 |  |
| www.dg.dial.pipex.com | 745 readers since 19 Aug 2007 |
| |
| www.dg.dial.pipex.com | 745 readers since 19 Aug 2007 |
Plowden (1967) Notes on the text Volume 2 Preliminary pages Foreword and Contents
The 1964 National Survey: Appendix 3 1964 National Survey
Appendix 8 Social services and primary education
Report (full text) about Plowden |
The Plowden Report (1967)
A Report of the Central Advisory Council for Education (England) London: Her Majesty's Stationery Office 1967
Volume 2 Appendix 2
Part I The health of primary school children and the early development of the School Health Service The early years 1. At the turn of the century, allegations (1) that 40 to 60 per cent of men enlisting in the army were unfit for military service led to the appointment of the Inter-Departmental Committee on Physical Deterioration. Their report in 1904 was instrumental in the establishment of the School Medical Service. The Committee made a number of recommendations of which two were that: (i) 'A systematical medical inspection of children at school should be imposed as a public duty on every school authority'; and that2. In fact, in 1905 periodic medical inspections were being carried out in 85 local authorities and a number of charitable organisations were providing school meals. But the arrangements for medical inspection and school meals were such that the Inter-Departmental Committee on Medical Inspection and Feeding of Children Attending Public Elementary Schools, set up in 1905, reported that there was 'much opening for improvement', and subsequent legislation did not permit local authorities to miss these openings. 3. The Education (Provision of Meals) Act 1906, allowed education authorities to provide meals free or at a reduced cost to necessitous children. The Education (Administrative Provisions) Act 1907, imposed on local education authorities the duty to provide for the medical examination of children in public elementary schools and allowed them to make any necessary arrangements for treatment. Table 1 Recorded incidence per 100 children examined of certain diseases and defects found at periodic medical inspections to require treatment 1915-1963 4. By 1915 routine periodic medical inspections had identified some important defects common to many school children (Table 1). That year, one third of the school population of 5.3 millions were examined and about 35 per cent of the children examined had a defect requiring treatment. Equally disturbing was the discovery that many of these defects were not being treated, partly on account of the poverty of the parents and partly because of inadequate treatment facilities. 5. It was intended that the role of the school medical service should be mainly preventive (2). But so many children required treatment for defects that hampered their progress in school that the authorities were obliged either to make arrangements for treatment with voluntary associations or local hospitals, or to make use of their power under the Education Act of 1907 to organise their own treatment service. In 1913 Exchequer Grants were made available for this purpose, and by 1915 450 clinics had been established; most of these were single school clinics, but some were part of a comprehensive system of clinics undertaking the treatment of all kinds of defects. 6. The outbreak of war in 1914 interrupted the development of the school medical service. The medical examination of close on two and a half million men had resulted in the rejection of one third as unfit for military service. This was a spur to renewed activity on the part of those who championed the service. Regulations under the Education Act 1918, required authorities to arrange for the treatment of children attending public elementary schools and the medical inspection of children in the secondary schools; authorities were also allowed to provide treatment for these older pupils. 7. However, the expansion of the school medical service was again curtailed by the economic difficulties of the early 1920s and the continuing need for the service was closely questioned. But a marked improvement in the health of the nation's children had already been achieved, and this continued over the next decade. Child health in 1931 8. In the period 1906-1910 the mortality rate for infants was 118 per thousand live births. It fell to 76 per thousand for children aged 1-4, 3.7 per thousand for those aged 5-9 and 2.12 per thousand for older school children aged 10-14. Nevertheless, in 1905, 193,913 children died and 19,655 of them were children of school age. 9. By 1931 infant mortality was down to 66.4 per thousand live births, and the age specific death rate per thousand for children aged 5-14 stood at 1.9 for the period 1926-1930. In 1931, 71,990 infants and children 0-14 died, including 11,813 school children. Respiratory diseases claimed 14 per cent of these deaths, and accidents another 12 per cent, but specific infections, included in Table 2, were still responsible for nearly half the deaths. 10. Seven infections that together caused 90 per cent of the deaths from specific infectious diseases are listed in Table 3. The highest tolls among school children were due to tuberculosis (1,744 deaths) and diphtheria (1,339 deaths). Methods of protecting children against these infections were not then available. The total number of children who survived after contracting a specific infection cannot be known, but it is certain that these diseases attacked several hundred thousands of children and left a trail of ill-health in very many of them. 11. Routine medical inspections revealed, however, that the school child was in a better physical state than in previous years and only one in five of those examined had a defect, excluding dental disease, requiring treatment (Table 1). In spite of increasing unemployment between 1920 and 1930, malnutrition reached a record low level of one per cent of pupils, although in areas in which there was exceptional social distress, for example, in the Rhondda Valley, malnutrition was five times more prevalent than in the country as a whole. Classical rickets was rarely seen, although special surveys showed that the condition was by no means uncommon in a mild form (3). Only 9.6 per cent of the children examined needed spectacles. Seven per cent of the children required treatment for a condition of the nose and throat, whilst less than one per cent had organic heart disease (Table 1). Table 2 Main causes and numbers of deaths in children under 15 in 1931 and 1963 Table 3 Number of deaths and notifications* of illness for certain infectious diseases in children aged 1-14 in 1931 and 1963 *Throughout this appendix 'notifications' means statutory notifications made to Medical Offices of Health. 12. The improvement in health was encouraging but still left much to be desired. For instance, contrary to common belief at the time, children living in rural areas were by no means healthier than urban children. Medical inspection showed that as many of them were physically unfit as elsewhere in the country, while arrangements for their treatment were less effective and facilities for school meals were poorer. Even though severe malnutrition was seen in only one per cent of the nation's children who were examined, nutrition was sub-normal in another 15 per cent. A similar proportion of children were verminous on arrival at school. Dental disease was still rife, and of the children inspected 68 per cent were in need of treatment. The medical inspection of children attending secondary schools had confirmed that many defects detected at a younger age persisted through later school life and others appeared then for the first time. Nineteen per cent of school leavers were still in need of some kind of treatment, half of them because of defective vision. 13. It had also become clear that children would not benefit fully from the medical services unless their physical environment also improved. The basic requirements for healthy growth - suitable and adequate food, fresh air, appropriate amounts of exercise and rest, and a minimum standard of personal hygiene - were too often absent. The slums that were the children's homes and the streets that were their playgrounds, even the unhealthy conditions of many school premises, encouraged the diseases, accidents and ailments which it was the aim of the school medical service to eradicate or prevent. A considerable amount of school building and renovation had been carried out immediately before and after the war, but, by 1928, there still remained in many areas 'grave defects in the structure and sanitation of the schools, and in some a deplorable lack of the common necessities of decency and cleanliness ...' (4). 14. The health of the children when first admitted to school, between the ages of three and six, was another matter for concern. Although the death rate for children aged one to four had been more than halved in 30 years, it was still 7.5 per 1,000 (Table 2). Three quarters of these deaths were due to infections, commonly of the respiratory tract. 15. The medical inspection of entrants had shown that they had a higher prevalence of disease and impaired physique than older school children. Reports of three special studies of young children (5) (6) (7), issued in 1931, revealed that 27 per cent of children aged two to six had physical or mental defects (excluding dental disease and visual defects). The nutrition of nearly two per cent was 'seriously affected', 10 per cent had obvious nose and throat disease, and five per cent had clinical evidence of bronchitis; three per cent had signs of organic heart disease, while signs or symptoms of rheumatism were present in half that number. Many school entrants had discharging ears. Only a quarter of them had perfect teeth and many of the remainder were urgently in need of dental treatment. More than one third of those requiring medical treatment had not received it. 16. Maternity and child welfare centres and day nurseries, and nursery schools and classes were the only form of public service, either municipal or voluntary, available to these children. But more than half of them had never attended a welfare clinic, those that had did not continue to attend for long enough, and there was a 'deplorable absence of following up the sick child until it received treatment' (8). 17. There was also a growing realisation of the need for early medical assessment of school children. 'The whole trend of modern medicine is the early detection of the beginnings of the disease and the fortifying of the normal person' (9). Principal school medical officers were exhorted to consider and investigate the possibility of making tests of visual acuity in children before they reached the age of eight. At that age all school children had a routine vision test, but examination of their hearing was omitted. Very few authorities had anything approaching an efficient system for discovering children's loss of hearing. But the gramophone audiometer had recently been invented and this had made possible the scientific assessment of the hearing of a complete school population. Child health between 1931 and 1963 18. The first half of this period was overshadowed by six years of war. Between 1939 and 1945 the school medical service aimed to keep the bare essentials of the pre-war service functioning with the minimum of staff. It is remarkable that the nutritional level of the children was raised in spite of food rationing, and the prevalence of specific infectious diseases declined in spite of the mass evacuation of thousands of children from target areas. Declining mortality of school children 19. Mortality rates in children from 1-14 have fallen sharply since 1931 (Table 2). The rate for children aged one to four in 1963 was 0.86 per 1,000 and twice that for school children (0.38 per 1,000). The improvement since 1931 has been more striking among the younger children. Although two million more children attended school in 1963 than in 1931, the number of school children who died in 1963 (2,347) was a fraction of the figure for 1931. The rate for schoolboys (0.44 - 1,528 deaths) was still appreciably higher than the rate for schoolgirls (0.28 - 909 deaths), largely because a greater number of boys die as a result of accidents and malignant conditions. 20. The chief reason for the fall in mortality has been the great reduction in deaths from infectious diseases. In 1963 fewer than 50 school children died from the seven infections specified in Table 3, compared with nearly 4,000 in 1931. Measles alone accounted for 29 of the deaths, three times as many as were due to the formerly dreaded tuberculosis. Even chicken-pox (five deaths) killed more pupils than diphtheria, scarlet fever, whooping cough and poliomyelitis together. Acute infective encephalitis and infective hepatitis, newly identified since 1931, caused the deaths of respectively 11 and nine school children. The control of infectious diseases 21. During the early years of the period 1931 to 1963, diphtheria was brought under control and the effects of other infections were appreciably mitigated. This was achieved largely by specific immunising programmes on a national scale and the control by drugs of certain infections and their complications. 22. The annual number of notifications of diphtheria in all ages in the first 40 years of the century was around 50,000 and it reached a peak of almost 65,000 in 1938. Immunisation against diphtheria became available a number of years before the 1939 war, but it was not until 1941 that a national scheme was adopted. So successful was it that by 1948 almost six million children under the age of 15 had been immunised and notifications for that year were a tenth of what they had been. Even so, 1,606 children of school age had diphtheria in 1948 and 69 of them died. In 1963, 26 school children were notified and only one died. 23. It is a matter for some concern that only 57 per cent of children under 15 were known, in 1963, to be adequately protected against diphtheria, compared with 63.5 per cent in 1948. It is still a deadly disease that showed a 3.8 per cent case fatality rate in 1963. 24. Almost 7,000 pupils were known to have been absent from school during 1930 because of tuberculosis; in about one third of cases infection was due to bovine tubercle bacilli in milk (10). In the following year 1,744 pupils died from the disease and, in a special survey of children in ten areas, 13 per cent of children ascertained as physically handicapped were crippled by tuberculosis. 25. In 1950, in a nationwide survey of 16,719 physically handicapped pupils (11), 1 per cent had tubercular disease. In 1963, 1,198 school children contracted tuberculosis; most of the cases were of a pulmonary type, and 10 children died. Twenty-two children aged one to four died, compared with 1,600 in 1931. 26. This change has resulted from better living conditions and an improved level of nutrition in children as well as from the specific effects of the modern treatment and prophylaxis. A marked reduction in surgical tuberculosis followed the pasteurisation of milk. Bovine infection has virtually been eliminated now that tuberculosis has been eradicated from the nation's herds of cows. 27. Mass miniature radiography, the compulsory chest X-ray examination of students in colleges of education (introduced in 1952), the X-ray examination of all contacts of new cases and BCG vaccination have all helped to reduce the incidence of tuberculosis in school children. 28. However, it is apparent from the tuberculin-testing of school entrants in many areas that between five and 10 per cent of children have the infection in pre-school years, commonly in a sub-clinical form. On the other hand, pre-vaccination testing has shown that by the age of 13, 15 per cent of children may be tuberculin positive. The number of notifications of tuberculosis among young people between 15 and 24 is still one and a half times as great as the number among children up to the age of 14. The interim report (12) of the Medical Research Council's Tuberculosis Research Unit gave early confirmation of the substantial degree of protection that BCG vaccination offered adolescents for at least the following two to three years. Yet, in spite of these facts, in 1962 the parents of one in four children did not accept the offer of BCG vaccination, and over 10 per cent of the negative reactors to pre-vaccination testing were not subsequently vaccinated. 29. Scarlet fever is another disease whose power and prevalence have waned since the turn of the century. For example, in 1863 of every thousand children born in Liverpool 27 died of the infection before their fifth birthday (13). Even 15 years ago 45,482 school children in the country were infected, of whom seven died, but in 1963 there were no deaths among 11,406 pupils notified. The reduction of case fatality has been attributed to a number of general social and medical factors, but particularly to an alteration in the virulence of the organism concerned and the introduction of chemotherapy. 30. There has been a parallel decline in the incidence of rheumatic fever, the most dangerous after-effect of scarlet fever. In 1931 the incidence of rheumatism in school children was 2.2 per cent and 401 children died from rheumatic fever. Special rheumatism clinics had been established and some of these were diagnosing 100-150 new cases a year. Accommodation in special hospitals for prolonged convalescence had more than doubled. Since 1948 the condition has been seen much less. Rheumatic fever with joint involvement is now rare, as also are cases of severe rheumatic carditis and chorea. Units that have specialised in the treatment of rheumatism now cater for children with other defects, especially congenital heart conditions, and the number of children with rheumatic hearts in schools for delicate children and in those for the physically handicapped has shown a marked decline (Table 6). In 1963 15 school children died of rheumatic fever; for those that survived, there is now the chance of a functional cure as a result of the skill of the modern cardiac surgeon. 31. The mortality and prevalence of measles and whooping cough are still highest in children under five (Table 3), but many children contract these infections during their early primary school years. For example, in 1944, when the total number of notifications of whooping cough was 94,044, there were 31,930 cases among school children, and 30 of them died. Whooping cough immunisation was not then nationally organised and the search for an effective therapeutic agent had not yet been successful. Nowadays, each year between 600 and 700 thousand children complete primary courses of vaccination against the disease. In 1963 the total notifications numbered 33,937; over one third of these were of children of school age, but only one pupil died. 32. Generally, there are epidemics of measles every two years, and the great majority of children have the infection as soon as they are exposed to it. In their study of children growing up in Newcastle-upon-Tyne, Miller and his co-workers (14) found it was the commonest of the infectious illnesses of the first five years, affecting two out of three children, that most of the remainder were infected during their first year at school (raising the proportion infected at six years to four out of five) and that it was spread mainly by pre-school children, with most of its transmission independent of school attendance. It is also the commonest specific infectious disease of childhood occurring in children of school age, although almost all episodes are confined to infant school children. 1963 was an epidemic year (Table 3) and over a quarter of a million children of school age had the infection, and 29 died. The number of school children notified during epidemic years has tended to be greater than 20 years ago. In the non-epidemic year of 1962 notifications were as low as 85,167 and deaths were 15. A fatal outcome is more common among children already handicapped by chronic disability or recent acute illness (15). 33. Measles is still a major cause of ill-health in childhood, especially in young children. In a study of 53,008 cases in 1961, Miller (16) found seven per cent of the children had a potentially severe complication, commonly bronchopneumonia or otitis media, and one per cent were admitted to hospital. A breakthrough against measles is now within sight, for a vaccine has been discovered, but it remains to be decided how best to apply vaccination on a national scale if this is found to be justified (17). 34. The most recently introduced national scheme of immunisation is vaccination against poliomyelitis. Only 15 cases occurred in children of school age in 1963, of whom one died; in 1931 there were 400 cases and 21 deaths. Accidents and malignant diseases 35. Today one in every three deaths in school children is the result of an accident, although the total of accidental deaths is lower than it was in 1931 (Table 2). In 1963 836 school children were accidentally killed. More than 60 per cent of them (534) were killed on the roads, as a pedestrian in 280 cases and as a pedal cyclist in 117 cases. Of the remainder, 130 were drowned and 108 died from burns. The number of other children who were injured or maimed by accident is not known, but it may be judged from the fact that on the roads alone for every one that died 18 were seriously injured (9,865 in all). There is no evidence of an increased road accident rate during school holidays, but casualties are more frequent during the four summer months than in the preceding and following periods of four months. Twice as many girls (72) as boys (36) were burned to death, while other accidental deaths in 1963 concerned four times as many boys as girls. 36. Fortunately, the actual number of children who die from all forms of accident is smaller each year (Table 2), On the other hand, cancerous conditions are disturbingly a main cause of death of young people. In 1963 these diseases caused more deaths of school children than motor accidents; leukaemia was responsible for half of them. 37. In 1963 15 per cent of the children examined were found to have a defect requiring treatment, but this represented a 50 per cent improvement on the situation 60 years ago. Among school children as a whole dental and visual defects are still the commonest to be detected, orthopaedic defects are the next commonest, followed by diseases of the nose and throat, ears and skin. Table 4 shows how the prevalence of certain defects varies according to age. It also shows that, in general terms, half the defects (excluding those affecting the eyes and skin) found to require treatment in children on entry to school have been successfully dealt with by the time the children are ready to leave school. Defects of vision 38. Diminished visual acuity is almost always due to mild developmental deviations rather than physical ailments or ill-health. A study, carried out in 1960 (18), of defects of vision among 2,262 children in primary and secondary schools found that about half the defects were myopia or myopic astigmatism and about one third were hypermetropia or hypermetropic astigmatism. 39. Cataract is the most frequent and myopia the second most frequent visual defect requiring ascertainment of a school child as partially sighted. The prevalence of partial sight is today 0.3 per 1,000 school children, compared with one per 1,000 in 1934 (19). Table 4 Recorded incidence of certain defects and diseases requiring treatment per 1,000 children examined, in age groups - 1963 40. Blindness in children has declined with the prevention of such infectious diseases as ophthalmia neonatorum, and nowadays it is mainly due to congenital hereditary and environmental abnormalities. Between 1948 and 1954 there was a temporary increase in blindness due to the occurrence of retrolental fibroplasia in premature infants. Orthopaedic defects 41. Excluding dental diseases, orthopaedic defects are the second commonest defects found in children between eight and 13, but the third commonest in entrants and leavers (Table 4). 42. The work of the orthopaedic clinics has changed greatly in recent years. One surgeon commented (20) that, before the last war, attention was given largely to discovering the more serious ailments and making sure that they were given adequate treatment; it was not unusual during a session to find cases of bone and joint tuberculosis that required in-patient treatment. Until only a few years ago poliomyelitis also accounted for many new cases at orthopaedic clinics each year. Since tuberculosis has come under better drug control and vaccination against poliomyelitis has been available to young children, the number of children crippled by these two diseases has fallen substantially. The great majority of the children attending school orthopaedic clinics today have only minor defects of posture and feet. For example, in Stoke-on-Trent during 1958 (21), over 1,000 children attended the authority's orthopaedic clinics, but 600 had flat feet and about 300 faulty posture. With the establishment of more chiropody and remedial exercise clinics (Table 14), it has become possible to concentrate on the prevention and early treatment of foot and postural defects. Special surveys have shown that about 30 per cent of the population have foot defects which originated in childhood. Hallux valgus and cramping of the toes are the two commonest conditions. Specific foot-fitting research has demonstrated a clear association between hallux valgus and the wearing of ill-fitting shoes (22) (23) (24). While minor degrees of this condition occur naturally in some children after the age of seven, more severe deformity, and in adult life the presence of bunions, commonly follow the persistent wearing of shoes of an unsuitable shape, type or fitting. 43. Rickets is often thought of as an evil of the past, but it still exists in special circumstances in this country. Among the Stoke-on-Trent children previously referred to, 20 were treated for the effects of rickets, and it was reported in 1963 (25) that 32 children with rickets were admitted to a Glasgow hospital during the four years 1959-1962, compared with only 12 during the prior six years. The virtual disappearance of nutritional rickets has given prominence to the problem of vitamin D resistant forms (26). A survey by the British Paediatric Association indicated that present measures are keeping these diseases under control in all ordinary circumstances. 44. Within the last 15 years there have been striking changes in the numbers of children attending special schools for physically handicapped pupils (Table 5) and in the nature of their chief disabilities. Table 5 Physically handicapped children 1951 and 1963 45. Congenital and rheumatic heart disease and cerebral palsy were the pathological conditions most frequently present among 16,719 school children known to be physically handicapped in 1951. Nowadays, more than half the pupils in these schools have neurological disorders, including cerebral palsy. 46. Since 1951 the trend has been for children with quite seriously disabling conditions to be taught in an educational environment, with appropriate medical treatment, rather than in a strictly medical setting with educational help. In 1951 there were more of these children in hospitals than in special schools, but in 1963 there were six times as many in the special schools as in the hospitals (Table 5). There are now more places in special schools, but this reversal also reflects the diminished severity of many of the disorders as well as the increasing ability of special schools to manage the more severely handicapped children. Today some children with the great disability of congenital deformity or absence of limbs are attending ordinary schools. The modern trend is to keep handicapped children in ordinary schools so far as possible (see Chapter 21, Vol. 1). Congenital abnormalities 47. With declining child mortality and disability due to conditions arising after birth, the relative importance and incidence of congenital abnormalities have increased. In Great Britain today one fifth of all stillbirths and one fifth of infant deaths under one year are due to congenital malformation, as are one seventh of the deaths of children aged one to four years and one eleventh of the deaths of children of school age (Table 2). They are the one remaining major cause of serious physical disability in children, for not all the children afflicted die. 48. A national system of notification of congenital abnormalities as observed at birth was instituted in 1964, and during 1965 13,599 notifications were made, giving a reported incidence of 18.9 per 1,000 live and stillbirths (27) in England and Wales. This may well prove to be an underestimate. For instance, the incidence in Birmingham in 1950-52 (28) rose from 17.3 to 23.1 per 1,000 when the children were kept under observation until the age of five. The incidence appears, however, to vary from place to place (29). Stevenson has estimated (30) that about 50 per 1,000 liveborn infants have disabling congenital defects; 25 of them will have actual malformations, of which 15 will be recognisable at birth and the majority by five years. 49. Neurological abnormalities form the largest single group, and one of the most disabling of such disorders is spina bifida. As a result of early surgery and improved medical and nursing care, many more children with spina bifida are surviving. Nash (31) (32) gives the number of deaths in 1942 as 1,400 and in 1961 as 653. Special surveys in Sheffield and Liverpool (33) suggest that the prevalence of the condition may be as high as one per 1,000 children, five times that of blind children in the country. Experience in Sheffield indicates that two out of three children surviving with spina bifida may be mentally normal and that one in three may be able to attend ordinary schools. Children with spina bifida represented 8.5 per cent of pupils in special schools for the physically handicapped in 1963, but this percentage is rising sharply. 50. There have always been a number of children born each year with congenital absence or deformity of one or more limbs. A Ministry of Health survey (34) showed that between January 1960 and August 1962 894 such babies were born in England, Scotland and Wales. This large number, over a relatively short period of time, was in part due to the toxic effect of the drug thalidomide taken by some of the mothers (certainly 237, possibly 349) during a phase of pregnancy which is critical for the normal development of limbs. Six hundred and ninety-five of these babies survived. Respiratory diseases 51. It has been said that respiratory diseases are the most important and the least understood of all diseases of early childhood. They are the chief single cause of death before the age of five, and half the children at risk in this age range attend their family practitioner every year because of them (35). In the five to 14 age group respiratory disease accounts for 10 per cent of deaths and causes one third of all children at risk to attend their family doctor annually; in some practices (36) (37) the number is nearer two thirds. 52. There is a low incidence of tonsillitis and pharyngitis in early life which may, however, partly be due to the inability of the young child to complain of sore throat. In contrast, there is a heavy concentration of the more serious respiratory illnesses, acute bronchitis and pneumonia, during the first three years of life. By the age of five respiratory illnesses begin to decrease and, as a child gets older, diseases of the lower respiratory tract (lungs and bronchi) become less frequent and cause less constitutional disturbance, whilst catarrhal symptoms associated with upper respiratory tract infections become more prominent. 53. Within this general epidemiological pattern a second peak incidence of both upper and lower respiratory infections has been noted as a child extends his social contacts. After two or three years of mixing in a group of children, during which there is an increase in the prevalence of these infections, there is a marked decline. The timing of the secondary wave may vary. Among the children in Newcastle-upon-Tyne (38) and Paddington, London (39), who start their social mixing long before school age, it occurs between two and four years. When appreciable group activities are postponed until school entry, as in Cleveland, Ohio (40) and Beckenham, Kent (41), it occurs between the ages of five to eight. 54. Among school entrants, diseases of the nose and throat are second only to diminished visual acuity among the conditions requiring treatment (excluding dental treatment). The removal by operation of tonsils and adenoids has for long been a feature in the treatment of these respiratory diseases. The frequency of operation has always shown wide geographical and social differences. The operation has been performed most often between the ages of four and six (42) (43), but a national survey among over a million school children in 1958 (44) showed that by the age of 10 to 12, 18.6 per cent of children had been operated on. In 1931, 11,023 school children underwent tonsillectomy. Recurrent tonsillitis is nowadays more often treated conservatively, and for the last few years 65,000 pupils in each year have had the operation. 55. As a result of better therapy and a waning of virulence of the haemolytic streptococcus, severe complications of acute throat infections occur less frequently. Over a ten year period reviewed by Fry (45) there were no cases of quinsy (peri-tonsillar spread of infection), no cases of rheumatic fever and only two cases of acute nephritis among 1,566 episodes of acute tonsillitis. 56. Throughout the school years a significant amount of lung disease is found in children examined at routine and special medical inspections (Table 6). It has not diminished since 1953: of every 1,000 children examined that year, 15.4 were found with lung disease and the figure was even higher (17.3) in 1963. In very many children these conditions were bronchitis and asthma: bronchiectasis is fast disappearing from among school children. 57. It may not be surprising that, in an average year, 57 per cent of children of primary school age may be examined by their family doctor for coughs, colds or catarrh. It may be less commonly realised that, among all children at risk over a period of three years, as many as 37 per cent may have an attack of bronchitis (46). In one practice survey among children under the age of ten (47), two out of every three episodes of respiratory illness occurred in school children. In spite of an appreciable reduction in the notifications of acute pneumonia, acute chest illnesses are seen by the general practitioner as frequently as ever (48) and in some practices rather more often than before (49), while the mortality from acute bronchitis and pneumonia was the same in 1963 as it was ten years ago. Table 6 Respiratory disease in children 1931-1963 58. A sizeable proportion of children have more than one attack of bronchitis (11 per cent of Fry's series and 43 per cent of the Newcastle children), and in a minority of children chronic disabling respiratory disease develops. Home child care factors are important in determining the course of an acute respiratory illness, especially in infants, but in the few children who subsequently suffer recurrent attacks there seems to be an individual predisposition to pulmonary disease. 59. It has been estimated that about one in five children experience one or more attacks of wheezing associated with a respiratory infection (50). Most of these children cease to react in this way to these infections by the end of their primary school years, and only five to 10 per cent of them are diagnosed as asthmatics. But asthma can still kill children of school age (Table 6). Asthma and bronchitis have now become the commonest conditions for which children are admitted to special schools for delicate pupils. Diseases of the ear and deafness 60. Infection of the middle ear (otitis media) is always a risk when a young child has an upper respiratory infection because of the anatomical relationship between the middle ear and the pharynx at this period of growth. As a result, the disease is predominantly one of young school children (Table 4). 75 per cent of all acute middle ear infections occur in children under the age of ten; the highest rates were among six year olds in the 1955 Medical Research Council Survey (51). In 1958, in Plymouth (52), among over 11,000 children examined most of those requiring treatment were school entrants. In a South London practice 42 per cent of the children at risk had sought treatment for at least one attack by the age of ten. Earache and diminished hearing are more often symptoms than discharge from the ear (53). 61. The introduction of the National Health Service made it easier for children to receive prompt and effective initial treatment. Complications are now less common and the condition is less often seen in its chronic form. In the 1930s as many as one in ten children might be operated on for mastoiditis, but by 1955 the rate was one in a thousand. Nevertheless, there are still some parents who are ignorant of the significance of painless ear discharge, and in some parts of the country, especially in industrial areas, suppurative otitis media continues to be a considerable problem. The severity and outcome of the condition are related to social patterns of child care, though not the actual incidence of the disease (54) (55). 62. One of the serious dangers of continuing ear discharge is permanent damage to the middle ear and progressive diminution of hearing. In 1952 all nine year old children in Sheffield were tested with a gramophone audiometer (56), and 313 of the 6,346 children had impaired hearing; on medical examination 112 of these children were found to have otitis media. In another joint study by members of the staffs of the Department of Otalaryngology and Education of the Deaf in Manchester University (57), it was found that of 354 children examined, including 288 of school age, 52 (14 per cent) had conductive deafness due to chronic suppurative otitis media. 63. Great strides have been made since 1944 in the organisation of services for deaf and partially hearing children. These have developed as advances in electronics have led to improved hearing aids and better instruments for use in testing and training children whose hearing is impaired. 64. The testing of pre-school children by health visitors and doctors instructed in the appropriate methods has helped in the earlier detection of significant hearing loss in very young children. The gramophone audiometer has been generally superseded by the pure tone audiometer for screening tests of hearing of school children, and all local education authorities had their own audiometers by 1963 or had alternative arrangements for the testing of pupils. Many new audiology units have been established (Table 13) for the full investigation of children who fail these screening tests, and it is now possible to ensure the optimum known conditions for enabling deaf and partially hearing children to learn to communicate. 65. Perceptive or nerve deafness is a much greater handicap than conductive deafness. It is more common than conductive deafness in young children and hence a serious impediment to the development of speech. It also causes greater educational problems, and many of the children in the special schools for deaf children suffer from perceptive deafness. 66. Since 1949 the number of deaf children in special schools has fallen from 5.7 to 4.7 per 10,000 school population. But during the same period the proportion of school children classified as partially hearing, and who needed special oral teaching methods, has increased from 1.3 to 3.0 per 10,000 school population (Table 7). This is, however, a measure of progress rather than the reverse. It results from fewer children passing through school with hearing loss undetected; it is also a consequence of the earlier recognition of hearing loss in young children, better diagnosis and treatment of some of the causes, early and more effective auditory training, and use of hearing aids, so that many children are now classified as partially hearing who, not so long ago, would have been regarded as deaf. Table 7 Deaf and partially hearing children in special schools and special classes in ordinary schools 1930-1963 67. The cause of deafness is usually unknown in one third of deaf and partially hearing children; in about half of them pre-natal factors have been responsible, including genetic factors and virus infections during pregnancy (for example, rubella). Meningitis and other acute infections, and the toxic effects of the drugs used in their treatment, account for only one in six of all cases. Quite a number of children in ordinary schools have a slight loss of hearing which is, nevertheless, sufficient to retard their educational progress. In many of these children the defect can be remedied by medical or surgical treatment. Speech disorders 68. The number of children referred from routine medical inspections for speech therapy has steadily increased, from 1.5 per 1,000 children in 1938 to 4.9 in 1963. This does not mean that a defect of speech is more common than it was 25 years ago. The difference is due to more complete discovery of the children who need therapy and more therapists to provide it. 69. Morley's intensive study (58) of speech defects in children in Newcastle revealed a prevalence of three per cent among the city's 12,000 school children. A small number of these children had a severe speech disability resulting from aphasia, dysarthria or a functional disorder; the majority had a developmental speech defect, of the kind that most children have during the normal course of speech development. Treatment was required for this latter group of children (and many more were boys than girls) because the deviation from normal speech was either excessive or prolonged beyond the age of six or seven, by which time most children have acquired normal speech. Among all the children studied by Morley, 14 per cent had a serious defect of articulation at the age of five, but only three per cent had a defect persisting after the age of six and a half. Of the seven year olds in the NCDS sample (Appendix 8, Table 18), 14 per cent had speech not fully intelligible on testing by school doctors. An experienced school doctor and speech therapist, in a study based on personal interviews of 2,000 four year olds in Leicester (59), found that only 2.7 per cent had an obvious speech defect necessitating further investigation. Table 4 also shows how the need for speech therapy diminishes with age. 70. Since 1951 the number of speech therapy clinics has more than doubled and so has the number of children treated (Table 9). However, there is still an acute shortage of speech therapists, especially in the north of the country and in the midlands. The equivalent of 220 full-time therapists were employed in the school health service in 1951 but, in spite of there being training places for about 80-100 therapists a year, in the 12 years up to 1963 the national increase has been only 172. Diabetes 71. The discovery of insulin in 1922 transformed the prognosis of diabetes, which until then had been virtually hopeless (Table 8). In the absence of accurate information about its incidence in children in this country a survey was made in 1948 (60). It covered 21 counties and county boroughs with a total child population of 540,000 aged under four and 767,000 aged five to 15. Only three children under five years were found (one case in 180,000 children), but 180 children of school age (one case in 4,250). On this basis there must be at the present time at least 1,650 pupils with diabetes, but recent small surveys of school children in one English county have found an incidence more than twice as great. Table 8 Deaths in children due to diabetes 1921-1963 Epilepsy 72. Epilepsy is a symptom rather than a disease in itself. The two most important reasons for the apparently unprovoked epileptic seizures of childhood are brain damage sustained by the child at an earlier age and a genetic predisposition. Age modifies fits, and the seizure patterns in children differ in certain respects from those in older people. 73. The earlier the age of onset of seizures the more likely they are to be major ones and the more likely they are to be the result of brain injury. Trauma in itself, however, seldom causes epilepsy: young children frequently survive quite severe brain injury without fits, and many children with cerebral palsy do not have seizures. 74. Some children, possibly two per cent of those under five (61), have a short major seizure at the onset of a rapidly rising temperature, but such febrile convulsions are extremely rare outside the age range of one to three years since this effect of fever is limited to immature brains. Only a few of these children have epilepsy in later childhood (62). Of 120 children in Cooper's series (63) who had their first fit before the age of two years, only six children were still having fits at the age of six and only three went on to have epilepsy in later childhood. Another 45 children had their first fit after the age of two, but for 28 of them this was their one and only fit. In a recent survey in three general practices (64), over 60 per cent of new cases of epilepsy were in children aged 14 or under. 75. Petit mal is classically an epilepsy of childhood, with a peak age of onset between five and ten. It is commonly stated that petit mal tends to cease as the child reaches adolescence, but this is by no means always so (65). 76. The prevalence of epilepsy in school children is probably in the region of eight per 1,000 (66) (67) (68) (69). There is no evidence of any real increase. The steadily mounting number of children known by school doctors to be under treatment for epilepsy (1,307 in 1947, but 3,251 in 1963) is but evidence of better understanding between parents, teachers and doctors and more complete ascertainment. Many of these children never have fits in school, and some parents are reticent about mentioning that their child has epilepsy when it does not apparently interfere with the child's work at school. Convulsions in childhood are still a serious matter and they may be fatal. In 1963 60 children of school age died as a result of epilepsy. Diseases of the skin 77. Skin diseases are the only ones that occur with increasing frequency as school children grow up (Table 4). They are also more prevalent. They were found in 17,728 children among approximately one and a half million children examined in 1947 and in 28,523 among two million examined in 1963. The detailed returns of treatment carried out in minor ailment clinics tell a similar story in that almost as many children were treated for 'other skin conditions' in 1963 as were treated in 1947 (Table 9). Table 9 Number of children known to have received treatment for certain defects 1947-1963 78. Against this may be put the remarkable change in the prevalence of the former 'terrible trio'; scabies, ringworm and impetigo. In all, 114,814 children were treated for those conditions in 1947, but only 12,487 in 1963. These are family diseases or infestations usually associated with overcrowding, insanitary living conditions and with poor personal hygiene. 79. An increase in the incidence of scabies has always followed closely upon the outbreak of a major war, and the Second World War was no exception. By 1947 the amount of scabies in school children had returned to its pre-war level. Within another five years it was down to a little more than 3,000 cases a year, and there has been little change since then. Ringworm was at one time a major problem to be dealt with by the school medical service; the first school nurse in London was called the 'Ringworm Nurse'. Now ringworm of the scalp is hardly ever seen and ringworm of the body is mostly confined to the feet. Impetigo is diagnosed eight times less frequently than in former years. 80. No doubt general practitioners treat a certain number of school children for these three skin conditions, but the sharp decline in the numbers known to have actually received treatment indicates a satisfactory improvement in the personal hygiene of children. 81. Among entrants to school the frequency of skin diseases is almost half that among older children, and especially school leavers. It is not known how much this reflects the reduced prevalence of scabies, ringworm and impetigo; there is little detailed information about the ages of the children treated for these, although impetigo is particularly contagious among young children. There is also little information about the nature of the 'other skin conditions' known to have been treated (Table 9), beyond the fact that the most frequently occurring conditions are acne, warts and psoriasis. Thus, it may well be that the majority of these other conditions occur predominantly in older children. Gastro-intestinal disorders 82. Dysentery has occurred with increasing frequency in recent years. Approximately 11,000 children, most of them of primary school age, have been notified annually since 1958, compared with a total among all ages of 800 per annum in 1931-33. These figures draw attention to the need for high standards of personal hygiene which are encouraged by the modernisation of school lavatory and sanitary facilities. The great increase in the number of school meals, which are prepared in bulk, has been a factor also in the increase in the number of outbreaks of food poisoning. Absence from school 83. Absence from school is usually due to illness. In a study during 1947/48 (70), respiratory diseases accounted for most of this absence, but much of it was also due to intestinal infections. In the 1947/48 study 26 per cent of infant school children and approximately 15 per cent of junior and senior school pupils were absent for practically one sixth of their possible attendance during a year. In the recent study of absence among 3,273 primary school children taking part in the National Survey of Health and Development (71) 37,832 weeks of school were lost in the four years between the ages of six and a half and ten and a half. At this rate over seven million weeks of school would have been lost by junior school children during 1963. Frequent episodes of absence have been found to be educationally more harmful than an occasional long one (72). Dental health 84. The prevalence of dental disease today is little less than in 1907. When the first school dental clinic was opened that year in Cambridge the dentist found only one in ten of three to four year old children and none of the children over ten had sound teeth. 85. The Education Act of 1918 had made it a duty for authorities to provide dental treatment for children in public elementary schools, but progress in establishing this service was slow. In his report for 1929, the Chief Medical Officer to the Board of Education stated that existing services covered less than half the need. The chief reason was the shortage of dentists. By the end of 1937, however, every authority had established a scheme of dental inspection and treatment. 86. The lack of dental officers was again acute by the end of the war in 1945. Fortunately, the demand for their services was to some extent less because of an apparent reduction since 1942 in the incidence of dental caries among the children (73). In 1944 the number of children found at routine dental inspections to require treatment had fallen to one of the lowest figures recorded, 58 per cent; 20 per cent of five year old children had sound teeth (74). 87. The introduction of the National Health Service in 1946 did not affect the administrative structure under which the school dental service worked, although in practice its effect was serious because of the higher incomes obtainable by dentists under the new general dental service. It was another four years before the strength of the service approached the pre-war level and, in the meantime, there had been another change for the worse in the prevalence of dental caries. 88. This reverse coincided with the gradual removal of food rationing. It has been noted that the consumption per head of sugar has closely followed the fluctuations in the prevalence of dental caries (Table 11), and there is now strong evidence that sweet, sticky articles of food are a major cause of dental decay, although their effect can be modified considerably by other factors, including diets enriched by vitamin D. 89. Quinquennial surveys since 1948 (Table 10) have shown that only within the last five years has there been any appreciable change for the better among five year old pupils and a slowing down of the deterioration among twelve year olds. Some 60 per cent of children inspected were found to need treatment in 1963. The improvement in dental health in five and twelve year old children in 1963 has, however, occurred in spite of a stationary consumption of sugar, and there is good reason to believe that parents and children are now more aware of the benefits of dental fitness and are more ready to seek and accept conservative treatment of early caries. The amount of treatment provided by the School Dental and Joint Dental Services has greatly reduced the number of emergency treatments needed. Table 10 Incidence of dental caries in school children 1948-1963 Table 11 Sugar consumption per capita in the United Kingdom ('Group' figures include sugar, glucose, honey) 90. The fluoridation of water supplies has been shown (75) to reduce substantially the amount of dental caries in children's teeth, but it is clear that this must be considered a useful adjunct to traditional health education methods and effective treatment services. It is encouraging that by the end of 1963 the equivalent number of full-time dental officers had reached the highest recorded figure of 1,215, a ratio of one to 5,840 pupils. However, the distribution of school dentists is still uneven throughout the country. Improvement in the physical health of school children 91. This chronicle of diminishing ill health and diminishing prevalence of ailments and defects seen by school doctors has been matched by more positive evidence of an improvement in the health of school children, in the form of accelerated physical growth (see Table 12) and better general physical condition. The result of all these has been a noticeable increase in the liveliness and physical activity of contemporary primary school children. Table 12 Average height of London school children 1905-1959 92. In the early days of the school medical service a general estimate of the quality of nutrition was recorded at medical inspections. As malnutrition in school children became rare a wider assessment of their general physical health was required. Their general physical condition is now classified as 'satisfactory' or 'unsatisfactory' (School Health Service and Handicapped Pupils Regulations, 1953). This has focused attention upon the need mainly to consider whether there is any way in which a particular child's physical condition and health can be improved as a result of treatment following investigation. The physical condition of more than 99 per cent of school children is nowadays assessed as satisfactory. The School Meals Service 93. The School Meals Service has made an important contribution to this state of affairs. By 1930 almost half of the 317 authorities were providing school dinners and 320,000 pupils were eating them. Many of the authorities were also assisting in schemes for 'milk clubs', enabling some 800,000 children to have one third of a pint of milk daily at school at the cost of one penny. 94. The Education Act 1944 made it a duty of local education authorities to provide school meals and milk, and since 1946 every school child has been entitled to one third of a pint of milk per day, free of charge. Consequently, during the last 20 years or so the annual number of children having school dinners has increased to 3,849,401 (59 per cent of the children at school), of whom 4.4 per cent were given free dinners. And in 1963 over 90 per cent of primary school pupils and two thirds of secondary school children - 5,855,307 pupils in all - had milk each day. 95. These figures relate the increasing use made of the school meals service. They do not reveal the change that has taken place in the character of the service during the last 25 years. 'Feeding centres' have given place to school canteens, many schools have their own kitchens and dining facilities, and school dinners have become an integral part of the school day. There is, however, some difference of opinion about the social value of the school meal in present conditions and about the desirability of the younger children staying at school for their dinner. 96. So much has the nutritional state of school children improved that it is now the fat boy who is beginning to present more of a problem to school doctors than the undernourished child. For example, in 1960, in Wakefield (76), as many as 2.7 per cent of children examined by school doctors were considered obese. The increase in obesity prompted the thought in 1962 that school children were getting too much to eat as a result of school meals. However, the Standing Committee on Medical and Nutritional Aspects of Food Policy of the Ministry of Health knew of no evidence from the health records of the school population or elsewhere that this was so, save perhaps in a minority of cases of obesity - a conclusion supported by a Departmental Working Party in their Report on the Nutritional Standard of the School Dinner and the Type of Meal (77). Even in these cases such factors as the diet at home and the sweets consumed, in relation to the amount of exercise taken, were considered to be causally more important than the lunches and milk taken at school. School milk and meals provide those who take them with a substantial part of their daily food requirements. One third of a pint of milk gives a primary school child about 10 per cent of the recommended daily allowance of protein, 23 per cent of his calcium and six per cent of his calories (78). A school dinner is intended to have an energy value of 650-1,000 calories, according to the age of the child, and supplies on average 20g (0.44 Ibs.) of animal protein and 25-30g (0.55 lbs.-0.66 Ibs.) of fat [*]; thus, it provides about a third of the total protein and calories required daily. There are still some children whose nutrition is likely to be dependent on food provided in school. Recent studies (79 and 80) have indicated that the diets that are least likely to be adequate are those of families with three or more children. Between 1950 and 1959 these and other groups showed appreciable reductions in protein intake associated with increased consumption of sugar and fat, both largely conveyors of 'empty calories'. About 1959 there was, however, some improvement both absolutely and in terms of the percentage of calories derived from protein. While no one would advocate a return to the austerities of rationing, it had at least the virtue that money spent on food was spent in ways that were nutritionally above reproach. [*These conversions are wrong: 20g is 0.044lbs (not 0.44lbs) and 25-30g is 0.055-0.066 Ibs (not 0.55-0.66 Ibs).] Infestation of children 97. In 1963 1.7 per cent of children (187,354) inspected by the school nurses were found to be verminous, compared with 14 per cent in 1931, and in many schools all the children have remained clean for year after year. Infestation has always been more prevalent in poor areas with bad social conditions and in densely populated industrial and urban areas than in rural parts of the country. It is essentially a social and family problem that has become less prominent as living standards have improved and as cleanliness has been promoted by health education in schools. The greater efficiency of the newer insecticides has also helped. Summary 98. In this Section, against the background of the early development of the School Health Service since its origin as a School Medical Service, we have traced the changing physical health of children of primary school age. In particular, we have noted: (a) the remarkable reduction in mortality due to the effective control of certain infectious diseases; 
Part II Development of the school health services since 1944 99. It is a truism that poor health in children may limit the influence of education. School doctors have always preferred to interpret health in terms of function; their concern has been less with diseases of childhood than that children should be functioning normally and living and growing in harmony with their environment. The responsibility of the school health service has therefore been to see that school children are not denied through unrecognised or untreated ill health the opportunity to make the most of what school can offer. This is as clearly the role of the service today as it was nearly 60 years ago. 100. By the Education Act of 1944, the School Medical Service was renamed the School Health Service. The present era of the service may be said to date from this Act and the National Health Service Act of 1946. 101. Under the Education Act parents of children in maintained schools were obliged to submit their children to medical inspection. The same facilities for free medical treatment that were already available to primary school children were extended to secondary school children. 102. The principal effect for children of the National Health Service Act was to entitle them to free medical attention from the general practitioner and hospital specialist services. Circular 179, issued by the Ministry of Education in 1948, broadly indicated the principles that were to underlie the coordination of the health and education services. In fact, local authorities now largely rely upon the National Health Service in discharging their obligations under the Education Act to provide free medical treatment for school children, and Regional Hospital Boards usually provide the services of specialists attending local education authority clinics. The clinics chiefly affected have been ophthalmic, orthopaedic and ear, nose and throat clinics; while these have continued mostly to be held in local authority premises they have sometimes been transferred to hospital premises. The provision of spectacles for school children has become the responsibility of the Supplementary Ophthalmic Service. Hearing aids are also provided by the National Health Service, except when an authority considers it is in the interests of a pupil to be supplied with a special aid. 103. The full range and number of clinical services provided by local education authorities and the special clinics arranged for school children in hospital out-patient departments are detailed in Table 13. There are now about 2,700 school clinic premises. Some of these are large with a wide range of services, others are small branch clinics with limited services. Some of the clinics are in fine modern buildings, but many are in adapted premises, quite a number of which are out of date, inconvenient for children and parents and poorly equipped and furnished. 104. The need for a special health service for children at school was admirably expressed in Circular 576, issued in 1907. It defined the purpose of school medical inspection as 'the medical examination and supervision not only of children known, or suspected, to be weakly or ailing, but of all children in the elementary schools, with a view to adapting and modifying the system of education to the needs and capacities of the child, securing the early detection of unsuspected defects, checking incipient maladies at their onset, and furnishing the facts which will guide education authorities in relation to physical and mental development during school life'. That there is still need for such a service today was emphasised in the Report (81), published in 1962, of a Joint Medical Committee appointed by the profession to review the work of the health services in Britain. 105. The function of the school health service is primarily preventive and advisory. It was not, and is not, a rival to the domiciliary and hospital medical services. This fact has sometimes been overlooked since, in its early years, the service was preoccupied with arranging treatment that was otherwise unavailable for the unfit child. However, the introduction of the National Health Service in 1948 enabled the school health service for the first time to concentrate on its primary objectives. 106. Table 13 also shows something of the changing nature of the work of the school health service since 1938. There are more audiology, speech therapy, child guidance, chiropody and remedial exercise clinics. There are fewer heart and rheumatism clinics. There are more clinics for asthmatic children and newly established clinics for enuretic children. Minor ailment clinics are more numerous, but the work is rather different. Practically all the skin diseases and external eye conditions referred to in Table 9 were treated in minor ailment clinics, and the 'Miscellaneous Conditions' in 1963 included many special examinations of children as well as BCG vaccinations given to 10 to 14 year old children. Table 13 Type and number of clinic services 1938-1963 107. These changes have occurred in response to a change in need, and the change in need is but a reflection of continuing improvement in the physical health of school children during this period. This has now reached the point when the school health service can justifiably pay much more attention to the mental health of school children. One of the most important changes in clinic services has been the establishment by local education authorities of child guidance clinics. 108. The detection and treatment of illness neither modify nor reduce their causes when these are environmental. In the last 30 years much has been done to combat and reduce the social evils which contribute to physical ill-health, but much remains to be done. Poverty has not been eliminated. Not all parents can afford sufficient clothes for their children and, in Bootle, for example, in 1958 (82), free clothing and footwear were provided for 898 school children. In 1963 well over a quarter of a million needy children were given free meals in school, 4.4 per cent of those taking school meals compared with 3.7 per cent five years previously. The living conditions of many children have improved beyond recognition - but not of all of them. Of the 5,000 children followed over 18 years since 1946, in the National Survey of Health and Development (83), more than 12 per cent always shared their bed with another child or adult, seven per cent lived throughout in homes that lacked several essential amenities and two per cent in homes that during the whole of their childhood were consistently overcrowded and lacked amenities. In terms of total population, two per cent of children under the age of 15 amount to nearly a quarter of a million children. 109. The role of the school in minimising the effects of such standards of living is made immeasurably more difficult when the hygienic arrangements in the school are themselves sub-standard. In 1962, amongst other deficiencies, one primary school in four lacked a hot water supply and two out of three had only outdoor sanitation (84). 110. Attention is now turning to the effects of the environment on mental health. Health is viewed in terms of mental harmony as well as adequate growth in size and stature and freedom from physical illness. It is acknowledged that the origin of some of the recurrent disorders in childhood lies in emotional disturbance rather than physical pathology. Such diverse conditions as alimentary infections, accidents, retarded growth and enuresis have been grouped together as diseases of the social environment (85), while others may form part of a family pattern of reaction to environmental stress (86). The physical health of a child is only a part of his total adjustment and adaptation to continually changing circumstances. Mental health 111. The prevalence of mental disturbance in school children is not accurately known; statistical assessment bristles with difficulties, from an elementary lack of definition of terms to the elusiveness of standardised measurements of personality and behaviour. When the Underwood Committee (87) commissioned enquiries in three areas in 1955, the estimates ranged from 0.3 per cent to nine per cent. On the other hand, surveys of the problem in rural and urban areas (88) (89) have put the figure as high as 20 to 30 per cent. In an educational and medical survey of children aged nine to ten, 6.3 per cent were found to be in need of psychiatric advice or treatment, including 2.2 per cent with severe disorders (90). 112. The increasing number of children attending child guidance clinics each year is a corollary to the increased number of such clinics available. Demand continually outstrips provision and the service is still at the stage when provision actually stimulates demand. In fact, this has been the case since the pioneer East London Clinic was opened in 1926. There are now 325 clinics, but the opening of additional clinics has been mainly limited by insufficient staff (Table 14). 113. Although some authorities have excellent child guidance clinic services many have none at all: others operate well below the optimum strength. In most areas the Regional Hospital Boards have provided at least a minimal child psychiatric service based on a hospital. As the usual arrangement in local authority child guidance clinics is for the Boards to provide the services of the psychiatrist, the governing factor remains the lack of these consultants. However, 40 local authorities are still without the services of a psychologist. On the whole, the South East and East are better provided for than the rest of the country. Table 14 Local authority child guidance clinic staff (in full-time equivalents) 114. The local authority clinic has always worked closely with the school, the educational psychologists sharing their time between the clinic and the school psychological service. By contrast, the hospital services have commonly had closer links with the general practitioners than with the schools, their interests being more towards family psychiatry. Whatever may be the cause of a child's disturbance, the influence of the school is considerable in either aggravating or modifying it. It is rare for children with recognised and significant behaviour disorders or physical symptoms of a predominantly neurotic nature not to experience difficulties in school, though their problems may be due as much to parental mismanagement as to their own constitution. The educational element is thus an exceedingly important one when dealing with maladjustment in school children. Nevertheless, a disturbed child comes so often from a disturbed family that local authority clinics are adopting increasingly a family approach to diagnosis and therapy, while maintaining their relationships with the schools. 115. Although the child guidance service aims, through family and child therapy, to prevent mental ill health in adolescence and adult life, it is not a truly preventive service because it is used only when a parent or teacher needs guidance in the care of a child already showing disturbance. True preventive work is a matter of education and involves teachers, school doctors and health visitors. The special contribution of the child guidance service might be in educating such staff in mental health, about which there is a large reservoir of knowledge which is hardly used in this direction (91). In-service training for school doctors and health visitors, as already provided by some clinics, is necessary if their role is to change from passive observer to that of effective worker at an appropriate level. 116. The rate at which this change is proceeding is still slow. The chief reasons are the shortage of clinic staff and pressure of other work upon an understaffed school health service. But there is a problem here which has yet to be resolved by many authorities: the selection of priorities and the organisation of the work accordingly. The work of the School Health Service 117. The work of the school health service today consists principally of: (a) the medical examination of children in school;Routine medical inspections of school children 118. The classical measure for detecting diseases and defects in school children has been the periodic medical inspection. Circular 576 of 1907 proposed four inspections during the school years: on entry, at the ages of seven and 11, and just before the child left school. The recommended conduct of the medical inspections would not be considered sufficient today: each inspection was to occupy on the average not more than a few minutes, and it was expected that as a rule the child would only need to have its clothes loosened or be partially undressed; children under six were not to have their vision tested, and tests of hearing were only to be given in a general way. However, the point was made even then that 'needless medical examination of healthy children should, for obvious reasons, be avoided' (92). Nevertheless, this remained the pattern for many years, and about two million children were examined annually. Almost the only new development was an increasing use of special examinations in clinics, which allowed a more thorough investigation of a child than was possible in a school inspection. 119. Thirty years ago some experienced school doctors began to question the need for so many medical inspections. It seemed to them that as a method of detecting the earliest deviations from normal health it could be improved upon and that the superficial examination of hundreds of thousands of normal healthy children was an uneconomical use of limited staff. Part of the case for modifying routine inspections still rests upon the need to concentrate the special skills of overtaxed staff on the children whose problems most require them. For this reason the revised School Health Service and Handicapped Pupils Regulations of 1953 and 1959 allowed authorities to experiment with less than three inspections during the school years. Staffing 120. The number of doctors employed in the school health service at various times since 1931 is given below (Table 15). In 1931 there was the equivalent of one whole-time school doctor for every 7,500 pupils. The situation is little better today. It is estimated that for the school health service to perform its proper function one school doctor is required for every 6,000 school children, a ratio only once achieved after the war. 121. The ratio of school nurses to school children is only a little more encouraging (Table 16). Although lower than desirable, it has remained stationary for ten years. Following the report of the Working Party on Health Visiting, published in September 1953 (93), an increasing number of school nurses have been qualified health visitors working in both local health and local education authority services. But relatively unskilled duties at clinics and medical inspections, and the simple screening tests for hearing and vision, are now being delegated to suitably instructed but unqualified assistant staff, leaving the school health visitor free to concentrate on the work for which she is especially trained. 122. There are no ancillary workers able to relieve the school doctor of his routine work. With so much to be done in the field of mental health and in the comprehensive assessment of handicapped children, and with so few doctors to do it, there must perforce be some modification of the routine work which does not give full value in terms of the time and skill employed. In the social circumstances prevailing in Britain today it is even more difficult than it was 30 years ago to justify the routine examination every year of one and a quarter million healthy children in the intermediate and school-leaving age groups. Table 15 Number of doctors in the School Health Service 1931-1963 Table 16 Number of school nurses 1931-1963 123. This view is now receiving much wider support. By 1964 more than a third of education authorities had adopted, to some extent if not throughout their school health service, a system of selecting for special examination only those children whose symptoms or behaviour indicate the need for it. A variety of selection methods has now been used (94) (95), including questionnaires completed by parents and teachers, special requests to teachers and health visitors for the names of children known to be causing concern either at home or in school, and perusal of attendance registers. Children whose names are brought forward, and returned questionnaires, are usually discussed by the school doctor, head teacher and health visitor before parents are advised of the need for selected children to be examined. These will include children noted at the school entry examination to need following closely. A number of authorities also invite parents to request a medical examination if they wish this for any reason. 124. In areas where a selective procedure has been carefully thought out, and introduced with conviction, it has been welcomed by parents, teachers and doctors. It has brought parents and teachers into closer touch with the school health service and focused attention on the children causing concern. It has commonly been accompanied by more frequent visits of the school doctor and, almost without exception, teachers prefer these new arrangements. 125. At present, selective medical inspections are used mainly as an alternative to the routine examination of all children either at the age of eight or between 10 and 12, or both. Only rarely have they replaced the routine examination of school leavers. 126. There is universal agreement on the value of a routine examination on entry to school. Almost invariably mothers accompany their children on this occasion. A full medical history may be obtained from the parent which adds to the value of the physical examination. Many thousands of young children already show by the age of five the marks of their brush with disease and a faulty environment. The interview of the child and his mother is also an occasion for a functional assessment of the growth and development of the child involving all aspects of his behaviour, and it should be as much concerned with a search for reasons why the child might have learning difficulties as for the presence of physical defects. 127. A comprehensive assessment and examination such as this cannot be done in a few minutes. All too often 20 to 25 children are called for in a session of two and a half to three hours, although the recommendation has been made (96) that 10-12 are quite sufficient for a session of this length. An appointment system is necessary when children are examined at intervals of 15 minutes. It has the added advantage of making some privacy possible for the interview with the parent, especially in those schools that do not have a medical inspection room. The Standards for School Premises Regulations 1959 do not require that a school has a medical inspection room, but that a room should always be immediately available for inspection and treatment of pupils. The introduction of selective medical examinations and the more frequent and regular attendance of the doctor at the school make it even more necessary that each school should have suitable accommodation available for such purposes as visits by the school doctor, nurse and the educational psychologist. As it is, there are many schools where inspections are done under deplorable conditions. The assessment of handicapped pupils 128. The importance of the early discovery of children with mental or physical handicaps was fully realised 20 years ago. The Education Act 1944 requires parents to submit their children for medical examination at any time after the age of two, if it is considered necessary by an education authority in order to carry out its duty of ascertaining which children may need special educational treatment as handicapped pupils. Many children with severe disabilities are referred by health visitors for assessment before they reach school age and even before the age of two. This may occur as a result of home visits by the health visitor or by the increasingly popular measure of the maintenance, by health departments, of a risk register of children in whom certain physical disorders are more likely to be present than is normally the case. Special diagnostic clinics and facilities for parent guidance have been arranged for children with certain specific disabilities, such as deafness, blindness and cerebral palsy. Ascertainment and counselling are a major responsibility of the school health service as well as the maternity and child welfare services (see Volume 1, Chapter 21). Health education 129. In the primary school, health education is mainly concerned with elementary personal hygiene and the prevention of infection, with dental hygiene, first aid and the prevention of accidents especially in the home. It is carried out mostly by teachers and health visitors. When school doctors are involved they usually undertake more responsibility for it in secondary schools, in the form of counselling of adolescents. Earlier maturity means that teachers in primary schools may expect more questions than formerly on the facts of reproduction and on personal relationships. Control of infectious diseases in school 130. The decline in severity and frequency of most of the specific infections, especially those of childhood, has led to a change in the pattern of infections seen in school children. Infective hepatitis, chicken pox and rubella remain and are not yet controlled by immunisation. The suppression of one disease has given added importance to the remaining ones. Less clearly defined infectious illnesses are now receiving more attention. Some of these are due to viruses which have been identified. The causes of others, such as winter vomiting, are not yet known. 131. The control of infectious diseases rests with the local authority, but principal school medical officers also have responsibilities to the education authorities. School doctors play a valuable role in supervising the hygiene of school premises, especially of canteens. They also assist in immunisation procedures. Vigilance is still needed against the specific infectious diseases described in Part I of this Appendix. Defence against several of these infections lies in the maintenance of an adequate state of immunity among a sufficiently high proportion of the susceptible population and a high level of personal hygiene among the children. Future trends affecting primary school children 132. For children below secondary school age it is recognised that trends in the school health service must be towards the earlier identification of the less severe disabilities in children which impede their growth and development and their education in school; an extension of screening procedures towards this end; a wider functional assessment of children around the age of entry to school; a more complete assessment of handicapped pupils with regard as much for residual abilities as for primary disabilities; and a greater participation by school doctors and nurses in the management of incipient maladjustment and in its prevention. Mental health depends to a large extent upon personal relationships. In the necessary expansion of advisory work with teachers and parents of all children, but especially of handicapped children, attention needs to be given to difficulties in emotional development that are associated with personal relations as well as to guidance regarding any specific disability when one is present. 133. The prime responsibility for health, and specifically sex education, rests with teachers, although school doctors may well have a part to play in advisory work. While at present children of secondary school age receive advice on personal relationships more than younger children, any raising of the age of transfer from primary to secondary education would mean that opportunities for dealing with this topic would have to be provided in the primary school. All schools need a policy for ensuring that children know the facts of reproduction before they leave the primary school and that questions including those touching on personal relationships are answered when they are raised. Health education to curb the increase in smoking amongst school children must begin in the primary school. Already 10 per cent of 12 year old schoolboys smoke regularly and some do so from as early as nine or ten (97). The recent anti-smoking campaigns, however, are having some effect. In recent years there has been some cessation of smoking in adolescents (98). 134. It is highly significant for the school health service that both research and clinical experience have clearly shown that the disturbance in mental health of many of the school children attending child guidance clinics (even of the 10 per cent of them who are of secondary school age) has its origin during the formative years before the child first goes to school. The amount of intellectual under-functioning in children is not known, but it is thought to be considerable. That failure in children, either social or educational, may profoundly affect their personality and produce behaviour disorders, is better understood than how much failure is due to preceding personality disturbance. This subject has recently been discussed in detail (99) in an international report which adds to the weight of evidence that experiences during the early years of childhood, especially the amount and quality of environmental stimulation, are as important for the realisation of full intellectual potential in later years as they are for emotional stability (see Volume 1, Chapter 2). 135. These facts point the way to measures which have as yet hardly begun to be exploited for the prevention and the early detection of emotional and intellectual handicaps. Regular developmental examinations during infancy and pre-school years can form the basis of an observation register, which can include the names of children still requiring to be kept under observation following examination because they have been in a perinatal 'at risk' group. Such registration might take account of the emotional vulnerability of some children during biologically sensitive periods of growth and development (100), and of others who are likely to have emotional difficulties as a result of bereavement or belonging to broken homes or families with special problems. 136. The observation register has the advantage over the risk register of being compiled from a screening procedure applied to a total age group. Screening tests are not intended to be diagnostic tests identifying those requiring treatment. Their value lies in their ability to detect potential disabilities at the pre-symptomatic stage for subsequent observation. For example, hearing loss of many children will fail to be revealed by reliance on a risk register alone. There is need for both kinds of approach to the discovery of children with handicaps. 137. The health services already use a number of screening procedures, including vision and hearing (audiometric) tests, measurements of height and weight, tuberculin tests and health questionnaires. These are not, however, being applied extensively. For instance, vision tests are not always given annually and hearing tests never are. The exact value of some of these screening tests, and how often they should be given, have yet to be determined in terms of their role in the continuing supervision of children in primary schools after an initial comprehensive assessment. It is necessary to search for and try out new screening devices. Limited experience with group tests of attainment or non-verbal intelligence justifies their wider application as a screening test for mental retardation and maladjustment. The results of current research (for example, The Isle of Wight Educational and Medical Survey, and The National Child Development Study) may result in the use of standardised questionnaires to identify children with learning and emotional difficulties in school. 138. It is disquieting that an assessment of developmental need for the child is so seldom made before he goes to school, except when he has a severe mental or physical disability. Thus, it is not possible to attempt any modification of the educational environment until after the child has been exposed to the risk of failure at an exceedingly vulnerable stage of life. Accordingly, a few authorities have experimented with a scheme for the routine medical inspection of children during the term before they are due to enter school (101). 139. Children's needs cannot be met by a single examination, whether this is just before or just after the child's admission to school. They result from insufficient demand for medical supervision during the years between infancy and school attendance, unless a severe mental or physical disorder in the child forces the parents to seek help. Parents are not obliged to use the services provided, in contrast to the situation when the child reaches school age. Supervision ought to be a continuing process, irrespective of the child's age. This means that the health service for children should be coordinated. The need for a coordinated health service for children 140. In the local authority services the duties of assistant medical officers and school medical officers already overlap. There is, indeed, almost complete integration of local health and school health services in all but a handful of authorities. The health visitors are school nurses in most authorities, and approximately 1,750 of the 1,900 doctors employed by local authorities work in both services. In addition, in many areas there is zoning of staff providing these services, so that a doctor will work with one or more health visitors and school nurses in a team based on a clinic and the surrounding infant and junior schools. He can then examine at medical inspections in schools the children he has seen as infants in the child welfare centres. 141. Close cooperation has not yet been achieved between general practitioners and the school health service. Yet in some parts of the country general practitioners are already working in the school health service on a sessional basis, and in one county this has been the pattern for nearly 60 years. In their report published in 1963 (102), The Gillie Committee observed that '... as family doctors find an increasing interest in the environmental circumstances of their patients, they will participate more fully in clinic work among those groups which are the responsibility of the health departments'. In 1963 there were 623 general practitioners and married women doctors engaged in school health service work, compared with 386 in 1931 (Table 15). This trend is welcomed in turn by the school health service. It is the most natural and satisfactory method of ensuring continuity of medical care and treatment for individual children throughout their childhood, and it increases the understanding and cooperation between doctors in the family practitioner and school health services. Furthermore, it allows for the fullest and most economical use of the time and particular skills of the doctors working full-time in the local authority child health services. 142. The work of these services involves knowledge of child development and psychology, of health and disease in children, of child neurology and child psychiatry. It is therefore regrettable that this work is not more widely recognised as a branch of paediatrics. If it were, much closer links might be forged between the school health service and the hospital paediatric service. 143. One of the recommendations of the Platt Committee (103) was that a new type of post of unlimited tenure - that of medical assistant - should be established in the hospital staffing structure. When this recommendation is implemented the further suggestion of the Platt Committee that some medical assistants might also be employed part-time in the local authority health services could well be adopted by the joint appointment of a doctor as medical assistant to a paediatric department in a hospital and as a senior medical officer in the school health service. 144. Herein lies a great opportunity to bring paediatric departments of hospitals into active collaboration with general practitioners and school doctors. In this way it would be possible to provide a continuous and coordinated health service for children, from infancy, through school years and adolescence. 145. The better physical health enjoyed by the majority of school children, and the facilities for treatment now provided by the National Health Service, mean that the School Health Service should take up the challenge presented by the various environmental factors that today disturb the development and learning of the children. The Service should be able to attend to its primary function of providing an advisory service for children, their parents and teachers within the school setting.
List of references (1) Report of Inter-Departmental Committee on Physical Deterioration. 1904. HMSO. (2) Circulars 576, 582 and 596. Board of Education. 1907. HMSO. (3) Report of Chief Medical Officer, Board of Education. 1931. HMSO. (4) Report of Chief Medical Officer, Board of Education. 1928. HMSO. (5) See (3) above. (6) See (4) above. (7) On the State of Public Health. 1931. HMSO. (8) See (3) above. (9) See (3) above. (10) Memorandum on Bovine Tuberculosis in Man. Ministry of Health Report on Public Health and Medical Subjects. No. 63. 1931. HMSO. (11) Report of the Chief Medical Officer, Ministry of Education. 1952/53. HMSO. (12) Report of the Medical Research Council's Tuberculosis Research Unit. 1956. Brit. Med. J. i. 413. (13) Monthly Bulletin of the Ministry of Health. Vol. 14. July 1955. London: HMSO. (14) MILLER FJ et al. 1960. Growing up in Newcastle-upon-Tyne. Oxford University Press. (15) Monthly Bulletin of the Ministry of Health. 1963, 22, 167. (16) MILLER DL 1964. Brit. Med. J. 11 July. (17) Report of Measles Vaccine Committee, Medical Research Council. 1965. Brit. Med. J. 1, 817. (18) Report of Chief Medical Officer, Ministry of Education. 1960/61. HMSO. (19) Report of the Committee of Enquiry into Problems Relating to Partially Sighted Children. 1934. HMSO. (20) Report of the Chief Medical Officer, Ministry of Education. 1954/55. HMSO. (21) Report of the Principal School Medical Officer, Stoke-on-Trent. 1958. (22) SHINE IB 1965. Brit. Med. J. 1, 1,648. (23) CRAIGMILE DA 1953. Brit. Med. J. 2, 749. (24) BURRY HS Brit. Boot, Shoe and Allied Trades Rs. Ass. Report. No. 147. (25) ARNEIL GC and CROSBIE JC 1963. Lancet 31 August. (26) STEWART WK et al. 1964. Lancet 28 March. (27) Report of Chief Medical Officer, Ministry of Health. 1965. (28) MCKEOWN T and RECORD RG 1960. In: Ciba Foundation Symposium on Congenital Malformations. London. (29) LAURENCE M 1965. Arch. Dis. Childh. 40, 451. (30) STEVENSON AC 1961. British Medical Bulletin 17, No. 3. (31) NASH E 1956. Brit. J. of Urology. Vol. XXVIII, No. 4. December. (32) NASH E 1963. Proc. Roy. Soc. Med. Vol. 56, No. 6. June. (33) Report of the Chief Medical Officer, Department of Education and Science. 1962/63. HMSO. (34) Deformities Caused by Thalidomide. Ministry of Health Report on Public Health and Medical Subjects. No. 112. 1964. HMSO. (35) FRY J 1958. Morbidity Statistics in General Practice, Vol. I. Medical and Population Subjects, No. 14. HMSO. (36) COOK N 1954. Medical World. 80, 539. (37) FRY J 1961. The Catarrhal Child. London. Butterworth. (38) See (14) above. (39) CRUICKSHANK R 1958. Brit. Med. J. 1, 119. (40) DINGLE J et al. 1953. Ann. Intern. Med. 43, 518. (41) See (37) above. (42) GLEN JA 1938. Proc. Soc. Med. 31, 1,219. (43) CARNE S 1956. Brit. Med. J. 2, 19. (44) Report of the Chief Medical Officer, Ministry of Education. 1958/59. HMSO. (45) See (37) above. (46) See (36) above. (47) See (37) above. (48) See (37) above. (49) BEAUCHAMP A 1958. Brit. Med. J. 2, 234. (50) See (37) above. (51) Report of Medical Research Council's Working Party for Research in General Practice: Acute Otitis Media in General Practice. Lancet 1957. 2, 510. (52) Report of Principal School Medical Officer, Plymouth. 1958. (53) See (51) above. (54) DOUGLAS JWB and BLOMFIELD JM 1958. Children Under Five. London: Alien and Unwin. (55) FRY J 1960. Morbidity Statistics in General Practice, Vol. II. Medical and Population Subjects. No. 14. London: HMSO. (56) Report of the Principal School Medical Officer, Sheffield. 1952. (57) See (44) above. (58) MORELY ME 1957. The Development and Disorder of Speech in Childhood. Edinburgh and London: Livingstone. (59) Report of Chief Medical Officer, Department of Education and Science. 1964/65. HMSO. (60) Report of Chief Medical Officer, Ministry of Education. 1948/49. HMSO. (61) LENNOX WG 1960. Epilepsy and Related Disorders. Churchill, Vol. 1. (62) MELIN KA 1954. Mschr. Kinderheilk. 102, 62. (63) COOPER JE 1965. Brit. Med. J. 1, 1,020. (64) POND DA et al. 1960. Psychiat. Neurol. Neurochir. (Amst.) 63, 217. (65) LEES F and LIVERSEDGE LA 1962. Lancet ii, 797. (66) See (63) above. (67) See (64) above. (68) Report by Research Committee of the College of General Practitioners. 1960. Brit. Med. J. 2, 416. (69) RUTTER M et al. 1966. Severe Reading Retardation: its relationship to maladjustment, epilepsy and neurological disorders (Isle of Wight Survey). Paper read at Association for Special Education International Conference, London. (70) BRANSBY ER 1951. Med. Off. 1st and 8th December. (71) DOUGLAS JWB 1964. Papers prepared at the request of the Central Advisory Council. (72) See (71) above. (73) Report of the Principal School Medical Officer, London County Council. 1943. (74) Report of the Chief Medical Officer, Ministry of Education. 1939-45, HMSO. (75) The Conduct of Fluoridation Studies in the United Kingdom and the Results Achieved After Five Years. 1962. HMSO. (76) Report of the Principal School Medical Officer, Wakefield. 1960. (77) The Nutritional Standard of the School Dinner. Report of the Departmental Working Party. 1965. HMSO. (78) British Medical Association Committee on Nutrition. 1950. HMSO. (79) The National Food Surveys, 1950-1963. (80) ABEL-SMITH B and TOWNSEND P The Poor and the Poorest. Occasional Papers on Social Administration. No. 17. Bell. 1965. LAMBERT R 'Nutrition in Britain', 1950-1960. Occasional Papers. No. 6. (81) A Review of the Medical Services in Great Britain. 1962. Social Assay, (Porritt Committee Report). (82) Report of the Principal School Medical Officer, Bootle. 1958. (83) DOUGLAS JWB 1964. Public Health. 4, 196. (84) The School Building Survey. 1962. HMSO. (85) See (14) above. (86) APLEY J 1963. Lancet 12th January. (87) Report of the Committee on Maladjusted Children. 1955. London: HMSO. (88) Report of the Principal School Medical Officer, Somerset. 1952. (89) Report of the Principal School Medical Officer, Birmingham. 1953. (90) RUTTER M and GRAHAM P 1966. Proc. Roy. Soc. Med. Vol. 59, No. 4. 382-387 (Section of Psychiatry, 30-35). (91) Expert Committee on Mental Health: Tech. Rep. Ser. No. 9 1950, No. 31 1951 and No. 73 1953. WHO: Geneva. (92) See (2) above. (93) An Enquiry into Health Visiting. 1956. HMSO. (94) See (18) above. (95) See (33) above. (96) See (18) above. (97) See (33) above. (98) Report of Chief Medical Officer to Ministry of Health. 1965. Page 90. (99) WALL WD, SCHONELL FJ and OLSEN WC 1962. Failure in School. UNESCO. (100) Chronicle of World Health Organisation. September 1955. (101) MELLOR MR, JONES JT and PEARSON RCM 1964. Med. Off. 20th November. (102) The Field Work of the Family Doctor. Report of the Sub-Committee of the Standing Medical Advisory Committee, Ministry of Health. 1963. HMSO. (103) Report of the Joint Working Party on the Medical Staffing Structure in the Hospital Service. 1961. HMSO. 
|