Public Health The Journal of The Society of Community Medicine (Formerly the Society of Medical Officers of Health ) Volume 89
Number 6
September 1975
H o w Best can w e Deploy our Health Visitors? Our health visitors are only to be described in the sort of terms that are used by King Solomon in his song describing his bride. There are not enough of these pearls among women to do the job we want them to do. This job is, primarily, one o f health education and prevention which they do in visits and by encouraging mothers to bring their children periodically to health centres (whether run by general practitioners or by the district health authority). Once there the mothers can talk to the other mothers, the health visitor and to the clinic doctor. They can receive periodic medical and developmental surveillance and can have their immunization programme. The health visitors can make contact with local schools as children grow older and with the second level social services. My bias as a paediatrician who worked in hospitals and twice a week in a child health clinic for 25 years is clear. I see the health visitor as a person with a major duty towards children and spending a considerable portion of her time supporting vulnerable families so that they do not become problem families. In our part of London we estimated vulnerable families as 5 ~o of our 800 families. (I am surprised to read a research report on problem families which were only one in 600.) The essence of a preventive service is that everyone in the population is known and seen periodically. Only in this way can early deviations--whether essentially medical, psychiatric, intellectual or social in origin or, as is usual, combinations of these causes--be discovered early and given the treatment or support which may enable those with them to keep coping with life. The population orientation of the former local authority health services--go out and find t h e p e o p l e who need help, don't wait for them to consult the doctor--is the only sound basis for successful preventive medicine. Perhaps another potential cause of being puzzled, emerging in some areas, is the change of status of the area nursing services. The doctors in hospitals and in the local authority health services had "their" nurses and "their" social workers. Doctors are getting used to recognizing the social services as an equal and developing allied profession. The general practitioner would be wise not to slip into thinking the health visitor is "his" health visitor; she is answerable to the area nursing officer. The area nursing officer is responsible for the 243
244
Ronald MacKeith
health visitor's training, and for the quality of her work be it in health education or developmental assessment. Doctors and nurses have behaved as if nurses were subservient. With greater responsibility the nursing profession will grow in self-respect and quality of the work it does. It is up to doctors to accept the nursing profession as equal in status and to make it evident that we do, whether the nurses we meet are in the wards or in our practices. After this digression, the topic of health visitors in community-run child health centres or family practices can be picked up again. The health visitor of a few years ago had a geographic area based on her local authority child health clinic where she worked in close co-operation with the clinic doctor. She went out and visited, taught parentcraft in the ante-natal clinics collaborating with midwives, and visited all the mothers who had had babies at home or had just returned from the hospital delivery ward. She answered mothers' questions, chased the children not brought to the child health clinic, visited homes. She knew which families were vulnerable and just beginning to fail to cope and supported them and the problem families. She knew the local G.P.s and their quality, she knew the local authority doctors, she knew the local hospital casualty and emergency department, the teachers in the schools in her area and the social workers who were concerned with the families she knew. Because she was a nurse she was acceptable to almost all mothers. This is partly because the medical profession is seen as a helping and caring profession. It is also partly because she was a member of what is essentially a non-judgmental profession. Families who feel they are failures may, with some justification, look on teachers as people who say "he could do better if he tried harder" and social workers who are also non-judgmental, do not have the aura of a healing profession. In those days if one of the families you knew moved to Northampton it was easy to contact the Northampton M.O.H. and get continued support for the family. The new pattern is for many health visitors to be attached to general practitioners. Here is what a good general practitioner has written. "The health visitor is the key person in the whole programme [or running a really good paediatric service in a general practice]. Her skills in assessing the growth and development of the normal child, her knowledge of the family, her contacts with child minders, play group leaders, nursery schools, primary and secondary schools are invaluable in providing information that can help the team to bring the best possible care to children in the practice. She is reasonably effective as a link between the general practitioner and the various community health educational and social services but as it is, without the health visitors there would be no links at all". (I cannot help asking why the G.P. cannot himself visit the local school teachers, community and hospital paediatricians and the social services but as Rudyard Kipling would have said, that is a different story.) This general practitioner goes on to say: "In some areas the attachment of health visitors to general practices has come into question. This is particularly where the attachment has been conspicuously unsuccessful. It is surprising that attachment works as well as it does. While the health visitor has been carefully prepared in her training for attachment to a general practice, the general practitioner has taken no steps to have formal instruction or preparation and often in consequence only lip service is paid to the vital role she can play in paediatrie health care. Some general practitioners have, from their ignorance, misunderstood the health visitor's preventive and educational role and have been bemused by her relative expertise in developmental medicine. Because of this the family doctor has been able to offer little or no support or help when situations arise calling for greater expert knowledge than the health visitor has. Many general practitioners are still puzzled about what the health visitor does and the health visitors may long to return to the child health clinic base and to responsibilities based on the families in a geographical area
How best can we deploy our health visitors ?
245
rather than on the families of a practice. In some inner city areas where there is a breakdown of primary care medical services this may be the only answer". I f all G.P.s were as good as the best i n - - a n d outside the Royal College of General Practitioners, we might opt for primary care services based on general practices. Until all G.P.s are good and interested in children, we may well feel that the welfare of children is so important that the provision of a rather illogical double service was and is wise. Perhaps the answer is that a long stop is not necessary when the wicket keeper is known to be good, but the trouble is that the good wicket keepers say all wicket keepers are good and long stops never required. It is generally felt that patients should be able to choose their G.P.s and G.P.s their patients. This means that, on the " n e w " pattern, health visitors are attached to a scattered general practice. As a result there may be a dozen health visitors visiting in one short street. The "family doctor" is often a sentimental fiction; father is on the list he was put in as a boy; mother is on the list of her mother's G.P., the children are on the lists of various doctors in practices near their new home. So that there may be several health visitors visiting one home and because the local surgery is a lock-up surgery the children are taken at night to the hospital for emergency advice, so that even if the health visitor is in a general practice, she may not learn all that is going on. Furthermore, many transient migrant and vulnerable families are slow to put themselves on any general practitioner list. Some of these problems are to some extent solvable if the population to be kept under observation is accepted as being no longer all the families in an area, but all the families in a practice. But the health visitor walking down a street will no longer notice an unfamiliar child and find out who he is because she can now say: " I expect he belongs to another practice." But a large problem is that in some instances, health visitors allocated to general practices have found themselv.es diverted to geriatric care and left with time to pay only one statutory visit to each new child. The ageing have some call on the health services, though as someone aged 67, I would opt for meals on wheels from the social services rather than for an intensive coronary care unit. It is true that the general knowledge of infant care and infant feeding is better than 30 years ago but the child health clinic team has still a great deal to do in health education of all families and in special care of vulnerable families. These ought not to be dropped to look after the aged. In summary the health visitors' potential contribution to the health of children today and of the adults of tomorrow is indeed still very great. How we deploy our relatively few health visitors is something to which we should be giving more thought. The more we respect and the more we pay general practitioners the better they will be. But at present we have our general practitioners split fifty-fifty between those who want to be family doctors and those who want to be consultoids within group practices and our general practitioners are split between those who are keen and those who are less keen. Perhaps some areas would do better to retain area-type health visitors while some areas have general practice attachments for health visitors. "Nurse practitioners are proving their value in many parts of Canada. But when asked to supply a practice the attitude of the Canadian University general-practice units is adamant; they agree only if the doctor concerned is willing to come to the unit for a training course designed to achieve an effective working partnership." Would it not be possible to work for some degree of voluntary rationalization of the attachment of patients to practices ? I f all members of each family were on one doctor's list it would help and it would help if some of the families living far from the practice centre were persuaded to change. This would encourage the doctor to be more population-minded
246
Ronald MacKeith
and to make closer contact with the other community services in his neighbourhood. While the health visitor is a specialist in prevention, it is desirable that the general practitioner himself develops greater interest in prevention and does not leave that entirely to the practice health visitor. One final point, the health visitor can consult experienced senior workers in the community services. Are there similar channels for the general practitioner? On problems of unusual or difficult symptoms or diseases there is a well-established pattern of his consulting the hospital paediatrician. Have we yet established a channel for him to consult his local community paediatrician about problems of educational and social paediatrics, about school problems, adoption, etc. ? Perhaps this is yet another field in which the practice health visitor could help her doctors to "bring the best possible care to children in the practice" by getting the community paediatricians and the general practitioners to meet. RONALD MAcKEITH
The Newth Prize
This prize, established in memory of Dr A. A. E. Newth, formerly P.S.M.O. of Nottingham and for many years Honorary Secretary of the School Health Service Group, is awarded annually by that Group. It is intended to recognize meritorious published work in the field of school health (wherever published), but may also be awarded irrespective of published work to persons in the School Health Service (or, exceptionally, outside it) who have rendered conspicuous service to the School Health Service. The assessors have considered various publications and have agreed that the prize should be awarded as follows: 1970-71 Dr P. Henderson for his published work, "Some continuing health problems of school children and young people and their implications for a child and youth health service." Public Health, London (1971), 85, 58-66. 1971-72 Dr J. Starkie for his services to the School Health Service and the School Health Service Group Council. 1972-73 Dr Hilary Crewe for her published work, "Fears and anxiety in childhood." Public Health, London (1973), 87, 165-71, and for her services to the School Health Group Council. 1973-74 Dr J. H. Whittles for his published work (jointly), "Hay fever--consideration and possible dangers in the large-scale desensitization of secondary school children." Public Health, London (1974), 88, 121-29, and for his services to the School Health Group Council during 1973-74.
Number 6
September 1975
H o w Best can w e Deploy our Health Visitors? Our health visitors are only to be described in the sort of terms that are used by King Solomon in his song describing his bride. There are not enough of these pearls among women to do the job we want them to do. This job is, primarily, one o f health education and prevention which they do in visits and by encouraging mothers to bring their children periodically to health centres (whether run by general practitioners or by the district health authority). Once there the mothers can talk to the other mothers, the health visitor and to the clinic doctor. They can receive periodic medical and developmental surveillance and can have their immunization programme. The health visitors can make contact with local schools as children grow older and with the second level social services. My bias as a paediatrician who worked in hospitals and twice a week in a child health clinic for 25 years is clear. I see the health visitor as a person with a major duty towards children and spending a considerable portion of her time supporting vulnerable families so that they do not become problem families. In our part of London we estimated vulnerable families as 5 ~o of our 800 families. (I am surprised to read a research report on problem families which were only one in 600.) The essence of a preventive service is that everyone in the population is known and seen periodically. Only in this way can early deviations--whether essentially medical, psychiatric, intellectual or social in origin or, as is usual, combinations of these causes--be discovered early and given the treatment or support which may enable those with them to keep coping with life. The population orientation of the former local authority health services--go out and find t h e p e o p l e who need help, don't wait for them to consult the doctor--is the only sound basis for successful preventive medicine. Perhaps another potential cause of being puzzled, emerging in some areas, is the change of status of the area nursing services. The doctors in hospitals and in the local authority health services had "their" nurses and "their" social workers. Doctors are getting used to recognizing the social services as an equal and developing allied profession. The general practitioner would be wise not to slip into thinking the health visitor is "his" health visitor; she is answerable to the area nursing officer. The area nursing officer is responsible for the 243
244
Ronald MacKeith
health visitor's training, and for the quality of her work be it in health education or developmental assessment. Doctors and nurses have behaved as if nurses were subservient. With greater responsibility the nursing profession will grow in self-respect and quality of the work it does. It is up to doctors to accept the nursing profession as equal in status and to make it evident that we do, whether the nurses we meet are in the wards or in our practices. After this digression, the topic of health visitors in community-run child health centres or family practices can be picked up again. The health visitor of a few years ago had a geographic area based on her local authority child health clinic where she worked in close co-operation with the clinic doctor. She went out and visited, taught parentcraft in the ante-natal clinics collaborating with midwives, and visited all the mothers who had had babies at home or had just returned from the hospital delivery ward. She answered mothers' questions, chased the children not brought to the child health clinic, visited homes. She knew which families were vulnerable and just beginning to fail to cope and supported them and the problem families. She knew the local G.P.s and their quality, she knew the local authority doctors, she knew the local hospital casualty and emergency department, the teachers in the schools in her area and the social workers who were concerned with the families she knew. Because she was a nurse she was acceptable to almost all mothers. This is partly because the medical profession is seen as a helping and caring profession. It is also partly because she was a member of what is essentially a non-judgmental profession. Families who feel they are failures may, with some justification, look on teachers as people who say "he could do better if he tried harder" and social workers who are also non-judgmental, do not have the aura of a healing profession. In those days if one of the families you knew moved to Northampton it was easy to contact the Northampton M.O.H. and get continued support for the family. The new pattern is for many health visitors to be attached to general practitioners. Here is what a good general practitioner has written. "The health visitor is the key person in the whole programme [or running a really good paediatric service in a general practice]. Her skills in assessing the growth and development of the normal child, her knowledge of the family, her contacts with child minders, play group leaders, nursery schools, primary and secondary schools are invaluable in providing information that can help the team to bring the best possible care to children in the practice. She is reasonably effective as a link between the general practitioner and the various community health educational and social services but as it is, without the health visitors there would be no links at all". (I cannot help asking why the G.P. cannot himself visit the local school teachers, community and hospital paediatricians and the social services but as Rudyard Kipling would have said, that is a different story.) This general practitioner goes on to say: "In some areas the attachment of health visitors to general practices has come into question. This is particularly where the attachment has been conspicuously unsuccessful. It is surprising that attachment works as well as it does. While the health visitor has been carefully prepared in her training for attachment to a general practice, the general practitioner has taken no steps to have formal instruction or preparation and often in consequence only lip service is paid to the vital role she can play in paediatrie health care. Some general practitioners have, from their ignorance, misunderstood the health visitor's preventive and educational role and have been bemused by her relative expertise in developmental medicine. Because of this the family doctor has been able to offer little or no support or help when situations arise calling for greater expert knowledge than the health visitor has. Many general practitioners are still puzzled about what the health visitor does and the health visitors may long to return to the child health clinic base and to responsibilities based on the families in a geographical area
How best can we deploy our health visitors ?
245
rather than on the families of a practice. In some inner city areas where there is a breakdown of primary care medical services this may be the only answer". I f all G.P.s were as good as the best i n - - a n d outside the Royal College of General Practitioners, we might opt for primary care services based on general practices. Until all G.P.s are good and interested in children, we may well feel that the welfare of children is so important that the provision of a rather illogical double service was and is wise. Perhaps the answer is that a long stop is not necessary when the wicket keeper is known to be good, but the trouble is that the good wicket keepers say all wicket keepers are good and long stops never required. It is generally felt that patients should be able to choose their G.P.s and G.P.s their patients. This means that, on the " n e w " pattern, health visitors are attached to a scattered general practice. As a result there may be a dozen health visitors visiting in one short street. The "family doctor" is often a sentimental fiction; father is on the list he was put in as a boy; mother is on the list of her mother's G.P., the children are on the lists of various doctors in practices near their new home. So that there may be several health visitors visiting one home and because the local surgery is a lock-up surgery the children are taken at night to the hospital for emergency advice, so that even if the health visitor is in a general practice, she may not learn all that is going on. Furthermore, many transient migrant and vulnerable families are slow to put themselves on any general practitioner list. Some of these problems are to some extent solvable if the population to be kept under observation is accepted as being no longer all the families in an area, but all the families in a practice. But the health visitor walking down a street will no longer notice an unfamiliar child and find out who he is because she can now say: " I expect he belongs to another practice." But a large problem is that in some instances, health visitors allocated to general practices have found themselv.es diverted to geriatric care and left with time to pay only one statutory visit to each new child. The ageing have some call on the health services, though as someone aged 67, I would opt for meals on wheels from the social services rather than for an intensive coronary care unit. It is true that the general knowledge of infant care and infant feeding is better than 30 years ago but the child health clinic team has still a great deal to do in health education of all families and in special care of vulnerable families. These ought not to be dropped to look after the aged. In summary the health visitors' potential contribution to the health of children today and of the adults of tomorrow is indeed still very great. How we deploy our relatively few health visitors is something to which we should be giving more thought. The more we respect and the more we pay general practitioners the better they will be. But at present we have our general practitioners split fifty-fifty between those who want to be family doctors and those who want to be consultoids within group practices and our general practitioners are split between those who are keen and those who are less keen. Perhaps some areas would do better to retain area-type health visitors while some areas have general practice attachments for health visitors. "Nurse practitioners are proving their value in many parts of Canada. But when asked to supply a practice the attitude of the Canadian University general-practice units is adamant; they agree only if the doctor concerned is willing to come to the unit for a training course designed to achieve an effective working partnership." Would it not be possible to work for some degree of voluntary rationalization of the attachment of patients to practices ? I f all members of each family were on one doctor's list it would help and it would help if some of the families living far from the practice centre were persuaded to change. This would encourage the doctor to be more population-minded
246
Ronald MacKeith
and to make closer contact with the other community services in his neighbourhood. While the health visitor is a specialist in prevention, it is desirable that the general practitioner himself develops greater interest in prevention and does not leave that entirely to the practice health visitor. One final point, the health visitor can consult experienced senior workers in the community services. Are there similar channels for the general practitioner? On problems of unusual or difficult symptoms or diseases there is a well-established pattern of his consulting the hospital paediatrician. Have we yet established a channel for him to consult his local community paediatrician about problems of educational and social paediatrics, about school problems, adoption, etc. ? Perhaps this is yet another field in which the practice health visitor could help her doctors to "bring the best possible care to children in the practice" by getting the community paediatricians and the general practitioners to meet. RONALD MAcKEITH
The Newth Prize
This prize, established in memory of Dr A. A. E. Newth, formerly P.S.M.O. of Nottingham and for many years Honorary Secretary of the School Health Service Group, is awarded annually by that Group. It is intended to recognize meritorious published work in the field of school health (wherever published), but may also be awarded irrespective of published work to persons in the School Health Service (or, exceptionally, outside it) who have rendered conspicuous service to the School Health Service. The assessors have considered various publications and have agreed that the prize should be awarded as follows: 1970-71 Dr P. Henderson for his published work, "Some continuing health problems of school children and young people and their implications for a child and youth health service." Public Health, London (1971), 85, 58-66. 1971-72 Dr J. Starkie for his services to the School Health Service and the School Health Service Group Council. 1972-73 Dr Hilary Crewe for her published work, "Fears and anxiety in childhood." Public Health, London (1973), 87, 165-71, and for her services to the School Health Group Council. 1973-74 Dr J. H. Whittles for his published work (jointly), "Hay fever--consideration and possible dangers in the large-scale desensitization of secondary school children." Public Health, London (1974), 88, 121-29, and for his services to the School Health Group Council during 1973-74.
