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The future of school health
Publ. ltlth, Lond, (1972) 86, I05-107
T h e Future of School Health WHAT IS going to happen to the School Health Service? This is in fact not one question but several, which many people have been asking over many months. The answers to some of them are now emerging and the answers to others are being diligently sought. We publish in this isstie a document of evidence, which the Society recently submitted to one of the most important answer-finding bodies--a special sub-comnaittee of the Working Party on cooperation in the reorganized Health and Local Government Services which is working at Departmental level---which ought to be useful to sundry other bodies and individuals who are looking constructively into the future. The Society is particularly grateful tbr the part which tile School Health Service Group has played in providing the material for the evidence. The special circumstances which have enabled that Group to have a large Council whose memberslaip is representative of all types of Authority in all parts of the country and includes school M.O.s from all levels have often benefited the Society and the Service but rarely more than in this case. It looks as if one of the principal questions has now found ks answer and that the S.H.S. will be transferred to the reorganized N.H.S. The opposition to the transfer has been strong and has had a substantial case. We have no doubt that some of those who opposed the transfer were interested in retaining as much as possible of a vanishing empire, but the motivation of most was a genuine feeling that a worthwhile and necessary service might suffer substantially by the change. They feared on the one hand that when the Service came to compete fbr its share of N.H.S. money with the more obviously urgent (and more glamorous) curative services it might be pushed into second place and on the other that the S.H.S. team, which needs for success in its task a partnership between the medical, teaching and educational administrative disciplines, could well be broken up. School M.O.s have been only too well aware of these dangers, but they have been also aware of the desirability of having an integrated service for child health as a whole. Their view has been that both the retention of a separate S.H.S. under the local education authority and the separation of the Service from tlae L.E.A. could be harmful but that given good will and good sense the transfer of the Service to the new health authorities was certainly the lesser evil. There would be undoubted gains and the losses could probably be reduced to insignificance. What are the gains? The S.H.S. has certainly suffered from its separation from pre-school child health work, in that too often by the time the child came under its care opportunities had been missed and at times even substantial damage to the child's health might have been done. It has also been hampered by difficulties in liaison with the clinical agencies. A unified child health service could not be other than beneficial to all parties., Be it noted that a change in organizational structure does not in itself make for unity in action. In the last resort, collaboration depends on the people who are expected to collaborate. But the new organization will at least improve understanding and provide better opportunities for that collaboration. In its discussions the S.H.S. Group has introduced a new term. it is thinking not merely of a unified Child Health Service but of a Child and Youth Health Service. To use an industrial metaphor, it has been concerned not only with deficiencies in the raw material which comes to the S.H,S. but with the fact that its final product is at risk of neglect. The youngster for w h o m it has laboured painstakingly to the age of fifteen passes
106
PUBLIC HEALTH VOL. 86 NO. 3
out of its care at a singularly vulnerable stage of development and is exposed to many hazards. A health service which helps to see the child through adolescence is absolutely essential at the present time. The Hunter Committee has obviously taken very seriously the difficulties which might arise from the transfer of the S.H.S. to the new N.H.S. It takes advantage of the fact that N.H.S. Areas will be coterminous with the new Local Education Authorities by recommending in its Report that the Community Medicine "Department of the health services should provide a formal medical adviser to the L.E.A. Moreover, it implies that since the N.H.S. at "district" level will be handling day to day work and that since at any rate the larger L.E.A.s will be decentralizing their services to units which will often correspond approximately with N.H.S. districts, there should be similar linkage at that level. We could, however, wish that the Committee had been more explicit. Probably it was conscious that its terms of reference related strictly to medical administrators when it was drafting the sentence: "We would expect the Chief Administrative Medical Officer of the area health authority to act as the chief medical adviser to the education authority." If, as is probable, two-thirds of the areas have populations over 300,000 and a number population s over one million, the education authorities will certainly need not merely incidenlal administrative advice for their school health work but senior, experienced medical officers of consultant status to do what is now done by thoge "senior" or "principal" medical officers who are de facto, if not de jure, serving L.E,A.s today as principal school M .O.s. In the larger areas we can also see the valu, of the district community physician serving in a capacity analogous to the Divisional School M.O. of today. The appendix to the Society's document of evidence ought certainly to dispel any lingering doubts which exist regarding the need for a school health service. We hope it will also dispel doubts about the need for school medical officers. There are still people who believe that school health work is a casual, perfunctory job which can be done in a perfunctory way by casual workers. The Hunter Committee plainly accepts that this is not the case and it is obvious that the L.E.A.s and the teachers have no illusions. We could wish that more paediatricians took this view. It is clear that many of them still see the S.H.S. as something which does no more than routinely inspect children who have no need ['or routine inspections. The appendix outlines the work of the Service and makes it clear that the S.M.O, must be able to understand the child's physical, emotional, social and educational needs both as an individual and as a member of the school community. He must be not merely the school's sanitary adviser but the friend, guide and partner of the teacher in all matters pertaining to the child's well-being, and a community physician concerned with the school's life as a community. And, outside these general functions, he must be something of an expert in watching over the well-being of the handicapped and ensuring that their special needs are being met as m a y be appropriate from time to lime as those r~eeds inevitably change. If this is not a specialty, then words have ceased to have meaning. We should like to see the time arrive when both the paediatrician and the G.P. are more involved in school health work, but at the present time the majority of both G.P.s and paediatricians do not have the training and experience which that work demands of those who take it seriously. This is the place to refer also ~o the " y o u t h " side of the new integrated service. Since most adolescents, at least up to the age of eighteen, will be receiving whole-time or parttime education in either schools or places of further education and since few of those who have left school will benefit by an adequate occupational health service, it would seem that adolescent health services will have to be school- and college-based and that they will develop as an extension of school health work. Few paediatricians have had much experience with adolescents and few young people deliberately seek health counsel from the family
TIlE FUTURE OF SCttOOL ttEALTlt
107
doctor. Here is another specialty consistent with what the school M.O. does at present; indeed it is part of what the S.M.O. is already doing in grammar and comprehensive schools. Its wider" development must obviously depend on him. It is our present purpose to stress the need for school health work and also to make it clear that those who are at present doing it are the people who should undertake it in the new integrated service. We emphasize that though it is a specialized task it is such within the totality ofchild health. We can see the risk that because those engaged in it have a very direct involvement with local education authorities and their activities outs-ide the N.H.S. they might become administratively isolated from those dealing with young-child health work, even though the young-child health work has a less direct involvement with the advisijlg of the social services department of the local authority on its multifarious child care functions. To have someone designated, perhaps, as " C o m m u n i t y Physician (School Health)" could easily lead to young-child health work, with all its social implications Jbr individual and community becoming a '*junior arm" of the clinical paediatric service. There is a strong case, in fact, for having the same community physician responsible tbr the appropriate aspects of child health work at all ages. No less strong is the case for having unification at field level and for developing a new type of ~'child health doctor" who would be a specialist in social paediatrics, in the widest sense, at all age levels. Some paediatricians, though as yet far too few, are learning to understand and practice a social kind of paediatrics. Many, though as yet not enough, ~'child welfare doctors" and school M.O.s have widened their knowledge of developmental paediatrics to bring them to a close approximation to the kind of doctor we have in mind. But the reorganization of the N.H.S. is due in 1974. Unless there is some shedding of preiudices, some positive thinking and some early constructive discussion between all those involved, medical and non-medical, which takes into account administrative needs and present resources, which begins to plan for the long term but which accepts that the next ten years are going to require flexibility, improvization and experiment, the new N.H.S. will be born into confusion and chaos.
T h e Future of School Health WHAT IS going to happen to the School Health Service? This is in fact not one question but several, which many people have been asking over many months. The answers to some of them are now emerging and the answers to others are being diligently sought. We publish in this isstie a document of evidence, which the Society recently submitted to one of the most important answer-finding bodies--a special sub-comnaittee of the Working Party on cooperation in the reorganized Health and Local Government Services which is working at Departmental level---which ought to be useful to sundry other bodies and individuals who are looking constructively into the future. The Society is particularly grateful tbr the part which tile School Health Service Group has played in providing the material for the evidence. The special circumstances which have enabled that Group to have a large Council whose memberslaip is representative of all types of Authority in all parts of the country and includes school M.O.s from all levels have often benefited the Society and the Service but rarely more than in this case. It looks as if one of the principal questions has now found ks answer and that the S.H.S. will be transferred to the reorganized N.H.S. The opposition to the transfer has been strong and has had a substantial case. We have no doubt that some of those who opposed the transfer were interested in retaining as much as possible of a vanishing empire, but the motivation of most was a genuine feeling that a worthwhile and necessary service might suffer substantially by the change. They feared on the one hand that when the Service came to compete fbr its share of N.H.S. money with the more obviously urgent (and more glamorous) curative services it might be pushed into second place and on the other that the S.H.S. team, which needs for success in its task a partnership between the medical, teaching and educational administrative disciplines, could well be broken up. School M.O.s have been only too well aware of these dangers, but they have been also aware of the desirability of having an integrated service for child health as a whole. Their view has been that both the retention of a separate S.H.S. under the local education authority and the separation of the Service from tlae L.E.A. could be harmful but that given good will and good sense the transfer of the Service to the new health authorities was certainly the lesser evil. There would be undoubted gains and the losses could probably be reduced to insignificance. What are the gains? The S.H.S. has certainly suffered from its separation from pre-school child health work, in that too often by the time the child came under its care opportunities had been missed and at times even substantial damage to the child's health might have been done. It has also been hampered by difficulties in liaison with the clinical agencies. A unified child health service could not be other than beneficial to all parties., Be it noted that a change in organizational structure does not in itself make for unity in action. In the last resort, collaboration depends on the people who are expected to collaborate. But the new organization will at least improve understanding and provide better opportunities for that collaboration. In its discussions the S.H.S. Group has introduced a new term. it is thinking not merely of a unified Child Health Service but of a Child and Youth Health Service. To use an industrial metaphor, it has been concerned not only with deficiencies in the raw material which comes to the S.H,S. but with the fact that its final product is at risk of neglect. The youngster for w h o m it has laboured painstakingly to the age of fifteen passes
106
PUBLIC HEALTH VOL. 86 NO. 3
out of its care at a singularly vulnerable stage of development and is exposed to many hazards. A health service which helps to see the child through adolescence is absolutely essential at the present time. The Hunter Committee has obviously taken very seriously the difficulties which might arise from the transfer of the S.H.S. to the new N.H.S. It takes advantage of the fact that N.H.S. Areas will be coterminous with the new Local Education Authorities by recommending in its Report that the Community Medicine "Department of the health services should provide a formal medical adviser to the L.E.A. Moreover, it implies that since the N.H.S. at "district" level will be handling day to day work and that since at any rate the larger L.E.A.s will be decentralizing their services to units which will often correspond approximately with N.H.S. districts, there should be similar linkage at that level. We could, however, wish that the Committee had been more explicit. Probably it was conscious that its terms of reference related strictly to medical administrators when it was drafting the sentence: "We would expect the Chief Administrative Medical Officer of the area health authority to act as the chief medical adviser to the education authority." If, as is probable, two-thirds of the areas have populations over 300,000 and a number population s over one million, the education authorities will certainly need not merely incidenlal administrative advice for their school health work but senior, experienced medical officers of consultant status to do what is now done by thoge "senior" or "principal" medical officers who are de facto, if not de jure, serving L.E,A.s today as principal school M .O.s. In the larger areas we can also see the valu, of the district community physician serving in a capacity analogous to the Divisional School M.O. of today. The appendix to the Society's document of evidence ought certainly to dispel any lingering doubts which exist regarding the need for a school health service. We hope it will also dispel doubts about the need for school medical officers. There are still people who believe that school health work is a casual, perfunctory job which can be done in a perfunctory way by casual workers. The Hunter Committee plainly accepts that this is not the case and it is obvious that the L.E.A.s and the teachers have no illusions. We could wish that more paediatricians took this view. It is clear that many of them still see the S.H.S. as something which does no more than routinely inspect children who have no need ['or routine inspections. The appendix outlines the work of the Service and makes it clear that the S.M.O, must be able to understand the child's physical, emotional, social and educational needs both as an individual and as a member of the school community. He must be not merely the school's sanitary adviser but the friend, guide and partner of the teacher in all matters pertaining to the child's well-being, and a community physician concerned with the school's life as a community. And, outside these general functions, he must be something of an expert in watching over the well-being of the handicapped and ensuring that their special needs are being met as m a y be appropriate from time to lime as those r~eeds inevitably change. If this is not a specialty, then words have ceased to have meaning. We should like to see the time arrive when both the paediatrician and the G.P. are more involved in school health work, but at the present time the majority of both G.P.s and paediatricians do not have the training and experience which that work demands of those who take it seriously. This is the place to refer also ~o the " y o u t h " side of the new integrated service. Since most adolescents, at least up to the age of eighteen, will be receiving whole-time or parttime education in either schools or places of further education and since few of those who have left school will benefit by an adequate occupational health service, it would seem that adolescent health services will have to be school- and college-based and that they will develop as an extension of school health work. Few paediatricians have had much experience with adolescents and few young people deliberately seek health counsel from the family
TIlE FUTURE OF SCttOOL ttEALTlt
107
doctor. Here is another specialty consistent with what the school M.O. does at present; indeed it is part of what the S.M.O. is already doing in grammar and comprehensive schools. Its wider" development must obviously depend on him. It is our present purpose to stress the need for school health work and also to make it clear that those who are at present doing it are the people who should undertake it in the new integrated service. We emphasize that though it is a specialized task it is such within the totality ofchild health. We can see the risk that because those engaged in it have a very direct involvement with local education authorities and their activities outs-ide the N.H.S. they might become administratively isolated from those dealing with young-child health work, even though the young-child health work has a less direct involvement with the advisijlg of the social services department of the local authority on its multifarious child care functions. To have someone designated, perhaps, as " C o m m u n i t y Physician (School Health)" could easily lead to young-child health work, with all its social implications Jbr individual and community becoming a '*junior arm" of the clinical paediatric service. There is a strong case, in fact, for having the same community physician responsible tbr the appropriate aspects of child health work at all ages. No less strong is the case for having unification at field level and for developing a new type of ~'child health doctor" who would be a specialist in social paediatrics, in the widest sense, at all age levels. Some paediatricians, though as yet far too few, are learning to understand and practice a social kind of paediatrics. Many, though as yet not enough, ~'child welfare doctors" and school M.O.s have widened their knowledge of developmental paediatrics to bring them to a close approximation to the kind of doctor we have in mind. But the reorganization of the N.H.S. is due in 1974. Unless there is some shedding of preiudices, some positive thinking and some early constructive discussion between all those involved, medical and non-medical, which takes into account administrative needs and present resources, which begins to plan for the long term but which accepts that the next ten years are going to require flexibility, improvization and experiment, the new N.H.S. will be born into confusion and chaos.