Fit for the Future: Lessons for the United States

804 PEDIATRICS Vol. 61 No. 5 May 1978 1975, p 11.

21. Miller RW, in discussion, The susceptibility of the fetus and child to chemical pollutants. Pediatrics

53(suppl):777, 1974.

22. Warren S: Radiation carcinogenesis. Bull NY Aced Med 46:131, 1970.

23. Favus MJ, Schneider AB, Stachura ME, et al: Thyroid cancer occurring as a late consequence of head and neck irradiation: Evaluation of 1,056 patients. N Engl I Med 294:1019, 1976.

24. Scientists’ Declaration on Nuclear Power. Cambridge, Mass, Union of Concerned Scientists, 1975.

Fit for the Future:

Lessons for the

United

States

The United States has its tradition of White House Conferences; the United Kingdom has its Royal Commissions or Special Committees. The

report of the Committee on Child Health

Services,’ which took three years for a “far reaching inquiry” on how to improve child health services in the United Kingdom, is in this tradition of both countries. It is a report well worth the waiting and worth careful thought by pediatri-cians and policymakers in the United States. Volume 1, 448 pages long, is the body of the report. Volume 2 is a statistical appendix.

At the outset, any reviewer of this extensive work must limit his comments to only a few areas

that seem most pertinent to our own scene.

Others will see more importance in other points.

Recommendations that seem most important to

me include the following.

An Integrated Child Health Service

The most important theme of the report is that child health services cannot exist in a vacuum and that as a result there must be an integrated child health service-integrated with the rest of medi-cine, with education, and social work. The social, economic, and educational setting and the state and organization of medicine in general all have

powerful effects on the ability of the child to

“grow to live a full adult, living, breathing life.” The limitation of medical care and the impor-tance of other factors on health are now familiar

strains in writings from both of our countries. This

limitation means that child health services are only one of several approaches that must be taken to improve children’s health. The question is,

How can physicians work most effectively in

these boundary areas? How can they integrate

services?

Boundary problems will always be difficult. If

one becomes too great a “lumper” without

boundaries, there is danger of getting nothing done

and

slipping into banal generalities. On the other hand,

too

narrow espousal of child health services to the exclusion of the other needs of the family

and

society will limit programs to ones of minor benefit to the child. I believe, as do the authors of this report, that the time is past for narrow advocacy, at any cost, of child health

services to the exclusion of the needs of others of

our society. But, I admit to frequent anxiety about how far beyond these narrow boundaries anyone can function with effectiveness. One of the force-Ilil conclusions of this report is “that, in the long run, only a combined approach from housing, health, education,

and

social services can even begin to eradicate the causes of the initial

disad-vantage.” How to achieve this combined

approach without sacrificing focused competence is the major agenda for both of our countries and is not fully addressed in this report.

Primary Care: Combining Preventive and Curative Services

The report recommends special training of

general physicians to provide primary care for children-a move toward the pattern of primary

care

pediatrics as practiced in the United States.

The dilemma emerges again. Narrowness is

some-times

limiting in effectiveness, especially in deal-ing with problems whose origin lies in the family or community; but breadth is sometimes limiting in quality, as those who wrote the report believe now exists among many general practitioners in the United Kingdom.

At a time when many pediatricians in this country are broadening their skills into ability to deal with adolescence, youth, family-focused services, education, emotional problems, and handicapped services, some family physicians in the United Kingdom are urged to narrow their focus by concentrating on children, while main-taming a family focus. But the report also recom-mends joining of curative

with

preventive services for children, a pattern characteristic of U.S. pediatrics but not traditional in the United

Kingdom. As is often the case, somewhere

between the traditional pattern of the United States and the United Kingdom lies a better balance. The report rejects a separate child health service (neat as that might appear), and instead opts for integration of child health within general family-centered health services, with upgrading

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COMMENTARIES 805

of the skills of the general physician and combi-nation of curative and preventive services to improve the quality. In this way, they hope to achieve integration and quality at the same time.

A Voice for Children’s Services

Much of the detailed recommendations on

organization of children’s services are necessarily particular to the United Kingdom, but a key issue in both countries is how to achieve a national voice for children’s services and at the same time avoid the narrow partisanship that so often self-defeating of such groups. The report recommends a joint children’s committee of the Central Health

Services and Personal Social Services councils,

thereby linking health and social services.

I

believe that a broadly focused children’s commit-tee should be (but rarely is the case now) a part of

all

health planning groups in the United States and might achieve some of this coordination.

It should be mirrored at the federal level-in other words a reconstituted Children’s Bureau, but with less “line” operational reponsibilities and more collaborative functions. As the U.K. report says, “the Council must be concerned with a wider field than child health services.” One of the main reasons for our Department of Health, Education, and Welfare is to achieve integration between these human services. Integration of

services has not occurred with sufficient

frequen-cy in my view, nor have children’s services received their due voice. Such a children’s coun-cil, endowed with power of policy and budget approval at local and federal level, could be very effective in this regard.

Nursing

Another valuable contribution is the review of the development of the profession of health visitor (the public health nurse), whose mission was, and is, to serve all, not merely the poor in the United Kingdom. The “secondment” of health

visitors to general practices in order to combine

curative and preventive services is to some degree similar to the development of pediatric nurse practitioners in the United States. The report recommends specialization of some health visitors into child health visitors, who would combine curative and preventive services to children and work with the general pediatric practitioner rath-er than spread themselves across all age groups. An important addition is the recommendation that the nursing officer, who coordinates a number of child health visitors, should have a “clear responsibility for a geographically-defined

patch,” in order to ensure that all children are registered in one practice or another. There is a need for ensuring the care of all children in both of our countries, and the designation of someone to be responsible for a defined population is a high priority. Public health nurses seem to be a logical group to have this responsibility.

School Health

Discussion of the school health services has a familiar ring.

Parents and teachers have found themselves faced with a school health service, which knew something of the child’s health at school and had skills in educational medicine, but

could scarcely provide treatment, and had no first-hand knowledge of the child’s behavior and development out of school; and a general practitioner service, which would provide treatment, but had no opportunity to study the child’s behavior in school and to discuss problems of health and adjustment with the teaching staff concerned, and had no experience of educational medicine.

The recommendation for development of a

consultant community pediatrician, a specialist counterpart of the primary care pediatri-cian-G.P.-who would spend a large part of his/ her time in educational (as well as developmental and social) pediatrics, is in part their answer to the

school

health problem. At the same time the

report recommends the assignment to every

school of a primary care G.P. pediatrician and nurse. This recommendation would lead to the eventual elimination of a discrete and separate school health service and is another recommenda-tion that should lead to integration of services, a recurrent theme of the report.

Other Matters

There are many other important recommenda-tions, such as that each health district have a special handicap team and a child psychiatry team, and there is much-needed stress on chil-dren’s dental services. The call for research is limited to a few areas, such as ways to educate parents in parenting, studies on the etiology of handicaps, and effectiveness of perinatal care

(prenatal diagnosis and fetal monitoring). The

lack of much stress on research, especially on different ways to organize care, or on biomedical research, is one absence I miss in the report.

The report also states, “The necessary

coordi-nation, cooperation, and understanding will not

be achieved solely by the pursuit of administra-tive procedures.” One of the most radical recom-mendations is that to achieve integration at the

individual

child level, there “should be common elements in

both

the initial and in-service training of these professions” (health, education, social

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services, etc.). Can we educate these professions for at least part of their time together? I believe

What Is There to Criticize in the Report?

REFERENCE

1. Fit for the Future: Report of the Committee on Child Health Services. London, Her Majesty’s Stationery Office, December 1976, vols 1 and 2.

806 PEDIATRICS Vol. 61 No. 5 May 1978

so.

From my enthusiastic review-not much. The only fundamental area not addressed adequately

is the growing recognition that services are not

enough. While there is very adequate presenta-tion of the role of social factors in producing ill health, there is little attention to the need for basic changes in the cause of these social factors. Perhaps it is unfair to criticize a report on child health services for not tackling in their policy recommendations the even more important prob-lems of family jobs, income, environment, and culture that so profoundly affect child health. But, every report has to have some boundaries. Fit

for the Future has so much of importance that it should not be too harshly criticized for this gap.

Finally, there is the problem of implementa-tion. Schemes for improving services abound.

Rereading the reports of past White House

Conferences on Children (especially the 1930 report) makes me realize that lack of implemen-tation rather than lack of ideas is the major problem in improving child health services. Competing forces will always

find

alternative use of the limited resources-time and money-unless the steps to achieve change are detailed. Fit for

the Future goes part way toward addressing this issue with a chapter on “Transition to the New Service”

and

on implications for training of the new breed of physicians and nurses. But to

this

observer, too much faith is put on the power of the logic of the blueprint (which is great) and on the goodwill of joint planning teams to achieve the goals and too little on the incentives and resources needed to accomplish them.

A

final chapter lists the priorities as seen by the

committee and recognizes the resource

con-straints.

Although this report is less concerned with costs and benefits than I believe it should be, it does what we in the United States have so far failed to do. It sets clear goals for child health services in the United Kingdom, and it provides a map of how to get there. A similar far-reaching report for the United States would advance child health.

Why not make this the goal of the next White House Conference?

Febrile

seizures:

An end to confusion

After years of conflicting advice from

numer-ous

experts about treatment or nontreatment of febrile seizures, there is now a sound basis on which the pediatrician can make decisions. Recent studies14 have approached the problems of febrile seizures from different viewpoints and are beginning to present a coherent, understand-able picture of their outcome and the results and problems of therapy.

Nelson and Ellenberg in this issue (p. 720) present the last in a series of articles on the 1,706 children with febrile seizures from the 54,000 pregnant women enrolled in the Collaborative Perinatal Project and followed up to the age of 7.

All

data were collected prospectively. They found that 3.5% of white children and 4.2% of black children between the ages of 1 month and 7 years had a seizure associated

with

fever unaccompan-ied by a recognized neurological illness. Of those children who had one seizure, one third had a second and one half of the latter had a third seizure. Only 9% of the total population had three or more febrile seizures. Recurrences were more likely when the first seizure occurred during the first year of life. Three quarters of recurrences came within one year of the first febrile seizure, and almost 90% of recurrences occurred within

two

years

of the onset. Nelson and Ellenberg found that febrile seizures caused no deaths, were not associated with permanent neurological defi-cit, and had no effect on IQ or academic perform-ance. Febrile seizures were associated with an increased risk of epilepsy, but only 2% of children

with

febrile seizures had become epileptic by age 7. Ninety-eight percent had not.

Nelson and Ellenberg found “risk factors” which were associated with increased risk of future epilepsy or “afebrile seizures.” When the first seizure was “complex,” i.e., longer than 15 minutes, focal, or part of a cluster, there was an increased risk of epilepsy. A family history of afebrile seizures

also

increased the risk of subse-quent epilepsy. An important predictive factor of subsequent epilepsy was whether the child was neurologically normal or abnormal (or suspect) prior to the first seizure. However, even when two or more of these “high-risk” factors were present, only 10% of the children developed epilepsy; 90% did not.

These data thus document what most

pediatri-R.J.H. cians have long suspected: that febrile seizures

are

both

common and benign.

Several questions might be posed. Can febrile seizures be prevented? Should they be prevented? What problems are associated with prevention?

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1978;61;804

Pediatrics

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