1522
BRITISH MEDICAL JOURNAL
medicine it is galling, even so, to note that this has been achieved without any knowledge of the nature of the disease or how the drugs act.
2
11 JUNE 1977
Cameron, J S, in Renal Disease, ed D A K Black, 4th edn. Oxford, Blackwell, in press.
Further reading
References ICamneron, J S, in Perspectives in Clinical Immunology II, ed J Zabriskie, H Villareal, and E L Becker. New York, John Wiley, 1977. In press.
Cameron, J S, in Glomerulonephritis, ed R Kluthe and S Batsford, pp 154, 217. Stuttgart, Thieme, 1976. Cameron, J S, Proceedings of 6th International Congress of Nephrology, Florence 1975, p 492. Basel, Karger, 1976.
Medicine in the 'Seventies Has the Court Report been misunderstood ? An interview with Professor Donald Court Since its publication in December 1976 Fit for the Future, the report of the Committee on Child Health Services, chaired by Professor S D M Court, has been widely debated. Recently, Professor Court discussed with one of the BMJ staff some of the criticisms made of the report and his responses to them. General practitioners, and in particular the GMS committee, have attacked the proposals on the grounds that the introduction of specially trained general
paediatricians (GPPs) would lead to their
practitioner
found themselves dealing only with adults? Professor Court thought that was an understandable fear. "All I can say," he went on, "is that in the limited number of practices where the GPP concept is being applied in greater or lesser degree this has not happened. There may have been some trend along those lines, but much less than might have been expected." It might be, he added, that the risk would be lower if no formal label were attached to the person with the special interest; the important thing was the quality of the training and the experience behind it.
remaining colleagues losing
vital part of their traditional care for the whole family. Professor Court saw this as a serious misconception. "The committee saw the GPP first and foremost as a general practitioner and a member of a primary health care team," he commented, "and we saw him adding
a
something to general practice which at the moment is Professor S D M Court, Emeritus Professor of Child Health in the University of Newcastle upon Tyne;* chairman of the Committee on Child
undeveloped or underdeveloped-namely, the develop.
mental surveillance of chil-
dren through childhood to adolescence and then to adult life. All the partners in the practice would continue to look after the children on their lists, and the GPP would simply be the doctor who would do two essential things by virtue of his special interest and additional training. Firstly, he would be a source for internal referral and consultation about the needs of children; and, secondly, he would ensure (but we emphasised that he or she would not necessarily personally provide) that the children in the practice received proper health surveillance and preventive care, particularly health education. The GPP would also be the named school doctor for one or more schools in the practice neighbourhood." What, then, was Professor Court's reply to those doctors who feared that the moment one of perhaps three doctors in a practice became labelled the child doctor then all of the child illnesses as well as the developmental examinations would be taken to him? Might not the GPP acquire in time the whole of the child population as his list, while the remaining partners Health Services.
Vocational training Given that the main role of the GPP would be in developmental assessments, where skills were appreciably lacking at the moment, was there not also in the report an implication that therapeutic skills in paediatrics were also not sufficiently well developed in general practice ? The evidence certainly suggested a gap between our increasing knowledge of child development and childhood illnesses and its application in practice. Professor Court thought the answer lay in well-planned vocational training in general practice. This had come late in the field, but it would be mandatory for all principals from 1980 and, he hoped, would contain a universal paediatric component. The committee saw improvement in the standard of therapeutic care of children as coming from the overall vocational training of GPs. True, that would be a very slow process-but so too would be the evolution of the GPP. The whole report had to be seen over a 15-20-year period if it was going to make sense. Furthermore, while vocational training should gradually improve general standards, there was a danger in putting the emphasis too firmly on initial training. The whole problem of rapidly advancing knowledge was that continuing education was needed to keep pace with it. "What will really matter is not only that the GPP has additional training over and above the general paediatric vocational training for general practice but that he maintains it."
The primary care team Better training in child health for GP and GPP was important in itself but also in developing and strengthening the
BRITISH MEDICAL JOURNAL
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"primary care team." Here the health visitor was the GP's closest partner and the committee saw a corresponding evolution in which some health visitors gave all or the major part of their time to children and their families. "For ready identification," Professor Court continued, "we referred to them as child health visitors (CHVs). This label, too, caused misunderstanding. Since child health can be understood and optimum care provided only in a family setting we naturally used her full title of child and family health visitor throughout the text. "Then our proposal that CHVs should each have a geographically 'limited patch' was an attempt to identify as many as possible of those families, in some communities and at some times as many as 20",,, who were not linked to a primary care team and to ensure that they were." The next misunderstanding concerned the provision by the CHV of nursing in the home. If a child required sustained and skilled nursing he should be in hospital; when he could safely be nursed at home the nurse was the mother. In keeping with Professor Court's committee's conviction that treatment and prevention were complementary aspects of a single process, they had wanted the CHV to help the mother to nurse the child correctly and confidently, convinced that this was not only necessary for young and inexperienced mothers but would make them more receptive to wider advice on child rearing. And in view of the limited time given to children by district nurses the committee felt that the CHV helped by the child health nurse could readily provide the home nursing required by the children of the practice.
Urban deprivation The report acknowledged that account had to be taken of geographical and social variations. Nevertheless, since clearly the worst areas in terms of childhood mortality and morbidity were the inner city areas, and since clearly also in many such areas general practice was at its weakest, was it wise to put so much of the responsibility for child health on to general practice ? Could it not be argued that it was unrealistic to move the emphasis for the care of children away from the clinic services and on to general practice in those areas ? "For a number of reasons," said Professor Court, "we failed to spell out clearly enough for our critics the kind of medical service the inner city areas need. I can therefore only say how our thinking went. First of all the problem is much bigger than medical services: it concerns urban renewal of a highly complex kind. And we were clear that we should not stray into the whole question of urban renewal. Secondly, we thought that a special service for the poor (and I don't mean necessarily the financially poor) has an unhappy habit of ending up as a poor service. We thought it right, therefore, to leave the general pattern of the primary health care team, the GPP, child health visitor, the school nurse. and liaison social worker, intact." At the same time the committee believed in adaptation in different communities; and for the inner city areas it had thought the first need was for all concerned to meet and face the problems together. At present they tended to go their separate ways. General practice could be strengthened in such areas without building prestigious health centres if all concerned accepted what each could give. Moreover, an experimental scheme in Sheffield had shown that if health visitors knew exactly what the problems were they could make a notable improvement in an index such as postneonatal mortality without any increase in numbers. "And one has got to face the fact that in the inner city areas the accident and emergency departments are going to be an essential part of the service," Professor Court continued. "GPs who find it impracticable to provide a seven-day service must accept that the accident and emergency departments are going to see many of their child patients, especially at the weekends. In view of the character
of inner city society we may well find that many patients go direct to the hospital, either because they don't know how to use the service, can't get it to work promptly, or are in a panic. It seemed to us that the staffing of the accident and emergency departments of the large children's hospitals or the large general hospitals with accident and emergency departments in inner city areas should be strengthened as it had been in Sheffield." In that context the committee had been conscious of the special problems of London, and in a sense it almost needed special examination in its own right. But the committee believed that if the specialist in community medicine (child health) was resourceful and had the respect of at least some of the professional elements in his or her parish then with minimal increases in actual staff improvement was possible. "Infant mortality in Sheffield is now getting towards the Swedish level," he said, "mainly, it would seem, as a result of sustained parent education -ability to use services, understanding of who to go to, awareness that if they do go to the accident and emergency department they are not going to be castigated. The Sheffield experiment merits serious attention and evaluation in other inner city areas."
Use of incentives
What about the committee's attitude towards incentives and sanctions which might be applied or used to encourage families and in particular parents to make full use of the child services ? "We examined that idea with great care," said Professor Court, "and also the pattern of services in France and Finland. We did not reject the French system: we left it open in the sense that we thought that until basic services were available far more equitably than they are at the moment the question of incentive was not the most urgent need. What impressed us about the French approach was that measured by child benefits children clearly stand higher in their scale of social priorities than here. Putting it very crudely the French child benefits are eight times as high as our own." The French have increasingly recognised that the health of the fetus and young child are the basis of the future health of the nation, and one expression of this has been their change from having social workers as the main domiciliary visitors to specialist children's nurses. Equally impressive was their economic as well as humane approach to handicap. They had estimated the high cost of maintaining severely handicapped adults, and their policy was based on governmental acceptance that this was financially uneconomical and therefore the country must commit itself seriously to the study of prevention. "We did not reject the French system of special antenatal payments or of inducement payments related to attendance for developmental examinations," Professor Court repeated. "We felt this was not something which would appeal immediately to people in Britain, that they ought to be given time to think about such a scheme, but that in the meantime we should certainly be getting on with levelling up services. I would like to leave that open: there were some members who felt that this was an important approach, but there was not a majority in favour of it." What about social and economic factors ? How important were they in determining the quality of child health ? "We did reemphasise that the factors that make for improvement in the child health of any community are first and foremost social in the sense of employment, national wealth, housing, education, and nutrition," said Professor Court. "The Government will always rightly pay attention to these in its priorities. But we were asked to look at the contribution of services, and I think it is important to remember that only in the last 35 to 40 years have medical services begun to make a significant contribution to child health-in terms of actually preventing or effectively modifying the course of disease." At the present stage, when broad factors such as immunisation and antibiotics, provided they were maintained, have had their major impact, it became vital to look at services as a whole. "Look at infant life wastage
1524 at birth and in the first year of life. Over the country as a whole it varies between 23 for 1000 total births in East Anglia to 33 per 1000 on Merseyside, and when we get down to localities and neighbourhoods we find quite alarming differences. Undoubtedly social and educational factors account for much of these differences. But-while I don't want to put more emphasis on the Sheffield experiment than it will bear-it would suggest that by helping people to make use of the medical services which are actually there we can achieve a significant improvement."
Clinic medical officers Another cause for anxiety about the report had been the future professional contribution of the clinical medical officers, especially as many worked part time-no more than four or five sessions a week. Was it going to be possible for them to become truly incorporated into general practice with a parttime commitment of that size ? Professor Court did not think that Britain could sustain a medical service when certainly 40) of medical undergraduates were women if indeed they saw their long-term contribution as about four or five sessions. Of course, as a paediatrician and as a father and grandfather he could see there was a period in a woman doctor's life when she was having her children when her contribution would be limited. It was important that during that time she should make the fullest use of the retainer scheme and maintain her professional skills. But once she had moved from that period he did not believe the country could afford, economically or professionally, to have a very part-time service from professional women. That was why in the report the committee had said that once that family period was past women should give of the order of seven sessions or more. "In our meetings we have been encouraged by the overwhelming response of women doctors sharing that view," he added. "There are increasing claims on woman power; so that while no one should be prevented from pursuing the education of their choice we haven't all the room to manoeuvre that we might like." At the same time training programmes and career structures which recognised the part-time element in women's contribution must be developed.
Timing of action While it was only six months since the report was published, it would be a year before long. Was the obligation on the DHSS or on the profession to do something ? "My view," said Professor Court, "is that the obligation first of all is clearly on Government to say whether there is a case for reform. Are the child health services falling below an acceptable standard? We need a general statement from Government that services are in need of improvement. Once the Government has accepted that our standards are less than might be expected in a country of our degree of prosperity and humanity, there are two things that should follow. Firstly, people should begin to examine their local resources, and particularly what could be done to improve local services without major capital expenditure. I see a report of this kind as a stimulus to local examination, to local adaptation, and I know already this is happening to some extent. But you can't leave it there. The need for reform has to be firmly grasped by the responsible training bodies; because essentially the improvement that we seek-while it demands some increases in manpower and woman power-depends fundamentally on an increase in understanding and insight and skills in dealing with children." There was, he believed, a clear responsibility on bodies like the Royal College of General Practitioners, the British Paediatric Association, the Faculty of Community Medicine, the Royal College of Physicians, the General Nursing Council, the Council for the Education and Training of Health Visitors, and the Council for Education and Training in Social Work to examine the training implications of the report and then to see how far
BRITISH MEDICAL JOURNAL
11 JUNE 1977
they could implement them. Yet would not this inevitably mean more teaching staff to provide the expertise envisaged in the report ? "There is certainly an urgent need for an expansion of the paediatric services," said Professor Court. "I simply do not see that 393 paediatricians in England and Wales can cope with the service and teaching demands that are made on them now, quite apart from the additional demands we have made in the report. Paediatricians are being drawn out of the hospital by the social and educational needs of children, and when they get out in to the community they become aware that they have not been equipped to cope. We need an increase in paediatricians with developmental and social skills."
Community paediatricians The committee believed that developmental, social, and educational paediatrics was underdeveloped. The committee accepted that this meant identifying somebody who would get the training and learn how to apply it, in the practical, everyday, social, and educational setting. "For the sake of brevity, though not without misgiving, we accepted that the word ''community" would identify the need which this person would meet. We believe that the day will come when all consultant paediatricians will see the two aspects of their work as complementary and when developmental and social ignorance will be as reprehensible as ignorance of clinical biochemistry and paediatric pharmacology. Again, this is a process in time; it will enlarge paediatrics in the interests of children and parents, just as we saw the GPP enlarging general practice in the interests of children and parents." The committee had thought that the first steps here should be taken in the university centres, so that the whole area of knowledge could be better defined and cultivated; its teaching beyond the university centres would then become possible. "We need flexibility in adaptation both at the primary and the supporting level," he added. We've seen the GPP concept working, and I believe that if accepted it will grow slowly. That slow growth is very desirable if we are to integrate the services and not leave the clinical medical officers in a no man's land in the centre." As the report had explained, clinical medical officers who did not want to become GPPs but who wanted to go on with their preventive and educational work could graft that on to a practice and be attached to it as child health practitioners. The committee had not felt competent to say how this "attachment" would be arranged, but that had not been intended to be evasive. The arrangements should be seen as a professional matter and not a committee matter. "I have myself really been quite encouraged," said Professor Court, "by the number of general practitioners who have actually said they would welcome our proposals for this attachment. They may be a minority-they probably arebut they would be glad to see this professional separation and this area of contradictory advice overcome." Might not the introduction of an ex-clinical medical officer as the paediatrician in a practice be less of a threat to the remaining partners than the full concept of having one of them become a GPP ? Professor Court accepted that this might be true. "I'm an evolutionist by temperament," he went on. "The words revolutionary and radical have been used about our main proposals, but I would submit that they are essentially evolutionary proposals. General practice has been changing remarkably in the last 25 years, singlehanded to partnerships, to group practice, to health centres, to vocational training, to an increasing awareness of social and developmental aspects of child health and childhood illness. While acute illness and injury still remain, and a good deal of it, the emphasis of paediatrics has changed. Nowadays we need to look at malformations, the residual hazards of birth, physical handicap, mental handicap, and psychiatric disorder in childhood-our estimate for the last was that in a given year it would be of the order of a million children." And as with paediatricians how can 188 child psychiatrists deal with the serious clinical problems, study their subject, and train the GPs, health visitors,
BRITISH MEDICAL JOURNAL
11 JUNE 1977
social workers, and paediatricians who must share the tasks with them ?
Needs of the people GPs, paediatricians, allied specialists, nurses, and therapists alike were becoming more aware of these changes; they recognised that they had not been educated to deal with the new problems, and that further continuing education was necessary if they were going to find professional satisfaction in their job. But we should start with and continually return to the needs of
Iproniazid was withdrawn from use in the USA because it caused liver damage. How widely is this drug used in Britain ? Details of the current prescribing of iproniazid are unobtainable. It is probably less widely used than isocarboxazid or phenelzine but is still sometimes employed after specialist advice. There is still a regular demand for this drug, and with careful selection and appropriate precautions its hazards are less than its initial use suggested. Would it be possible to achieve pertussis immunity without risk using the intradermal route of administration, either separately or in conjunction with the other constituents of triple antigen ? I have been unable to find any reference to using the intradermal route for pertussis vaccine. It is theoretically unlikely, however, that adequate immunity would be achieved by this method.
What are the hazards of giving a mother diazepam during labour ? There are no particular hazards in giving diazepam so far as the mother is concerned, and the drug should be evaluated largely in terms of its effect on the fetus. It is a respiratory depressant and as such should be used with caution in patients with emphysema or asthma. Because of its respiratory depressant effect it is not a good drug to use routinely, certainly not in conjunction with barbiturates. It is not analgesic and the best that most obstetric textbooks can say for it is that it reduces the need for pethidine. It is an anticonvulsant and has a hypotensive effect and therefore has a place in treating epileptic fits in labour or in severe pre-eclampsia, although for the latter most obstetricians prefer a more specific anticonvulsant such as chlormethiazole. When used for epileptic fits it may be given intravenously but only in hospital, where the means for mechanical ventilation are to hand.
A patient with osteogenesis imperfecta cannot tolerate an intrauterine device. She has been advised not to take oral contraceptives because her hearing is defective owing to a bony inmperfection in the ear, and an ENT surgeon was concerned that oral contraceptives could harm the ear further. Would there be any extra risks in her taking an oral contraceptive ?
The Any Questions ? section is a popular site for traps, and this question follows the tradition. At first sight any connection between deafness and oral contraceptives seems remote, and tracing it involved an excursion into the territory of the stapedial crura, a strange land for an endocrinologist. The connection, of course, is oestrogens. The deafness associated with osteogenesis imperfecta is due to otosclerosis. Osteogenesis imperfecta is a disease of collegen metabolism whose basic abnormality is hypoplasia of the mesenchyme. Oestrogens affect collagen metabolism, probably influencing the degree of polymerisation. The ENT surgeon is probably proceeding from the sensible generalisation that in such cases the less interference with collagen metabolism the better. I do not know of any direct study of the effects of oral contraceptives on this type of otosclerosis but would be inclined to support him. Oestrogens have, in fact, been used to treat osteo-
1525
people. Much of the debate on the report had been in the terms of what was acceptable or not acceptable to particular professions; too little attention had been given to the needs of children, the rightful expectations of parents, and how they could be met. "We started with the needs of children and parents and asked are the services meeting these, and if not how can they meet them better," he explained. "That is where the debate continually goes off course. Particularly in view of recent 'reorganisation' it is understandable that any prescription for change should be firmly and critically examined, but I can't see that we will get a satisfactory health service for children who can't speak for themselves unless we start with needs and ask how services can be developed to meet them."
genesis imperfecta without notable good effect. The subject has been ably reviewed recently.' 1 Shoenfeld, Y, Fried, A, and Ehrenfeld, N E, American Journal of the Diseases of Children, 1975, 129, 679.
What, if any, are the real medical hazards of a vegan diet? Can vitamin
B12, for instance, be obtained from any plant source? Some vegan patients say they can get vitamin B,, from the comfrey plant. The only medical hazard in a vegan diet is a lack of vitamin B12. Even so, quite a few vegans manage without any. Most of them nowadays take vitamin B that is a byproduct of the fermentation of Streptomyces griseus in the manufacture of streptomycin. Although claims have been made that vitamin B,2 can be prepared from comfrey, this is quite untrue: there are no measurable amounts of vitamin B12 in any known plant.
What is the correct treatment for whooping cough in (a) babies and young children if diagnosed 10-14 days after the onset of symptoms, which is when the characteristic cough usually shows up, and (b) for unimmunised young siblings who are contacts ? Is any antibiotic safe and effective ? The relative ineffectiveness of antibiotic treatment for whooping cough is one reason why many feel that, despite rare complications of immunisation, immunisation should continue. The antibiotics to consider are erythromycin, ampicillin, tetracycline, and chloramphenicol. Erythromycin is probably the drug of choice: it reduces the period of infectivity and therefore makes the patient noncontagious, but does not alter the clinical course.'-3 It may perhaps reduce the incidence of bacterial complications or be useful for treating them once they have developed.2 3 Linnemann et a12 found that erythromycin was more effective than chloramphenicol or tetracycline in reducing the period of infectivity. Adasek et a14 compared the use of ampicillin, tetracycline, and a combination of both, and found that none had any effect on the infectivity. Bass et all compared ampicillin, oxytetracycline, chloramphenicol, and erythromycin with no treatment, and found that none changed the clinical course. They found that ampicillin prolonged rather than shortened the infective period. An MRC trial5 found that chloramphenicol and tetracycline were slightly beneficial for treatment if given only in the first eight days; but chloramphenicol cannot be advised because of the possible damage to the bone marrow, and tetracycline is contraindicated for any child aged under 8 years because of staining of the teeth. Some of the clinical ineffectiveness of antibiotics may be due to the fact that some cases of whooping cough are due to a virus infection and not to the Bordetella pertussis or Bordetella parapertussis. In the past atropine methonitrate was used for treating whooping cough, but it is contraindicated because it may dry the secretions. Phenobarbitone may be of some value. As for preventing whooping cough in a sibling, the odds are that by the time the infection has been diagnosed in the first child the others will have been infected already, and there is nothing that can be done about it: it is too late. Human immnune globulin was used in the past, but I doubt whether it is used or available now. I certainly would not advise a prophylactic antibiotic. Bass, J W, et al, Journal of Pediatrics, 1969, 75, 768. 2 Linnemann, C C, et al, J'ournal of Pediatrics, 1974, 85, 589. 3Islur, J, Anglin, C S, and Middleton, P J, Clinical Pediatrics, 1975, 14, 171. ' Adasek, P J, Meyer, M N, and Ray, C G, Pediatrics, 1969, 44, t06. 5Medical Research Council, Lancet, 1953, 1, 1109.
BRITISH MEDICAL JOURNAL
medicine it is galling, even so, to note that this has been achieved without any knowledge of the nature of the disease or how the drugs act.
2
11 JUNE 1977
Cameron, J S, in Renal Disease, ed D A K Black, 4th edn. Oxford, Blackwell, in press.
Further reading
References ICamneron, J S, in Perspectives in Clinical Immunology II, ed J Zabriskie, H Villareal, and E L Becker. New York, John Wiley, 1977. In press.
Cameron, J S, in Glomerulonephritis, ed R Kluthe and S Batsford, pp 154, 217. Stuttgart, Thieme, 1976. Cameron, J S, Proceedings of 6th International Congress of Nephrology, Florence 1975, p 492. Basel, Karger, 1976.
Medicine in the 'Seventies Has the Court Report been misunderstood ? An interview with Professor Donald Court Since its publication in December 1976 Fit for the Future, the report of the Committee on Child Health Services, chaired by Professor S D M Court, has been widely debated. Recently, Professor Court discussed with one of the BMJ staff some of the criticisms made of the report and his responses to them. General practitioners, and in particular the GMS committee, have attacked the proposals on the grounds that the introduction of specially trained general
paediatricians (GPPs) would lead to their
practitioner
found themselves dealing only with adults? Professor Court thought that was an understandable fear. "All I can say," he went on, "is that in the limited number of practices where the GPP concept is being applied in greater or lesser degree this has not happened. There may have been some trend along those lines, but much less than might have been expected." It might be, he added, that the risk would be lower if no formal label were attached to the person with the special interest; the important thing was the quality of the training and the experience behind it.
remaining colleagues losing
vital part of their traditional care for the whole family. Professor Court saw this as a serious misconception. "The committee saw the GPP first and foremost as a general practitioner and a member of a primary health care team," he commented, "and we saw him adding
a
something to general practice which at the moment is Professor S D M Court, Emeritus Professor of Child Health in the University of Newcastle upon Tyne;* chairman of the Committee on Child
undeveloped or underdeveloped-namely, the develop.
mental surveillance of chil-
dren through childhood to adolescence and then to adult life. All the partners in the practice would continue to look after the children on their lists, and the GPP would simply be the doctor who would do two essential things by virtue of his special interest and additional training. Firstly, he would be a source for internal referral and consultation about the needs of children; and, secondly, he would ensure (but we emphasised that he or she would not necessarily personally provide) that the children in the practice received proper health surveillance and preventive care, particularly health education. The GPP would also be the named school doctor for one or more schools in the practice neighbourhood." What, then, was Professor Court's reply to those doctors who feared that the moment one of perhaps three doctors in a practice became labelled the child doctor then all of the child illnesses as well as the developmental examinations would be taken to him? Might not the GPP acquire in time the whole of the child population as his list, while the remaining partners Health Services.
Vocational training Given that the main role of the GPP would be in developmental assessments, where skills were appreciably lacking at the moment, was there not also in the report an implication that therapeutic skills in paediatrics were also not sufficiently well developed in general practice ? The evidence certainly suggested a gap between our increasing knowledge of child development and childhood illnesses and its application in practice. Professor Court thought the answer lay in well-planned vocational training in general practice. This had come late in the field, but it would be mandatory for all principals from 1980 and, he hoped, would contain a universal paediatric component. The committee saw improvement in the standard of therapeutic care of children as coming from the overall vocational training of GPs. True, that would be a very slow process-but so too would be the evolution of the GPP. The whole report had to be seen over a 15-20-year period if it was going to make sense. Furthermore, while vocational training should gradually improve general standards, there was a danger in putting the emphasis too firmly on initial training. The whole problem of rapidly advancing knowledge was that continuing education was needed to keep pace with it. "What will really matter is not only that the GPP has additional training over and above the general paediatric vocational training for general practice but that he maintains it."
The primary care team Better training in child health for GP and GPP was important in itself but also in developing and strengthening the
BRITISH MEDICAL JOURNAL
1523
11 JUNE 1977
"primary care team." Here the health visitor was the GP's closest partner and the committee saw a corresponding evolution in which some health visitors gave all or the major part of their time to children and their families. "For ready identification," Professor Court continued, "we referred to them as child health visitors (CHVs). This label, too, caused misunderstanding. Since child health can be understood and optimum care provided only in a family setting we naturally used her full title of child and family health visitor throughout the text. "Then our proposal that CHVs should each have a geographically 'limited patch' was an attempt to identify as many as possible of those families, in some communities and at some times as many as 20",,, who were not linked to a primary care team and to ensure that they were." The next misunderstanding concerned the provision by the CHV of nursing in the home. If a child required sustained and skilled nursing he should be in hospital; when he could safely be nursed at home the nurse was the mother. In keeping with Professor Court's committee's conviction that treatment and prevention were complementary aspects of a single process, they had wanted the CHV to help the mother to nurse the child correctly and confidently, convinced that this was not only necessary for young and inexperienced mothers but would make them more receptive to wider advice on child rearing. And in view of the limited time given to children by district nurses the committee felt that the CHV helped by the child health nurse could readily provide the home nursing required by the children of the practice.
Urban deprivation The report acknowledged that account had to be taken of geographical and social variations. Nevertheless, since clearly the worst areas in terms of childhood mortality and morbidity were the inner city areas, and since clearly also in many such areas general practice was at its weakest, was it wise to put so much of the responsibility for child health on to general practice ? Could it not be argued that it was unrealistic to move the emphasis for the care of children away from the clinic services and on to general practice in those areas ? "For a number of reasons," said Professor Court, "we failed to spell out clearly enough for our critics the kind of medical service the inner city areas need. I can therefore only say how our thinking went. First of all the problem is much bigger than medical services: it concerns urban renewal of a highly complex kind. And we were clear that we should not stray into the whole question of urban renewal. Secondly, we thought that a special service for the poor (and I don't mean necessarily the financially poor) has an unhappy habit of ending up as a poor service. We thought it right, therefore, to leave the general pattern of the primary health care team, the GPP, child health visitor, the school nurse. and liaison social worker, intact." At the same time the committee believed in adaptation in different communities; and for the inner city areas it had thought the first need was for all concerned to meet and face the problems together. At present they tended to go their separate ways. General practice could be strengthened in such areas without building prestigious health centres if all concerned accepted what each could give. Moreover, an experimental scheme in Sheffield had shown that if health visitors knew exactly what the problems were they could make a notable improvement in an index such as postneonatal mortality without any increase in numbers. "And one has got to face the fact that in the inner city areas the accident and emergency departments are going to be an essential part of the service," Professor Court continued. "GPs who find it impracticable to provide a seven-day service must accept that the accident and emergency departments are going to see many of their child patients, especially at the weekends. In view of the character
of inner city society we may well find that many patients go direct to the hospital, either because they don't know how to use the service, can't get it to work promptly, or are in a panic. It seemed to us that the staffing of the accident and emergency departments of the large children's hospitals or the large general hospitals with accident and emergency departments in inner city areas should be strengthened as it had been in Sheffield." In that context the committee had been conscious of the special problems of London, and in a sense it almost needed special examination in its own right. But the committee believed that if the specialist in community medicine (child health) was resourceful and had the respect of at least some of the professional elements in his or her parish then with minimal increases in actual staff improvement was possible. "Infant mortality in Sheffield is now getting towards the Swedish level," he said, "mainly, it would seem, as a result of sustained parent education -ability to use services, understanding of who to go to, awareness that if they do go to the accident and emergency department they are not going to be castigated. The Sheffield experiment merits serious attention and evaluation in other inner city areas."
Use of incentives
What about the committee's attitude towards incentives and sanctions which might be applied or used to encourage families and in particular parents to make full use of the child services ? "We examined that idea with great care," said Professor Court, "and also the pattern of services in France and Finland. We did not reject the French system: we left it open in the sense that we thought that until basic services were available far more equitably than they are at the moment the question of incentive was not the most urgent need. What impressed us about the French approach was that measured by child benefits children clearly stand higher in their scale of social priorities than here. Putting it very crudely the French child benefits are eight times as high as our own." The French have increasingly recognised that the health of the fetus and young child are the basis of the future health of the nation, and one expression of this has been their change from having social workers as the main domiciliary visitors to specialist children's nurses. Equally impressive was their economic as well as humane approach to handicap. They had estimated the high cost of maintaining severely handicapped adults, and their policy was based on governmental acceptance that this was financially uneconomical and therefore the country must commit itself seriously to the study of prevention. "We did not reject the French system of special antenatal payments or of inducement payments related to attendance for developmental examinations," Professor Court repeated. "We felt this was not something which would appeal immediately to people in Britain, that they ought to be given time to think about such a scheme, but that in the meantime we should certainly be getting on with levelling up services. I would like to leave that open: there were some members who felt that this was an important approach, but there was not a majority in favour of it." What about social and economic factors ? How important were they in determining the quality of child health ? "We did reemphasise that the factors that make for improvement in the child health of any community are first and foremost social in the sense of employment, national wealth, housing, education, and nutrition," said Professor Court. "The Government will always rightly pay attention to these in its priorities. But we were asked to look at the contribution of services, and I think it is important to remember that only in the last 35 to 40 years have medical services begun to make a significant contribution to child health-in terms of actually preventing or effectively modifying the course of disease." At the present stage, when broad factors such as immunisation and antibiotics, provided they were maintained, have had their major impact, it became vital to look at services as a whole. "Look at infant life wastage
1524 at birth and in the first year of life. Over the country as a whole it varies between 23 for 1000 total births in East Anglia to 33 per 1000 on Merseyside, and when we get down to localities and neighbourhoods we find quite alarming differences. Undoubtedly social and educational factors account for much of these differences. But-while I don't want to put more emphasis on the Sheffield experiment than it will bear-it would suggest that by helping people to make use of the medical services which are actually there we can achieve a significant improvement."
Clinic medical officers Another cause for anxiety about the report had been the future professional contribution of the clinical medical officers, especially as many worked part time-no more than four or five sessions a week. Was it going to be possible for them to become truly incorporated into general practice with a parttime commitment of that size ? Professor Court did not think that Britain could sustain a medical service when certainly 40) of medical undergraduates were women if indeed they saw their long-term contribution as about four or five sessions. Of course, as a paediatrician and as a father and grandfather he could see there was a period in a woman doctor's life when she was having her children when her contribution would be limited. It was important that during that time she should make the fullest use of the retainer scheme and maintain her professional skills. But once she had moved from that period he did not believe the country could afford, economically or professionally, to have a very part-time service from professional women. That was why in the report the committee had said that once that family period was past women should give of the order of seven sessions or more. "In our meetings we have been encouraged by the overwhelming response of women doctors sharing that view," he added. "There are increasing claims on woman power; so that while no one should be prevented from pursuing the education of their choice we haven't all the room to manoeuvre that we might like." At the same time training programmes and career structures which recognised the part-time element in women's contribution must be developed.
Timing of action While it was only six months since the report was published, it would be a year before long. Was the obligation on the DHSS or on the profession to do something ? "My view," said Professor Court, "is that the obligation first of all is clearly on Government to say whether there is a case for reform. Are the child health services falling below an acceptable standard? We need a general statement from Government that services are in need of improvement. Once the Government has accepted that our standards are less than might be expected in a country of our degree of prosperity and humanity, there are two things that should follow. Firstly, people should begin to examine their local resources, and particularly what could be done to improve local services without major capital expenditure. I see a report of this kind as a stimulus to local examination, to local adaptation, and I know already this is happening to some extent. But you can't leave it there. The need for reform has to be firmly grasped by the responsible training bodies; because essentially the improvement that we seek-while it demands some increases in manpower and woman power-depends fundamentally on an increase in understanding and insight and skills in dealing with children." There was, he believed, a clear responsibility on bodies like the Royal College of General Practitioners, the British Paediatric Association, the Faculty of Community Medicine, the Royal College of Physicians, the General Nursing Council, the Council for the Education and Training of Health Visitors, and the Council for Education and Training in Social Work to examine the training implications of the report and then to see how far
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they could implement them. Yet would not this inevitably mean more teaching staff to provide the expertise envisaged in the report ? "There is certainly an urgent need for an expansion of the paediatric services," said Professor Court. "I simply do not see that 393 paediatricians in England and Wales can cope with the service and teaching demands that are made on them now, quite apart from the additional demands we have made in the report. Paediatricians are being drawn out of the hospital by the social and educational needs of children, and when they get out in to the community they become aware that they have not been equipped to cope. We need an increase in paediatricians with developmental and social skills."
Community paediatricians The committee believed that developmental, social, and educational paediatrics was underdeveloped. The committee accepted that this meant identifying somebody who would get the training and learn how to apply it, in the practical, everyday, social, and educational setting. "For the sake of brevity, though not without misgiving, we accepted that the word ''community" would identify the need which this person would meet. We believe that the day will come when all consultant paediatricians will see the two aspects of their work as complementary and when developmental and social ignorance will be as reprehensible as ignorance of clinical biochemistry and paediatric pharmacology. Again, this is a process in time; it will enlarge paediatrics in the interests of children and parents, just as we saw the GPP enlarging general practice in the interests of children and parents." The committee had thought that the first steps here should be taken in the university centres, so that the whole area of knowledge could be better defined and cultivated; its teaching beyond the university centres would then become possible. "We need flexibility in adaptation both at the primary and the supporting level," he added. We've seen the GPP concept working, and I believe that if accepted it will grow slowly. That slow growth is very desirable if we are to integrate the services and not leave the clinical medical officers in a no man's land in the centre." As the report had explained, clinical medical officers who did not want to become GPPs but who wanted to go on with their preventive and educational work could graft that on to a practice and be attached to it as child health practitioners. The committee had not felt competent to say how this "attachment" would be arranged, but that had not been intended to be evasive. The arrangements should be seen as a professional matter and not a committee matter. "I have myself really been quite encouraged," said Professor Court, "by the number of general practitioners who have actually said they would welcome our proposals for this attachment. They may be a minority-they probably arebut they would be glad to see this professional separation and this area of contradictory advice overcome." Might not the introduction of an ex-clinical medical officer as the paediatrician in a practice be less of a threat to the remaining partners than the full concept of having one of them become a GPP ? Professor Court accepted that this might be true. "I'm an evolutionist by temperament," he went on. "The words revolutionary and radical have been used about our main proposals, but I would submit that they are essentially evolutionary proposals. General practice has been changing remarkably in the last 25 years, singlehanded to partnerships, to group practice, to health centres, to vocational training, to an increasing awareness of social and developmental aspects of child health and childhood illness. While acute illness and injury still remain, and a good deal of it, the emphasis of paediatrics has changed. Nowadays we need to look at malformations, the residual hazards of birth, physical handicap, mental handicap, and psychiatric disorder in childhood-our estimate for the last was that in a given year it would be of the order of a million children." And as with paediatricians how can 188 child psychiatrists deal with the serious clinical problems, study their subject, and train the GPs, health visitors,
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social workers, and paediatricians who must share the tasks with them ?
Needs of the people GPs, paediatricians, allied specialists, nurses, and therapists alike were becoming more aware of these changes; they recognised that they had not been educated to deal with the new problems, and that further continuing education was necessary if they were going to find professional satisfaction in their job. But we should start with and continually return to the needs of
Iproniazid was withdrawn from use in the USA because it caused liver damage. How widely is this drug used in Britain ? Details of the current prescribing of iproniazid are unobtainable. It is probably less widely used than isocarboxazid or phenelzine but is still sometimes employed after specialist advice. There is still a regular demand for this drug, and with careful selection and appropriate precautions its hazards are less than its initial use suggested. Would it be possible to achieve pertussis immunity without risk using the intradermal route of administration, either separately or in conjunction with the other constituents of triple antigen ? I have been unable to find any reference to using the intradermal route for pertussis vaccine. It is theoretically unlikely, however, that adequate immunity would be achieved by this method.
What are the hazards of giving a mother diazepam during labour ? There are no particular hazards in giving diazepam so far as the mother is concerned, and the drug should be evaluated largely in terms of its effect on the fetus. It is a respiratory depressant and as such should be used with caution in patients with emphysema or asthma. Because of its respiratory depressant effect it is not a good drug to use routinely, certainly not in conjunction with barbiturates. It is not analgesic and the best that most obstetric textbooks can say for it is that it reduces the need for pethidine. It is an anticonvulsant and has a hypotensive effect and therefore has a place in treating epileptic fits in labour or in severe pre-eclampsia, although for the latter most obstetricians prefer a more specific anticonvulsant such as chlormethiazole. When used for epileptic fits it may be given intravenously but only in hospital, where the means for mechanical ventilation are to hand.
A patient with osteogenesis imperfecta cannot tolerate an intrauterine device. She has been advised not to take oral contraceptives because her hearing is defective owing to a bony inmperfection in the ear, and an ENT surgeon was concerned that oral contraceptives could harm the ear further. Would there be any extra risks in her taking an oral contraceptive ?
The Any Questions ? section is a popular site for traps, and this question follows the tradition. At first sight any connection between deafness and oral contraceptives seems remote, and tracing it involved an excursion into the territory of the stapedial crura, a strange land for an endocrinologist. The connection, of course, is oestrogens. The deafness associated with osteogenesis imperfecta is due to otosclerosis. Osteogenesis imperfecta is a disease of collegen metabolism whose basic abnormality is hypoplasia of the mesenchyme. Oestrogens affect collagen metabolism, probably influencing the degree of polymerisation. The ENT surgeon is probably proceeding from the sensible generalisation that in such cases the less interference with collagen metabolism the better. I do not know of any direct study of the effects of oral contraceptives on this type of otosclerosis but would be inclined to support him. Oestrogens have, in fact, been used to treat osteo-
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people. Much of the debate on the report had been in the terms of what was acceptable or not acceptable to particular professions; too little attention had been given to the needs of children, the rightful expectations of parents, and how they could be met. "We started with the needs of children and parents and asked are the services meeting these, and if not how can they meet them better," he explained. "That is where the debate continually goes off course. Particularly in view of recent 'reorganisation' it is understandable that any prescription for change should be firmly and critically examined, but I can't see that we will get a satisfactory health service for children who can't speak for themselves unless we start with needs and ask how services can be developed to meet them."
genesis imperfecta without notable good effect. The subject has been ably reviewed recently.' 1 Shoenfeld, Y, Fried, A, and Ehrenfeld, N E, American Journal of the Diseases of Children, 1975, 129, 679.
What, if any, are the real medical hazards of a vegan diet? Can vitamin
B12, for instance, be obtained from any plant source? Some vegan patients say they can get vitamin B,, from the comfrey plant. The only medical hazard in a vegan diet is a lack of vitamin B12. Even so, quite a few vegans manage without any. Most of them nowadays take vitamin B that is a byproduct of the fermentation of Streptomyces griseus in the manufacture of streptomycin. Although claims have been made that vitamin B,2 can be prepared from comfrey, this is quite untrue: there are no measurable amounts of vitamin B12 in any known plant.
What is the correct treatment for whooping cough in (a) babies and young children if diagnosed 10-14 days after the onset of symptoms, which is when the characteristic cough usually shows up, and (b) for unimmunised young siblings who are contacts ? Is any antibiotic safe and effective ? The relative ineffectiveness of antibiotic treatment for whooping cough is one reason why many feel that, despite rare complications of immunisation, immunisation should continue. The antibiotics to consider are erythromycin, ampicillin, tetracycline, and chloramphenicol. Erythromycin is probably the drug of choice: it reduces the period of infectivity and therefore makes the patient noncontagious, but does not alter the clinical course.'-3 It may perhaps reduce the incidence of bacterial complications or be useful for treating them once they have developed.2 3 Linnemann et a12 found that erythromycin was more effective than chloramphenicol or tetracycline in reducing the period of infectivity. Adasek et a14 compared the use of ampicillin, tetracycline, and a combination of both, and found that none had any effect on the infectivity. Bass et all compared ampicillin, oxytetracycline, chloramphenicol, and erythromycin with no treatment, and found that none changed the clinical course. They found that ampicillin prolonged rather than shortened the infective period. An MRC trial5 found that chloramphenicol and tetracycline were slightly beneficial for treatment if given only in the first eight days; but chloramphenicol cannot be advised because of the possible damage to the bone marrow, and tetracycline is contraindicated for any child aged under 8 years because of staining of the teeth. Some of the clinical ineffectiveness of antibiotics may be due to the fact that some cases of whooping cough are due to a virus infection and not to the Bordetella pertussis or Bordetella parapertussis. In the past atropine methonitrate was used for treating whooping cough, but it is contraindicated because it may dry the secretions. Phenobarbitone may be of some value. As for preventing whooping cough in a sibling, the odds are that by the time the infection has been diagnosed in the first child the others will have been infected already, and there is nothing that can be done about it: it is too late. Human immnune globulin was used in the past, but I doubt whether it is used or available now. I certainly would not advise a prophylactic antibiotic. Bass, J W, et al, Journal of Pediatrics, 1969, 75, 768. 2 Linnemann, C C, et al, J'ournal of Pediatrics, 1974, 85, 589. 3Islur, J, Anglin, C S, and Middleton, P J, Clinical Pediatrics, 1975, 14, 171. ' Adasek, P J, Meyer, M N, and Ray, C G, Pediatrics, 1969, 44, t06. 5Medical Research Council, Lancet, 1953, 1, 1109.
