309
deepest gratitude.
National Health Service CLINICAL MEDICAL OFFICERS
(CHILD HEALTH) The Challenge of the Next Few Years SHELAGH TYRRELL*
After 1974, no-one came to work in the child-health services through public health, for it no longer existed. Younger doctors came via hospital paediatrics or through general practice. Many were well qualified and with considerable registrar experience in pxdiatrics. Some of them had, alas, to suffer the sympathy of their hospital colleagues, who saw entry into community child health as slipping off the paediatric ladder.
Senior Medical Officer (Child Health) TURNING BACK ON COURT
the feet of an eminent paediawho trician, brought great fame to his provincial city. told us that much childhood illness arose from a lack He of continuous loving care from the mother. Bowlby’s theories had been totally accepted, often no doubt by men who liked their carpet slippers laid out against their return. But, for this paediatrician, in the Bowlby view, there must be no exceptions, least of all among doctors. "All mothers must stay and look after their children until they reach five years of age; and then they must work only part-time during school -hours." His penetrating eyes moved in my direction: "All mothers," he glowered—"and I mean all mothers." Some of us fought hard not to be intimidated. We had got into medicine with a struggle, and we became clinical medical officers because there was a job to do and it fitted our home routines; and, for those of us who came there through general practice, or paediatrics, it seemed a good use of our skills. We knew we needed an even more professional attitude to our job than those who worked full-time. We paid to go on G.P. courses, we paid to take diplomas, giving up sessional income to do so. We haunted the clinical meetings and ward rounds in our local hospitals. It was us, and not others in the profession, who first suggested that two married women, each working half-time, might put more commitment into a job than one full-timer. Before 1974, we were an integral part of the publichealth service. Once our children were older, we had the prospect of working full-time as principals in an administrative service, with some clinical responsibilities. The service was responsible for school health, the under-5s, and handicapped children. Yet even the clinical work was remote from the paediatricians, who were rarely consulted, and who sometimes appeared hardly to know that the service existed. If they did, many of them saw us as the "hat-and-gloves brigade", and we were regarded with some contempt. No wonder the Court report commented on the poor service offered to parents of handicapped children, who were "dealt with" away from the mainstream of paediatric care. How else could a hypothyroid boy reach the age of 12 labelled a "mongol", diagnosed by a clinic doctor without chromosome studies? Several doctors saw him each year, and "he seemed quite bright for a mongol", one wrote, as he was transferred to a school for the educationally subnormal. Only a few paediatricians showed an interest in the plight of the clinical medical officer, doing mainly surveillance work, away from hospital paediatrics, so it was possible to suffer paediatric disuse atrophy and miss the little real disease that did come our way. But those few pxdiatricians were stalwart supporters and deserve our MANY years ago, I sat
at
-
*Address: The Red House, The Drive, Belmont,
Surrey
SM2 7DP.
Into this confused situation, the Court recommendations made sound sense. Prevention and treatment were to be together again. But the G.P.s rejected it, and the hospital paediatricians took little notice; it is strange that in academic circles at least, they did not realise that for the medical student of the future one day in the community could reveal more clinical material (which students love) than the wards could show in weeks. The clinical medical officers, already demoralised, found themselves back with the community physicians, some of whom, reasonably, did not want them either. They found that their position of subordination to the community physicians, which they thought was historical and likely to change with the implementation of Court, was becoming fixed. What other group of doctors is "subordinate" to another, except in training? What sense is there in a clinical doctor being subordinate to an administrator, whose clinical skills, if they ever existed, are getting very rusty? Some may argue that for the best community physicians this subordination is nominal. I know: I work for one of them. But others are less sure of their role, and make the subservience a fact. "Under no circumstances may you contact my doctors" I have been told. Abandoned by those who turned down Court, we find ourselves beholden to community medicine, with whom we have little in common, and powerful forces try to sweep us towards an "independent" service. We are on the brink of turning the clock back thirty years to the unsuccessful "tripartite" service. The clinical medical officers would then be independent of the pxdiatricians and general practitioners, with whose work with children their own is so closely linked, and subservient to the community physicians, with whom they have little in common. THE NEEDS OF THE SERVICE
On the 30th anniversary of the N.H.S., when we are told of the necessity for preventive health care, an integrated child-health service makes sense, and it is a corof the "philosophy of Court", which the Government supports. Within such a service, the clinical medical officer would have continued pxdiatric support, and the community physicians would be free to do their real work, which is to look at the needs of their area, and find ways of bringing quality care to all children. They would spell out the needs to clinical medical officers, G.P.s, and consultants, who must all act on the information they are given. The role of the community physician is enhanced rather than diminished by an intenerstone
grated child-health service. Why do I say "the challenge when it
seems
of the next few years", that the die is cast, and our future within
310
community medicine, divorced from paediatrics, is assured? Every clinical medical officer in the country should think what this means for him or her, as well as how the service and the low morale will affect the children. One suggestion for our new career is that there should be one training grade for those in training and as a dumping ground for those, mainly women, who "do not want to go any further". Our medical duaghters would not stand for this lack of professional commitment and they would despise us if we sold our hopes so lightly. They would remind us that there are eminent women at the top of every profession, and in every area of medicine, who have combined a career and a family, giving time, energy, and dedication to both.
Commentary from From
our
Westminster
Parliamentary Correspondent
Industrial Relations in the N.H.S. POSSIBLE new machinery for resolving disputes within the National Health Service is now being considered by the Government working-party set up to find ways of improving industrial relations in the service. At the moment the suggestion is one of several which have been thrown into the arena by the parties involved. The committee’s deliberations, under Mr Eric Deakins, Parliamentary Secretary at the Department of Health and Social Security, are at a very early stage. All the parties round the table, health-service unions and the British MedicalAssociation, are feeling their way. Ideas are being canvassed and eventually the best will go forward for deeper consideration. The need for a new disputes machinery will be one of the working-party’s main preoccupations. One idea is that the health service should have its own ACAs, the Advisory, Conciliation, and Arbitration Service set up by the Government some years ago. Another is that the Whitley Council system should be extended to give it new machinery at regional and local level. Regional Whitley Councils were suggested by the McCarthy report in 1976, the idea being that they would apply flexibility in national agreements, negotiating hours of work, deciding policy on the physical welfare of employees, and exercising appeals functions. Although the regional health authorities were in favour of more flexible agreements, they were strongly against regional councils. At the moment, however, it is felt that there is a serious gap in the procedure for dealing with disputes which suddenly blow up in the N.H.S. The unions, N.U.P.E. and C.O.H.S.E., are anxious to use the talks for establishing machinery which would eliminate not just the symptoms of disputes but also their causes. Alongside those who believe that there is scope for developing the Whitley Council system, which is regarded as being out of touch with events at local level, are others who think that ACAs should be extensively brought into the N.H.S. It has already been used on a number of occasions, although Mr Deakins recently expressed his opposition to the growing tendency of health authorities to call in ACAs at the first sign of trouble. While not all the unions agree that ACAS is the most suitable instrument for solving N.H.S. disputes, there is no disagreement about the gap which now exists. They
In the final analysis the D.H.S.S. is responsible for the service to children, and those who make decisions are not faceless administrators but often doctors who have been paediatricians themselves, and they see the needs. Surely they cannot turn their back on the often-quoted "we accept the philosophy of Court" and sell us to an independent service thirty years our of date?
My views are not necessarily those of our newly founded Association of Clinical Medical Officers, which grows daily and accepts the challenge for the next few years. If anyone, not only clinical medical officers, wants to know more about the Association, I will happy to tell them. We are having our first Annual General Meeting on Saturday, Sept. 30, at 10 A.M., at the Royal Institution, 21 Albemarle Street, London Wl. blame it on neglect of personal and industrial relations in the service. As one union official told me: "If people are looking for reasons why we now have commonplace industrial action in the N.H.S. it is partly because it has been paternalistically administered for so long". The B.M.A., for its part, appears willing to consider the idea of some new machinery. Its major preoccupation in the talks, however, is to try to mitigate the effects of industrial disputes on patients. It began by suggesting that the right to strike should be removed from all N.H.S. employees. Predictably this idea fell on stony ground as far as the unions were concerned. Now the B.M.A. is proposing that some code of practice be drawn up, identifying those areas which should not suffer as a result of industrial action. Resolutions for the Labour Conference REGULAR critics of the National Health Service often point to deteriorating standards; its customary friends do so less often. Consider then the following: "This conference is extremely concerned at the deterioration in the standards of service provided by the National Health Service and calls upon the Government to give first priority to a substantial and continued increase in expenditure on the N.H.S.". It could easily be a motion before a Conservative Party conference. In fact, it is a resolution for the annual Labour Party conference scheduled for Blackpool in October. The conference will not go ahead if there is an autumn election, but the resolutions submitted by the constituency parties still make instructive reading, because they reflect opinion among Labour Party workers. One interest in this year’s resolutions, published last week, is the tone towards the N.H.S. Virtually all the resolutions are highly critical of the deteriorating state of the Service. Indeed it is this aspect, rather than the Party’s continuing preoccupation with private medicine, which dominates the resolutions. The Sidcup constituency party, for instance, "deplores the decline in the apparent availability of facilities in the N.H.S.", Wellingborough refers to "the present intolerable state of affairs", while Chester "notes with concern the beginning of a deterioration which must be halted". The recipe proposed by most constituencies is, of course, an increase in finances. But other demands include the abolition of all charges, the integration of the familypractitioner service into the N.H.S., the nationalisation of the pharmaceutical and drug manufacturing industry, and a reorganisation of administration with the removal of one tier. Maybe the Government will not be too unhappy if the Blackpool conference is cancelled.
deepest gratitude.
National Health Service CLINICAL MEDICAL OFFICERS
(CHILD HEALTH) The Challenge of the Next Few Years SHELAGH TYRRELL*
After 1974, no-one came to work in the child-health services through public health, for it no longer existed. Younger doctors came via hospital paediatrics or through general practice. Many were well qualified and with considerable registrar experience in pxdiatrics. Some of them had, alas, to suffer the sympathy of their hospital colleagues, who saw entry into community child health as slipping off the paediatric ladder.
Senior Medical Officer (Child Health) TURNING BACK ON COURT
the feet of an eminent paediawho trician, brought great fame to his provincial city. told us that much childhood illness arose from a lack He of continuous loving care from the mother. Bowlby’s theories had been totally accepted, often no doubt by men who liked their carpet slippers laid out against their return. But, for this paediatrician, in the Bowlby view, there must be no exceptions, least of all among doctors. "All mothers must stay and look after their children until they reach five years of age; and then they must work only part-time during school -hours." His penetrating eyes moved in my direction: "All mothers," he glowered—"and I mean all mothers." Some of us fought hard not to be intimidated. We had got into medicine with a struggle, and we became clinical medical officers because there was a job to do and it fitted our home routines; and, for those of us who came there through general practice, or paediatrics, it seemed a good use of our skills. We knew we needed an even more professional attitude to our job than those who worked full-time. We paid to go on G.P. courses, we paid to take diplomas, giving up sessional income to do so. We haunted the clinical meetings and ward rounds in our local hospitals. It was us, and not others in the profession, who first suggested that two married women, each working half-time, might put more commitment into a job than one full-timer. Before 1974, we were an integral part of the publichealth service. Once our children were older, we had the prospect of working full-time as principals in an administrative service, with some clinical responsibilities. The service was responsible for school health, the under-5s, and handicapped children. Yet even the clinical work was remote from the paediatricians, who were rarely consulted, and who sometimes appeared hardly to know that the service existed. If they did, many of them saw us as the "hat-and-gloves brigade", and we were regarded with some contempt. No wonder the Court report commented on the poor service offered to parents of handicapped children, who were "dealt with" away from the mainstream of paediatric care. How else could a hypothyroid boy reach the age of 12 labelled a "mongol", diagnosed by a clinic doctor without chromosome studies? Several doctors saw him each year, and "he seemed quite bright for a mongol", one wrote, as he was transferred to a school for the educationally subnormal. Only a few paediatricians showed an interest in the plight of the clinical medical officer, doing mainly surveillance work, away from hospital paediatrics, so it was possible to suffer paediatric disuse atrophy and miss the little real disease that did come our way. But those few pxdiatricians were stalwart supporters and deserve our MANY years ago, I sat
at
-
*Address: The Red House, The Drive, Belmont,
Surrey
SM2 7DP.
Into this confused situation, the Court recommendations made sound sense. Prevention and treatment were to be together again. But the G.P.s rejected it, and the hospital paediatricians took little notice; it is strange that in academic circles at least, they did not realise that for the medical student of the future one day in the community could reveal more clinical material (which students love) than the wards could show in weeks. The clinical medical officers, already demoralised, found themselves back with the community physicians, some of whom, reasonably, did not want them either. They found that their position of subordination to the community physicians, which they thought was historical and likely to change with the implementation of Court, was becoming fixed. What other group of doctors is "subordinate" to another, except in training? What sense is there in a clinical doctor being subordinate to an administrator, whose clinical skills, if they ever existed, are getting very rusty? Some may argue that for the best community physicians this subordination is nominal. I know: I work for one of them. But others are less sure of their role, and make the subservience a fact. "Under no circumstances may you contact my doctors" I have been told. Abandoned by those who turned down Court, we find ourselves beholden to community medicine, with whom we have little in common, and powerful forces try to sweep us towards an "independent" service. We are on the brink of turning the clock back thirty years to the unsuccessful "tripartite" service. The clinical medical officers would then be independent of the pxdiatricians and general practitioners, with whose work with children their own is so closely linked, and subservient to the community physicians, with whom they have little in common. THE NEEDS OF THE SERVICE
On the 30th anniversary of the N.H.S., when we are told of the necessity for preventive health care, an integrated child-health service makes sense, and it is a corof the "philosophy of Court", which the Government supports. Within such a service, the clinical medical officer would have continued pxdiatric support, and the community physicians would be free to do their real work, which is to look at the needs of their area, and find ways of bringing quality care to all children. They would spell out the needs to clinical medical officers, G.P.s, and consultants, who must all act on the information they are given. The role of the community physician is enhanced rather than diminished by an intenerstone
grated child-health service. Why do I say "the challenge when it
seems
of the next few years", that the die is cast, and our future within
310
community medicine, divorced from paediatrics, is assured? Every clinical medical officer in the country should think what this means for him or her, as well as how the service and the low morale will affect the children. One suggestion for our new career is that there should be one training grade for those in training and as a dumping ground for those, mainly women, who "do not want to go any further". Our medical duaghters would not stand for this lack of professional commitment and they would despise us if we sold our hopes so lightly. They would remind us that there are eminent women at the top of every profession, and in every area of medicine, who have combined a career and a family, giving time, energy, and dedication to both.
Commentary from From
our
Westminster
Parliamentary Correspondent
Industrial Relations in the N.H.S. POSSIBLE new machinery for resolving disputes within the National Health Service is now being considered by the Government working-party set up to find ways of improving industrial relations in the service. At the moment the suggestion is one of several which have been thrown into the arena by the parties involved. The committee’s deliberations, under Mr Eric Deakins, Parliamentary Secretary at the Department of Health and Social Security, are at a very early stage. All the parties round the table, health-service unions and the British MedicalAssociation, are feeling their way. Ideas are being canvassed and eventually the best will go forward for deeper consideration. The need for a new disputes machinery will be one of the working-party’s main preoccupations. One idea is that the health service should have its own ACAs, the Advisory, Conciliation, and Arbitration Service set up by the Government some years ago. Another is that the Whitley Council system should be extended to give it new machinery at regional and local level. Regional Whitley Councils were suggested by the McCarthy report in 1976, the idea being that they would apply flexibility in national agreements, negotiating hours of work, deciding policy on the physical welfare of employees, and exercising appeals functions. Although the regional health authorities were in favour of more flexible agreements, they were strongly against regional councils. At the moment, however, it is felt that there is a serious gap in the procedure for dealing with disputes which suddenly blow up in the N.H.S. The unions, N.U.P.E. and C.O.H.S.E., are anxious to use the talks for establishing machinery which would eliminate not just the symptoms of disputes but also their causes. Alongside those who believe that there is scope for developing the Whitley Council system, which is regarded as being out of touch with events at local level, are others who think that ACAs should be extensively brought into the N.H.S. It has already been used on a number of occasions, although Mr Deakins recently expressed his opposition to the growing tendency of health authorities to call in ACAs at the first sign of trouble. While not all the unions agree that ACAS is the most suitable instrument for solving N.H.S. disputes, there is no disagreement about the gap which now exists. They
In the final analysis the D.H.S.S. is responsible for the service to children, and those who make decisions are not faceless administrators but often doctors who have been paediatricians themselves, and they see the needs. Surely they cannot turn their back on the often-quoted "we accept the philosophy of Court" and sell us to an independent service thirty years our of date?
My views are not necessarily those of our newly founded Association of Clinical Medical Officers, which grows daily and accepts the challenge for the next few years. If anyone, not only clinical medical officers, wants to know more about the Association, I will happy to tell them. We are having our first Annual General Meeting on Saturday, Sept. 30, at 10 A.M., at the Royal Institution, 21 Albemarle Street, London Wl. blame it on neglect of personal and industrial relations in the service. As one union official told me: "If people are looking for reasons why we now have commonplace industrial action in the N.H.S. it is partly because it has been paternalistically administered for so long". The B.M.A., for its part, appears willing to consider the idea of some new machinery. Its major preoccupation in the talks, however, is to try to mitigate the effects of industrial disputes on patients. It began by suggesting that the right to strike should be removed from all N.H.S. employees. Predictably this idea fell on stony ground as far as the unions were concerned. Now the B.M.A. is proposing that some code of practice be drawn up, identifying those areas which should not suffer as a result of industrial action. Resolutions for the Labour Conference REGULAR critics of the National Health Service often point to deteriorating standards; its customary friends do so less often. Consider then the following: "This conference is extremely concerned at the deterioration in the standards of service provided by the National Health Service and calls upon the Government to give first priority to a substantial and continued increase in expenditure on the N.H.S.". It could easily be a motion before a Conservative Party conference. In fact, it is a resolution for the annual Labour Party conference scheduled for Blackpool in October. The conference will not go ahead if there is an autumn election, but the resolutions submitted by the constituency parties still make instructive reading, because they reflect opinion among Labour Party workers. One interest in this year’s resolutions, published last week, is the tone towards the N.H.S. Virtually all the resolutions are highly critical of the deteriorating state of the Service. Indeed it is this aspect, rather than the Party’s continuing preoccupation with private medicine, which dominates the resolutions. The Sidcup constituency party, for instance, "deplores the decline in the apparent availability of facilities in the N.H.S.", Wellingborough refers to "the present intolerable state of affairs", while Chester "notes with concern the beginning of a deterioration which must be halted". The recipe proposed by most constituencies is, of course, an increase in finances. But other demands include the abolition of all charges, the integration of the familypractitioner service into the N.H.S., the nationalisation of the pharmaceutical and drug manufacturing industry, and a reorganisation of administration with the removal of one tier. Maybe the Government will not be too unhappy if the Blackpool conference is cancelled.
