9 Physician’s R,

Primary Health Care in a School Setting Jerry Newton, MD

For the past few years. physicians, school nurses and health educators have started to become involved in a slow but unceasing change in traditional methods of health care delivery. As ever larger segments of our population are unable to obtain traditional, every-family-has-its-own doctor type of med- ical care, more individuals, federal agencies and private institutions are substituting alternate methods.

Rising costs are only one factor causing these changes. Although many people do not feel the direct impact of their medical bills because the money to pay for medical expenses is often withheld from paychecks in the form of income tax and social security deductions, the costs are real, ever present and increasing yearly.

There are many ongoing efforts to provide good medical care at a reasonable cost. Kaiser Foundation Clinics have offered an innovative, prepaid medical plan to many thousands of employees in California for many years, and their plan still continues satisfactorily. In 1965, the federal govern- ment began the Medicare program for the elderly and, more recently, Medicaid for the indigent, dependent and disabled. Lately, HEW has backed the concept of Health Maintenance Organizations (HMOs), another form of prepaid medical care.

Now, a new concept is causing a great deal of discussion in medical and educational circles throughout the U.S. - primary health care in (or near) the schools. “After all,” say its proponents, “that’s where the children are!” With so many one-parent homes or homes with both parents employed, why not offer medical care to children with minor illnesses right there at school. Since about 75% of childhood diseases are minor and self-limited, surely some method can be devised whereby children can receive simple medical treatment without requiring an expensive visit to the doctor’s office and absence from school.

The regular school nurse would logically be the child’s first contact in the health care system. Secondly, the nurse practitioner or the physician’s assistant (under a physician’s supervision) could attend most routine medical problems. This would allow the physician, with his greater expertise in the diagnosis and treatment of illnesses, to supervise more than one health center. Obviously, it would be impossible to supply a doctor to every school; but a health center could serve a cluster of schools.

The health center, with a full-time profes- sional health educator, could also direct a program of health education in the schools. This is one of the most essential components of a good school health program and one most often neglected. In this type of health delivery system, health education would be the integral and important link between the clinic and the classroom. A plan of this nature combines the talents of the school nurse, nurse practitioner, health educator and physician and offers a complete school health system that embodies all aspects of school health. This is not just a pie-in-the-sky pipe dream. There are more than 20 school systems in the U.S. that are now offering some type of primary health care, though few are as complete as they would like to be.

As many health professionals know, there is another side to this concept. Many educational administrators, as well as physi- cians, feel that the school’s function is not to provide primary health care but to educate, and that health care should be offered in a “medical” setting. How can schools, now under fire for not adequately meeting their primary objectives of teaching and basics of reading, writing, and arithmetic, be expected to provide proper health care as well? Most school administrators hold these two objec- tions - there is not sufficient funding for such a program. and the school is not the proper provider for health care.

As one might expect, there is also a good deal of opposition from organized medicine. However, responsible medical opposition is not based on feared loss of income; rather, physicians feel that to provide health services in this manner (in the school or building adjacent to the school) is to further weaken a health care delivery system that has served many Americans well. Witness: (1) the increased use of hospital emergency rooms as the first place many people go when they get sick, and (2) doctors developing “emergency house call” practices out of a VW van - two examples of one-time episodic care.

The American Academy of Pediatrics strongly recommends the concept of a “pediatric home” for every child regardless of ability to pay. This could be a private physician’s office, a neighborhood or com- munity clinic, a teaching hospital outpatient department or other “medical” type facility. This would allow the type of doctor/patient relationship to develop that would tend to lessen the increasing episodic type of care that is fragmenting services, downgrading both the science and art of medicine, reducing the doctor to a kind of technical engineer and ultimately robbing the patient of a relation- ship with a potentially-skillful healer and friend, something every patient has the right to expect.

It is from this dialogue of pros and cons that suggestions, compromises and solutions will emerge. We are in the middle of revolutionary changes in the methods of health care delivery, and there will be no returning to the “good old days.”The federal government through HEW and private foundations such as the Robert Wood Johnson Foundation is already heavily involved in identifying the role that school health systems may play in health care delivery. It behooves the entire membership of ASHA to examine the pros and cons discussed here, become informed and make our opinions known.

54 THE JOURNAL OF SCHOOL HEALTH JANUARY 1979