860 COMMUNITY MEDICINE THE 1974 rearrangements in the National Health Service gave promise of a powerful force to be marshalled under the banner of community medicine. There was to emerge a specialty of great breadth which would concern itself with populations rather than individuals and make early provision for peoples’ identified needs rather than patients’ expressed wishes for treatment. Though much has been achieved, the uncertainties which beset the role and organisation of this area of medical care in the U.K. persist; and two working parties have produced discussion documentsi which are the centre of brisk argument and which will be further examined at the annual community medicine conference on June 16. One working party (on the state of community medicine as a whole) was established jointly by the British Medical Association and the Faculty of Community Medicine; and the other (on the work and training of community health doctors, by which is meant those at present called "clinical medical officers") was set up by the B.M.A.’s Central Committee for Community Medicine. It is no light task for those who must now assess the outcome of these deliberations to recognise how one report impinges on the other. Though the B.M..2 believes it was unfortunate that the two reports were produced quite separately, there are those who argue that they should be considered as covering two distinct areas. Part of the difficulty lies in terminology (particularly the use of the titles "consultant" and "specialist") and in differences in interpretation between areas, especially those with many districts. The first report includes the customary regrets about failure to achieve all the expectations placed upon community physicians. One reason for this disappointment is said to be that there are not enough of them (734 posts filled in the United Kingdom and 182 vacant). Another is that back-up services are inadequate to the point of starvation in administrative support. A distinction is sought between career posts which include permanent membership of multiprofessional management teams and those which do not. The vital move, however, may not be the labelling of managerial posts but the selection of the best people for training in executive roles; and, as elsewhere in medicine, they will be the ones whose qualities are such that they can most effectively gather, interpret, and act upon the views of their colleagues. A questionable recommendation is the regrouping of community physicians into departments of community medicine and the discarding of specialist labels, such as "child health". Here lies the fear of "genericism", now being heard: a fear which springs partly from the jack-ofall-gaps reputation which has damaged the credibility of community physicians in the eyes of their clinical colleagues. The community physician is an individual specialist (whether in management or not) and should be seen to be so by training and by a well-defined scope of
duty. Elsewhere much doubt surrounds the role, now and in the future, of clinical medical officers and their relationship with community physicians. Having inherited the work of school doctors and the local-authority clinic doctors in infant care and family planning, clinical med1. See Br. med. J. Feb. 17, 1979, 2. ibid Feb 17, 1979, p 438
p. 438, 503, and March 3, 1979, p. 636.
ical officers are mostly engaged in surveillance of healthy children and children with known handicaps and in preventive, social, and educational paediatrics. Could not much of their work be done by general practitioners and paediatricians (who might be less busy than they were - or by the general practitioner/paediatrician of the Court report? Of course it could, with suitable training for general practitioners-but enthusiasm for this takeover is not always manifest among those who might acquire these extra tasks. The work is there to be done and since 1974 young doctors with full training in paediatrics have been joining the ranks of those who do it. The post now called clinical medical officer has always been attractive to a woman who was unable or did not wish to accept heavier commitments and who had no lengthy formal postgraduate training or experience. It comes low on the medical scale of prestige. Some general practitioners remain dubious about the activities of school and clinic doctors; and feelings can be further ruffled when item-of-service payments are an issue. The stature of a new generation of clinical medical officers would undoubtedly be raised by insistence on mandatory formal training; and the newly formed Association of Clinical Medical Officers is not alone in setting out proposals. The working party on community health doctors envisages a stiff (and perhaps too broad) training programme of three years, leading to an examination and a diploma and then to an appointment as "community clinician". The specialist in community medicine (child health) would "monitor" the work of the community clinicians; and the area medical officer would take ultimate decisions about the work of community clinicians in times of emergency or other difficulty. These administrative proposals are meeting opposition, notably from those who favour a comprehensive district child health service3 in which clinical medical officers at present engaged in community child-health services would work with the staff of the pxdiatric department of a district general hospital (an arrangement which might be said to exist already in some places). This, then, would be a move away from the precincts of administrative community medicine towards a hospital-based specialty, rather than towards the general-practice focus of the Court report or the third-force separate status pictured by the working party. Whatever the mechanism, there is everything to be said for closer contacts all round, so it is hard to accept the working party’s view that clinical medical officers (whatever their title may become) should undertake no routine hospital work. If these doctors are to aspire to true specialist status-as community paediatricians (or, for example, as
community geriatricians or obstetricians)-and some to achieve consultant rank, they must have support and
recognition during their training years and thereafter a place in a structure which enables their contributions to blend harmoniously with those of all the other specialists, including the general practitioners and the doctors in management. If this ideal is
to become more than an who undertake this doctors optimistic vision, more ambitious career have much to do not onlv in the training years and later but also as supporters of the campaign’* to extend the opportunities and attainments of women in the whole of medicine. women
3. Whitmore, K., Bax, M., Tyrrell, S.ibid Jan. 27, 1979, p 242. 4. See Lancet, March 31, 1979,p
736.
duty. Elsewhere much doubt surrounds the role, now and in the future, of clinical medical officers and their relationship with community physicians. Having inherited the work of school doctors and the local-authority clinic doctors in infant care and family planning, clinical med1. See Br. med. J. Feb. 17, 1979, 2. ibid Feb 17, 1979, p 438
p. 438, 503, and March 3, 1979, p. 636.
ical officers are mostly engaged in surveillance of healthy children and children with known handicaps and in preventive, social, and educational paediatrics. Could not much of their work be done by general practitioners and paediatricians (who might be less busy than they were - or by the general practitioner/paediatrician of the Court report? Of course it could, with suitable training for general practitioners-but enthusiasm for this takeover is not always manifest among those who might acquire these extra tasks. The work is there to be done and since 1974 young doctors with full training in paediatrics have been joining the ranks of those who do it. The post now called clinical medical officer has always been attractive to a woman who was unable or did not wish to accept heavier commitments and who had no lengthy formal postgraduate training or experience. It comes low on the medical scale of prestige. Some general practitioners remain dubious about the activities of school and clinic doctors; and feelings can be further ruffled when item-of-service payments are an issue. The stature of a new generation of clinical medical officers would undoubtedly be raised by insistence on mandatory formal training; and the newly formed Association of Clinical Medical Officers is not alone in setting out proposals. The working party on community health doctors envisages a stiff (and perhaps too broad) training programme of three years, leading to an examination and a diploma and then to an appointment as "community clinician". The specialist in community medicine (child health) would "monitor" the work of the community clinicians; and the area medical officer would take ultimate decisions about the work of community clinicians in times of emergency or other difficulty. These administrative proposals are meeting opposition, notably from those who favour a comprehensive district child health service3 in which clinical medical officers at present engaged in community child-health services would work with the staff of the pxdiatric department of a district general hospital (an arrangement which might be said to exist already in some places). This, then, would be a move away from the precincts of administrative community medicine towards a hospital-based specialty, rather than towards the general-practice focus of the Court report or the third-force separate status pictured by the working party. Whatever the mechanism, there is everything to be said for closer contacts all round, so it is hard to accept the working party’s view that clinical medical officers (whatever their title may become) should undertake no routine hospital work. If these doctors are to aspire to true specialist status-as community paediatricians (or, for example, as
community geriatricians or obstetricians)-and some to achieve consultant rank, they must have support and
recognition during their training years and thereafter a place in a structure which enables their contributions to blend harmoniously with those of all the other specialists, including the general practitioners and the doctors in management. If this ideal is
to become more than an who undertake this doctors optimistic vision, more ambitious career have much to do not onlv in the training years and later but also as supporters of the campaign’* to extend the opportunities and attainments of women in the whole of medicine. women
3. Whitmore, K., Bax, M., Tyrrell, S.ibid Jan. 27, 1979, p 242. 4. See Lancet, March 31, 1979,p
736.
