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Dr Hart and co-workers comment

We welcome the Thomas Coram Centre team's success in achieving nearly 100% attendance at their inner city clinics.1 It shows that high attendance rates can be achieved without resorting to Draconian measures. However, we challenge whether it represents an 'ideal' service, or whether frequent attendance should be synonymous with 'good'. The team's system of 7 formal physical, developmental, and behavioural checks by a doctor before age 5 years, in addition to non-routine consultations, uses a great amount of medical time. Our experience in less wellstaffed clinics shows that such a system results in the doctor being too busy to spend sufficient time with a child with a difficult problem, and encourages the child most at risk not to attend. We doubt if repeated routine consultations reveal persistent (rather than transient) remedial abnormalities hitherto undetected; perhaps the Thomas Coram Centre has some data on this subject. In a group of 252 children (most of them under 2 years) routine examinations at an inner city clinic in Nottingham revealed only one child with an abnormality of clinical significance that had not previously been detected. As practising clinic doctors we wonder to what extent routine checks duplicate, and therefore undermine, the work of health visitors and parents. Is the health visitor, parent, general practitioner (GP), or clinic doctor best at detecting abnormalities? In poor countries there would be no doctor available to make frequent medical checks on children; such primary care would be the responsibility of nursing staff with very basic training. In this country we deny well-trained health visitors such responsibility by insisting that checks are made by a clinic doctor. Surely primary detection is part of the role of the health visitor? We suggest that the clinic doctor or GP should have a secondary role; he should make fewer checks and look at problems identified by parents or health visitors. We are developing such a system in Nottingham. Obviously this system will be successful only if there are sufficient staff and they are of adequate quality. Hart et al.1 make this point for doctors; we would make it equally strongly for health visitors. It is a pity that the DHSS does not have current guidelines on the patient load appropriate to health visitors. Hart et al. implied a norm of 1 health visitor for 200 families with children under 5 years, but this would not be adequate for inner cities. As the health visitor would also have older children and pensioners on her case load, we would prefer a ratio of 1 health visitor for 100 families if her role were to be enlarged to include primary screening. Finally we are concerned that an 'ideal' service appears to exclude the GP. The role performed by Hart et al. would appear to be very similar to that performed by a GP (paediatrician), and we believe that a strong primary care service for children under 5 should integrate the GP and not bypass him.