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There is a need here to point to what impresses us as a basic weakness in your reorganization. We hasten to add that we invariably experience the same in our country with this type of reorganization. It is organized from the top down, instead of from the bottom up. It is structured to facilitate and safeguard the work of the bureaucrat rather than to give prime consideration to the citizen in need. Beautiful organization charts have been prepared that show the Secretary of State and the Department and the Region and the Area and the District, with a maze of interconnecting lines of responsibility and communication. But nowhere to be found are John and Mary Smith and their severely handicapped son, Billy.

My husband and I have visited, as consultants in mental retardation, some 35 countries, and of necessity we had to develop some approaches, some techniques, to assess the effectiveness of national systems of care. We, of course, studied the kind of organization chart I just described, which always would be handed to us, but then we tried to design a reverse chart, starting with the front line person, be she a health visitor, a recreation worker, the teacher in a day care centre, or a caseworker on a large ward in a large institution. From whom do they get guidance? Who monitors their work? And, a very important question for people we lock away in institutions, who is there to provide staff guidance and supervision and to monitor the programs over the long dreary weekend? The picture one gets in that way does look quite different from the organization chart.

The other technique we always utilize is to bring down the discussion to a specific case. For this we have a formula that can be used anyplace: It is, as the sociologists like to say, a culture-free test. We simply ask, "Suppose a child is born in your town or village tomorrow and is found to be severely handicapped, an infant with Down's syndrome, perhaps; or suppose the mother decides that she will no longer be put off by her physician who says her two-year old child will outgrow its obvious retardation, and she is looking for help: what does your town, your village have to offer to such a mother and to her child?"

Our third and often most vital approach is to turn to the consumer, to go to the parent. We are indebted to individual parents and the local societies of parents of mentally handicapped children and adults for so much of what we have learned in the last 15 years about the realities of mental handicap.

It is on this basis that we have been trying, during our present stay in England, to get a realistic picture of how the services connect with the parent client, or how the parents can connect themselves to the services. We are, of course, well aware that there are many excellent services in this country, services which have really set the tone for other countries, but this is not the question here. It is little comfort to the mother with a Down's syndrome infant in East Rutherford that 80 miles away in West Springfield there is a splendid assessment centre which connects effectively with the various services.

Let us be fair. We understand there is a fixed beginning service for this mother, and that is the visit from the District Nurse which the mother of the new born handicapped infant would get at home if she leaves the hospital within 10 days after delivery. The District Nurse presumably would alert the Health Visitor, and indeed many of the services needed, some of which I have outlined earlier, could well be provided by a Health Visitor, such as assistance in feeding the child. Less clear is from which source the Health Visitor would get consultation with a more complicated problem a mother encounters in feeding her child, one that calls for consultation with a nutritionist. And what about some of the other areas where the family of the handicapped child needs help, problems that relate not so much to physical factors as to his or her general growth in terms of speech development, sensory and motor training, and early cognitive responses? This does not seem to be an area in which Health Visitors are trained, nor is it something that has been covered by the conventional training of the social worker in the local social service department. And how about educators? They seem to be tied to the classroom or in any case (because there are domiciliary teachers) to the school curriculum, which does not include this type of consideration.

It seems then that the relatively simple array of services which constitute a program of early intervention are not at the moment in the competence of the front line workers in the local departments of health, education, or social service. This then is a problem that urgently calls for remedial action. However, we do not believe that it calls so much for a new "caring profession," as has been suggested, but rather for a reorientation in the training of health visitors and social workers. At the moment, educators seem rather far removed from this area, but we strongly agree with Barbara Tizard's recent statement in the Times Educational Supplement, in which she made an eloquent case for the need for nursery school education (Tizard, 1975). Once we get properly trained staff for this type of activity into the local education departments, we will have the kind of staff that will be able to assist parents.