The future maternity and child welfare service

PUBLIC HEALTH, May, 1948

144 THE

FUTURE MATERNITY AND WELFARE SERVICE*

CHILD

By S. C. GAWNE, M.D. (LOND.), B.S., M.R.C.S., L.II.C.P., D.C.H., D.P.H.~ Barrister-at-Law,

Deputy County Medical Q(ficer, Lancashire With the Passing of the National Health Service Act, m o s t 9 f us are wondering what the future has in store, what will be the scope of the local health authorities' work in relation to maternity and child welfare and to what extent this work will continue to offer a satisfying professional career comparable with those of our colleagues in the hospital service or in general practice. T h e Minister of Health, commenting on the effect upon local authorities of the passing of the Act, remarked that a painful operation had been performed. He was, of course, referring to the transfer to the Regional Hospital Boards o f the hospital services which, in 1929, seized, and since have almost monop01ised, the interest of the major authorities. It was natural that the major authorities should shed a tear, at the prospect of losing t h e i r favourite child which they adopted and which, it is fair to say, has developed and thrived under their care. But the change may well be a blessing in so far as it will serve once again to focus the interests of the local authorities on the preventive services which were their first concern. If the major authorities have been relieved of an obligation, they have, on the other hand, had placed upon them new duties which include those relating to mental health, home nursing and the provision of health centres. In addition, their responsibilities in respect to maternal care and child health are, in the case of the county councils, to be extended to embrace the areas of many welfare authorities who have in the past enjoyed autonomy. M a n y welfare authorities, often small in size, have developed highly efficient personal services within their areas. Success in this field has largely been achieved ,by that local interest and enthusiasm which arises out of a sure knowledge of local needs. It is highly desirable that this spirit should be preserved in maternity and child welfare work, which is essentially personal and local in nature, dealing as it does with persons in or close to their homes. But whilst pride is rightly taken in what has been achieved in the past there have inevitably been inequalities in the result because the welfare services have developed piecemeal, and doubtless one of the intentions of the legislators was to secure the removal of these inequalities. But a drab uniformity should not be :instituted and certainly this would not be the aim or the desire of the progressive local health authority. This is a matter of great moment for those county districts which are at present welfare authorities. T h e y are to lose the responsibility for the control of a service which they have established and which they have seen grow in size and in importance under their direction for many years. T h e y may perhaps wonder if :there is a risk of the creation of a new administrative machine with its centre remote from the field of operations and which may therefore be insensitive to local requirements. Such a set-up would be wholly undesirable and its obvious disadvantages were already foreseen by many local health authorities before the Ministry of Health itself stressed the necessity for decentralisation. It is thus certain that the schemes to be formulated by the county councils will provide for some form of delegation of management to the periphery, and this can be achieved in the large counties by the setting up o f a system of divisional administration, which may take one of two forms. It can take place executively at the officer level only, the administration being retained in the hands of the central committee. Alternatively, divisional administration can take place at the committee level, the divisional committees being sub-committees of the central committee with a Divisional Medical Officer attached to the Divisional Committee. ¢~Presidential Address to the North-Western Maternity and Child Welfare and School Health Service Sub-Groups, October 24th, 1947.

In any form of decentralisation the most important consideration should be the ease and effectiveness with which the local health authority's services can be co-ordinated with other groups of medical service--the hospital service, general practitioner service, environmental services, etc., and Health Divisions might, therefore, with advantage be drawn up so as to be co-terminous with the areas defined as the " hospital areas " of the Regional Hospital Board. Divisional Committees, if established, would be composed of members of the local health authority and of the district councils within the division, together wit]a representatives from the Hospital Management Committee and the Educational Divisional Executive within the area, and from the Executive Council for domiciliary medical services. By such means a high degree of co-ordination between the several health services would be possible, and if district council representatives formed the largest section of the Divisional Committee all the advantages of local management and direction w o u l d be preserved. A health division of this size containing a population of approximately 100,000 would be large enough to facilitate the development within its confines of a complete and comprehensive maternity and child welfare service adequately staiTed, and small enough to enable the principal medical officer of the division to maintain a close interest in its day-to-day management. The Prospect for M. & C. W. Personnel H o w will the personnel of the maternity and child welfare services be affected by the implications of the Act ? T h e y will be involved in two ways--first, as a result of the administrative changes, and secondly, and later, by the policy of the Minister whereby there is envisaged the participation of the general practitioner in preventive work and a process of specialisation on the part of the whole-time assistant medical officers employed by the local authorities. T h e institution of a system of divisional administration will create a demand for senior medical officers whose duties will be mainly administrative in nature. Deputy medical officers will also be required, and though doubtless the deputy in a division will be engaged to a great extent in clinical work, such administrative duties as will fall to him will undoubtedly render him a suitable candidate for the senior posts as these fall vacant. T o this extent there will be a greater number of posts carrying administrative responsibility, and with them additional salary, and there will continue to be scope for those medical officers who have an administrative bent but who like to retain a clinical interest. The General Practitioner in Preventive Services T h e role to be played by the general practitioner in the sphere of maternity and child welfare raises many interesting points for consideration. T h e Ministry have already indicated the part to be played by the general practitioner in domiciliary midwifery and in the ante-natal and post-natal clinics. Most of us will agree with the policy of setting up panels of practitioners suitably qualified for this work, though few of us will envy those whose duty it will be to decide the merits or demerits of a particular applicant. T h e intention of the legislators undoubtedly is to bring about sooner or later a participation of the family doctor in the preventive services. How soon can this desire be implemented ? It is likely that to older practitioners preventive work has no special appeal. T h e younger practitioners may have a desire to take part, but with the increased calls upon their time inevitable with a national medical service, how many will be able to afford the time to undertake regular attendance in clinics and welfare centres, where the work being educative in nature cannot be quickly performed ? Another difficulty is the necessity for some preliminary training for those practitioners who desire to take part in preventive work. T h e work in clinics and welfare centres is truly specialised and the general professional training of the majority of practitioners has had little emphasis on child health or maternal care. M y own feeling is that practitioners

PUBLIC HEALTH, May, 1948 to take part in this work should be selected to form a panel in the same way as it is intended to set up a panel of general practitioner obstetricians. A Paediatrie Branch of Public Health

For these reasons I am convinced that whole-time medical officers must for some time to come continue to undertake the routine work in the school health and maternity and child welfare services. Moreover, whole-time officers will be required to deal with the problems of t h e special child. T h e truth is that the assistant medical officers have acquired a specialist knowledge and recognition of this is due. Certainly the efficiency of the service will depend in the future, as in the past, on the quality of its personnel. A young and expanding service succeeded in attracting to its ranks men and women of good professional standing, eager to take part in a field of work which not only appealed to their higher sentiments but which, as the curative side of the work became extended, provided a variety of interest. From experience of the routine duties in the field in the school medical and child welfare services of a large authority, I am certain that any arrangement whereby work in the clinics can be supplemented by duties in the obstetrical or paediatric department of a hospital is a wise one. Routine school medical inspection and routine work in child welfare centres can become very monotonous and uninspiring if unrelieved by contact with one's fellows and with the curative and hospital services. I had long hoped for the development o f ' a paediatric service as a distinct branch of public health whereby the whole-time assistant medical officer undertaking the conduct of clinics and routine inspections in the school medical and child welfare services would also have charge of a number of beds in the children's wards of the local authority's hospitals. It is, therefore, heartening to read in Circular 118/47 of the Ministry of Health that it is considered desirable that the medical staffs of the local health authority should also be employed by the Regional Hospital Board in appropriate duties in the hospitals. I hope that further regulations will make obligatory a joint use of staff on these lines wherever suitable arrangements can be made. Much emphasis has been placed recently on the close correspondence between the work of a clinic medical officer and the work of a general practitioner. T o my mind, there is an even greater need to secure liaison between the personal preventive services and the hospital curative services. Let there be a channel between t h e hospitals and the clinics along which an interchange of staff can freely take place to the mutual advantage of both services. In this way the assistant medical officers in the employ of local authorities would no longer be confined to a limited field of work but would become recognised experts in paediatries or obstetrics, with a corresponding rise in status. T o this end they would do well to obtain a suitable higher qualification in obstetrics .or in child health. Extended Functions of Local Health Authorities

There is, of course, nothing novel in the functions allocated to Local Hea!th Authorities in Part I I I of the National Health Service Act. T h e maintenance of a maternity and child welfare service becomes obligatory instead of permissive and the scope of the health visitor is enlarged. Health visiting will become a speciality in its own right; the extensions to the work are truly impressive. T h e giving of advice in the home to all persons suffering from illness and the service for prevention, care and after care, mean there must be a close link between the health visitors and the hospitals and the general practitioners. T h e sett.ing up of health centres will also bring the health visitor into close contact with the general practitioner service, so her field of work will be an ever-increasing one. It has been suggested that much visiting in the home might well be undertaken by a person other than a nurse, one possessed with rather different qualifications, perhaps with a background in social welfare rather than in nursing. We must distinguish considerations of economics and health, related as they are, for though the health visitor is on occasions concemed with the economic position of the family and should indeed have a lively appreciation of its implications, her prime

145 interest is in health and in the teaching of a healthy way of living. It is certain that if the duties of health visitors are to be extended more staff will be required. Already the number of health visitors in many areas is insufficient to permit of all the home visiting which is desirable. Standard for Health Visiting

T h e recent Scottish Report on Infantile Mortality advocates a standard of siaffing which may appear unattainable for a long time to come, though we must agree with the principles from which the standard is based. It is suggested that one whole-time health visitor should urldertake the supervision of no more than 500 pre-school children. Few authorities approach this standard, and the present difficulties in the recruitment of new staff are not likely to abate in the immediate future. Progress can only be slow, and certainly it would be a mistake to attempt to counter the deficiency in health visitc;rs by the appointment of less highly trained workers. In this sphere of personal preventive work it is, above all, quality which counts. T h e r e is no official of the health authority who has more power for good than an efficient and a sympathetic health visitor. With the impressive growth of the welfare centre movement, we perhaps underestimate the important contribution made by the health visitors in their visits to the home. T h o u g h this work is less spectacular, its value is beyond question. Welfare centres have done much to secure the education of mothers in groups, but teaching reaches the individual level in the home and is here most effective. Significantly, the countries with a low infantile mortality rate are those which lay great emphasis upon home visiting. T o such an extent is the treatment of children concerned with the results of misunderstanding and mismanagement in the home that it would be advantageous to have included in the curriculum of medical students the making of visits to the home in company w i t h a health visitor. This is not to decry the work of the welfare centres in promoting the health of mother and infant. I say infant advisedly, for we must admit that the toddlers' attendances have been disappointing. Here the service can be criticised not for the work it does but for its limited scope. Perhaps in the past we have concentrated on the care of the infant, to the detriment of the older pre-school child. It behoves us to encourage the attendance of these older children, for this period of life is one during which the seeds of ill-health may be sown. Hopes o~ Health Centres

What of the standard of accommodation provided in our maternity and child welfare centres ? Some localities are fortunate in having modern spacious and well-planned welfare centres. These are the lucky ones whose building programme reached that stage of development before the war. Other areas are less fortunate ; by war and its aftermath, they have been the victims of the general postponement of building programmes and have to carry on with old premises, often illadapted for the purpose. Personnel are more important than buildings, but the best doctors and health visitors are handicapped by cramped and dingy premises. It will generally be desirable and convenient to provide welfare centre accommodation within the same curtilage as the new health centres to be set up for the doctors engaged in the curative services. I believe the health centre will be valuable by virtue of its serving as a meeting place for the consultant, the general practitioner and the whole-time public health officers. It will provide opportunities favourable for the development of the team spirit and should prove to be the link between the curative and preventive branches of the health service. I do not favour the replacement of small welfare centres by a central centre, for although such a policy has some attractions and advantages in the way of simplicity of administration and economy of the time of staff, it would mean a long journey On the part of many mothers which is not likely to be undertaken unless the child is ailing. It will, therefore, be necessary to continue and even to extend the system of welfare centres situated within easy reach of the homes of all who are likely to benefif. T h e r e is, however, one great advantage in the establishment

146 of a central centre, namely that it would f o r m an admirable training ground for doctors specialising in paediatrics and w o u l d facilitate teaching and research in regard to the healthy child. H e r e the universities and local authorities can cooperate and recent developments, culminating in the establishm e n t of professional Chairs of Child Health, augur well for the future. Prematurity

T h e problem of the p r e m a t u r e child is one to which the attention of the local health authorities is specially directed, and with regard to which proposals are required to be submitted to the Minister. T h e problem is considerable. Some 3% of babies suffer from prematurity. I n m a n y cases the resources of a hospital are necessary, in others by the use of improvisations in the h o m e m u c h can be done to give t h e infants a fair chance. No scheme, however, can be effective which does n o t make provision for a consultant paediatric service. Paediatricians are needed not only to take charge of specialised units in the hospitals, b u t also to undertake consultant work in the home. T h i s is where those assistant medical officers of health with the necessary qualifications and experience in paediatrics can be usefully employed. O f special concern to us as experts in preventive m e d i c i n e is the knowledge that the incidence of prematurity is affected by the quantity and quality of the m o t h e r s ' diet. A careful investigation in this country showed that in relation to the accepted requirements of the period m a n y expectant m o t h e r s did n o t increase their food intake during the last three m o n t h s of pregnancy as t h e y ought to have done, and it appeared that m o t h e r s of premature and stillborn babies were also seriously u n d e r f e d as regards quality. T h e most c o m m o n deficiencies in the diet were protein, calcium, iron and vitamins A and C. T h e effect of diet upon birth weight seems to be greatest in the case of the y o u n g primigravida. Obviously, education and instruction in ante-natal clinics can help to solve this problem, and we m u s t regard time spent in this w o r k as well spent as t h a t in ante-natal care of a purely obstetrical nature. T h e health visitor here again has an important role to play by following up this educative work in the home. T h e U n m a r r i e d M o t h e r and h e r Child

A n o t h e r important field of welfare work is that e m b r a c i n g t h e care of the unmarried m o t h e r and child. D u r i n g the war years the illegitimacy rate per thousand total live births reached a figure of m o r e than seventy, and although a decline in the rate has since taken place the problem is still considerable. M o s t welfare authorities have m a d e use of the facilities provided by the voluntary associations for moral welfare who have done m u c h to alleviate the distressing plight of the illegitimate • infant and its m o t h e r by arranging for institutional confinement, hostel care, placing and adoption. Some authorities have supplemented these arrangements by appointing to their staffs specially qualified social workers, and others have a r r a n g e d for selected health visitors to acquire experience in case work with a worker attached to the local moral welfare association. S o m e welfare authorities have been able to m a k e a practical contribution by making available accommodation in their nurseries for those children whose mothers have taken up work and in this way a satisfactory solution to the immediate difficulties has been found. Similar considerations apply to the orphaned child. Day a n d R e s i d e n t i a l N u r s e r i e s D a y and residential nurseries have been subjected to m u c h c r i t i c i s m - - s o m e of it very relevant. O n medical grounds m a n y have grave doubts as to the w i s d o m of separating the child from its m o t h e r and placing it at a tender age in contact with a community. However, there can be no d o u b t that in the case of the illegitimate or orphaned child nurseries of this kind are invaluable. A n t e - and P o s t - N a t a l H o s t e l s

O n e cannot overstress the importance of the ante-natal and post-natal hostels which are maintained b y m a n y voluntary associations. T h e y have justified themselves time and time

PUBLIC HEALTH, May, 1948 again, and from the educational point of view well-run hostels provide u n i q u e opportunities for the teaching of mothercraft. M a n y believe that hostel provision shouM be extended to provide accommodation for m o t h e r and child for periods of a year or so after the birth of the baby. T h e y believe that in this way the m o t h e r m a y be trained and find work, or b e c o m e reconciled with her parents. Others take the view that the segregation of young w o m e n of this kind, often of a low moral standard, has serious disadvantages and should not be encouraged. T h e care of the u n m a r r i e d m o t h e r and her Child and of orphaned and other " deprived " children, is a field of e n deavour in which health, education and moral welfare authorities all take a part. It is clear that m u c h thought m u s t be given to the future of this import_ant f o r m of welfare work. T h e s e are some of the problems which confront us as experts in maternal care and child health. T h e r e are m a n y others. Tl~e field is immense, and though we have achieved m u c h in the past m u c h remains for future development. I do n o t doubt that u n d e r the n e w conditions which will prevail there will continue to be r o o m for enterprise and for local initiative. I believe the health services of the local health authority will occupy a key position. Prevention is still better than cure, and economic considerations demand that the preventive services take pride of place in any comprehensive national health service. I f we needed sustaining in t h a t belief we m i g h t t u r n to the recent R e p o r t of the Working P a r t y in the Recruitm e n t and T r a i n i n g of Nurses, w h i c h says, w i t h reference to the p r o b l e m of sickness : " Clearly the p r o b l e m . . . c a n be attacked quite as m u c h by reducing the n u m b e r o f patients as b y increasing the n u m b e r of nurses. A scientific study of the health needs of the c o m m u n i t y would enquire w h a t is the greatest reduction in the value of work lost through sickness which could be b r o u g h t a b o u t by increase in expenditure on public preventive services." As whole-time public health officers engaged in m a t e r n i t y and child w e l f a r e - - a great personal preventiv~ s e r v l c e - - w e have a vital and satisfying part to play. In connection with the two special articles on cleanliness of eating and drinking utensils published in our February issue, the following extract from Health N e w s (organ of the Health League of Canada) for November, 1947, is of interest : HOW TO RATE RESTAURANT CLEANLINESS By DUNCAN HINES 1. Are rest rooms far enough away from kitchen to assure good sanitary conditions ? 2. Are the rest rooms clean ? If not, you can lay odds that the kitchen is dirty too. 3. Is the restaurant careful a b o u t little things--clean tops to ketchup bottles, no smears• on sugar bowls ? 4. Does the place smell of rancid grease ? If so, I always back out, for this is a sure sign of careless,, unsanitary food preparation. 5. Is the general appearance good--clean floors, clean linen, clean wails ? Are dishes, silverware and glasses gleaming ? 6. Are waiters' and waitresses' uniforms immaculate ? 7. Have waiters and waitresses been trained in sanitary precautions? In handling silverware, do they avoid touching the parts that you'll put i n your mouth ? Do they carry glasses so as not to touch the rims ? 8. Is there a " N o Admittance" sign on the kitchen door ? The final test of a restaurant's cleanliness is its kitchen. A restaurant which will not allow guests to inspect the kitchen is open to question. (The above was compiled by Duncan Hine% known as the unofficial arbiter of the American tourist's eating habits, and was published in Coronet. Mr. Hines is author and publisher of "Adventures in Good Eating," " L o d g i n g for a Night," and " Adventures in Good Cooking.") In connection with Mr. Hines' remarks concerning rest rooms, Health N e w s would like to point out that untidy, dirty conditions in these places are largely due to the users themselves. A little bit of the " think-of-the-other-fellow " spirit would do much to keep these rooms in a sanitary condition. Both proprietors and patrons have a responsibility where rest room sanitation is concerned.