Essential Community Medicine: Including relevant social services

600 Pages·1983·16.28 MB·English

by  R. J. Donaldson OBE

Essential
Community Medicine
(including relevant social services)
' ... full marks for being up to date. . .. 1 would congratulate the
Donaldsons. Their work will serve both medical students and trainees in
community medicine weil, especially if it is used as a co re book. It is good
value.'
British Medical Journal
' ... there are ... few useful reference books which describe the pattern of
problems and the pattern of services as carefully and dearly as this one
does.'
Lancet
'This is an extremely interesting and useful book. I know of no other that
brings together all the strands of community health, in a style that
everyone from a member of a regional health authority to the consumer
can understand and enjoy ... deserves a place on the bookshelves of Iocal
dinics and surgeries as weil as schools of nursing libraries.'
Nursing Times
' ... essential reading for students of medicine, nursing, public health and
social work .... for a book running to almost 600 pages it has to be one of
the best buys in its field.'
Royal Society 0/H ealth Journal
' ... likely to become the definitive work in Community Medicine. The book
is weil produced; the writing style is dear, there has been great attention to
accuracy and complex matters are explained simply and weil, there are a
large number of good illustrations and helpful tables.'
Medical Record
'I like this book. It is amazingly good value, the production is pleasing and
it is pleasant to handle .... recommended to general practitioners and
hospital doctors as a source book on epidemiological facts, and
information on the structure and workings of the NHS .... it is a bargain.'
Update
'This book is never dull-the text is basic, concise, dear and factual and weil
tabulated. Intriguing historical introductions coupled with most imagina
tive explanatory etchings enhance readability for the student.'
Jrish Medical Journal
'Hooray! Here is a book I can unreservedly recommend .... we have needed
a book like this for some time. It deserves to corner the market.'
Health and Social Service Journal
Essential
Community Medicine
(including relevant social services)
R. J. Donaldson
üBE, CStJ, MB, BCh, FFCM, DPH
Royal Free and St. Mary' s Hospital Schools of Medicine,
Hampstead Health Authority;
Formerly Director of Studies,
Centre for Extension Training in Community Medicine,
London School of Hygiene and Tropical Medicine
L. J. Donaldson
MSc(Anat), MD, FRCS(Ed), MFCM,
Regional Medical üfficer and Head of Clinical Policy,
Northern Regional Health Authority;
Formerly Senior Lecturer in Epidemiology,
University of Leicester
*
~ MTP PRESS LIMITED
~ a member of the KLUWER ACADEMIC PUBLISHERS GROUP
.. LANCASTER / BOSTON / THE HAGUE / DORDRECHT
Published in the UK and Europe by
MTP Press Limited
Falcon House
Lancaster, England
British Library Cata/oguing in Pub/ication Data
DonaIdson, R. J.
Essential community medicine.-(Essential series)
1. Public health 2. Medical care
I. Title Il. DonaIdson, L. J.
362.1 '0425 RA425
ISBN-13: 978-94-011-6251-7 e-ISBN-13: 978-94-011-6249-4
DOI: 10.1007/978-94-011-6249-4
Published in the USA by
MTPPress
A division of Kluwer Academic Publishers
101 Philip Drive
Norwell, MA 02061, USA
Library 01 Congress Cata/oging in Pub/ication Data
DonaIdson, R. J. (Raymond Joseph)
Essential community medicine.
Bibliography: p.
lncludes index.
1. Public health-Great Britain. 2. Medicine, preventive-Great Britain.
3. Community health services-Great Britain. I. DonaIdson, L.J. Il. Title.
(DNLM: 1. Community medicine. W 84.5 D676E)
RA485.D661982 362.1 '0941 83-708
First published 1983
Reprinted with minor changes 1983
Reprinted 1984
Reprinted with updated material 1985
Reprinted with further updating 1987
Reprinted and updated 1988
Copyright © 1983 R. J. Donaldson and L. J. Donaldson
Softcover reprint of the hardcover I st edition 1983
All rights reserved. No part of this publication may be reproduced, stored in
a retrieval system, or transmitted in any form or by any means, electronic,
mechanical, photocopying, recording or otherwise, without prior permissio
from the publishers.
Phototypesetting by Georgia Origination, Liverpool
Contents
Acknowledgements VI
Preface vii
1 Health data and their sourc es 1
2 Patterns of disease 61
3 Origin of diseases and their prevention 113
4 The National Health Service and sodal
services 165
5 Physically handicapped persons 237
6 Mothers and children 271
7 Mentally disordered people 353
8 Elderly people 423
9 Communicable diseases and parasites 467
10 Environmental health 537
Index 581
Acknowledgements
One of the benefits of a long professional career is that I havi
made a wide range of contacts in different disciplines. It is a grea
pleasure for me to name those who have freely contributed thei
specialist knowledge in reading various parts of the text: laI
Alexander, John Ashley, John Ashton, Bill Bate, Michael Bishop
Sidney Chave, Philip Clements, John Collins, Cliff Darley, Patricl
Hamilton, Deirdre Hine, Jill Moore, Anne Parker, Peter Pharoah
Roy Pilsworth, Derek Prinsley, Emer Shelley, Bernard Streeter, Hugl
Thomas and Linda Thckey. They are in no way responsible for an:
errors or misinterpretation.
Additionally, I would like to thank the many students in medicißt
and nursing whose pertinent comments at different stages greatl:
helped in the development of this book. I was particularly fortunate il
having a cooperative publisher and would especially like to thank Phi
Johnstone who exhibited infinite patience throughout the variou
stages of the production of the book.
R.J.D
vi
Preface
This basic textbook of Community Medicine, which includes
descriptions of the related social ~ervices, is intended for a wide range
of readers who require knowledge and understanding of the essential
aspects of the subject. These include undergraduate medical students
and qualified doctors who are engaged in postgraduate courses of
study or training schemes, particularly those in community medicine
and general practice. When writing this book we also had in mi nd the
needs of students of nursing at all levels at a time when an increasing
emphasis on the community is being reflected in the content of
curricula and the composition of examination papers.
It is our view that this account of community medicine will also be of
value to established practitioners - community physicians, community
health doctors, senior nurses and health visitors - who wish to con
solidate or update their knowledge. The growing involvement of the
professions in the management and planning of health services means
that many general practitioners, hospital doctors and nurses are being
called upon to take a population perspective and to become acquainted
with many of the concepts and issues discussed in this book.
In addition, there are those professionals who work closely with
medicine and nursing and have a common concern in providing care
and promoting prevention - groups such as social workers and health
education personnel. For all these reasons we would ho pe that many
groups might read the book and find it useful.
In presenting the material we have drawn on our own practical and
teaching experience, as weIl as the very extensive literature. In so doing
we are ever conscious of the debt we owe to our colleagues, both past
and present, in shaping and modifying our approach to the subject.
In the first chapter, we have introduced the main steps to be taken in
'diagnosing' the health problems of a population. This is often a field
of study, involving as it does a wide range of health data, wh ich
students find daunting. In attempting to demystify it we have put
special emphasis on providing simple descriptions and definitions of
the concepts involved and explaining the origins of the common types
vii
viii Essential community medicine
of routinely available data, as weIl as giving examples of their uses. An
outline of basic statistical methods is also included.
Chapter 2 describes the ways in which the nature and frequency of
health problems can vary within different groups of the population,
from one time period to another or in different geographicallocations.
Examining the pattern of disease in populations in this way can provide
the starting point for studies investigating the causes of disease or
encourage service initiatives. At the end of the chapter a systematic
description is given of the main features of several common causes of
death in industrialized countries: lung cancer, breast cancer, stomach
cancer, ischaemic heart disease, cerebrovascular disease and accidents.
In Chapter 3, we deal with the concept of 'cause' before moving on
to introduce the reader to one of th~ most important and exhilarating
aspects of community medicine: prevention. Few would deny the
importance of preventive medicine, but it has seldom enjoyed the
financial support commensurate with the apparent esteem in which it is
held. The main strategies in prevention are introduced and fully
described in this chapter: health education, immunization and
screening and change in legislation and social policy.
In these first three chapters many of the scientific foundations of
community medicine are laid down. Throughout, the reader is made
aware of the strengths and limitations of the data, the traps that lie in
wait for those drawing hasty or superficial conclusions from them and
the practical difficulties involved in pursuing preventive goals.
The modern welfare state is a large and complex structure with
diverse origins and traditions. During the last decade social services
departments have been created and the National Health Service itself
has undergone two major reorganizations in 1974 and 1982. Chapter 4
brings together in one place adescription of the present structure,
organizational framework and method of functioning of this wide
range of services. Health and social services are delivered within a
complex legal framework and a very brief account is given of the
relevant legislation. In undertaking such a description it is necessary to
strike a balance between over-complexity and undue simplicity. Hence,
to preserve clarity oniy the broad issues have been dealt with and are in
general terms correct, though it must be accepted that there are
inevitably exceptions to some of the statements made.
The measurement and description of health problems, aspects of
cause and prevention, service provision and legislation are dealt with in
Chapters 5 (Handicapped People), 6 (Mothers and Children), 7 (The
Mentally Disordered) and 8 (The Elderly). In describing the services
provided for these important groups of the population, we have tried
to avoid merely cataloguing them, but have commented, where
relevant, on their availability and highlighted innovations and
Pre/ace ix
deficiencies. Changes as a result of recent legislation such as the Child
Care Act 1980, Education Act 1981 and in the law in relation to mental
dis order have been taken into accounL
Control of communicable diseases can be achieved only by
adherence to a set of rules and these are outlined in Chapter 9. The
main features of so me important infectious conditions occurring in
Great Britain are given, including those about which there has recently
been some concern, such as the haemorrhagic fevers and hepatitis.
As weIl as the more traditional aspects of environmental health, we
discuss in Chapter 10 the impact of environment al noise, air pollution
and radiation in the light of the latest knowledge. The validity of the
historical association between housing and health is also re-examined.
Some of the illustrations are reproduced from teaching material and
we thank Angela Chorley and Julia Polonski who originally drew
them. Government material is reproduced with the permission of the
Controller of Her Majesty's Stationery Office.
We would like to record our thanks to Geraldine McNeill for her
expert help with the final manuscript and to Lesley Williams for
secretarial support at various stages. The generous and cheerful way in
which Peter Waters provided his administrative skills was greatly
appreciated. We owe a great debt to David Hall for his assistance, not
only on statistical matters but also on more general aspects of the sub
jecL We are particularly grateful to Jeannette Coyle for the speedy and
accurate way in which she prepared the many drafts.
January 1987: For this reprinting, the opportunity has been taken to
update the text with the inclusion of the changes in NHS management
following the Griffiths Report, new information on AIDS, a change in
Social Security information and updating of the position in relation to
child abuse as weIl as other minor amendments.
R. J. Donaldson
L. J. Donaldson
1
Health data and their sources
INTRODUCTION
The hospital doctor, the general practitioner, the ward nurse,
the district nurse and the health visitor spend most of their working
lives making contacts with a succession of individual patients and their
families. Impressions about individual illnesses - how common they
are, what course they follow, how successful treatment is - are largely
formed on the basis of this experience. Such a perspective is inevitably
too restricted to be used to draw general conclusions about the health
of whole populations. Before undertaking to provide new services or
making adjustments to existing services, those concerned with the
health of a population must have an accurate picture of the range and
extent of health problems within it. The desirability of such an over
view may seem self-evident, but it has very seldom been accomplished,
even on a small scale. It is often easier and more rewarding to bring
high technology medicine to the aid of the sick individual than to
identify and grapple with the range and complexity of generalized
health problems thrown up by modern society.
The first step in this process is the realization that a population of
even a few thousand is not necessarily an homogeneous entity. On the
basis of their personal characteristics (the elderly, the single parent
family), their work (the foundry worker, the company director), their
place of residence (the inner city poor) or their life-style (the cigarette
smoker, the motorcycle rider) people can be divided into groups with
an identifiable range of health problems. There is no single source
which provides this information; sources are many and varied but in
general have not been designed to supply information on the health of a
population, hence they have limitations when called upon to do so. Yet
by piecing together information from different sources, of different
types and to which differing levels of importance are attached, it is
possible to develop a composite picture of the health of a population,
and hence make a 'population diagnosis' . In some ways, the process is
analogous to that carried out by a doctor forming a clinical impression
1
2 Essential community medicine
of a patient. By assembling information from history-taking, physical
examination, radiological investigation, haematological and bio
chemical tests, according different importance to each, he formulates
the c1inical problem and begins to solve it.
One of the key processes in monitoring the health of a community is
to look at information which is collected, analysed and presented on a
routine basis. Information from specially conducted surveys is another
valuable source.
This chapter will firstly give a general description of the measure
ment of disease, introducing some common concepts such as rates,
standardization, incidence and prevalence. It will then describe the
main ways of obtaining information which can contribute to the assess
ment of a community's health. The three main types of routinely
collected information are:
Population data
Mortality data
Morbidity data
They are described in detail with special emphasis on the source, uses
and limitations of each type. All three, to a varying degree, are subject
to quantitative and qualitative deficiencies which limit the conc1usions
that can be drawn from them. These drawbacks are best appreciated by
being familiar with the way in which the data are gathered and there
fore this is also described.
MEASURING DISEASE
The rate
The basic unit of measurement used in studying disease in populations
is the rate. The rate consists of three components: a nurnerator, which
is the number of people in the population who experience the events of
interest (e.g. deaths, cases of disease, births, admissions to hospital); a
denominator, which is the total number of people in the population
being considered (the population at risk) and a specified time period
during which the events took place.
The use of a rate allows comparison between different populations,
different subgroups within the same population or populations at
different times. A statement of absolute numbers, such as: '2000 cases
of hypertension were diagnosed last year in District A compared with
700 in District B', may help to plan workload (number of outpatient
sessions, number of beds or staffing levels) but does not tell us whether
hypertension is a greater health problem amongst the inhabitants of
District A compared to District B, since the relative sizes of the two
populations are not given.