CIRCULAR OF MINISTRY OF HEALTH. Ministry of Health, Whitehall, S.W.1. Sir, I am directed by the Minister of Health, as having the powers vested in the Local Government Board under the National Registration Acts, to state that he does not propose to take any steps to secure the continuance of those Acts beyond the date when they will otherwise expire in pursuance of the provisions of Section 16 (2) of the National Registration Act, 1915. The precise date of expiry will be notified to local registration authorities as soon as it has been determined by Order in Council under the Termination of the Present War (Definition) Act, 1918. But in the meantime authorities will doubtless desire to effect immediate economies in respect of staff, etc., by discontinuing administrative operations under the Acts in anticipation of the date of their expiry; and, in the circumstances indicated above, authorities are accordingly advised that, in the view of the Minister of Health and with his approval, so far as such approval is requisite, all duties devolving under the Acts whether upon the authorities themselves or upon the public may properly be suspended. A further communication will in due course be addressed to local registration authorities with regard to the expenses incurred by them under the Acts. I am, Sir, Your obedient Servant, ROBERT L. MORANT, Secretary. To the Clerk to the Local Registration Authority. CIRCULAR OF MINISTRY OF HEALTH. THE TRAINING OF HEALTH VISITORS, ESPECIALLY FOR MATERNITY AND CHILD WELFARE WORK. Ministry of Health, Whitehall, S.W.1. July 14th, 1919. Sir,-1. The Minister of Health is desirous of inviting the attention of Local Authorities and others concerned in maternity, child welfare and other departments of public health to the important Regulations just made by the Board of Education, after consultation with this Ministry, for the payment, from that Board, of grants in aid of the training of women to become Health Visitors. 2. The functions of Health Visitors have become widely known and appreciated in the last ten years; but it may tend to the better understanding of the purpose of the now projected developments, both in the new Regulations of the Board of Education and in the consequent higher standards to be looked for by this Ministry in local work, to recall here, briefly, the history of their origin and past development. It was the London County Council (General Powers) Act, 1908, which first empowered sanitary authorities in London to appoint suitable women to be known as Health Visitors whose duties would include (a) giving advice on the proper nurture, care and management of young children, (b) the promotion of cleanliness as the basis of health, and (c) such other analogous duties as might be assigned to them. The Local Government Board were authorised by the Statute to make Regulations prescribing the qualifications, duties, salary, mode of appointment and tenure of office of Health Visitors appointed under the Act, and it was stipulated that no appointment should be made otherwise than in accordance with such Regulations. 3. Although at the time of the passing of the Act a number of women known as Health Visitors had already been appointed to advise mothers as to the care of their infants, the Board had not then had sufficient experience of the scope of their work, and of the qualifications necessary for it, to justify them at that time in establishing or requiring a special course of training for the Health Visitors who were to be appointed under the Act. The qualifications which the Local Government Board then prescribed in their Order were as follows: (a) a medical degree, or (b) the full training of a nurse, or (c) the certificate of the Central Midwives Board, or (d) some training in nursing and the Health Visitor's certificate of a Society approved by the Board, or (e) the previous discharge of duties of a similar character in the service of a Local Authority. 4. At that period, and in subsequent years, great impetus was given to the appointment of Health Visitors by the Notification of Births Act, 1907 (which was made compulsory by the Extension Act of 1915), and by the institution of the Exchequer grants in aid of the local provision of arrangements for maternity and child welfare in 1914. And it may now be said that, although at the present time the number of Health Visitors is still seriously insufficient for the needs of the population, some provision is made for health visiting. in most parts of England and Wales. 5. The standard of efficiency of this health visiting, however, varies greatly. Outside London no qualifications have hitherto been prescribed for Health Visitors. But the Local Government Board have constantly recommended that the women appointed to undertake this work by Local Authorities should possess one or more of the qualifications prescribed by the London Order, with the addition of the certificate of a Sanitary Inspector; and investigation has shown that at the present time nearly all of the Health Visitors at work in England and Wales possess one or more of these various qualifications; but this, of course, especially taken in conjunction with the inadequacy of the numbers, is not sufficient to secure such a standard of work generally as the nation has a right both to expect and to receive nowadays in this important sphere of public welfare. 6. The Act of 1908 quoted above, and the Board's Order made under it, permitted the duties of Health Visitors to cover a wide field. In practice, however, their special function in London has usually been maternity and child welfare work, with particular regard to the care of infants. The value of the work which they have done in assisting the campaign against infant mortality has been widely recognised. In addition to the regular visiting of infants in their homes, they are now frequently employed to assist in supervising, under medical control, the health of children under school age, to attend Maternity and Child Welfare Centres, and to investigate the circumstances in cases of still-births and the deaths of young children. The varied nature of their duties requires, it is obvious, a carefully devised course of professional training. But it has been found in practice that the qualifications set out above, though admittedly comprising the most useful existing qualifications for the discharge of these duties, include certain subjects not directly relevant and omit certain subjects on which it is eminently desirable that Health Visitors should be well informed. 7. It may be said, in this connection, that from the beginning it has been recognised that, when circumstances permitted, it would be necessary that a special course of training for Health Visitors generally should be prescribed. Now that the time seems opportune for the institution of such a course, the Ministry of Health have welcomed, and have been glad to co-operate in, the action of the Board of Education, as the Department responsible to Parliament for the provision of education and training, in framing regulations defining the terms and conditions which should govern the disbursement of Exchequer grants in aid of the provision of efficient courses of training for future Health Visitors. 8. It will be observed that the Board of Education Regulations (copy enclosed) which have been framed in consultation with the Ministry of Health and with direct regard to the duties of Health Visitors as prescribed by the Ministry of Health under the Acts above referred to, make provision (a) for a course of two years for candidates without previous training, and (b) for a course of one year in the case of fully trained nurses, of women with experience of health visiting, or of those possessing a University Degree or its academical equivalent-assuming in each case that the individual possesses sufficient general knowledge or experience to profit by such a course. 9. In view of the great importance of securing the appointment of properly trained persons as Health Visitors, and of the enlarged opportunities that will arise under the developments just described, the Ministry of Health have now decided that, in cases requiring Government sanction and grant, the Ministry will require that all women appointed for the first time as Health Visitors on and after a date of which due notice will be given, must have obtained the certificate described in these Regulations of the Board of Education, with or without other qualifications. Women intending to enter the profession in the future are therefore advised to take a course of training at one of the Institutions recognised by the Board of Education, who will announce a list of such institutions. It is to be noted that these requirements by the Ministry as to candidates having been trained in a course under these Regulations will apply only to salaried Health Visitors. At many Maternity and Child Welfare Centres (both municipal and voluntary) unpaid workers are engaged, who, where they undertake the regular discharge of definite duties, render valuable assistance to the work of the Centre. These workers should be experienced and competent, and some training is desirable for them also; but they need not necessarily possess certificates given after a formal course of training. 10. It is further to be understood that, until such time as the Ministry consider that there have become available a sufficient number of candidates who have completed a course recognised under the Training Regulations, women who are now acting as Health Visitors, and women who may be appointed during the intervening period as Health Visitors, will not be required to have taken either the full or the shortened course of training as a condition of repay ment of half their salary from the Maternity and Child Welfare grant. At the same time, it is hoped that local authorities will afford facilities to such Health Visitors to take an approved course of training where they desire to do so, and where the Medical Officer of Health is of opinion that it would increase their efficiency. The Ministry of Health would also recommend that Local Authorities making new appointments of Health Visitors from the present time, until women qualified under the new Regulations are available, should always endeavour to secure more than one of the qualifications already prescribed for London and recommended for the rest of the country by the Local Government Board, as set out in the third and fifth paragraphs of this Circular. For it should now usually be possible to obtain women possessing more than one of these qualifications; and the Ministry will not, as a rule, be prepared, after a date of which due notice will be given, to pay grants in respect of the salary of any newly appointed Health Visitor who has only the qualification of a midwife or of a Sanitary Inspector, unless she has previously rendered satisfactory service as a Health Visitor in another District. II. While the Ministry of Health will accept the standard of training laid down by these Training Regulations as a sufficient qualification both for Health Visitors and for Tuberculosis Visitors and Nurses, it is recognised that some local authorities may desire further qualifications in the women they appoint in those capacities, especially where they are called upon to perform additional duties to those enumerated above. The following observations may be useful regarding such additional duties. 12. It is often urged that, generally speaking, and especially in country districts, the Health Visitor should discharge all the duties akin to those of health visiting in the "district assigned to her, on the grounds that such an arrangement reduces the size of the district allotted, and tends to minimise the time spent in travelling. It also reduces the number of inspectors who may visit a house for various purposes, a matter of considerable importance. This principle, however, needs to be adopted and applied with circumspection and careful regard to local circumstances, and to the conditions requisite for attaining a sufficiently high standard of efficiency, especially in centres of congested population. This is especially true. in respect of work in connection with Tuberculosis and Mental Deficiency, which are the other functions most often allotted to Health Visitors in several areas in England and Wales. 13. Many Health Visitors at present act as Assistant Inspectors of Midwives under the Medical Officer of Health or the Assistant Medical Officer of Health. The Ministry of Health consider that the inspection of midwives, including routine as well as special inspections, should be carried out by a medical practitioner, preferably a medical woman; and it is urged that all supervising authorities under the Midwives Act who have not already done so should, as |