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Vision and Reality Arch Dis Child: first published as 10.1136/adc.58.2.83 on 1 February 1983. Downloaded from Child care and the family doctor 83 Can it be achieved? does impart a desirable sense of urgency. Neverthe- less, the requirement for additional financial I have not read anything in recent years so heartening expenditure will not endear the report to the as this splendid report, which throws the great Treasury in the present economic climate and much strength of the Royal College of General advocacy and hard groundwork will be needed. The Practitioners into the struggle to create a better brave new world is not yet here. health service for British children. The critical question is whether family doctors throughout the References land will accept its message and seize the future British Paediatric Association. Paediatrics in the seventies- Oxford: University Press, 1972. offered with both hands or whether it will founder 2 Black D A K, chairman. Inequalities in health. Report ofa like so many of its predecessors on the rocks of research working group. London: DHSS, 1980. medical conservatism and official apathy. This may 3 Court S D M, chairman. Fitfor the future. Report of the well represent the last real chance for our generation committee on child health services. London: HMSO, 1976. 4 Royal College of General Practitioners. Healthier children to set a new course to better standards of child -thinking prevention. Report from General Practice health care and so to promote the interests of No 22. London: RCGP, 1982. children and their parents, which have always been 6 Brotherston J H F, chairman. Towards an integrated child and must continue to be our first concern. health service. Report ofa Sub-Group on the Child Health Service of the Joint Working Party on the Integration of The opportunity is there but it is too early to Medical Work. Edinburgh: HMSO, 1973. rejoice, for promise is not achievement and, as the 6 Forfar J 0, chairman. Report of Joint Working Party on report says, actions speak louder than words. The the training of clinical medical officers in child health. Working Party of the Royal College of General Br Med J 1982; 284; 637-40. Practitioners clearly believes that the recommenda- Ross G MITCHELL tions are realistic and urges an immediate start to Department of Child Health, implementing them. The end of 1987 is suggested as University of Dundee, the target date for attaining the main objectives and, Ninewells Hospital and Medical School, although this may be considered impracticable, it Dundee DDJ 9SY Vision and reality The report Healther children-thinking prevention is team approach, and the new relationships between http://adc.bmj.com/ a remarkable publication. For those familiar with doctors, colleagues, parents, and children which will The pilgrim's progress it is like seeing a vision of The be called for. Celestial City from the hill Difficulty.' Additional training is considered essential, and The contents have been carefully gathered, the the requirements for the transitional and the style is clear, and the whole presentation infused with established phases are well argued. Does the report sincerity and purpose. The message to readers, and then merit unreserved approval? In a change of such to the Royal College of General Practitioners, is that extent and complexity, there are bound to be prevention should now become a first responsibility omissions. A cynic, unfamiliar with recent develop- on October 1, 2021 by guest. Protected copyright. in the medical care of children. ments in general practice, might dismiss it as a well The report first considers environmental factors intentioned fantasy. I prefer to see it as prophetic which can help or hinder children's growth and vision, and to remember that 'where there is no health, and its conclusions support those of vision the people perish'. McKeown2 and Black :3 environmental advantage or Why then did I add 'reality' to vision in the title? disadvantage is the main determinant of children's Because the gap between intention and implementa- health; the wide regional and neighbourhood tion is wide and may be growing wider. Visionaries differences are unacceptable; where needs are are also tempted to accept assumptions as evidence; greatest, services are least satisfactory. to believe they have found a solution when they have The late Ronald Mackeith would have been only found a phrase. For example, the report states delighted by the report's developmental framework. that 'the adverse effects on the children of parents It consists of a preface and conclusions, and between who separate or divorce are well known'; in reality them 18 short, crisp chapters which deal with the these effects have still to be uncovered. reasons for setting prevention in primary care, the re- Again it is implied that accurate monitoring of sponse required from contemporary practice, the chronic childhood illness by general practitioners is Arch Dis Child: first published as 10.1136/adc.58.2.83 on 1 February 1983. Downloaded from 84 Court widely accepted when in practice it is still the What is holding the profession back? The reason, exception rather than the rule. almost universal when communities are faced by There is a more serious defect. The report quickly change, is captured in some lines by John becomes concerned with existing and future services, Drinkwater6: without first defining the preventive needs and possibilities on which the pattern of these services Knowledge we ask not-knowledge Thou hast should depend. What can we prevent with existing lent, knowledge? What conditions are most likely to yield But, Lord, the will-there lies our bitter need, to prevention and should be the priority in preventive Give us to build above the deep intent, research ? The deed, the deed. The report recognises general practitioners' lack of time; it omits, except by inference, their inability to Criticism is not rejection, and it would be unjust as keep abreast of rapidly advancing knowledge. well as unfriendly to end on a critical note. This Without a mechanism for achieving this their entry report is one of the most significant and inspiring into a new field of medicine, namely prevention, attempts to extend and improve the medical care of would be unsatisfactory, and the synthesis of children in this century. When before have we been prevention and treatment in the doctors' mind and told: 'The systematic surveillance of a defined group practice made more difficult still. of children is the central plank of our concept of The authors are fully aware of the need for mutual modern child care' or, 'the supreme activity of respect and friendship within the primary care team. medical education is to prevent disease and to They know that if its potential is to be realised, the promote health'. synthesis of prevention and treatment by each This report is a challenge to paediatrics to examine member must be achieved. They rightly praise health its own services in the face of changing needs in visitors' commitment to prevention but say nothing children and families and to create a closer partner- of their persistent unwillingness to help mothers to ship with general practice and primary care. cope with sick children in the home. Clinical medical It merits detailed study by general practitioners officers are also committed to prevention. At an and paediatricians, health visitors, social workers, earlier stage of the dialogue many of them accepted and other members of the primary care team, and the need for the integration of prevention and provides a valuable addition to undergraduate and treatment; however, disenchanted by their graduate education in child health. continuing professional isolation, and, until recently, by the inertia of paediatrics and general practice, References on an independent http://adc.bmj.com/ they are now insisting remaining 1 Bunyan J. The pilgrim's progress. third force. The college is well aware of the 2 McKeown T. The role of medicine: dream, mirage, or schismatic potential of the present situation, but this nemesis. Rock Carling Fellowship. London: Nuffield report hopes for little more than 'we expect that in Provincial Hospitals Trust, 1976. some practices in the future clinical medical officers 3 Black D, chairman. Inequalities in health. Report of a will join these teams....' The authors say that the Research Working Group. London: DHSS, 1980. 4 Forfar J 0, convenor. Report of Joint Working Party on Forfar report,4 the most comprehensive and training of clinical medical officers in child health. Br Med coherent proposals for resolving the obstacles so far, J 1982; 284: 637-40. 'is endorsed'. The real question is when will it be 5 Shakespeare W. Julius Caesar. IV, iii, 217. on October 1, 2021 by guest. Protected copyright. implemented? 8 Drinkwater J. A prayer. There is a time in the affairs of men, DONALD COURT Which taken at the flood leads on to fortune; 8 Towers Avenue, Omitted, all the voyage of their life, Jesmond, Is bound in shallows and in miseries'.5 Newcastle upon Tyne NE2 3QE.
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