536 Craft

and provision of training in surveillance the elderly, or the disabled. The value of their

without a solid basis in paediatrics is of limited health promoting activities with children is Arch Dis Child: first published as 10.1136/adc.75.6.536 on 1 December 1996. Downloaded from value. Many general practice trainees under- being questioned. Court's analysis was that the take a senior house officer post in paediatrics health visitor was ideally placed to take on the but spend too much time dealing with sick care of sick children in the community, children on the wards and not enough learning supported where necessary by a more special- about the problems that are common for the ised nurse based within the hospital depart- general practitioner. There are still insufficient ment. Most of those who fiercely declare their senior house officer posts for all general faith in health promotion oppose Court's view. practice trainees, with no immediate prospect Nevertheless many health visitors would wel- of rectifying this situation. We need a carefully come the opportunity to undertake the care of planned paediatric syllabus and training plan sick children at home, with appropriate sup- for every trainee, designed so that even those port; indeed, this already happens in many who cannot obtain a paediatric post can informal ways. The sad fact is that we still have participate in structured training. little research data to help us decide whether Community secondary care services are now his proposals would (in 1990s jargon) produce well established, but there are many unsolved more 'health gain' than a purely health problems. Little is known about the functions promoting model of health visiting. of the 'district handicap team' and the child protection service, or the reasons for the differ- In conclusion ences between trusts in the standard and The first law of 'O' level economics tells us that breadth of service provided. There is an resources are, and always will be, scarce. Don- impending manpower crisis in children's audi- ald Court wrote hopefully of a future time ology services. We are still very bad at assessing when 'the financial crisis would be contained and the benefits of what we do. Information there would once again be sustained growth in technology promised so much, but at present resources and public expenditure' (page 364) but our computers ingest immense amounts of he did not live to see this Utopian state of data at considerable expense, yet give little real affairs and I doubt if I shall either. information back. The description and analysis Rereading Fit for the Future, I reflected that of specific learning disability has generated a since 1976 the number of consultant paediatri- vast literature; and the service needs of school cians has increased more than threefold. age children and the place of the school health Should investment in medical care continue to service have been reviewed recently.8 expand at such a rate? Can we make better use Nevertheless, research into the potential ben- of existing resources? Is there a law of efits of sophisticated 'educational ', diminishing returns as we spend more and the multidisciplinary assessment of children more on health care? Would we do better to with problems affecting learning, is still virgin invest our 'sustained growth in resources', if it territory. ever comes, in housing and education rather

than the health care system? http://adc.bmj.com/ Child health visitors 1 Court SDM. Fit for the future. Report of the Committee on 'The main justification for the distinction between Child Health Services. London: HMSO, 1976. prevention and treatment has been that they cannot 2 British Medical Association. Report ofthe Joint Working Party on Medical Services for Children. London: BMA, 1993. be combined without an unacceptable sacrifice of (EL(93)28.) preventive work ... [but] this distinction is wasteful 3 British Paediatric Association and Specialist Advisory Committee of the Joint Committee on Higher Medical and confusing to the parents and underestimates Training. Transition guidelines for non-consultant career-grade one doctors. London: BPA, 1996. the value to the family of having familiarfig- on September 25, 2021 by guest. Protected copyright. 4 British Paediatric Association. Towards a combined child ure . .. ifor] health promotion andfor illness' (page health service. London: BPA, 1991. 108). 5 Anonymous. Surgery needed-a survey of health care. The Economist 6 July 1991: 3-22 (suppl). Health visitors are currently uncertain of 6 Department of Health. Child health in the community: a guide their role. In addition to their traditional work to good practice. London: Department of Health, 1996: 21-2. with children and mothers, they are asked to 7 Hall DMB. Health for all children: report of the Joint Working undertake community development projects, Party on Child Health Surveillance. Oxford: Oxford Univer- sity Press, 1989 (lst Ed), 1996 (3rd Ed). specialist work such as tuberculosis contact 8 Polnay L. The health care needs of school aged children. tracing, and health promotion with adult men, London: British Paediatric Association, 1996. Donald Court: man of vision (1912-94)

A W Craft

The 1970s were a time of consolidation and 1942 in . Among the new reflection for paediatrics in the UK. Paediatrics group ofyoung enthusiastic doctors who came Department of Child had begun to develop as a separate specialty into paediatrics after the war was Donald Health, Royal Victoria before the second world war and noteworthy Court. In the 20 year postwar period the Infirmary, Newcastle landmarks were the formation of the British organisation of the care of children underwent upon Tyne NEI 4LP Paediatric Association (BPA) in 1928 and the a rapid expansion with paediatric units being Correspondence to: establishment of the first full time professor of set up in most major, and many smaller, hospi- Professor Craft. child health James Spence) in in tals. This growth had been largely uncoordi- Donald Court: man ofvision 537

nated and there was clearly a need to take stock after three years switched to medicine qualify-

and reflect on how far we had come and where ing in Birmingham in 1936. His early work at Arch Dis Child: first published as 10.1136/adc.75.6.536 on 1 December 1996. Downloaded from to go in the future. Donald Court, one of the Great Ormond Street and the Westminster leaders of the postwar paediatricians, took a Hospital was followed by the Emergency leading role in this and in 1970 he entitled his Medical Service during the war and then to Charles West Lecture, delivered to the Royal Newcastle as a Nuffield fellow to work with College of Physicians of London, 'Child Professor James Spence in his newly formed Health in a Changing Community'. In this he department. This was a time of great said 'we must continue to strengthen the founda- opportunity and he joined a team which was tions ofpaediatrics in the biology of development, planning the 'Thousand Families' study in extend our studies of the social determinants of which he was particularly active between 1947 health and disease in child andfamily, especially by and 1954. The Thousand Families work and the use ofwell planned local records; seek with psy- domiciliary visits led him to the homes of over chology and psychiatry for a better understanding 3000 families during his first 15 years in New- of the development ofpersonality in the hope that castle and these clearly left a great impression we may find ways of diminishing maladjustment, on him and eventually led to the ideas first excessive anxiety and destructive aggression in our expressed in the Charles West Lecture.' In children and parents: treat our patients with 1950 on his return from the United States he increasing skill and consideration and try to as was appointed reader in child health and honestly as we can overcome the dichotomy of succeeded to the chair in 1955 after the treatment and prevention: establish these principles untimely death of Spence in 1954. in the education ofdoctors and others professionally He always had a view outside ofhis own spe- involved in the care of children'.' These ideas cialty and this was fostered when Spence were further developed in Paediatrics in the encouraged him to take an interest in speech. Seventies which he wrote with Tony Jackson This led to him being instrumental in setting when they were chairman and secretary of the up the Department of Speech Therapy in the Academic Board of the BPA.' It was no university and he was also a prime mover surprise therefore when Court was invited by behind the new Department of Human Genet- the secretary of state to chair a working party ics. He had a great ability to work closely with on the future of the child health services, its others and his collaborations with Issy Kolvin report being universally known as the Court in child and adolescent psychiatry and Philip report.' This report bears his stamp on every Gardner in virology were among the more page, written in beautiful English, quite unlike notable. His work with the virologists was the ugly verbiage of many such reports. It was especially important in cementing the links full of compassion, clearly reasoned, and based between the largely clinical descriptions of res- on careful research. He was greatly saddened piratory illness from the past with the rapidly and disappointed when it was received with less expanding scientific side, enabled by Gardner's than enthusiasm by the medical profession and pioneering work in rapid viral diagnosis.5

by the politicians who had commissioned it. Imparting his philosophies to medical students http://adc.bmj.com/ In 1978 when Donald Court was being pre- was seen as an important part ofhis life and he sented with the of the was not only an inspiring and popular teacher BPA the report was described by Otto Wolff as but also recognised the stress of medical being a decade or so ahead of its time.4 This student training and played a major part in the indeed has proved to be so. Court took quiet establishment of a personal tutor system. pride in seeing most of the reports recommen- His recognition that much of paediatric care dations over the being slowly implemented takes place outside of hospital was evident in on September 25, 2021 by guest. Protected copyright. next 20 years even though his committee were the book which he edited, with the help of 12 never given any real credit. It had however local general practitioners entitled The Medical clearly achieved its main purpose, to make the Care ofChildren.' country, government, and profession more Donald Court was undoubtedly a man of aware of the needs of children and how they vision and he was fortunate to follow in the had previously failed them. footsteps of Spence who had started the There is no doubt therefore that Donald revolution in thinking on the care of children Court was one ofthe most influential paediatri- which he successfully carried through. cians of recent times. What then were the He was a master wordsmith and his writings sources of greamess, of his depth, his integrity, are a model of clarity and precision. He was and his humanity? He was born in Wem, always able to produce, at the drop at a hat, the Shropshire, the only child of a headmaster. His apt poetical quotation, often from his favour- mother was the youngest of 17 and it is perhaps ites Auden and T S Eliot. On research it is per- understandable why they stopped at Donald. haps worth quoting Court himself: 'Without One of his major early achievements was a continuing enquiry there is no progression. My plea school certificate examination in gardening of is that we should apply the same critical energy to which he was most proud and which was the study of social as we do to cellular behaviour'. clearly evident in the planning ofhis gardens in There is no doubt that Court was greatly the future. However he was not a practical man helped in his life and work by his strong Quaker and left the execution and manual work to oth- philosophy. He came to Quakerism as a student ers. It was once said of him 'give him the job and put the same degree ofeffort into this as he and he will finish the tools'. Time for him was did to most other things in his life. Much ofhis better spent in reading than changing a plug. thinking about the conflict between religion He initially decided on a career in dentistry but and science is encapsulated in two articles 538 Craft

which were published in 1965 and 1970. These using phrases like "through the chair" and other

were entitled 'A Scientific Age and a Declining committee speak. I would never have got round to Arch Dis Child: first published as 10.1136/adc.75.6.536 on 1 December 1996. Downloaded from Church'7 and 'Leading a Double Life'.8 making any contribution at all if Donald had not He was a 400 metre runner in his student gone out of his way to ask what each parent days and this fleemess of foot and agility was representative thought at important moments in the constantly manifest in his future life developing discussion. He gave me the courage to speak and the into a well developed political ability. His belief that my views and the views of all children advice to one young doctor embarking on a and theirfamilies were important'. potential career in academic paediatrics was There is no doubt that the health of children that his secret of success was to 'keep both feet in the 1990s has been greatly influenced by firmly planted in mid air!' Donald Court. It would be fitting to close with Donald Court had a superb capacity to sum- one of his favourite quotes from T S Eliot. marise and synthesise and he was in great We shall not ceasefrom exploration demand as a chairman. It was no surprise And the end of all our exploring therefore that he was asked to bring together a Will be to arrive where we started group ofindividuals from all walks oflife under For to make an end is to make a his chairmanship as the Committee of Enquiry beginning into the Child Health Services. That he The end is where we startedfrom. brought out the best in people is exemplified by the words of Lady Jean Lovell-Davies. 'Donald 1 Court SDM. Child health in a changing community. BMJ 197 l;ii: 125-31. Court would have liked to have had children repre- 2 Court D, Jackson A. Paediatrics in the seventies. London: senting their own views on the committee butfortu- Nuffield Provincial Hospital Trust, 1972. natelyfor me he had to settlefor parents. I was one 3 Court SDM. Fit for the future. Report of the Committee on Child Health Services. London: HMSO, 1976. of three parents chosen to putforward the views of 4 Wolff 0. James Spence medallist, 1978, Seymour Donald users of the services. I had never previously sat on Mayneord Court. Arch Dis Child 1978;53:609-10. 5 Gardner PS, McQuillan J, Court SDM. Speculation on any sort ofcommittee and, at thefirst meeting, was pathogenesis ofdeath from respiratory syncitial virus infec- totally intimidated by the sight ofa huge table with tion. BMJ 1970;i:327-30. 6 Court SDM, ed. The medical care of children. London: names infront ofevery seat,just like the ones I had Oxford University Press, 1963. seen on television reports of United Nations 7 Court SDM. A scientific age and a declining church-what has a friend to say? The Friend September 1965. meetings. The feelings of foreboding and anxiety 8 Court SDM. Leading a double life. The Friend September expressed themselves in giggles when I heardpeople 1970. http://adc.bmj.com/ on September 25, 2021 by guest. Protected copyright.