Universal vs. selective services: the case of British health visiting.
OBJECTIVE
This paper discusses whether there should be universal or selective provision of health visiting services. The aim is to show the central relevance of the work of the late epidemiologist, Geoffery Rose, to arguments advocating the retention of a universal health visiting service.


BACKGROUND
In the United Kingdom (UK), health visiting moved, in the early years of the twentieth century, from being focused on the needs of poor families to becoming a universally provided service. Recent debates about the future of British health visiting have again raised the issue of whether health visiting remains a universal service, or should be targeted only on the most needy.
Following an exposition of Rose's work, two kinds of problems with which health visitors are concerned, depression and child abuse, are used to illustrate the ways in which Rose's approach can be applied to health visiting. CENTRAL THESIS: Rose argued that the bulk of problems in society arise in the many who are not at especially high risk, rather than in the few who are at high risk. This is because of a very large number of people who are not at especially high risk. Consequently, following Rose, this paper argues that in relation to such problems as depression or child abuse, to target health visiting services only on those at high risk would be to leave untouched a vast burden of health and social problems. In the context of identifying people who are at greatest risk, Rose argued that no screening instrument can ever be sufficiently precise to accurately identify those most likely to suffer problems. In corroboration of Rose's argument, this paper illustrates the pitfalls of health visitors' attempts to screen for families at greatest risk through the use of such instruments as checklists of risk factors.


CONCLUSIONS
It is concluded that it is neither possible to screen accurately for those at greatest risk, nor desirable to target services only on those at greatest risk. Therefore, it is advocated that health visiting should remain a universal service. However, it is recognized that within a universally provided service, some clients will require a greater intensity of input than others. In assessing the need for services, it is argued that the professional judgements of health visitors are crucial.
Elkan
R
R
School of Nursing, University of Nottingham, Nottingham, UK. ruth.elkan@nottingham.ac.uk
Robinson
J
J
Williams
D
D
Blair
M
M
D002648:Child; D002649:Child Abuse / Q000517:prevention & control; D003152:Community Health Nursing / Q000458:organization & administration*; D003863:Depression / Q000451:nursing / Q000517:prevention & control; D006285:Health Planning; D006801:Humans; D008403:Mass Screening / Q000458:organization & administration; D020380:Needs Assessment / Q000458:organization & administration; D011314:Preventive Health Services / Q000458:organization & administration*; D013222:State Medicine; D006113:United Kingdom; D019472:Universal Health Insurance