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Editor,—This important review of the school entry medical (SEM) examination1 is so flawed that the key messages cannot be supported. The School Health Service was introduced as a therapeutic, not just an epidemiological tool, when the Boer War revealed the extent of untreated disease for which neither treatment nor care was available. In 1976, the Court Report recommended that the SEM should be a statutory examination: not to identify missed disease, but to support needy children, because of the profound impact of indifferent health, disadvantage, and developmental delay on educational progress. The Polnay Report, Health needs of school age children (1995), clearly advised that the health care assessment by school nurses at entry should also advance health promotion.
School health varies dramatically between inner city, urban, and rural schools. In our Trust serial audits2 3 to ascertain thedecisions made about care and support offered to childrenat school entry, have demonstrated a skew in need with an eightfold increase in schools serving disadvantaged areas. The content of the work has changed dramatically over the past 30 years: consider child protection work, the integration of special needs children in mainstream school, the effects of serial parenting on young children. Medical time in school is spent with children with significant problems, not on healthy children nor on perusing letters and reports. Numerical comparisons of pick up rates of defects over time (1962–96) and place are not meaningful.
Let us move the argument from the value of screening to the real issue of how to provide effective health care for the many children who start school with health and developmental disadvantages.
Drs Barlow and Stewart-Brown comment:
We agree with Dr Leff that the most important role of the SEM is the provision of effective health care for children who start school with health and developmental disadvantages, through the identification of unmet health needs. It is, however, unclear how it is possible to assess the effectiveness of the SEM in meeting these needs without assessing the effectiveness and efficiency of the screening procedures used in their identification.
We have stated that the evidence shows that large numbers of children are identified as having a problem at school entry and that many of these problems are newly identified as a result of the SEM. Furthermore, a large proportion of these problems result in referral for further investigation. However, the failure of most studies to follow up referrals to assess the number of false positive cases, or indeed to follow up the cohort to identify false negative cases, precludes the possibility of establishing the extent to which the SEM is actually successful in identifying and meeting children’s health needs. Neither is there any evidence available to show the success of either routine or selective SEMs in providing “care and support” to “needy children” as an integral part of the SEM, or in the positive promotion of health and the maintenance of a body of knowledge in the community regarding child health and development.
We agree that the “numerical comparison of pick up rates” is unsatisfactory. However, this is all the literature appears to provide for evidence of the effectiveness of the SEM, and we have endeavoured to explain in our paper why this type of research design is inadequate.
Systematic reviews inevitably reflect past rather than current research and clinical practice. In community child health, both of these have developed considerably over recent years. However, researchers and clinicians are likely to make more progress if they are able to reflect on the inadequacies of past research and practice. The real problem of providing effective health care for children who start school with health and developmental needs will not be resolved by burying our heads in the sand.
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