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The future of the health visitor
EDITORIAL
123
in others, unification of medical services would not guarantee a better liaison between medical and social services and might well make things worse by separating the health services from the other local authority types of provision. There is still oftcn a gap between the hospital and the vocational aspects of the work, as well as bctween the vocational and the social. The Ministry of Pensions and the Ministry Of Labour m a y sonletimes scem to work at cross purposcs in that the "earnings rules" of the former may impede the desires o f the latter to lcad the re-trained worker progressively from part-time to wholc-linle cmploymcnt. There are also employers' insurance schemes, sick pay schemes and superannuation schemes which can provide obstacles to the employment of the disabled. Tile Piercy Committee, in 1956, oullined possible methods of co-ordination which might help to link the services together. To our mind they had two disadvantagcs. Largely regional and based on hospitals, they might welt stress the medical rather than the social and though they might bring the agencies together at regional level they would not necessarily be able to provide the periphcral contact, based on intimate local knowledge and understanding, which is necessary if a system ~ to be flexible enough to meet individual necds. It would seem to us that whether or not Piercy-type co-ordination is introduced there is a part which the local health department can play locally. The W.H.O. Report is quite spccific on this p o i n t ~ " T h e medical officer in charge of the local health services, because of the wide range of the services he directs and because of his medical knowledge and background, can play a very useful part in achieving co-ordination, and it is 'particularly important that he should have good contact with the hospital and general medical practice". In Britain this is already manifest in the development o f stroke rehabilitation and in constructive geriatric work and we can see m a n y reasons for, and few against, it being carried through into the more general rehabilitation field. No amending legislation is necessary to permit a start; the main need is for the M.O.H. to understand more about the subject. It is with this in mind that we are devoting the major part of this issue to an outline of certain aspects of rehabilitation. We believe that our authors speak cogently and hope that what they have to say will carry conviction as well as information.
THE
FUTURE
OF
THE
HEALTH
VISITOR
CRYSTAL-GAZING is obviously one of the most popular pastimes of the nineteen-
sixties; there are moments when one might wonder whether this eagerness of the professions to explore their respective futures can be evidence that they are ashamed of their pasts, or whether they merely feel insecure in their presents. There is surely plenty of reason for uncertainty and insecurity in several medical and allied fields, and this must be a valid reason for speculation, but we are
12,4
PUBLIC
HEALTH
VOL.
LXXVIll
NO.
3
aiso encouraged to believe that much of the current probing ahead has a considerably more positive reason. The medical and social sciences are advancing and expanding, and the shape of society itself is changing. It is, therefore, proper to consider whether the techniques o f the past are still valid or whether new circumstances demand a new approach on new lines. The Health Visitors' Association included in the programme of its winter residential course a symposium on "The Health Visitor of the Future" in which people engaged in field work, administration and teaching, together with a hospital almoner and a local authority member, exchanged views, and some important issues were usefully considered. Training obviously looms large, especially with the new Health Visitors" Training Council coming into operation. The panel on this occasion clearly had misgivings about the established pattern. It is difficult to prescribe a syllabus in detail to meet the needs of health visitors in practice in, say, ten years" time and there is a strong case for allowing flexibility in training courst~. Present trends, which are laying more emphasis on the social side of the job, on mental health and on health education, are to be encouraged, but it is obvious that the elements of child care are still going to be needed, together with other traditional techniques, for many years to come. Can the old and the new be adequately covered in the one academic year which is now allotted to the H.V. course? The panel doubted it, and so do we. How feasible is it to lengthen the course? Is a total of Ihree years of nursing education, plus basic midwifery plus two years of special training too long? If so, which is to be sacrificed'? It seems to be agreed that a foundation of nursing training is essential, and it was interesting that the panel had an eye to the suggestion, made in the nineteen-forties, that nursing training itself needed reviewing and might be reorganized on a basis of two years" general training with the third year spent in more specialized work. A nurse who had given her third year, under such a System, to child health work or pmdiatric nursing, might well be able to complete her health visitor training in a one-year course devoted mainly to the newer aspects of health visiting. The place of the health visitor's training, though less important than its content, is not to be ignored. There has recently been much thought of giving the task to the universities. We cannot believe that universities are the only places which are capable of the right level of teaching. We accept that since officers .of comparable status in other local authority services are increasingly acquiring university degrees and diplomas there is a risk of the health visitor being thought, or even thinking herself, inferior to them unless she too acquires the university stamp, but we doubt whether this argument should have decisive validity. We have some sympathy with the critics who wonder whether a university training course might not be a little too academic for a person whose job must be eminently practical. On the other side it has to be remembered that a course for health visitors may be enriched if it can make use of the
EDITORIAL
125
resources of a university or a college of technology and that the health visitor student has led a rather segregated life during her midwifery and nursing training, so that contact with students in other disciplines has something important to offer her. Some kind of compromise needs to be found. How is the training to be financed? The panel was unhappy about the present system of local authority sponsoring with its associated requirement, in most places, that the student should undertake to stay for a year or more in the service of the sponsoring authority. This is something which needs careful consideration. In a time of staff shortages it is easy to forgive the authority which wants to keep the student in its service after she has completed the course, but it would be interesting to know how well this works out in practice. If the newly-fledged health visitor leaves her sponsoring authority as soon as the contract period is over, has the authority really had full value for its morxey ? If, as a general rule, she stays on for a long period, might she not have done so without the element of coercion? It is not to be expected that the majority of authorities will be so public-spirited as to sponsor the training of someone who is probably going to work for someone else when she has qualified, though in the long run the establishment of a common pool 'of health visitors ought to leave everyone better off. But can it be that some potential health visitors are deterred from taking training because they must commit themselves in advance to a period of work in a particular area, and may there not be positive advantages to be gained from training schemes in which the cost of the course and the subsistence of the student are met out of central rather than local funds ? Should the work of the health visitor be rationalized? In the view of the panel, this certainly needs consideration. There are still places where health visitors do unnecessary clerical work. Obviously they must keep their own basic records and do some of their own correspondence and memorandum-writing, but it is wasteful for them to do jobs which are within the scope of general division clerks. Many authorities fail to appreciate the need for adequate transport. But there may also be some professional work which could be done by S.R.N.s or even by enrolled nurses and we suspect that the very limited experiments now being carried out with male equivalents to the health visitor could be profitably extended. W h a t is the future of the Group Adviser ? H o w far is it possible to ~ v e health visitors some type of specialized work in addition to more general duties ? How can the present tenuous contacts between health visitor and hospital be developed and strengthened ? These too were among the questions which the panel considered. So was that of t h e contact between health visitor and G.P. It is now generally agreed that this last is something to be fostered and most M.O.s H. accept it in principle, though its practical application in places where general practice is still highly individualistic is hedged about with a multitude of difficulties. It may be that the time has come when practical, as
126
PUBLIC
HEALTH
VOL.
LXXVII[
NO.
3
opposed to academic, discussion on the whole o f the lraining and the work of health visitors is a matter o f urgency, and, if so, the public health service itself should embark on that discussion and try to find its own solution to the problems. The risk is that if the service waits too long it may find impractical and unsatisfactory solutions being forced on it from outside, with deplorable consequences.
REFRESHER
COURSES--A
NEW
VENTURE
FOR a considerable time there has been dissatisfaction with the training provided for M.O's in the school health and child welfare services. Neither the D.P.H. nor the D.C.H. has quite filled the bill. The various refresher courses organized by the Society's groups have been highly successful in what they have attempted and Dr. Nora Wattle, in her Presidential Address to the Society, provided a stimulus which brought the groups together to consider something more ambitious. The aim has been to organize a course, lasting for six weeks, which would give M.O'sH. a general picture of child health and development from birth to school leaving age and would pay particular attention to the early diagnosis and assessment of all types of handicapped children and to the principles underlying their care and education. The difficulties of organizing such a course are obvious, but they are not insuperable and we confidently expect that the tirst course will be held early in 1965. The organization will be shared by the Society and the London School of Hygiene and the course will be held in London. It is intended to take full advantage of the wide range of facilities available and it is expected that a number of hospitals and institutes will collaborate in arranging lectures and demonstrations. Dr. Mary Sheridan, whose qualifications need no advertisement here, has accepted :an invitation to act as course tutor; it would be hard to find a better person to provide a unifying influence. It is the Society's hope that in the tong run a course of this kind will become .established as "required training" for all M.O's in the child health services and we believe that the Ministries of Health and Education are sympathetic to this view. Meanwhile, this first course has been designed to meet the needs of M.O's substantially engaged in clinical work who have had a fair amount of experience in the service a n d might welt be specially suitable for those who have been designated by their authorities to keep a watch over "risk register" children. The detailed programme will be circulated shortly; a pre-view of it suggests that it will be absorbingly interesting ~o the majority of child welfare and school M.O's and that the necessarily limited number of places will be barely adequate for those who would like to attend.
123
in others, unification of medical services would not guarantee a better liaison between medical and social services and might well make things worse by separating the health services from the other local authority types of provision. There is still oftcn a gap between the hospital and the vocational aspects of the work, as well as bctween the vocational and the social. The Ministry of Pensions and the Ministry Of Labour m a y sonletimes scem to work at cross purposcs in that the "earnings rules" of the former may impede the desires o f the latter to lcad the re-trained worker progressively from part-time to wholc-linle cmploymcnt. There are also employers' insurance schemes, sick pay schemes and superannuation schemes which can provide obstacles to the employment of the disabled. Tile Piercy Committee, in 1956, oullined possible methods of co-ordination which might help to link the services together. To our mind they had two disadvantagcs. Largely regional and based on hospitals, they might welt stress the medical rather than the social and though they might bring the agencies together at regional level they would not necessarily be able to provide the periphcral contact, based on intimate local knowledge and understanding, which is necessary if a system ~ to be flexible enough to meet individual necds. It would seem to us that whether or not Piercy-type co-ordination is introduced there is a part which the local health department can play locally. The W.H.O. Report is quite spccific on this p o i n t ~ " T h e medical officer in charge of the local health services, because of the wide range of the services he directs and because of his medical knowledge and background, can play a very useful part in achieving co-ordination, and it is 'particularly important that he should have good contact with the hospital and general medical practice". In Britain this is already manifest in the development o f stroke rehabilitation and in constructive geriatric work and we can see m a n y reasons for, and few against, it being carried through into the more general rehabilitation field. No amending legislation is necessary to permit a start; the main need is for the M.O.H. to understand more about the subject. It is with this in mind that we are devoting the major part of this issue to an outline of certain aspects of rehabilitation. We believe that our authors speak cogently and hope that what they have to say will carry conviction as well as information.
THE
FUTURE
OF
THE
HEALTH
VISITOR
CRYSTAL-GAZING is obviously one of the most popular pastimes of the nineteen-
sixties; there are moments when one might wonder whether this eagerness of the professions to explore their respective futures can be evidence that they are ashamed of their pasts, or whether they merely feel insecure in their presents. There is surely plenty of reason for uncertainty and insecurity in several medical and allied fields, and this must be a valid reason for speculation, but we are
12,4
PUBLIC
HEALTH
VOL.
LXXVIll
NO.
3
aiso encouraged to believe that much of the current probing ahead has a considerably more positive reason. The medical and social sciences are advancing and expanding, and the shape of society itself is changing. It is, therefore, proper to consider whether the techniques o f the past are still valid or whether new circumstances demand a new approach on new lines. The Health Visitors' Association included in the programme of its winter residential course a symposium on "The Health Visitor of the Future" in which people engaged in field work, administration and teaching, together with a hospital almoner and a local authority member, exchanged views, and some important issues were usefully considered. Training obviously looms large, especially with the new Health Visitors" Training Council coming into operation. The panel on this occasion clearly had misgivings about the established pattern. It is difficult to prescribe a syllabus in detail to meet the needs of health visitors in practice in, say, ten years" time and there is a strong case for allowing flexibility in training courst~. Present trends, which are laying more emphasis on the social side of the job, on mental health and on health education, are to be encouraged, but it is obvious that the elements of child care are still going to be needed, together with other traditional techniques, for many years to come. Can the old and the new be adequately covered in the one academic year which is now allotted to the H.V. course? The panel doubted it, and so do we. How feasible is it to lengthen the course? Is a total of Ihree years of nursing education, plus basic midwifery plus two years of special training too long? If so, which is to be sacrificed'? It seems to be agreed that a foundation of nursing training is essential, and it was interesting that the panel had an eye to the suggestion, made in the nineteen-forties, that nursing training itself needed reviewing and might be reorganized on a basis of two years" general training with the third year spent in more specialized work. A nurse who had given her third year, under such a System, to child health work or pmdiatric nursing, might well be able to complete her health visitor training in a one-year course devoted mainly to the newer aspects of health visiting. The place of the health visitor's training, though less important than its content, is not to be ignored. There has recently been much thought of giving the task to the universities. We cannot believe that universities are the only places which are capable of the right level of teaching. We accept that since officers .of comparable status in other local authority services are increasingly acquiring university degrees and diplomas there is a risk of the health visitor being thought, or even thinking herself, inferior to them unless she too acquires the university stamp, but we doubt whether this argument should have decisive validity. We have some sympathy with the critics who wonder whether a university training course might not be a little too academic for a person whose job must be eminently practical. On the other side it has to be remembered that a course for health visitors may be enriched if it can make use of the
EDITORIAL
125
resources of a university or a college of technology and that the health visitor student has led a rather segregated life during her midwifery and nursing training, so that contact with students in other disciplines has something important to offer her. Some kind of compromise needs to be found. How is the training to be financed? The panel was unhappy about the present system of local authority sponsoring with its associated requirement, in most places, that the student should undertake to stay for a year or more in the service of the sponsoring authority. This is something which needs careful consideration. In a time of staff shortages it is easy to forgive the authority which wants to keep the student in its service after she has completed the course, but it would be interesting to know how well this works out in practice. If the newly-fledged health visitor leaves her sponsoring authority as soon as the contract period is over, has the authority really had full value for its morxey ? If, as a general rule, she stays on for a long period, might she not have done so without the element of coercion? It is not to be expected that the majority of authorities will be so public-spirited as to sponsor the training of someone who is probably going to work for someone else when she has qualified, though in the long run the establishment of a common pool 'of health visitors ought to leave everyone better off. But can it be that some potential health visitors are deterred from taking training because they must commit themselves in advance to a period of work in a particular area, and may there not be positive advantages to be gained from training schemes in which the cost of the course and the subsistence of the student are met out of central rather than local funds ? Should the work of the health visitor be rationalized? In the view of the panel, this certainly needs consideration. There are still places where health visitors do unnecessary clerical work. Obviously they must keep their own basic records and do some of their own correspondence and memorandum-writing, but it is wasteful for them to do jobs which are within the scope of general division clerks. Many authorities fail to appreciate the need for adequate transport. But there may also be some professional work which could be done by S.R.N.s or even by enrolled nurses and we suspect that the very limited experiments now being carried out with male equivalents to the health visitor could be profitably extended. W h a t is the future of the Group Adviser ? H o w far is it possible to ~ v e health visitors some type of specialized work in addition to more general duties ? How can the present tenuous contacts between health visitor and hospital be developed and strengthened ? These too were among the questions which the panel considered. So was that of t h e contact between health visitor and G.P. It is now generally agreed that this last is something to be fostered and most M.O.s H. accept it in principle, though its practical application in places where general practice is still highly individualistic is hedged about with a multitude of difficulties. It may be that the time has come when practical, as
126
PUBLIC
HEALTH
VOL.
LXXVII[
NO.
3
opposed to academic, discussion on the whole o f the lraining and the work of health visitors is a matter o f urgency, and, if so, the public health service itself should embark on that discussion and try to find its own solution to the problems. The risk is that if the service waits too long it may find impractical and unsatisfactory solutions being forced on it from outside, with deplorable consequences.
REFRESHER
COURSES--A
NEW
VENTURE
FOR a considerable time there has been dissatisfaction with the training provided for M.O's in the school health and child welfare services. Neither the D.P.H. nor the D.C.H. has quite filled the bill. The various refresher courses organized by the Society's groups have been highly successful in what they have attempted and Dr. Nora Wattle, in her Presidential Address to the Society, provided a stimulus which brought the groups together to consider something more ambitious. The aim has been to organize a course, lasting for six weeks, which would give M.O'sH. a general picture of child health and development from birth to school leaving age and would pay particular attention to the early diagnosis and assessment of all types of handicapped children and to the principles underlying their care and education. The difficulties of organizing such a course are obvious, but they are not insuperable and we confidently expect that the tirst course will be held early in 1965. The organization will be shared by the Society and the London School of Hygiene and the course will be held in London. It is intended to take full advantage of the wide range of facilities available and it is expected that a number of hospitals and institutes will collaborate in arranging lectures and demonstrations. Dr. Mary Sheridan, whose qualifications need no advertisement here, has accepted :an invitation to act as course tutor; it would be hard to find a better person to provide a unifying influence. It is the Society's hope that in the tong run a course of this kind will become .established as "required training" for all M.O's in the child health services and we believe that the Ministries of Health and Education are sympathetic to this view. Meanwhile, this first course has been designed to meet the needs of M.O's substantially engaged in clinical work who have had a fair amount of experience in the service a n d might welt be specially suitable for those who have been designated by their authorities to keep a watch over "risk register" children. The detailed programme will be circulated shortly; a pre-view of it suggests that it will be absorbingly interesting ~o the majority of child welfare and school M.O's and that the necessarily limited number of places will be barely adequate for those who would like to attend.