In England Now
1
413 principle that supervision is continuous and that the child has only-one doctor. With daily clinics and domiciliary visits, an ordinary general-practitioner service is provided. Children aged 4 years or more, who are too old for infant-welfare supervision, are invited to attend by appointment once a year for a complete physical examination, including anthropometry and tuberculin testing. This provides an opportunity for a check on the child’s immunisation state and for a talk with the parent on matters of physical and mental health that would not be raised in the busy rush of an ordinary surgery. The results of this routine examination form a valuable standard with which to compare the child if he or she should later become ill. I am hoping that the detailed records will provide material for inquiry into morbidity in children. Children who have to be seen routinely more often than once a year are given appointments for special sessions. They include tuberculosis contacts and children with primary tuberculosis, asthma, nephritis, or mal- nutrition. The absence of waiting in a queue encourages mothers to bring their children regularly. CONCLUSIONS ’Four years’ experience of running a wholly paediatric general practice has convinced me that the service given to children is more efficient and effective than that obtainable under the ordinary piecemeal arrangements ; but I cannot claim that all difficulties have been sur- mounted. It has not been possible, so far, to examine Hengrove Child Health Centre members in the school, and this means that, for one attempting a comprehensive child-health service, valuable contact with the child’s teachers is lacking. School medical examinations will always have a place in a child-health service, partly because personal contact with the teachers and school atmosphere is essential for an understanding of the many management and behaviour problems that one has to treat in children, and partly because they are the only means of reaching the children of a small minority of parents who will never bring their children for examination when invited. It is a valid criticism that the general-practitioner paediatrician may be ignorant of important facts about the health of his patients’ parents when he does not see them professionally, and that lack of this knowledge may lead to a misunderstanding of the child’s symptoms. An obvious example is the family where a parent has tuber- culosis but does not acquaint the child’s doctor of the fact. However, this disadvantage is small compared with the many advantages of general paediatric practice and it diminishes considerably when the G.r. paediatrician is in close contact with the doctor caring for the parents, as would be the case in a health centre. Finally, like all other general practitioners, the G.P. paediatrician must have access to hospital beds, because so many children’s diseases require skilled nursing more than any other form of treatment. The method of remuneration in general practice in the National Health Service is an effective deterrent to a wide- spread development of the scheme described here. To provide efficient care of the child in health and sickness, 1000 child patients is a maximum for one doctor ; and for adequate recompense he must receive a much higher capitation fee than exists at present. I am well aware that a child-health service such as that described above is not unique : indeed such arrang- ments are commonplace in the United States, Russia, and possibly some other countries. But at a time when the conduct of general practice is so much under, exami- nation, an account of the Hengrove Experiment may be, of general -interest. - .. REFERENCES Mackay, H. M. M. (1949) Publ. Hlth, 63, 37. Moncrieff, A. A. (1950) Brit. med. J. ii, 795. In England Now A Running Commentary by Peripatetic Correspondents ’ THE small hours found me in the theatre dealing with a chid ill with peritonitis. Outside frost sparkled on the car as I drove home to cut sandwiches and heat coffee before I set out for London, 100 miles away. Twelve hours later I was back at work in the same theatre. But in those twelve hours I had seen the passing of a king. I had watched, in the sober charm that only London knows, the sun glow suddenly to light the rich gold, azure, and gules of the Royal Standard draping the coffin, seen its light flash back from the jewels of the crown and sceptre as the wind ruffled the petals of the Queen Mother’s wreath. I had seen the sun glint on scarlet and steel of breastplate and tunic as the House- hold Cavalry rode by. I had heard the beat of the reluc- tant footsteps of slowly marching men, half muffled by the skirl of the pipers’ lament. But above all I had shared with thousands of my countrymen the privilege of saying farewell to our King. * * * The winter sunlight shone through the clear windows of St. George’s Chapel, and the pale blue of the sky seemed caught and concentrated in the blue carpet in the centre of the nave. A gleam reflected from the pillars illuminated the red uniforms of the Yeomen of the Guard, posted on either side of the entrance to the choir. The scene had a timeless quality, as though the interlacing tracery of the roof had, centuries ago, caught time and held it in a net of stone. And, some- how outside time, we waited, while Elgar’s music answered one enigma with another. Then the choir, wearing their surplices over mulberry- coloured cassocks, followed by the Prelate of the Order of the Garter and the Archbishops, came slowly down the nave to stand at the open west door ; and all the company stood, waiting with them in a silence which strangely sharpened our senses of sight and sound. The music of the pipes, accompanied by the rhythm of muffled drums, drew slowly nearer ; and then we heard the staccato marching of feet and the broken clatter of horses’ hooves, after which there was a short silence, suddenly pierced by the shrill wail of the bo’suns’ whistles. Then came the slow, gentle tread of eight men, united by their burden, and, as the funeral service began, the coffin, covered by the red and gold Royal Standard, and bearing the crown, the orb, and the sceptre, was borne, glittering in the oblique sunlight, into the dim sanctuary beyond. Here was high drama, but it was drama, literally a doing, which was also reality : it was symbolism not abstracted from life, but added to it. Kingship is a symbol made by man but greater than men, so that both King and subject are alike subject to it, and from the monarch it exacts a submission greater than any he requires from his people. The ancients might have called it fate, but fate is too external and mechanical a compulsion. It was the virtue of George VI that he accepted willingly and fully the obligation laid upon him, and by simply doing his duty he became great. To be born great, to have greatness thrust upon one, and then to achieve greatness is a conjunction Shakes- peare can hardly have contemplated. And if the price was to work without ceasing, to subordinate even human relationships to the claims of duty, and to be lonely yet never- to be left alone, it was a price paid gladly. It is not for the subject to pity his Sovereign, but to accept the sacrifice’with pride and humility, and to see in it an example for his own life. : So, as the coffin was lowered into the vault and." this our-brother " was committed to the ground, we returned into time with the sense that we ,had indeed been shown, a mystery. , this paradox results from failure to take seriously, the ‘ main responsibility of a clinical chief, which is teaching. As medical teachers are chosen today. it is accidental ff_ superior talent for teaching - adorns the odd assortment of characteristics demanded of jfnedical department heads."—Ir. WILLIAM BENNETT BEAN. J. Lab. clin. med. 1952, 39, 3.
Transcript of In England Now
413
principle that supervision is continuous and that thechild has only-one doctor.With daily clinics and domiciliary visits, an ordinary
general-practitioner service is provided. Children aged4 years or more, who are too old for infant-welfare
supervision, are invited to attend by appointment oncea year for a complete physical examination, includinganthropometry and tuberculin testing. This providesan opportunity for a check on the child’s immunisationstate and for a talk with the parent on matters of physicaland mental health that would not be raised in the busyrush of an ordinary surgery. The results of this routineexamination form a valuable standard with which tocompare the child if he or she should later become ill. Iam hoping that the detailed records will provide materialfor inquiry into morbidity in children.Children who have to be seen routinely more often
than once a year are given appointments for specialsessions. They include tuberculosis contacts and childrenwith primary tuberculosis, asthma, nephritis, or mal-nutrition. The absence of waiting in a queue encouragesmothers to bring their children regularly.
CONCLUSIONS
’Four years’ experience of running a wholly paediatricgeneral practice has convinced me that the service givento children is more efficient and effective than thatobtainable under the ordinary piecemeal arrangements ;but I cannot claim that all difficulties have been sur-mounted. It has not been possible, so far, to examineHengrove Child Health Centre members in the school,and this means that, for one attempting a comprehensivechild-health service, valuable contact with the child’steachers is lacking.School medical examinations will always have a place
in a child-health service, partly because personal contactwith the teachers and school atmosphere is essential foran understanding of the many management and behaviourproblems that one has to treat in children, and partlybecause they are the only means of reaching the childrenof a small minority of parents who will never bring theirchildren for examination when invited.
It is a valid criticism that the general-practitionerpaediatrician may be ignorant of important facts aboutthe health of his patients’ parents when he does not seethem professionally, and that lack of this knowledge maylead to a misunderstanding of the child’s symptoms. Anobvious example is the family where a parent has tuber-culosis but does not acquaint the child’s doctor of thefact. However, this disadvantage is small compared withthe many advantages of general paediatric practice andit diminishes considerably when the G.r. paediatrician isin close contact with the doctor caring for the parents,as would be the case in a health centre.
Finally, like all other general practitioners, the G.P.paediatrician must have access to hospital beds, becauseso many children’s diseases require skilled nursing morethan any other form of treatment.The method of remuneration in general practice in the
National Health Service is an effective deterrent to a wide-spread development of the scheme described here. Toprovide efficient care of the child in health and sickness,1000 child patients is a maximum for one doctor ; andfor adequate recompense he must receive a much highercapitation fee than exists at present.
I am well aware that a child-health service such asthat described above is not unique : indeed such arrang-ments are commonplace in the United States, Russia,and possibly some other countries. But at a time whenthe conduct of general practice is so much under, exami-nation, an account of the Hengrove Experiment may be,of general -interest. - ..
REFERENCES
Mackay, H. M. M. (1949) Publ. Hlth, 63, 37.Moncrieff, A. A. (1950) Brit. med. J. ii, 795.
In England Now
A Running Commentary by Peripatetic Correspondents ’
THE small hours found me in the theatre dealing witha chid ill with peritonitis. Outside frost sparkled onthe car as I drove home to cut sandwiches and heatcoffee before I set out for London, 100 miles away. Twelvehours later I was back at work in the same theatre. Butin those twelve hours I had seen the passing of a king.I had watched, in the sober charm that only Londonknows, the sun glow suddenly to light the rich gold,azure, and gules of the Royal Standard draping the coffin,seen its light flash back from the jewels of the crownand sceptre as the wind ruffled the petals of the QueenMother’s wreath. I had seen the sun glint on scarletand steel of breastplate and tunic as the House-hold Cavalry rode by. I had heard the beat of the reluc-tant footsteps of slowly marching men, half muffled bythe skirl of the pipers’ lament. But above all I hadshared with thousands of my countrymen the privilegeof saying farewell to our King.
* * *
The winter sunlight shone through the clear windowsof St. George’s Chapel, and the pale blue of the skyseemed caught and concentrated in the blue carpet inthe centre of the nave. A gleam reflected from thepillars illuminated the red uniforms of the Yeomenof the Guard, posted on either side of the entrance tothe choir. The scene had a timeless quality, as thoughthe interlacing tracery of the roof had, centuries ago,caught time and held it in a net of stone. And, some-how outside time, we waited, while Elgar’s musicanswered one enigma with another.Then the choir, wearing their surplices over mulberry-
coloured cassocks, followed by the Prelate of the Orderof the Garter and the Archbishops, came slowly down thenave to stand at the open west door ; and all the companystood, waiting with them in a silence which strangelysharpened our senses of sight and sound. The musicof the pipes, accompanied by the rhythm of muffleddrums, drew slowly nearer ; and then we heard thestaccato marching of feet and the broken clatter ofhorses’ hooves, after which there was a short silence,suddenly pierced by the shrill wail of the bo’suns’ whistles.Then came the slow, gentle tread of eight men, unitedby their burden, and, as the funeral service began,the coffin, covered by the red and gold Royal Standard,and bearing the crown, the orb, and the sceptre, wasborne, glittering in the oblique sunlight, into the dimsanctuary beyond.Here was high drama, but it was drama, literally a
doing, which was also reality : it was symbolism notabstracted from life, but added to it. Kingship is asymbol made by man but greater than men, so thatboth King and subject are alike subject to it, and fromthe monarch it exacts a submission greater than anyhe requires from his people. The ancients might havecalled it fate, but fate is too external and mechanical acompulsion. It was the virtue of George VI that heaccepted willingly and fully the obligation laid uponhim, and by simply doing his duty he became great.To be born great, to have greatness thrust upon one,and then to achieve greatness is a conjunction Shakes-peare can hardly have contemplated. And if the pricewas to work without ceasing, to subordinate evenhuman relationships to the claims of duty, and to belonely yet never- to be left alone, it was a price paidgladly. It is not for the subject to pity his Sovereign,but to accept the sacrifice’with pride and humility,and to see in it an example for his own life. "
:
So, as the coffin was lowered into the vault and." thisour-brother " was committed to the ground, we returnedinto time with the sense that we ,had indeed been shown,a mystery. ,
this paradox results from failure to take seriously, the ‘
main responsibility of a clinical chief, which is teaching. Asmedical teachers are chosen today. it is accidental ff_superior talent for teaching - adorns the odd assortment ofcharacteristics demanded of jfnedical department heads."—Ir.WILLIAM BENNETT BEAN. J. Lab. clin. med. 1952, 39, 3.
