, to a full parade of all the pupils round their classrooms. Obviously the last is practicable only in a small school and with-a willing head teacher (it is firmly written into our scheme that school medical officers do not enter classrooms as o f right), and its value perhaps lies in the contact it promotes with the class teacher and the opportunity to observe footwear, rather than observation of the children them-
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selves. Apart from very small schools, observation can only be on a sampling basis anyway; but even so it is of value if it leads to an enhanced appreciation by the head, or better still by the teacher of physical education, of the types of posture and foot faults that we are looking for. Observation of one or two classes engaged in bare-foot physical education is indeed the best means of securing the very necessary contact with the physical education teacher, and in secondary schools is well worth going for. In primary, and particularly infant, schools, there is rarely a specialist teacher of physical education in Hampshire: at this age foot and posture faults are fewer, but by watching the children in the playground one may observe the obese, the lethargic, the clumsy, the timid, and the unhappy. Direct observation of the children aims primarily, though not wholly, at detecting "orthopaedic" defects, and there is evidence (vide infra) that these are recorded less frequently than by periodic inspection. IMPROVED
LIAISON
BETWEEN
DOCTORS
AND
TEACHERS
Looking back to the planning of our scheme, and reviewing the first two years of its working, one thing stands out clearly. We set out to devise an improved defect-finding procedure; what has emerged is an opportunity for vastly improved doctor-teacher relationships--so much so that if, at any future time, we were to decide that any form of intermediate inspection must be re-introduced, I am certain that we would wish also to retain the selection visit in addition. It would be wrong to convey that in our old procedure we were at loggerheads with the teachers; on the contrary most of our doctors and heads got along very wellwbut it was in many cases that polite friendliness which thrives on brief and infrequent contact! Certainly our selection procedure was viewed with deep distrust by the head teachers' representatives in the discussion stage. They had a good deal to say about encroachments upon school time; they resisted any suggestion that the school medical officers should have a right to see children in the classroom, including the physical education class; and they reacted strongly against a suggestion that in large schools someone, for instance the physical education teacher, might act on the head teacher's behalf as a sort of "health spotter" with a special interest in the children's health. But in spite of these difficulties the scheme, supported by a clearsighted county education officer, was agreed substantially as proposed; and, once accepted, it has received loyal and consistent support from the heads' representatives. The closer contact which the selection visit provides is doubly beneficial: not only do the heads learn what the school medical officers are looking for and aiming to do, but also the doctors have a fuller opportunity to learn of the practical problems, both for the head and for the class teacher, of providing special educational treatment, or of making any sort of special provision for individual children. Of course we in the School Health Service
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must make such recommendations, and do all we can for the "lame duck" in the ordinary school, but if our recommendations are to be respected they must be made with a clear knowledge of just what they entail for the staff and the rest of the children. The selection visit provides a suitable occasion for the school medical officer to discuss with the head teacher children who are backward and may require ascertainment as educationally subnormal. The value of the "2 H.P. examination" is enormously enhanced (whatever the findings and recommendation) if it includes, preferably before the recommendation is finally made, a discussion between the head teacher and the doctor: this is now greatly facilitated. This improved liaison is the dearest result of the selection visit; but it is also due to the more frequent contacts now provided. The objective of a termly visit has not been achieved (vide infi'a) but even so our visits are far more frequent than formerly, particularly in the primary schools, and this of itself obviously makes for closer liaison. DEFECT-FINDING
BY
SELECTIVE
INSPECTION
The results of selective inspection, in terms of defects found, are very difficult to assess. The figures are not comparable with those relating to periodic inspection. The latter related to all defects found among all children of a particular age, including those already under treatment, and without regard to the duration of the defect. This cross-section effect no doubt has an interest and a value, but it gives a somewhat misleading picture of the health of school children as a whole. The defects which we are now recording (apart from those in entrants and part of those in leavers) are, or should be, for the most part newly arisen, and related to all age groups. It has in fact proved quite impossible to draw any valid conclusion from the defect statistics as to the effectiveness of selection. The test of this will be the discovery, by school medical inspection or otherwise, of defects which appear to be of long standing, and we are watching closely for these: but only over years can information of this sort accumulate, and even then it will have to be weighed against the disadvantages of age group inspection which by its very nature fails to find most newly-arisen defects. Although there is no direct statistical comparability, something may be learned by studying the relative frequency of different types of defect recorded under the old method and the new. Up to the present we have discerned two clear trends--one is towards a reduction in the number of children found with "orthopaedic" defects; the other is an increase in those with "psychological" difficulties. ORTHOPAEDIC
DEFECTS
"Rox:~nd backs" and "flat feet" constituted about one-third of the defects rec~',rcjed ~ our previous intermediate and leavers' inspections, half of these
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being referred for observation only. In 1960---our first full calendar year of selective inspection only one-fifth of the defects recorded among leavers were "orthopaedic" (of which three-quarters were referred for observation); while among "specials", which of course includes many more younger children, only one-ninth of all defects recorded were "orthopaedic". (The number and proportion of "orthopaedic" defects among entrants is practically unchanged). Naturally we ask ourselves if this represents a failure of the selection procedure --are we missing real defects that ought to be found and treated ? This must be, to some extent, a matter of personal opinion. The wide variation as between medical officers in the number and type of "orthopaedic" defects found by them, under either system, is itself evidence of this. The foot-faults found mostly fell into two groups--"flat feet" (pes planus, or valgus ankles, with or without "knock knees") and "shoe-pressure defects" (hallux valgus, hammer toes, crowded or overlapping toes, etc.). The former were much the more numerous, and it seems likely that few of them were accompanied by any functional inefficiency: our selection procedure we hope and believe should pick out the child whose feet are in any way incompetent. The less numerous "shoe pressure" faults are important: the earlier we can detect them the better--all we feel justified in claiming at the moment is that the selection visit provides some, if limited, opportunities for observing both feet and footwear term after term, whereas our intermediate inspection provided no such facilities between age 6 and age 11 or 12. Similar considerations apply to "round backs". A child may slump at medical inspection, though mobile, active and straight in the playground or gym.; and our present methods seem to offer the best hope of picking out, with the help of the physical education teachers, those whose posture is bad when they are in action and at ease. Nevertheless, it is, as 1 have said, in relation to "orthopaedic" defects more than any other: that we feel the need for critical and constant appraisal of the selection visits.. P S Y C H O L O G I C A L PROBLEMS The number of children reported as requiring treatment or obs~,:~'a|i~iti ~ d e r the heading "psychological--stability" has increased by abov.jt ~)i!g-third (excluding entrants). This might mean no more than that a great many more children have come under review: as emotional troubles tend to be transient the majority would have passed unrecorded under a system of periodic inspection. But I think there is a little more to it than this: our medical officers are making special inquiry as to children whose happiness or whose education may be suffering as a result of undue emotional stresses, and many heads have welcomed and responded to this type of inquiry. Selective inspection provides valuable opportunities to learn more about the age of onset of various disabilities. Statistics based upon age group inspections are notoriously fallacious in this respect. It is not, however, to be supposed that this information is automatically provided by the system. The office
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procedure of itself provides information as to new defects arising at all ages, but those ages ~re not recorded in preparing the stalislics required by the Ministry (except in respect of defective vision), and to do this in respect of all defects would place a greater burden upon the office slaff than they could carry. But nevertheless the system permils of it and il will be easy enough to make this sort of inquiry in respecl of one or two sclccled defects in each year. ADMINISTRATION ANt) STAFFING Tile introduction of the new system imposed a heavy strain upon the office
staff in the School Health Section, This was not because the administration it more complex or time-consuming than wilh the old system: but of course it had all to be learned and applied by the entire staff" at once, whereas the other had grown gradually dlrough ~he years. No addilional clerical slaff were employed, but it must be admilled tha! the goirJg was heavy for the first year. Nor were additional medical or nursing staff appointed, excepl that the equivalent of one whole-time school nurse was added 1o lhe establishment to meet the additional demands of annual vision testing: the actual work is of course spread equally among all the healfll visitor/school nurses. 11 was not possible to calculate exactly whether any additional medical staff would be required. In tile complex equation between longer entrant examinations, termly selection visits, and additional "special examinatio~ls °' on the one hand, and shorter leavers' examinations and abolished intermediate examinations on the olher, the big unknown was the number of children who would be selected for inspection. We thought we mighl '~break even", and proceeded on this assumption. We are in fact badly behindhand and in 1960 averaged only about one and a half seiections visils and one and a half inspcclions per school, instead of the intended lhree of each. This does not mean that the new procedure requires twice as much medical (and nursing) time as the old: possibly it needs no more at all. Deficiency on our eslablishmenI, our rapidly growing school population, and the demands of immunisation and vaccination have accumulated to embarrass the work : it is notorious that when doctors are short school medical inspection is the first thing to go, because it does not work by fixed sessions. Also there is no doubt~il is already apparent~ thal in tile initial stages of the scheme the selection visils look longer, and the number of children selecled for examination was greater: the "law of diminishing returns" applies. Tile origi~al intention was to average two selection visits per session. This has proved impracticable, not for lack of time but because of the difficulties in relaling lhe selection visits to the subsequent medical inspections--so that medical time has undoubtedly been wasted by unfilled sessions, lit has now been decided that school medical officers shall proceed after the selection visit to examine any children due for re-examination whose parents are not required to be present. In spite of our failure to carry out our
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34"/
intended termly visits, we are in fact averaging )m))-e visits per school per year lhan under the old system. Our selcclive inspection procedure is now a going concern. Such few qlties as lhcre were occt)rrcd in lhc fitsl tcrnl and were due almost entirely ~durc to understand the scheme, It is of course subject Io continuous ~t:~Jew, and lo ailcr~tion if necess,ary; but it has been going long enough Io show lhal it is pcrfeclly workable ~nd theft it Ires some very teal advantages over our previous syslcm. 1 am indcbled 1o Dr, I, A, MacDaugall, County Medical Oltlcer and Principal School Medical Otticcr fi)r llampshirc, for permission Io publish
lhls account of a service for which he is responsible, Mu~h of the infi~rm~lion conlaincd in lhis p~tper was included in a paper presenled at the Hc~llh Congress of lhe Royal Socicly of ticalth in April, 1961, and is here reproduced wilh (he Socicly's permission. A t' p ~ 1',1l) I x I ttAMI)SItlRE SC)IOOI,
(Form S H S 21) COUNTY MIT. 1) I C A L
COUNCIl,
INSPECTION
This form should be compleled and relurned to the ltend Teacher as soon as possible. Child's Name Date of (in full) ............................................................... B i r l h ....................................... School ......................................... Class o r F o r m .......... T h e f o l l o w i n g i v ) f o r l n a t i o n w i l l be a~ked f o r f o u r l i m e s in n child',~ s c h o o l life
--al ages 5, 8, 12 and 14 or older approximately ; ~ If your child is age 5, please give information as from 8, ,, ,, ,, 12, ,, ,, ,, 14 or older, ,, ,, ,, It
91
)P
birth, age 5, ,, 8, ,, 12.
ln.&cttous Illness
ltiTmunt,~at to~ts
If your child ha~ had 'lay of the following illnesses, please stale when lhey occurred :--
ttas your child been vaccinated or immunised ag~ains! any of the fi)llowing illnesses ? If so, please ~l,'tte when : ~
Year or Age
Whooping Cough .................. Measles . . . . . . . . . . . . . . . . . . . . . . . Scarlet Fever . . . . . . . . . . . . . Mumps ........................ Chicken Pox . . . . . . . . . . . . . . . . German Measles .............. Olher . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Year or Age
(a) Smallpox (this is the ordinary vaccination of babies) ,,. (b) Diphtheria ...... (c) Whooping Cough ,., (d) Tetanus . . . . . . . . . (e) Tubercl loses (vaccination with "B.C.G.") . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ................................ ( f ) Poliomyelitis (g) Any other disease ,
.
,1[
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Other illness (please state illness and year or age)
Year or Age
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Operations (please state operation and year or age) Serious Accident or Injury (please state nature of accident or injury and year or age) iias Yourch~"[d~fferedin tie"PasiTH'REEYEARs fro;lan); ofthe foliowing sympioms or conch'tions ? I f so, please underline. Difficulty in ~earing Earache, or discharge from the ears Asthma
Rheumatism or joint pains Fits or fainting attacks
Has your child suffered in the PAST YEAR from an), of the following symptoms or conditions ? 1.]"so,please underline. Skin rash or sores Boils, abscesses Chilblains Difficulty in seeing Sore eyes Headaches Sore throats Catarrh Hay fever Difficulty with speech Enlarged glands Shortness of breath Chronic or frequent cough
Weakness or pain in arms, legs, hands or feet Backache Bedwetting Nervousness Difficult or abnormal behaviour Sleeplessness, nightmares or sleepwalking Stomach pains Poor appetite Sickness Constipation Nose-bleeds Travel-sickness Pain or difficulty in passing water Excessive or painful monthly periods.
Is there an), particular matter upon which you wouM like tile Doctor's advice ? To Parents of Entrants (usually 5-year-olds) and Leavers (14 years or older), you will be very welcome at the examination. Will you be present ?............................................................ Please give the name of your Family Doctor .......................................................................................... Date ................................................................ Signed .......................................................................................... (Parent or Guardian) Present Address ...................................................................................................................................................... APPENDIX
THE
II
SELECTION
VISIT--A
SUGGESTED
PATTERN
(1) Inquire as to physical activities (physical education, dancing, games, play) that (2)
(3)
will be taking place during the probable period of the visit, with a view to breaking off and watching the children at the appropriate times. Go through the SHS 21's (if any) with the school nurse, separating out those already down for re-examination, and dividing the rest into those clearly to be selected, those not and those doubtful (depending on information to be sought from head teacher). Go through the SHS 21's with the head teacher, informing him which children you would like to select (and why), consulting with him as to the "doubtfuls," and giving him the opportunity to comment also on the ones you
SELECTIVE SCHOOL MEDICAL INSPECTION
(4)
(5) (6) (7) (8)
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have not selected : i.e. go throus;~ all the S H S 21"s with the Head Teacher mthus ensuring that every child is individually considered, however briefly, at age 8 and 12. Also inquire as ~o any S H S 2 r s not retur~:~' ~md consider, on information given by the school nurse and the he~d teacher, whether they should be "selected" ; or possibly home-visited by the school nurse. Ask the Head Teacher for names ofchiidren he wishes to recommend for examination. Endeavour to satisfy yourself : w (a) either that the head teacher has an adequate personal knowledge of all tile children, or that his list has been compiled after adequate consultation with the class teachers : it is preferable that there should be provision for referral by class teachers at any time, and not only a " w h i p r o u n d " before the selection visit. Referral slips (to txi held by class teachers) are available to head teachers who want them. (b) that head teacher is fully informed of all the kinds of child we are interested in. It may be necessary to ask leading questions to ensure this, and it is suggested that these should include :-(i) non-progressing (as well as backward) children. Meet the teacher of the backward class (if any) if possible. (it) speech-defective children. (iii) those with possible hearing-loss (bearing in mind particularly high-frequency loss). (iv) those with any evidence of emotional disturbance (the" unhappy" as well as the nuisances). (v) knicker-wetters. (vi) those who avoid, or are bad at, games or physical education. Meet the teacher of physical education (if any) if possible. (vii) those ,with abnormal home backgrounds. Inquire re absentees and if thought necessary and advisable go through the attendance registers with the head teacher. Ask the School Nurse for names of any additional children known to her who may warrant selection, on account of home conditions or otherwise. In Infants' Schools ask the head teacher if there are any new entrants she wishes seen as " specials " rather than waiting for the normal " E n t r a n t s " inspection in their second term. Go through any 2 H.P.'s with the head teacher (Check typed list with Head Teacher for any children who have left.) (inquire as to next term's leavers.) (Discuss with Head Teacher the children already down for re-examination.) (Inquire, and if necessary inspect, as to hygienic conditions in the school.)