LONDON BOROUGH OF BEXLEY REPORT OF THE MEDICAL OFFICER OF HEALTH AND PRINCIPAL SCHOOL MEDICAL OFFICER FOR THE YEARS 1965, 1966, 1967, 1968 and 1969 H.L. Settle, M.Sc., M.D., D.P.H., F.R.S.H., A.R.P.S. Medical Officer of Health BEX 30 LONDON BOROUGH OF BEXLEY REPORT of the MEDICAL OFFICER OF HEALTH and PRINCIPAL SCHOOL MEDICAL OFFICER for the years 1965, 1966, 1967, 1968 and 1969 H.L. Settle, M.Sc., M.D., D.P.H., F.R.S.H., A.R.P.S. Medical Officer of Health CONTENTS Page Members of Committees 3 Health & Welfare Department Staff 8 Introduction 9 SECTION A. Statistics and Social Conditions 15 SECTION B. Health Services in the Area 27 SECTION C. Prevalence and Control of Infectious and Other Diseases 55 SECTION D. Environmental and Sanitary Circumstances in the Area. 65 SECTION E. Housing 81 SECTION F. Food and Drugs 85 SECTION G. General 95 Report of the Principal School Medical Officer 103 Report on the Dental Services (1969) by the Chief Dental Officer, J.H. Forrester, L.D.S., R.C.S.(Eng.). 111 APPENDIX A. Atmospheric Pollution 119 APPENDIX B. Observations on the Green Paper on the National Health Service 129 APPENDIX C. Observations on the Seebohm Report 133 An index is given at the beginning of each Section. 1 LONDON BOROUGH OF BEXLEY MEMBERS OF THE HEALTH COMMITTEE (as at December 1965) Ex-Officio: The Worshipful the Mayor (Councillor Mrs. Marjorie E. Barron, J.P.) Chairman: Councillor J. Kerr Vice-Chairman: Councillor Mrs. M.M. Eccles Alderman N.H. Antenbring ,, C. Brett-Smith ,, H.W.T. Coomes ,, Mrs. F.M. Schuch ,, F.P. Sellors ,, W.E. Sutton Councillor F.W. Archer ,, J.C. Canton ,, H.W. Friend ,, J.N. Harrington ,, Mrs. R.M. Irvine ,, J.C. McLean, J.P. Councillor Mrs. H.F. Piggott ,, Mrs. F.M. Pilbrow ,, Miss E. Rhodes ,, Mrs. E.M. Sheppard ,, Mrs. J. Sidders ,, W. Smith ,, Mrs. E. Swift ,, A.Turner ,, E.E. Virrels ,, Mrs. E.M. White ,, T.L. Winch Co-opted Members: Dr. D.H. Bolton, M.R.C.S., L.R.C.P. Mrs. C.A. Driver (Local Organiser, W.R.V.S.) SUB-COMMITTEES:- Domiciliary Care Councillor Mrs. F.M. Pilbrow (Chairman) ,, J.C. Canton ,, J. Kerr ,, Mrs. J. Sidders Maternity and Child Welfare Councillor Mrs. M.M. Eccles (Chairman) ,, F.W. Archer ,, Mrs. H.F. Piggott ,, Mrs. E.M. Sheppard Mental Health Councillor J. Kerr (Chairman) Alderman N.H. Antenbring ,, H.W.T. Coomes ,, Mrs. F.M. Schuch Councillor F.W.Archer ,, H.W. Friend ,, J.C. McLean, J.P. ,, E.E. Virrels ,, T.L. Winch Personal Services (Health) Councillor Mrs. E.M. Sheppard (Chairman) ,, F.W. Archer ,, Mrs. M.M. Eccles ,, J.N. Harrington ,, Mrs. R.M. Irvine ,, J. Kerr ,, Mrs. F.M. Pilbrow ,, W. Smith ,, T.L. Winch 3 MEMBERS OF THE HEALTH COMMITTEE (as at December 1966) Ex-Officio: Chairman: Vice-Chairman: The Worshipful the Mayor (Councillor Kenneth J. Smith, J.P.) Councillor Mrs. E.M. Sheppard Councillor Mrs. M.M. Eccles Alderman C. Brett-Smith ,, Mrs. F.M. Schuch ,, F.P. Sellors ,, L.L. Smith Councillor F.W. Archer ,, J.C. Canton ,, H.W. Friend ,, J.N. Harrington ,, Mrs. R.M. Irvine Councillor J.C. McLean, J.P. ,, Mrs. H.F. Piggott ,, Mrs. F.M. Pilbrow ,, Miss E. Rhodes ,, Mrs. J. Sidders ,, Mrs. E. Swift ,, A.Turner ,, E.E. Virrels ,, T.L. Winch Co-opted Members: Dr. P.E. Kapff, M.B., B.S., M.R.C.S., L.R.C.P. Mr. A. Howells, M.P.S. SUB-COMMITTEES:- Mental Health Councillor F.W. Archer (Chairman) Alderman Mrs. F.H. Schuch ,, F.P. Sellors Councillor H.W. Friend ,, J.N. Harrington ,, J.C. McLean, J.P. ,, Mrs. E.M. Sheppard ,, E.E. Virrels ,, T.L. Winch Personal Services (Health) Councillor Mrs. E.M. Sheppard (Chairman) Alderman C. Brett-Smith ,, L.L. Smith Councillor Mrs. M.M. Eccles ,, J.N. Harrington ,, Mrs. F.M. Pilbrow ,, A.Turner ,, T.L. Winch 4 MEMBERS OF THE HEALTH COMMITTEE (as at December 1967) Ex-Officio: The Worshipful the Mayor (Councillor John W. Schuch, J.P.) Chairman: Councillor Mrs. E.M. Sheppard Vice-Chairman: Councillor Mrs. M.M. Eccles Alderman C. Brett-Smith ,, Mrs. F.H. Schuch ,, F.P. Sellors Councillor F.W. Archer ,, J.C. Canton ,, P.E. Daynes ,, H.W. Friend ,, J.N. Harrington ,, Mrs. R.M. Irvine *Councillor J.C. McLean, J.P. ,, Mrs. H.F. Piggott ,, Mrs. F.M. Pilbrow ,, Miss E. Rhodes ,, Mrs. J. Sidders ,, Mrs. E.M. Swift ,, A.Turner ,, E.E. Virrels ,, T.L. Winch Co-opted Members: *Represents South-East Metropolitan Regional Hospital Board Dr. P.E. Kapff, M.B., B.S., M.R.C.S., L.R.C.P. Mr. A. Howells, F.P.S. SUB-COMMITTEES Mental Health Councillor F.W. Archer (Chairman) Alderman F.P. Sellors Councillor Mrs. M.M. Eccles ,, H.W. Friend ,, J.N. Harrington ,, J.C. McLean, J.P. ,, Mrs. E.M. Sheppard ,, E.E. Virrels ,, T.L. Winch Personal Services (Health) Councillor Mrs. E.M. Sheppard (Chairman) Alderman C. Brett-Smith Councillor Mrs. M.M. Eccles ,, J.N. Harrington ,, Mrs. F.M. Pilbrow ,, A.Turner ,, E.E. Virrels ,, T.L. Winch 5 MEMBERS OF THE SOCIAL SERVICES (AND CHILDREN'S) COMMITTEE (as at December 1968) Ex-Officio: The Worshipful the Mayor (Councillor Cecil Jamieson-Harvey, M.B.E.,J.P.) Chairman: Councillor J.D. Minett Vice-Chairman: Councillor Mrs. B.J. Antenbring Alderman J.F.L. Gates, M.B.E. ,, Mrs. A.E.F. Orange ,, L.L. Smith ,, H.E. Sutton Councillor F. Ambrose ,, N.C. Austin ,, D.I. Evans, T.D.,J.P. ,, H.W. Friend Councillor G.F.Gerloff ,, F.K. Hallett ,, Mrs. N.I. Hooper ,, S.P. James ,, Mrs. D.M. MacLean ,, A.A. Pease ,, J.E. Prangnell ,, D.A. Price Co-opted Members: Mr. A. Howells, F.P.S. Dr. P.E. Kapff, M.B., B.S., M.R.C.S., L.R.C.P. Mrs. C.A. Driver (Local Organiser W.R.V.S.) Mr. J.C. McLean, C.B.E., J.P. Mr. A.J. Saunders, A.I.B., A.C.I.S. Mr. A.C.B. Reid, M.A., LL.B. 6 MEMBERS OF THE SOCIAL SERVICES (AND CHILDREN'S) COMMITTEE (as at December 1969) Ex-Officio: The Worshipful the Mayor (Councillor Norman H. Antenbring) Chairman: Councillor J.D. Minett Vice-Chairman: Councillor Mrs. B.J. Antenbring Alderman H.W.T. Coomes ,, J.F.L. Gates, M.B.E. ,, Mrs. A.E.F. Orange ,, H.E. Sutton Councillor N.C.Austin ,, D.I. Evans, T.D.,J.P. ,, G.F. Gerloff ,, F.K. Hallett Councillor Mrs. N.I. Hooper ,, B.J. Ilsley ,, S.P. James ,, Mrs. D.M. MacLean ,, A.A. Pease ,, D.A. Price ,, T.L. Winch ,, S.J. Woolterton Co-opted Members: Mr. J.N. Powrie — Executive Council for South East London and Kent. Dr. P.E. Kapff, M.B., B.S., M.R.C.S., L.R.C.P. Mrs. C.A. Driver, W.R.V.S. Mr. J.C. McLean, C.B.E., J.P. Mr. A.J. Saunders, A.I.B., A.C.I.S. Mr. G.B. Hodgson, M.B.E. 7 PRINCIPAL STAFF OF THE HEALTH AND WELFARE DEPARTMENT (at 31st December 1969) Medical Officer of Health, Principal School Medical Officer and Director of Welfare Services Herbert Leslie Settle, M.Sc., M.D., D.P.H., F.R.S.H., A.R.P.S. Deputy Medical Officer of Health, Principal School Medical Officer and Director of Welfare Services Ian Browne Millar, M.D., B.Ch., B.A.O., D.P.H. Principal Medical Officer Fanny Stang, M.D., M.R.C.S., L.R.C.P., D.P.H. Chief Dental Officer Chief Public Health Inspector Deputy Chief Public Health Inspector Chief Administrative Assistant Senior Administrative Assistant Chief Welfare Officer Deputy Chief Welfare Officer Principal Mental Welfare Officer Deputy Principal Mental Welfare Officer Superintendent of District Nurses and Non-Medical Supervisor of Midwives Deputy Superintendent of District Nurses and Non-Medical Supervisor of Midwives Superintendent Health Visitor Deputy Superintendent Health Visitor Home Help Organiser Chief Chiropodist Senior Speech Therapist Public Analyst J.H. Forrester, L.D.S., R.C.S.(Eng.) P.R. Hickson, M.R.S.H., M.A.P.H.I. A.W. Kent, M.R.S.H., M.A.P.H.I. F.E. Young G.A. Pearson I.A. Connor, B.Sc.(Econ.) R.J.B. King H.E. Causey, C.S.W., M.R.S.H., M.S.M.W.O. J.R. Allam, C.S.W. Miss M.C. Gooderham, S.R.N., S.C.M., Queens Certificate, H.V. Certificate Mrs. F. Pearce, S.R.N., S.C.M., District Nurse Certificate Mrs. N.G.V. Cooper, S.R.N., S.C.M., H.V. Certificate, Nursery Nurses Certificate Miss J.M. Patchett, S.R.N., C.M.B.(Part I), H.V. Certificate Miss J.M. Smith, Inst. H.H.O. B.R. March, M.C.H.S., S.R.C.H. Mrs. C. Leech, Lie. of College of Speech Therapists H. Amphlett Williams, Ph.D., A.C.G.F.C., F.R.I.C., F.R.S.H. 8 Health and Welfare Department, 9 Brampton Road, Bexleyheath, Kent. To: The Council of the London Borough of Bexley. Mr. Mayor, Ladies and Gentlemen, I have the honour to present the first report on the health and sanitary circumstances and on the school health service in the London Borough of Bexley. I am pleased to be able to report that during the period under review there has been no serious outbreak of infectious disease and the health of the inhabitants has been satisfactory. Normally the reports of the Medical Officer of Health and Principal School Medical Officer are presented annually, but due to the exceptional circumstances which have affected the establishment of the new department it has not been possible to prepare full and separate reports for each year and instead a combined document covering the first five years of the new authority has been produced. Time has not permitted detailed reports to be prepared on all the various activities of the School Health Service and only statistical information has, therefore, been included. It is hoped that future reports will cover these important activities in detail. The Medical Officer of Health is also Director of Welfare Services but it has only been possible to include brief references to the welfare services which embrace a wide field of social care covering the aged, the handicapped and the housebound and certain categories of homeless persons. Many problems were encountered in establishing the new department and providing and maintaining the various services to the public and these are referred to in detail later. Despite the many problems it is gratifying to report that from the 1st April, 1965, all essential needs of the public were met and the services available to the public prior to that date were not only fully maintained but extended and improved wherever possible. This will be my only report to the Council as having reached an age when I am eligible to retire voluntarily I have decided to exercise my right and after thirty years in the Public Health Service will leave the local government service at the end of 1969, to take up a less onerous and less demanding appointment in the hospital service. Thanks are due to the various Chairmen and Members of the committees who have been responsible for the services provided by the Health & Welfare Department for their encouragement and support. The complexities of modern local government services are such that a Health & Welfare Department cannot function without the assistance of others and I wish to record my indebtedness to my colleagues the Chief Officers and Heads of Department and their staffs, medical colleagues in both hospital and general practice and the various voluntary and other organisations with which the department collaborates closely, for their invaluable and willing assistance. 9 Finally I offer my sincere thanks to all members of the staff of the department, past and present, for their loyalty and support often under most difficult and trying circumstances. Your obedient Servant, H.L. SETTLE Medical Officer of Health, Principal School Medical Officer and Director of Welfare Services December 1969. 10 HISTORICAL The London Borough of Bexley was formed by the amalgamation of the Municipal Boroughs of Bexley (population 90,160) and Erith (population 45,970), the Urban District of Crayford (population 33,600) and the Sidcup portion of the Urban District of Chislehurst and Sidcup (population 87,480). The combined population of the new authority was estimated by the Registrar General to be 215,480 in 1965. Members of the new authority were elected in May, 1964. The Medical Officer of Health was appointed in June 1964 and the Deputy Medical Officer of Health in August 1964. A Health Committee was appointed to plan future services and to ensure a smooth transfer of responsibilities on the 1st April 1965. During the period June 1964 to 1st April 1965, the Medical Officer of Health and the Deputy Medical Officer of Health continued in their previous appointments and were only able to devote part-time service to the London Borough of Bexley. During this period it was necessary to obtain full details of all existing services and facilities in the area and to plan the new services and the departmental structure. A large number of persons employed by the constituent authorities had to be interviewed for appointments and where no suitably experienced person was available, posts had to be advertised firstly among the other authorities affected by the re-organisation in the Greater London area. If no suitable applicants were found, special authority had to be obtained from the Staff Commission to advertise nationally. As will be appreciated, this all took time and caused many problems by delays. Great difficulty was also encountered because the Personal Health, the Welfare and the School Health Services (with the exception of Bexley Municipal Borough, which was an excepted district for School Health Services) were all provided and administered by Kent County Council and no senior staff, medical nor lay, were available for transfer from the County Council. This meant we had to try and recruit from the London market at a time when experienced personnel were being sought by the other London Boroughs and very attractive offers of posts were available elsewhere. A number of very important senior posts, e.g. Senior Medical Officers, Chief Administrative Assistant, Welfare Officer, Superintendent Nursing Officer, Superintendent Health Visitor, Senior Mental Welfare Officer, etc. could not be filled from local staff. These posts were advertised in the London area and in some instances nationally, and as a result of the inevitable delay most of the persons appointed to these posts did not take up duty until after the 1st April 1965 and were not available to assist in planning the new department at a vital stage. In my opinion the interim period of nine months between appointment of the Chief Officer and the coming into operation of the new department was insufficient and in any future re-organisation of local government a much longer period would be beneficial. It would also help if the newly appointed Chief Officer could function in a full-time capacity from the date of appointment, and if other key personnel could be appointed full-time at an early date to facilitate the planning and organisation of the new department. Great difficulty arose from the absence of adequate accommodation in which to house the new and greatly enlarged department, a problem which also affected other departments of the new authority. For the Health & Welfare Department it was decided to use the offices of the Bexley 11 Municipal Borough Health Department at 8 Brampton Road, Bexleyheath, an old private residence, together with the small purpose built Divisional Education Office of the Kent County Council opposite at No.9 Brampton Road. The separation of the two buildings by a busy road inevitably meant administrative inconvenience and some inefficiency but these were unavoidable. Because of the inadequacy of these premises the Home Help Service continued to be operated from premises in Queen Street, Erith. The Brampton Road premises were far too small to house the new department but fortunately the garden at the rear of No.8 Brampton Road was large and additional office accommodation in large wooden huts was provided. Once again we were unfortunate to encounter great difficulties in this project also. It had been agreed that at least 4,600 sq.ft. of hutted accommodation would be needed, but a few days before all the formalities could be completed, a government restriction on office building was introduced, as a result of which only 2,500 sq.ft. could be provided and only this reduced area was avilable for the new department on the 1st April 1965. This serious loss of accommodation prevented the proper development of many services of the department at a crucial time. Repeated representations were made to try and get permission to increase the area of the temporary office accommodation, but this was not forthcoming from the Board of Trade until October 1965 and the erection of part of the balance of the accommodation (1,400 sq.ft.) was not completed until March 1966. Before completion of this second phase it was very obvious that still further accommodation would be needed and the third stage (2,800 sq.ft. (approx.)) was only completed in April 1968. Another serious problem encountered was the inadequacy of many of the facilities available in the Borough for transfer to the new authority from the constitutent authorities. The personal health services and the welfare services had been provided by Kent County Council which had facilities such as Old People's Homes, training centres for adult mentally sub-normal persons and Part III accommodation, etc. available outside the Borough. On the appointed day the London Borough of Bexley became responsible for 157 old people resident in Kent County Council Homes in the county and 73 in voluntary homes elsewhere outside the Borough, a total of 230 persons. There were also 145 old persons on the waiting list for residential accommodation. However, only two Kent County Council Homes were situated in Bexley London Borough and therefore transferred to the new authority. These were St. Mary's in Bexley with 38 beds and Russell House, Bexleyheath, with 48 beds, and it was necessary to come to an arrangement with Kent County Council to retain Bexley persons in their other Homes in the County until new accommodation could be provided by the London Borough of Bexley. No Part III temporary accommodation was transferred on the appointed day. There were four Bexley families in Kent County Council accommodation and arrangements were made for Kent County Council to continue to look after these persons until new provision could be made in Bexley London Borough. The magnitude of the problem due to inadequate facilities is revealed in the "Ten Year Plan for the Development of Local Authority Health and Welfare Services" which was approved by the Council in March 1966. In order to provide the necessary Health and Welfare facilities for the Borough it was estimated that a minimum capital expenditure of £4.6 millions would be needed over the ten years 1966—1975. The types of provision needed include homes for the elderly, centres for the handicapped, training centres for the mentally subnormal, hostels for mentally subnormal and mentally ill persons, day nurseries, health centres, etc. 12 Without proper facilities such as the above, it is impossible for the staff in the various sections of the department to do their job properly and this leads to feelings of frustration in keen and qualified staff who cannot enjoy the satisfaction of a job well and properly done. Unless proper facilities are provided within a reasonable time, retention of good officers will be difficult. Serious illness among senior staff also added to the department's problems in the early years, no less than three section heads being off duty for long periods (one for a year), thereby adding additional burdens to other staff already fully occupied. For some time after the 1st April 1965 there was also considerable movement of staff between departments in this authority and even between London Boroughs and a number of key members of the staff was lost by this means. The last major headache encountered in establishing the new department was the inception of the Thamesmead Health Centre project by Guy's Hospital in June 1965. At a time when we were more than fully occupied with local matters and problems it was necessary to co-operate with the Ministry of Health, Guy's Hospital, the Greater London Council, Executive Councils and the South East Metropolitan Regional Hospital Board, etc. in planning a completely new idea in the provision of integrated health services for the future new town of Thamesmead. Unfortunately, owing to the rigid timetable set by the Greater London Council for this £250,000,000 scheme, no delays could be permitted and much time which was urgently needed to deal with problems in this Borough had to be devoted to the Thamesmead project and attending frequent meetings. The above matters have been dealt with in some detail because they cannot have been foreseen when the decision to re-organise London Local Government was being taken. The problems encountered in Bexley were probably unique and were not met with in most, if in any, of the other London Boroughs. In future local government re-organisation, detailed attention to the likely availability of suitable staff, office accommodation and facilities essential for the services to be provided should receive full and adequate consideration by the responsible body before decisions are taken. Finally, before the new department had been properly organised and become fully effective it was subjected to further re-organisation in 1968 following the Maud Report on Management of Local Government. On the basis of the Maud Committee's recommendations, the Council's committee structure was simplified, including the amalgamation of the Health, Welfare and Children's Committees. In the near future there are likely to be further major changes in the departmental structure as a result of the Seebohm Committee's proposals in respect of the local authority social services and the proposed re-organisation of the medical services in the country, both of which will affect the present responsibilities and structure of the department. Copies of Special Reports made by the Medical Officer of Health on both these proposals are reproduced in Appendix B and Appendix C. The re-organisation of local government in London has been expensive, but one aspect which has been overlooked is the cost in health of senior and other staff of all departments who, from 13 mid-1964, were subjected to endless demands on their services and who have been working under stress and strain far more prolonged and severe than could have been foreseen. It will be interesting from the preventive medicine point of view to see the effect of this on the health of these officers in the future and even on their span of life. It is possible that many of the senior officers in the older age groups will have had their expectation of life materially reduced as a result of the prolonged mental and physical stresses to which they have been subjected. COMMITTEE ARRANGEMENTS During the interim period up to 1st April 1965, a Health Committee was appointed to deal with all Health, Sanitary and Welfare matters. On the 1st April 1965 the Committee was redesignated the Health & Welfare Committee. In 1966 this combined Committee was replaced by two independent committees dealing with Health and Welfare matters respectively, but leaving the combined departmental structure unchanged. In 1968, following the Maud Report on Management of Local Government, the committee structure was again altered, the Children's Committee being abolished and a single Social Services (& Children's) Committee became responsible for all the functions of the previous Health, Welfare and Children's Committees. The Children's Department still remained an independent department under the Children's Officer who continued to report independently to the Social Services (& Children's) Committee. In 1968 the meetings of the Social Services (& Children's) Committee were opened to the press and public whilst matters of general interest were under consideration. Items of business involving the personal affairs of individuals or matters which it was not in the public interest to divulge at that stage, were dealt with separately without the press and public being present. The number of members of the public attending the meetings during the first year was very small. 14 SECTION A STATISTICS AND SOCIAL CONDITIONS Page Physical Features of the Borough 17 Social Conditions 17 Immigrants 17 General Statistics 18 Vital Statistics 18 Live births 18 Still births 18 Infant Deaths under 1 year of age 19 Infant Mortality Rate 19 Neo-Natal Mortality 19 Maternal Mortality 19 Premature Births 19 Number of Births and Birth Rate comparison 20 (London Borough of Bexley and England and Wales) Infant Mortality Rate comparison 20 (London Borough of Bexley and England and Wales) Tables of Causes of Infant Deaths under 1 year of age 1965 21 do 1966 22 do 1967 23 do 1968 24 do 1969 25 15 PHYSICAL FEATURES OF THE BOROUGH The London Borough of Bexley is bounded on the north by the River Thames, to the west by the London Borough of Greenwich, to the south by the London Borough of Bromley and to the east by the Municipal Borough of Dartford and the Rural District of Dartford. The greater part of the Borough stands on elevated ground from sea level to 270 feet above sea level. There is a low lying strip of land about one mile in width adjoining the River Thames which is marshy and liable to flooding. This has until recently been mainly open marsh and grassland except in the Erith area where considerable heavy industrial development has taken place. The Greater London Council's Southern Outfall Sewage Works (Crossness) occupies a large area of the low lying land in the Abbey Wood area and the new development of Thamesmead is being built in this area also. Two small rivers run through the Borough. The River Cray passes through the southern part of the Borough via North Cray, Bexley and Crayford to join the River Darenth on the north-east boundary which then crosses Crayford marshes before discharging into the River Thames; the River Shuttle is small and traverses the Borough centrally from west to east joining the River Cray at Hall Place. Geologically the Borough lies in the London basin mainly on the London clay. There are also beds of alluvium, sand and pebbles. Underlying all these beds is the chalk of the Eocene period. SOCIAL CONDITIONS Bexley is mainly a residential area although important industries are located in the Borough. The heavy industries are mainly in Erith and also in Crayford. Considerable light industry is to be found in Sidcup and Foots Cray. A large part of the housing in the Borough is owner-occupied and was erected between the two world wars and therefore is still in good condition and fully in accord with modern housing standards. There has also been much post-war development. Since 1966 extensive development of the early stages of the new town of Thamesmead has been taking place on the low lying ground bordering the River Thames at Abbey Wood, which will ultimately provide accommodation for approximately 17,000 additional residents in the Borough. There is no slum clearance problem, although in the older parts of the Borough small pockets of ageing and sub-standard accommodation exist which are dealt with by closure and demolition from time to time. The proportion of elderly persons over 65 years of age in the community is 10.9% (for England and Wales 12.5%). IMMIGRANTS There is a relatively small number of immigrants, other than Scots, Irish and Welsh, in the Borough, the Erith area being the most popular place of residence. The London Borough of Bexley 17 is among those with the lowest population of immigrants, the most recent figure available being 3,740 (1.7% of the population). To assist the Asian immigrants to obtain the maximum benefit from the various services available in the Borough, an interpreter is employed by the Bexley Council of Social Service, the local authority making a grant to the Council of Social Service towards her salary. The interpreter's services are freely available to the various sections of the Health & Welfare Department as required. A number of immigrants are employed in the department as medical officers, health visitors, district nurses, midwives, social workers, etc. which is of great help when dealing with their compatriots. GENERAL STATISTICS Area in acres — 15,896 1965 1966 1967 1968 1969 Population (Registrar General's estimated) 215,480 215,180 215,300 215,470 215,610 Rateable Value £10,182,009 £10,324,459 £10,454,965 £10,663,098 £11,175,821 Product of a penny rate £42,482 £43,712 £44,163 £44,603 £45,600 Number of dwellings 68,776 69,514 70,209 70,785 72,255 Number of Council dwellings 10,734 10,797 11,091 11,293 11,442 VITAL STATISTICS LIVE BIRTHS Live Births 1909 (M) 1889 (M) 1908 (M) 1735 (M) 1802 (M) 1884(F) 1847(F) 1770 (F) 1735(F) 1674(F) TOTAL 3793 3736 3678 3470 3476 Birth Rate per 1000 population 17.6 17.4 17.1 16.1 16.1 ILLEGITIMATE LIVE BERTHS 76 (M) 77(F) 91 (M) 78 (F) 86 (M) 101 (F) 81 (M) 97 (F) 86 (M) 79(F) TOTAL 153 169 187 178 165 Percentage of total live births 4.0 4.2 5.1 5.1 4.7 STILLBIRTHS 36 (M) 19(F) 23 (M) 24 (F) 22 (M) 31(F) 30 (M) 21 (F) 21 (M) 16(F) TOTAL 55 47 53 51 37 Rate per 1000 total live and still births 14.3 12.6 14.2 14.0 11.0 18  1965 1966 1967 1968 1969 TOTAL LIVE AND STILL BIRTHS 1945 (M) 1912 (M) 1930 (M) 1765 (M) 1823 (M) 1908(F) 1871 (F) 1801 (F) 1756 (F) 1690 (F) TOTAL 3848 3783 3731 3521 3513 INFANT DEATHS (under 1 year) 28 (M) 22 (M) 37 (M) 30 (M) 33 (M) 28 (F) 25 (F) 21 (F) 22 (F) 21 (F) TOTAL 56 47 58 52 54 INFANT MORTALITY RATE Total infant deaths per 1000 live births 14.76 12.58 15.77 14.77 16.0 Legitimate ditto 14.56 12.90 16.04 14.89 15.0 Illegitimate ditto 19.61 5.92 10.70 16.85 30.0 NEONATAL MORTALITY Early neo-natal mortality rate Perinatal mortality rate 8.70 3.71 11.15 8.65 10.0 22.87 18.77 25.19 23.0 20.0 MATERNAL MORTALITY Number of deaths 2 3 Rate per 1000 live and still births - — .54 .85 - PREMATURE BIRTHS Live 167 236 250 204 192 Stillborn 23 30 31 33 23 19 BIRTHS The number of births in the borough and the birth-rate have been falling since 1965. This fall follows the national trend. The birth and still-birth rates each year in Bexley have been lower than those for England and Wales. Birth Rate Still Birth Rate Bexley England & Wales Bexley England & Wales 1965 17.6 18.1 14.3 15.8 1966 17.4 17.7 12.6 15.3 1967 17.1 17.2 14.2 14.8 1968 16.1 16.9 14.0 14.3 1969 16.1 16.3 11.0 13.0 (The Birth Rate is the number of live births per thousand population) (The Still Birth Rate is the number of still-births per thousand total births) INFANT DEATHS The infant mortality rate (total infant deaths per thousand live births) is considerably lower in Bexley London Borough than the national average Bexley London Borough England and Wales 1965 14.76 19.0 1966 12.58 19.0 1967 15.77 18.3 1968 14.77 18.3 1969 15.00 18.00 The following tables show the causes of death of all infants in the Borough, by age groups:- 1965. INFANT DEATHS  AGE GROUPS Under Total under one month 1—2 months 2 — 4 months 4 — 6 months 6 — 8 months 8—10 months 10 — 12 months Total deaths for 1965 1 week 2 weeks 3 weeks 4 weeks Bronchopneumonia 1 1 2 Acute tracheo-bronchitis 3 1 1 5 Asphyxia 4 4 4 Atelectasis 7 7 7 Congenital heart disease 1 1 2 1 3 Prematurity 8 2 10 10 Hyaline membrane disease 1 1 1 Cerebral haemorrhage 2 2 2 Meningitis 1 1 1 2 Hydrocephalus 1 1 2 1 3 Hepatic failure 1 1 Fibrocystic disease of pancreas 1 1 Fibro plastosis of heart 1 1 1 Diabetes mellitus 1 1 Cerebral anoxia 1 1 Acute gastro enteritis 1 1 Anencephalus 1 1 1 Subdural haemorrhage 1 1 1 Pneumonia 2 2 Myocardial infarction 1 1 1 Pulmonary oedema 1 1 1 Congenital abnormalities 1 1 1 Intracranial haemorrhage 1 1 1 Acute cardiac failure 1 1 1 Superior sagittal sinus thrombosis 1 1 Nephrotic syndrome 1 1 33 3 2 1 39 7 2 4 – 2 2 56 21 1966. INFANT DEATHS AGE GROUPS Under Total under one month 1—2 months 2 — 4 months 4 — 6 months 6 — 8 months 8—10 months 10 — 12 months Total deaths for 1966 1 week 2 weeks 3 weeks 4 weeks Bronchopneumonia 1 1 1 3 5 Acute tracheo-bronchitis 1 1 1 3 Asphyxia 3 3 3 Congenital heart disease 1 1 2 3 Prematurity 14 14 14 Hydrocephalus 1 1 1 Pneumonia 1 1 1 1 1 4 Pleural effusion 1 1 1 Agenesis of kidneys 1 1 Intracranial haemorrhage 1 1 2 2 Cardiac failure 1 1 1 2 Duodenal atresia 1 1 1 Uraemia 1 1 1 2 Septicaemia 1 1 1 Cord round neck 1 1 1 Arterial haemorrhage 1 1 1 Acute epiglottitis 1 1 1 Nephrotic syndrome 1 1 23 3 2 3 31 5 4 1 3 2 1 47 22 1967. INFANT DEATHS AGE GROUPS Under Total under one month 1 — 2 months 2 — 4 months 4 — 6 months 6 — 8 months 8—10 months 10 — 12 months Total deaths for 1967 1 week 2 weeks 3 weeks 4 weeks Acute bronchopneumonia 3 1 4 1 5 Acute tracheo-bronchitis 2 3 1 6 Asphyxia 3 3 3 Atelectasis 4 4 4 Congenital heart disease 1 1 1 2 Prematurity 16 16 16 Respiratory failure 3 1 4 4 Patau's syndrome 1 1 1 Peripheral circulatory failure 1 1 Anencephaly 3 3 Acute enteritis 1 1 Septal defect 1 1 1 Complete absence of left diaphragm 1 1 1 Multiple congenital abnormalities 1 1 1 Status epilepticus 1 1 Cardiac failure 1 1 2 Intracranial haemorrhage 1 1 1 Intra-partum anoxia 1 1 1 Accidental haemorrhage 1 1 1 Acute leukaemia 1 1 Compound presentation 1 1 1 Abdominal haemorrhage 1 1 (Manslaughter) 39 1 1 4 45 3 3 1 2 2 2 58 23 1968. INFANT DEATHS AGE GROUPS Under Total under one month 1— 2 months 2 — 4 months 4 — 6 months 6 — 8 months 8—10 months 10—12 months Total deaths for 1968 1 week 2 weeks 3 weeks 4 weeks Acute bronchopneumonia 1 1 2 1 1 4 Acute tracheo-bronchitis 3 1 4 Asphyxia 2 2 2 Atelectasis 1 1 1 1 3 Congenital heart disease 1 1 1 3 1 4 Prematurity 17 17 17 Hyaline membrane disease Hydrocephalus 1 1 1 1 1 1 Anencephaly 1 1 1 Pneumonia 1 1 Congenital aortic stenosis 1 1 Apnoea 1 1 1 Intracranial haemorrhage 2 2 1 3 Cerebral haemorrhage 3 3 3 Placental insufficiency 1 1 1 Hyperkalemia 1 1 Cardiac failure 1 1 1 1 3 Operation for arterial and ventricular septal defects 1 1 31 1 - 4 36 2 8 3 - 2 1 52 24 1969. INFANT DEATHS AGE GROUPS Under 1 — 2 months 2—4 months 4 — 6 months 6—8 months | 8 — 10 months 10 — 12 months Total deaths for 1969 1 week 2 weeks 3 weeks 4 weeks Total under one month Respiratory distress 1 1 2 2 Bronchopneumonia 2 2 1 3 Acute tracheo-bronchitis 2 2 2 1 7 Prematurity 13 13 13 Congenital abnormalities 5 5 5 Asphyxia 1 1 1 Peritonitis 1 1 1 Acute gastro enteritis 1 1 Brain damage at birth 2 2 2 Atelectasis 1 1 1 Anancephaly 1 1 1 Tracheotoesophageal fistula operation 1 1 1 Meningitis 1 1 1 Meningocele 1 1 2 2 Cardiac failure 1 1 1 Cerebral haemorrhage 3 3 3 Acute epiglottitis 1 1 Congenital heart disease 1 1 1 2 Placental insufficiency 1 1 Hydrocephalus 1 1 1 2 Dehydration 1 1 Renal infarction 1 1 Interstitial pneumonia 1 1 1 35 3 1 - 39 3 8 2 1 1 - 54 25 SECTION B HEALTH SERVICES IN THE AREA Page Hospital and Specialist Services 29 Co-ordination and Co-operation with Hospitals and Family Doctors 29 Nursing Homes 29 Local Authority Services 30 Clinic and Welfare Centres 30 Distribution of Welfare Foods 32 Day Nurseries, Child Minders and Play Groups 32 Premature Infants 33 Congenital Defects at Birth 34 Medical Services for Pre-School Children 34 Health Visiting 35 Child Welfare Sessions 36 General Midwifery Provision 36 Training of Midwives 37 District Nursing 38 Incontinence Pads and Means of Disposal 38 Nursing Aids 39 Domestic Help 39 Recuperative Care (Convalescence) 40 Mental Health Service 40 Re-Instate Ltd. 41 Mentally Sub-Normal Persons 42 Junior Training Centres 42 Swimming Instruction 42 Adult Training Centre 43 Hostel for Mentally Sub-Normal Children 43 Social and Recreation Club for Mentally Sub-Normal Adults 43 Family Planning 44 Chiropody 44 Health Education 46 27 HEALTH SERVICES IN THE AREA (contd.) Page Renal Dialysis 46 Health Centres 47 Thamesmead 47 Cancer 50 Cervical Cytology 50 Local Authority Clinics - 51 Mortuary 52 Medical Examinations 52 Staff 52 Other Categories 53 28 HOSPITAL AND SPECIALIST SERVICES The Hospitals in the Borough are as follows: — Bexley & Welling Hospital, Bexleyheath 26 beds for acute cases Bexley Maternity Hospital, Bexleyheath 31 beds for maternity cases Russell Stoneham Hospital, Crayford 28 beds for maternity cases Erith & District Hospital, Erith 45 beds for acute cases Hainault Maternity Hospital, Erith 20 beds for maternity cases Queen Mary's Hospital, Sidcup A general hospital with 354 beds, mainly for acute cases. A new maternity block with 56 beds and 14 cots for special care cases was opened in 1966. Residents are also well served by a number of hospitals in the surrounding areas and in the County of Kent. The provision of hospital beds for maternity and acute cases is generally adequate, but difficulties have been encountered in finding beds for chronic sick and senile persons. Persons suffering from mental illness are accommodated at various hospitals in Kent. Full co-operation is maintained with the various hospitals in and around the Borough and with the local medical practitioners. Although formal attachment of Health Visitors, District Nurses and Midwives to general practices has not been adopted for administrative reasons, the services of all these categories of officers are readily available on request. A number of medical practitioners hold special ante-natal sessions for their patients at which the appropriate midwives attend and others hold well-baby clinics at which Health Visitors are present. Close co-operation also takes place with the hospitals. Student Health Visitors and Pupil Midwives are accepted in the department for part of their training and pupil nurses from Queen Mary's Hospital, Sidcup and Bexley Maternity Hospital pay a visit to the department in the course of their training. The number of nursing homes registered with the Council under the Public Health Act 1936 and subsequent legislation is 5. All nursing homes are inspected regularly by a medical officer and/or a senior nursing officer. All homes have been found to be satisfactory. Improvements or modernisation have been carried out at some homes during the period under review. CO-ORDINATION AND CO-OPERATION WITH HOSPITALS AND FAMILY DOCTORS NURSING HOMES 29 The accommodation available is for 83 chronic sick and aged persons. No unregistered homes have come to the notice of the department. There are no private maternity homes in the Borough. 30 LOCAL AUTHORITY SERVICES CLINIC AND WELFARE CENTRES At the end of 1969 the following sessions were being held : — CLINICS Clinics Child Welfare Ante-Natal Relaxation and Mothercraft Bexley: Murchison Avenue Tues: 2—4 p.m. Thurs: 2—4 p.m. - Weds: 10—12 noon (by appointment) (Dental, Orthopaedic and Speech Therapy by appointment) Ex-Servicemen's Club, High Street Mons: 2—4 p.m. - - Bexleyheath: 315, Broadway Mons: 2—4 p.m. Tues: 9.30—11.30 p.m. Weds: 2—4 p.m. Fridays: 2—4 p.m. Fridays: 10—12 noon (by appointment) (Dental by appointment) Mayplace School, Woodside Road (Dental and Speech Therapy by appointment) - - Welling: Wrotham Road Tues: 2—4 p.m. Thurs: 10—12 noon Toddlers Clinic 1st Wed. in month: 2—4 p.m. Mons: 2—4 p.m. Weds: 9.30-11 a.m. Station Approach (Orthopaedic by appointme Tues: 2—4 p.m. Weds: 10—12 noon Thurs: 2—4 p.m. it) Fri: 10—12 noon (by appointment) R.A.C.S. Hall, Weds: 2—4 p.m. _ The Green, Falconwood Thurs: 10—12 noon Little Danson, _ _ — Dansington Road (Dental and Ophthalmic by appointment) Sidcup: Bedensfield, Tues: 2—4 p.m. — — Ellensborough Road Thurs: 2—4 p.m. Congregational Hall, Mons: 2—4 p.m. _ Station Road Weds: 2—4 p.m. Cytology appointments arranged through Health Department. School Clinic appointments arranged through Health Department. Child Guidance Clinic: 18, Crook Log, Bexleyheath — open all week. 31 Clinics Child Welfare Ante-Natal ation and Mothercraft St. Andrew's Hall, Wren Road Tues: 2—4 p.m. — _ The Oval, Sherwood Park Avenue Tues: 2—4 p.m. Weds: 2—4 p.m. Fridays: 10—12 noon Weds: 10—11.30 a.m. Toddlers — Fridays: 2—4 p.m. (by appointment) 69, Sidcup Hill (Dental and Speech Therap Tues: 10—12 noon y by appointment) Thurs: 1.30—3.30 p.m. (1st in month) Thurs: 9.30-12.30 (by appointment) Erith: Hainault, Lesney Park Road (Dental and Ophthalmic by Tues: 10—12 noon Thurs: 2—4 p.m. appointment) Tues: 2—4 p.m. (by appointment) Belvedere: Congregational Hall, Picardy Road Tues: 2—4 p.m. Thurs: 2—4 p.m. — — St. Augustine's School, Abbeu Road Weds: 2—4 p.m. Fridays: 2—4 p.m. — Weds: 10—12 noon (by appointment) Bedonwell School, Bedonwell Road (Dental by appointment) Tues: 2—4 p.m. Fridays: 2—3 p.m. Weds: 2—3 p.m. Weds: 10—12 noon (by appointment) Crayford: Town Hall (Ophthalmic and Orthopae Weds: 2—4 p.m. Fri: 9.30- 11.30 a.m. die by appointment) Thurs: 1.30—3.30 p.m. (by appointment) Slade Green: Colyers Lane Tues: 2—4 p.m. Weds: 2—4 p.m. - Thurs: 9.30— 11.30 a m (by appointment) Community Centre, Fridays: - — Bridge Road 10—12 noon 2—4 p.m. Barnehurst: Methodist Hall, Thurs: 2—4 p.m. — — Risedale Road Fridays: 2—4 p.m. (2nd and 4th in month) Thamesmead: Temporary Health Centre, 200 Lensbury Way, Abbey Wood, S.E.2. Friday: 2—4 p.m. DISTRIBUTION OF WELFARE FOODS Certain proprietary brands of dried milk and dietary supplements, e.g. vitamin preparations, together with National Dried Milk, cod liver oil and orange juice are on sale at Welfare Centres and National Dried Milk, cod liver oil and orange juice at the offices at 8 Brampton Road, Bexleyheath, Erith Town Hall, Erith and 71 Sidcup Hill, Sidcup. Details of the annual issues are as follows : — 1965 1966 1967 1968 1969 National Dried Milk (Packets) 10,826 13,078 7.630 4,908 3,687 National Orange Juice (Bottles) 62,900 86,074 82,750 77,645 78,600 National Cod Liver Oil (Bottles) 2,594 3,094 2,737 2,488 2,320 A. & D. Tablets (Packets) 3,430 4,395 3,608 3,369 3,243 Proprietary Dried Milk (Packets) 35,928 46,778 48,146 51,335 50,580 Proprietary Vitamin Preparations (items) 26,309 37,356 37,764 36,300 34,091 Other (Packets) 10,249 13,740 11,736 10,679 10,272 Mothers are educated and encouraged to give their infants balanced diets and not become dependent on dietary supplements. As far as possible, these are issued only when there is a danger that a child's health may be at risk if the supplements are not provided. DAY NURSERIES, CHILD MINDERS AND PLAY GROUPS Under the Nurseries and Child Minders Regulation Act, 1948, the Council is required to register all nurseries in the area and all persons who, for reward, receive children under five years of age into their homes. The Health Service and Public Health Act, 1968, amended the 1948 Act laying down stricter requirements for the care of children under five and making it obligatory for certain information to be supplied regarding the health of the staff at nurseries and child minders and generally requiring higher standards of accommodation, equipment, meals, etc. than had previously applied. Regular inspections by medical and health visiting staff are made to all nurseries and child minders' accommodation. There is no Council owned nursery in the Borough. There is a need for such provision and a site has been available in Belvedere close to the station and convenient for many industrial undertakings. Unfortunately planning and financial problems have delayed the provision of this much needed facility. The number of nurseries, child minders and playgroups in the Borough is shown in the following table 1965 1966 1967 1968 1969 Day Nurseries 15 17 5 3 4 No. of Places 520 536 152 148 178 32 1965 1966 1967 1968 1969 Child Minders 14 13 9 12 223 No. of Places 128 198 172 101 495 Playgroups - - 22 30 42 No. of Places - - 690 908 1286 PLAY GROUPS At two Child Welfare Clinics — Wrotham Road, Welling and Ellenborough Road, North Cray — mothers clubs are running play groups on mornings when the clinic premises are not otherwise in use. The authority provides the premises, heating and lighting, free of charge. At Ellenborough Road Child Welfare Clinic on two mornings a week, a special group of mainly physically handicapped infant children is accommodated for play activities under a trained nursery nurse and this has proved not only therapeutic for the children but a great aid to the medical officer for assessment of the future needs of these children. Suitable mentally handicapped children are also accepted into the play groups when necessary. At the end of 1969 there were 36 children (aged between 3 and 5 years) attending the Wrotham Road group and 7 children (aged between 31/2 and 5 years) attending the Ellenborough Road group. PREMATURE INFANTS The number of premature infants born each year to residents of the Borough, together with other relevant information, is given in the following table : — 1965 1966 1967 1968 1969 (a) Born at home 13 25 26 11 3 (b) Born in hospital 154 211 224 193 189 Premature stillbirth 23 30 31 33 23 The numbers of illegitimate children born each year were : — 1965 (9 months only) 1966 1967 1968 1969 153 169 187 178 165 ILLEGITIMATE CHILDREN From 1965 to 1967 there was a home with places for 20 unmarried expectant mothers at Oakhurst, Lesney Park Road, Erith, under the aegis of the Centerbury & Rochester Diocesan Council for Social Work. The Home was next door to Hainault Maternity Hospital, Erith, where the girls were confined; a most convenient arrangement. The Borough Council assisted financially. The Home was closed at the end of December 1967. 33 The following cases were dealt with through the Diocesan Council : — 1965 3 1966 2 1967 5 CONGENITAL DEFECTS AT BIRTH In 1967 a register was established for all babies "At Risk", e.g. those exposed to pre-natal or hereditary dangers, those who showed signs or symptoms at or soon after birth which might be an indication of some disability in the future and those who were involved in a difficult birth, etc. and who might, as a result, be adversely affected later in life. Midwives and doctors attending the birth or in attendance on the child following birth, inform the department of any congenital abnormalities or other deviations from normal. Some cases are referred immediately for specialist attention, others are kept under observation. A proportion of the cases put on the register ultimately develop normally and are removed from the register. The number entered on the register in 1969 was 1490, and of this number 369 were removed during the year. MEDICAL SERVICES FOR PRE-SCHOOL CHILDREN The full-time medical officers who conduct Child Welfare Clinics are also School Medical Officers and the specialist clinics of the School Health Service, i.e. Dental, Audiology, Speech Therapy, Ophthalmic, Physiotherapy and Child Guidance, are all available for advice and treatment for any pre-school children. Close co-operation is maintained with the patient's private practitioner and with hospitals, in respect of children requiring treatment not available through the Local Authority services. The number of pre-school children referred to the special clinics was Clinic 1965 1966 1967 1968 1969 Audiology - - - 20 58 Child Guidance 30 22 22 16 19 Dental 208 225 210 287 421 Ophthalmic - 2 21 21 24 Physiotherapy 27 18 27 27 15 Speech Therapy 18 23 48 41 52 34 HEALTH VISITING Health Visitors are State Registered Nurses who have taken either Part 1 of the Midwifery qualification or are State Certified Midwives, and who have then taken a further course of training and examination for the Health Visitor's Certificate. As will be seen, they are highly qualified and widely experienced officers. The Section comprises a Superintendent Health Visitor, a Deputy Superintendent Health Visitor, two Group Advisers and an establishment of 42 Health Visitors, but this figure has never been reached due to the national shortage of Health Visitors. The Council sponsors up to five Student Health Visitors per annum for training. In order to relieve Health Visitors of activities not requiring their special qualifications, Clinic Nurses who are State Registered Nurses, undertake the routine procedures in respect of school medical inspections and infant welfare clinics, etc. In 1969 there were 29 Health Visitors, 14 Clinic Nurses (some part-time) and 4 Students on the staff. The role of the Health Visitor has been changing in recent years. She now devotes a considerable part of her time to health education in clinics, homes and schools and also gives social advice, working in close conjunction with the other social services in the department and elsewhere. The Superintendent Health Visitor gives a course of lectures on environmental health to the student nurses at Queen Mary's Hospital School of Nursing and the student nurses spend a day with a Health Visitor in the community as part of their training. The Health Visitors undertake preliminary home investigation of cases of infectious disease, other than tuberculosis, which gives them access to families they may otherwise never meet in their professional capacity. In the case of tuberculosis, the system adopted by Kent County Council whereby a Health Visitor was attached to each Chest Clinic solely to undertake domiciliary supervision and health education, was continued until 1968. Two Health Visitors were seconded for this work, one serving Erith and the other at Queen Mary's Hospital. Since the retirement of Miss Harvey in 1968, the remaining Tuberculosis Health Visitor serves both clinics with assistance from the district Health Visitors. Due to the shortage of Health Visitors, it has not been possible to attach a Health Visitor to every medical practice in the Borough, but co-operation is encouraged between the general practitioners and the Health Visitors whose services are available to any doctor on request. One large practice holds a "well-baby" clinic twice a week. This is very popular and the numbers attending require the attendance of two Health Visitors at each session. Full use is not yet being made by all general practitioners of the assistance available from Health Visitors. At three senior girls' schools, the Health Visitors give a course of lectures as part of the school curriculum, covering such matters as parentcraft, dangers of smoking, personal hygiene, etc. The majority of Bexley Health Visitors have been trained in the early detection of deafness and other of the less obvious handicapping disabilities of babies and infants, so that further investigation and in appropriate cases, treatment, can be carried out as appropriate, as early as possible. 35 The following tables show the various activities of the Health Visitors during the past five years 1965 1966 1967 1968 1969 Child Welfare Sessions Held by Assistant Medical Officers 340 516 841 911 1056 Held by sessional doctors 957 1331 1057 963 833 Held by Health Visitors 89 111 99 144 129 Total number of children under 5 attending 3926 10770 13391 13105 13842 Total seen by Doctor 9550 13207 26753 26838 24090 Total number of attendances 54314 75629 75956 73922 72617 Health Visitors and ClinicNurses attended the following sessions : Periodical School Medical Inspection 440 334 461 976 1021 School Hygiene Inspections 189 188 107 148 140 B.C.G. sessions 32 121 63 90 53 M. & C.W. Clinic sessions 4272 4976 4292 4956 5071 Cases visited by Health Visitors Total number of visits to children 5037 7772 16344 14411 13903 under 5 Persons aged 65 or over 74 97 206 183 182 Mentally disordered persons 39 27 14 24 25 Persons, excluding maternity cases, discharged from hospital (other than mental hospitals) 10 8 11 17 12 Number of tuberculous households visited 13 754 14 125 26 Number of households visited on account of other infectious diseases 143 1160 976 821 1072 Number of tuberculous households visited by tuberculosis health visitors 23 724 1239 707 703 GENERAL MIDWIFERY PROVISION A comprehensive domiciliary midwifery service is available in the Borough, the Council employing a Supervisor, Deputy Supervisor and 15 Midwives in 1969. In addition, there are three general practitioner maternity units at the Maternity Hospitals and an obstetric unit at Queen Mary's Hospital, with 56 beds. This unit opened in 1966 and in 1969 had a staff of 76 midwives. 36 The number of midwives employed by the department in each year is shown below, together with the number of confinements they attended : From 1st April 1965 1966 1967 1968 1969 No. of domiciliary midwives 17 20 18 17 16 Home confinements 938 965 766 642 584 No. of cases delivered in hospital by domiciliary midwives NIL NIL 20 37 105 Total births attended 938 965 786 679 689 Early discharges from hospital attended 190 202 268 294 215 Total number of cases attended 1128 1167 1054 973 904 The above table shows the changing pattern of the midwifery service over recent years. Whereas in the past the majority of normal confinements took place at home, the trend now is to admit women to hospital for their confinement and if there are no complications, to discharge them home within 48 hours to the care of the domiciliary midwife. To avoid the midwife becoming a maternity nurse, arrangements have been made with a number of maternity hospitals for the domiciliary midwife who has looked after a woman in the ante-natal period to carry out the delivery in hospital and then continue supervision of the patient at home after early discharge. The hospitals co-operating in this scheme at the end of 1969 are Hainault Maternity Hospital, Erith West Hill Hospital, Dartford Queen Mary's Hospital, Sidcup. TRAINING OF MIDWIVES A number of the domiciliary midwives are recognised by the Central Midwives Board as teachers for the district training of pupil midwives. The number of midwives so recognised was 5 in 1965 and 10 in 1969. The number of pupils dealt with each year has increased from 16 in 1965 to 40 in 1969. Pupils attached to midwives have come from the following hospitals Bexley Maternity Hospital, Bexleyheath Queen Mary's Hospital, Sidcup British Hospital for Mothers and Babies, Woolwich Beckenham Hospital, Beckenham (from 1969) West Hill Hospital, Dartford 37 DISTRICT NURSING On the appointed day the department took over all the Kent County Council District Nurses operating in the area of the new Borough. The establishment of nurses has fluctuated as the following table shows. The number of patients treated each year is also shown. No. of District Nurses No. of Patients 1965 34 2013 1966 35 2560 1967 30 2657 1968 33 2227 1969 33 2426 In December 1968 in order to enable the District Nurses to concentrate on activities requiring their special skills. Home Bathing Attendants were appointed. These persons undertake the routine bathing of chronic sick or elderly patients who do not require the special skill of the nurse. They work under the supervision of theNurse in charge of the patient. The number of baths given by the Bathing Attendants each year is as follows 1968 274 1969 6710 Recently (1969) the Council has agreed to the employment of eight Nursing Auxiliaries. These are unqualified persons with an interest in simple nursing who must undergo training in elementary nursing procedures before undertaking the care of patients in their own homes and always under the direction and supervision of a qualified nurse. It is hoped to combine the duties of Bathing Attendants referred to above with those of the proposed Nursing Auxiliaries and the present Bathing Attendants will be eligible to transfer and undergo training. The District Nurses also play an important role in the provision of nursing aids to the sick and physically handicapped and carry out preliminary investigations as to need and suitability of the aids requested and instruct in the use of the aid where necessary. INCONTINENCE PADS AND MEANS OF DISPOSAL One of the major problems in nursing the elderly or chronic sick at home arises when the patient is incontinent. To assist when this situation exists incontinence pads are issued, free of charge, by the department through the District Nurses. The number of pads issued each year since 1965 is given in the following table No. of pads issued 1965 19,200 1966 37,700 1967 35,427 1968 47,500 1969 35,000 Disposal of soiled pads is by burning or where this is not convenient, the department supplies, free of charge, waterproof bags which enable the soiled pads to be removed hygienically with the domestic refuse. The demand for waterproof bags had been very small so far. 38 NURSING AIDS Various appliances to assist the sick or the handicapped can be borrowed either from the department or through the British Red Cross Society local branches. Aids are only issued on the instructions of a district nurse or medical practitioner. The types of appliance issued include walking aids, commodes, wheeled-chairs, bed-pans, bedrests, beds, bedding, etc. The department also issues on loan major items such as bed-hoists, ripple-beds, etc. which are expensive and which require regular servicing to maintain safety or efficiency. The numbers and types of appliances issued are shown below : — 1965 1966 1967 1968 1969 TOTAL ISSUED BV HEALTH & WELFARE DEPARTMENT Major items (included in above total) 301 300 402 553 590 Beds 15 12 12 15 19 Hoists 8 7 9 12 14 Ripple Beds - 11 10 24 21 Wheel-chairs - 2 4 8 9 TOTAL ISSUED BY BRITISH RED CROSS SOCIETY 424 441 435 544 932 DOMESTIC HELP Approximately 300 Home Helps are employed by the Department, all on a part-time basis. Home Helps are available for assistance in the home where on account of age, illness, infirmity, or some similar reason there is no suitable person in the home to care for the patient or family. The Home Helps generally attend maternity cases for two weeks following the day of confinment. It should be noted that a Home Help is not a nurse and she must not undertake nursing duties. The majority of the clients are persons over 65 years of age and once on the books in most cases they remain there as they tend to become more and more dependent on the service. The following table shows the number of cases over 65 and under 65 dealt with each year, together with the principal complaints affecting the under 65 age group 39 1965 1966 1967 1968 1969 Age 65 or over on first visit in the year 1276 1648 1606 1654 1768 Under 65 years Chronic sick and T.B. 118 143 145 155 163 Mentally disordered 7 10 9 4 7 Maternity 149 160 148 69 78 Others 184 297 262 291 177 TOTAL 1734 2258 2170 2173 2193 RECUPERATIVE CARE (CONVALESCENCE) Since the 1st April 1965, Recuperative Care has been provided at approved Nursing Homes on the coast, to persons who have recently recovered from a severe acute illness or an operation, and for whom convalescence was considered necessary. The number of persons sent each year was : — 1965 37 1966 35 1967 22 1968 18 1969 21 Holidays for the chronic sick, the elderly and the physically handicapped are dealt with through the Welfare Section of the department. MENTAL HEALTH SERVICE Great difficulty was encountered in recruiting staff for this service in 1965 and at one stage there was only the Senior Mental Welfare Officer in post and he was virtually on 24 hour duty for five months. After re-organising the section and regrading the posts in 1966, recruitment improved and the establishment was ultimately filled. This section deals with the welfare of mentally ill and mentally retarded persons. Mental Welfare Officers also arrange admissions to hospital and have responsibilities in respect of guardianship- The following table shows the number of mentally sick persons on the register and under active supervision by the section as at December 1969 40 Mentally III Elderly Mentally Infirm Psychopathic Under 16 16 & Over Under 16 16 & Over M F M F M F M F M F 1 1 130 205 14 47 - - 2 - There are no mental hospitals situated in the Borough and mentally ill patients are admitted mainly to hospitals in Kent, e.g. Bexley, Stonehouse and Mabledon Hospitals at Dartford and Oakwood Hospital at Maidstone. RE-INSTATE LTD. In 1965 an approach was made to the department from Bexley Hospital regarding establishing a rehabilitation unit for patients from the Hospital who were making good progress and who would soon be fit for discharge. The rehabilitation unit was to be a half-way house before they returned to their homes and their jobs. It was the intention to establish a similar type of unit for mentally sick persons in the community as part of the department's plans, but not for some years. The suggestion from Bexley Hospital was welcomed as an early means of providing this much needed unit. It was expected that once the unit was established and running smoothly, it would be able to earn a considerable part of the running costs. Re-Instate Ltd. was set up as a limited company independent of both the Hospital and the Local Health Authority and the unit came into operation in 1966. operation in 1966. To enable it to commence, the Council gave a grant of £3,500 for the first year and in subsequent years as shown in the following table 1966 1967 1968 1969 £3,500 £1,500 £2,000 £2,250 The Council has appointed three elected Members to represent it on the Board of Re-Instate Ltd. Cases can be admitted to the workshop from the community on the request of the Health & Welfare Department. The numbers in attendance each year have been : — 1966 1967 1968 1969 Bexley Residents who are Bexley Hospital Patients 5 10 17 15 Patients from the community 2 4 9 6 The centre can accommodate 60 persons of both sexes and undertakes light engineering and similar work for local industry. Firms have been most helpful in providing work and in loaning machines and other equipment. 41 There is a need for hostel accommodation for mentally ill persons recovering after hospital treatment, etc, and this could usefully be situated within convenient travelling distance of the Re-Instate Ltd. premises. MENTALLY SUB-NORMAL PERSONS JUNIOR TRAINING CENTRES Two junior training centres in the Borough were transferred from Kent County Council in 1965, one with 80 places at Crayford and the other with 40 places at Sidcup. There was also a proposal by Kent County Council to purchase a site at The Hollies Children's Home, Sidcup, previously owned by the London County Council, but transferred to Southwark London Borough, on which a new junior training centre was to be built to replace the inadequate rented premises of Sidcup Training Centre. The London re-organisation occurred before negotiations had been completed between the London County Council and the Kent County Council and it was four years before the site was finally bought by Bexley London Borough from Southwark London Borough. A new centre for 60 places capable of future expansion to 80 places to replace Sidcup Centre is now under construction and should be completed by early or mid-1970. It will be known as the Marlborough Training Centre. A further project under consideration is a new junior centre to replace the Crayford premises either on a site adjoining the present Centre or as part of a joint scheme with Greenwich London Borough and the South-East Metropolitan Regional Hospital Board in the grounds of Goldie Leigh Hospital. This scheme would offer the widest facilities for training and also medical supervision of the children. Discussions are still taking place in respect of this project. In-service training courses for the staffs of training centres were introduced in 1966. Since 1967 two such courses have been held each year in conjunction with the Health Departments of the neighbouring London Boroughs of Bromley and Greenwich and staff from both these authorities and from Goldie Leigh Hospital attend and the courses are held in each Borough in turn. SWIMMING INSTRUCTION During the last quarter of 1967 trainees at the Shenstone and Sidcup Junior Training Centres were, with the consent of their parents, given swimming instruction at the Crook Log Baths. Trainees attended normally one morning each week under the supervision of the Centre Supervisors. The number of attendances made by children were 1967 98 1968 363 1969 365 42 ADULT TRAINING CENTRE Up to 1968 there was no Adult Training Centre in the Borough. A few selected patients over16 years of age attended the junior c entres, but others were accommodated at the Adult Centres operated by the Kent County Council at Darenth Park Hospital (males) and Swanley Senior Training Centre (females). In 1967 the upper floor of Shenstone, which had been used for Civil Defence Training purposes became vacant and it was adapted to take 35 male and female adult trainees. Whilst far from ideal accommodation, it has proved very useful and convenient and is doing very good work. As a result of opening this centre, the adult trainees have been transferred from our own junior centres and also from the Kent County Council centres at Darenth and Swanley. The trainees are employed in a variety of tasks, e.g. dismantling old telephones, packing small goods, assembling plastic commodities, etc. for which they receive payment on a scale related to their usefulness and the income received by the centre for the work. Both sexes are admitted. In 1969 it was possible to increase the available accommodation and to increase the number of trainees attending to 45. In 1969 a site for a new purpose-built adult training centre was obtained at Carlton Road, Sidcup, on land owned by the Education Committee. This site of approximately one acre is well situated with extensive open space adjacent. Plans have been drawn up for a centre to accommodate 100 adult trainees and it is hoped that building will commence in 1970 and the centre will be in use by 1972. HOSTEL FOR MENTALLY SUBNORMAL CHILDREN A site at Falconwood, Welling was transferred to the Health Committee from the Kent County Council in 1965. This site was being used temporarily for allotments. In 1967 the Council approved a scheme to erect a residential home for 13 mentally subnormal children up to 16 years of age on the land. This home is situated in a pleasant residential area and will be convenient for the children to attend the new Marlborough Junior Training Centre referred to above. The home is expected to open early in 1970. SOCIAL AND RECREATION CLUB FOR MENTALLY SUB-NORMAL ADULTS The local branches of the National Society for Mentally Handicapped Children offered to assist in running a social and recreation centre for severly handicapped subnormal adults and the Council permitted the use of Wren Road Clinic, Sidcup, on one evening a week. Staff from this department serve on the committee and also attend as helpers. The number of persons attending averages 30 per week, comprising 14 males and 16 females aged between 16 and 35 years old. 43 FAMILY PLANNING In 1965 the Council agreed to co-operate with the Family Planning Association and to make available clinic premises to the Association free-of-charge. The Council also agreed to accept financial responsibility for cases referred by the Health & Welfare Department under Sections 22 and 28 of the National Health Service Act 1946 and for necessitous cases referred by general medical practitioners. By 1967 the Family Planning Association was using four clinic premises in the Borough for a total of 10 sessions per week, seven of these being in the evenings. The method of payment to the Family Planning Association was changed in 1968 when an annual lump sum grant was substituted for per capita payments. By the end of 1969, the Family Planning Association clinics were being held in five Council welfare centres for 121/2 sessions per week and in two hospitals for 31/2 sessions per week. In accordance with the National Health Service (Family Planning) Act 1967, family planning advice, etc. is available to any person who needs advice on family planning on social grounds and not as hitherto only for medical reasons, i.e. women likely to suffer detriment to their health as a result of pregnancy. No distinction is made between married and unmarried persons. CHIROPODY Chiropody is available for the elderly, the physically handicapped and expectant mothers. Treatment is carried out either by chiropodists in private practice under contract to the Council or by chiropodists on the staff of the Health & Welfare Department — the "Direct" service. Treatment is also available in the patient's home if they are incapable of visiting a private chiropodist's surgery or a clinic. The number of local authority clinics has been increased each year since 1966. There are now four in operation covering the main areas of the Borough as follows : — 315 Broadway, Bexleyheath 69 Sidcup Hill, Sidcup Town Hall, Crayford St. Augustine's Church Hall, Belvedere. A chiropody service for the residents of the Council's Old People's Homes undertaken by staff of the Health & Welfare Department was introduced in 1966 and a domiciliary service by our own staff commenced in 1967. The following tables show the growth of this service over the past five years. 44 DIRECT SERVICE Clinics Year From April 1965 1966 1967 1968 1969 No. of Clinics 1 1 2 3 4 Sessions 92 191 359 359 480 Treatments 484 1193 2002 1884 2642 Patients 120 295 306 382 461 Domiciliary Year From April 1965 1966 1967 1968 1969 Sessions Nil Nil 60 74 120 T reatments Nil Nil 220 323 564 Patients Nil Nil 90 89 150 Old People's Homes Year From April 1965 1966 1967 1968 1969 Sessions Nil 14 61 92 92 T reatments Nil 102 463 709 746 CONTRACTUAL SERVICE Year From April 1965 1966 1967 1968 1969 Surgery Treatments 7997 10689 10965 9208 9034 Domiciliary T reatments 3068 4826 5187 5174 4838 Patients 2734 2813 3752 2843 2869 Annual figures are not available by eligible categories, but the proportion has not significantly varied from year to year. 45 HEALTH EDUCATION Although provision was made in the establishment of the Department for a Health Education Officer and an Assistant, lack of accommodation to house such a section and administrative problems have so far prevented implementation of this proposal. Nevertheless, the Department has met all requests for talks on health matters, but it has not been possible to organise large-scale health campaigns nor exhibitions. In the early years requests for speakers were met by volunteers from the personnel of the appropriate section of the Department. In 1967 one of the Health Visitors expressed an interest and showed aptitude for this type of work and she now undertakes a considerable proportion of the talks. All Health Visitors give talks to and hold discussion groups for the mothers at their centres and in some centres meetings are held regularly at fortnightly intervals. The Health Visitors also give talks in schools to senior pupils. Posters are displayed in the Borough on topical health matters and leaflets are freely available for distribution to the public at all centres, etc. The Department owns three slide projectors and screens and can obtain the use of a 16 mm cine projector as necessary. RENAL DIALYSIS Sufferers from certain kidney diseases can benefit from the use of an "artificial kidney" machine which removes from the patient's blood the impurities normally removed by the kidneys. The patient's blood is allowed to circulate for some hours through complex equipment where dialysis occurs and the impurities are removed and the "purified" blood returned to the patient. The patient is connected to the apparatus by tubes inserted into veins in the arm, so that a continuous flow of blood occurs from the patient into the kidney machine and back to the patient. The treatment last some hours and has to be repeated every 3 or 4 days. Apparatus is now available which permits selected patients who have been trained in a hospital dialysis unit to treat themselves at home. The expensive apparatus is loaned by the hospital but the local authority is required to assist the patient in providing a room at his home suitably adapted to house the equipment. Among the requirements for the room are waterproofing of the floor, suitable wall finish, cupboards, heating, provision of hot and cold water supply and drainage etc. Where a spare room is available in a home, the problems are easily resolved, but where no spare room exists, this has to be provided by major alterations to the house. Adaptations so far undertaken have cost from £200 to £750 per case. The patients contribute towards the cost in accordance with the Council's assessment scales. By the end of 1969 four adaptations had been completed. Many difficulties have been encountered in dealing with these cases including technical problems with the floors, legal problems over reinstatement of tenanted houses should the patient remove, etc. etc. Bearing in mind the cost of adaptation and the intermittent use made of the expensive 46 apparatus and the special room, I am of the opinion that consideration should be given by the Council to adapting one or more Council-owned houses in the Borough where the necessary apparatus would be installed at which patients would attend and undergo treatment two or three times per week on a rota basis. This would enable the maximum use to be made of the expensive equipment and would avoid costly alterations and adaptations at patient's own homes with all the attendant problems this involves. A fully trained nurse would be in charge of the "Dialysis Centre". To cope with emergencies she would be resident with a flat on the first floor, the ground floor rooms being adapted for dialysis purposes. This suggestion was being actively pursued at the end of 1969. HEALTH CENTRES In 1966 the Council agreed to co-operate fully with the general medical practitioners in the Borough in providing Health Centres wherever there was sufficient demand from the local medical practitioners. Discussions between the Medical Officer of Health and the local medical practitioners have taken place on a number of occasions, but apart from the two special schemes referred to below, no firm request has yet been received from the medical practitioners for a centre. In anticipation of future needs, the Council acquired a property and land adjoining the Welfare Centre in the Broadway, Bexleyheath, which together offer a good site of adequate size for a future Health Centre at which general medical and dental and local health authority services can be provided. The two projects which are going ahead are at Thamesmead and Erith. THAMESMEAD At Thamesmead a temporary health centre came into use in mid-1969 with essential minimum facilities for general medical and general dental care for the early residents on Stages I and II of the Thamesmead project. The Centre comprises four timber units combined to provide two doctors'consulting rooms, a nurses' treatment room, a room for a health visitor or social worker, office, waiting area, dental surgery and dental workshop. The temporary centre is to be replaced by a permanent building which is expected to open in 1971. This building will have comprehensive facilities for both general medical and general dental care, together with the local health authority services. (See plans on pages 48 and 49). The permanent Thamesmead health centre is unique in that it will provide facilities for medical and dental students to attend as part of their training at Guy's Hospital. The planning of the centres and the whole of the health services for Thamesmead has been done jointly by the Bexley London Borough Council, Guy's Hospital, the South East Metropolitan Regional Hospital Board, the Executive Council for South East London and Kent, together with Greenwich London Borough Council and the London Executive Council as the later stages of the Thamesmead project are situated in Greenwich. 47 The first medical practitioner to the Scheme, Dr. P.M. Higgins, M.B., B.S., M.R.C.P., was appointed in 1968. The first dental practitioner, Mr. David W, Johnston, B.D.S., M.P.H., was appointed in 1969 and took up duty on the 1st September 1969. To ensure the fullest integration of all branches of the health services, both these officers have been given oppointments on the staff of Guy's Hospital and it is intended they will also undertake the clinical care of all the categories of persons for whom the local authority has responsibility, as part-time officers of the Health and Welfare Department. ERITH Under the redevelopment proposals for the centre of Erith, already under consideration before 1965, the premises of three medical practices will be affected and will have to be demolished. It was agreed that alternative accommodation in the new development would be provided for the doctors concerned as near as practicable to their existing premises. The doctors concerned expressed a willingness to co-operate with the local health authority for the joint use of any premises provided. This was a most acceptable offer as the nearest local authority clinic at Hainault is in unsatisfactory and inadequate buildings and is also inconveniently sited. The Council agreed to co-operate fully with these medical practitioners and a site was allocated for a Health Centre and plans prepared. In the course of a review of the redevelopment proposals it was found necessary to find a fresh site for the Health Centre and at the end of 1969 a stage had been reached where a new site acceptable to both the medical practitioners and the Health & Welfare Department had been earmarked and detailed plans for the new centre were being prepared. CANCER Due to the ageing of the population. Cancer is now one of the main causes of death. Whilst our knowledge of this disease and its cause and treatment is far from complete, there are certain types of cancer in which a cause is well established, e.g. certain chemicals used in industry which can cause skin or bladder cancer, lung cancer from cigarette smoking, etc. Prevention of the industrial forms of cancer is mainly a matter for Industrial Medical Officers and the Factory Inspectorate, as prevention is closely allied to technical procedures. In the case of lung cancer due to cigarette smoking, prevention lies entirely in the hands of the individual. The Health Department displays posters and issues leaflets and gives talks to school children and other organisations in an attempt to bring home to people the great danger of lung cancer. CERVICAL CYTOLOGY Another form of cancer in the prevention of which the department has been active, is cervical cancer in women. The exact cause of this cancer is not known, but a simple, painless test enables women who are liable to develop this type of cancer of the womb to be detached at a very early pre-cancerous stage when a relatively simple operation can be performed to prevent the onset of cancer later. 50 Special clinics were opened in 1966 at three of the Child Welfare Centres at which all women aged between 25 and 65 were encouraged to attend. Cervical cytology is also carried at Queen Mary's Hospital, Sidcup, and by the Family Planning Association at its clinics at Erith and Bexley. To encourage women to have this test, a number of industrial concerns employing large numbers of women were approached and arrangements made for the test to be performed at a temporary clinic established in the factory premises and manned by medical and nursing staff of the department and the firms concerned. The co-operation and assistance of these firms is very much appreciated. The following table shows the number of women dealt with each year through the above arrangements. 1966 1967 1968 1969 Local Authority Clinics Colyers Lane, Erith 767 889 850 1076 The Oval, Sidcup 731 692 756 958 Sidcup Hill, Sidcup 619 749 237 784 Other (non-local authority Clinics, G.P.'s, Industry, etc.) 1620 1400 1380 3085 TOTAL 3737 3730 3223 5903 The specimens taken at the clinics are sent to special laboratories at Orpington or Joyce Green Hospitals. In addition to cancer the test occasionally reveals some less serious condition of which the patient may be unaware and in these cases information is passed to the patient's own doctor and the patient is advised to consult him regarding further treatment. The following table shows a break down of the results of the smears taken at the local authority clinics. 1966 1967 1968 1969 Total smears examined 2115 2320 1821 2798 Positive for cancer 3 7 8 6 Revealing other condition 210 636 444 725 Normal 1902 1677 1369 2067 No smear taken 2 10 22 20 DEATHS FROM CANCER The following table of deaths from cancer shows the commoner sites of the disease Site 1965 1966 1967 1968 1969 Malignant Neoplasm Stomach 37 49 47 33 38 Intestine - - - - 57 Lung and Bronchus 115 132 127 138 140 51 Site 1965 1966 1967 1968 1969 Breast 41 39 46 40 53 Uterus 21 13 8 15 13 Buccal Cavity, etc. - - - - 7 Oesophagus - - - - 13 Prostate - - - - 17 Other Malignant and Lymphatic Neoplasms 204 230 205 236 141 Benign and Unspecified Neoplasms - - - 10 8 Leukaemia, Aleukaemia 14 17 16 - - Leukaemia - - - 17 18 MORTUARY An old fashioned unsatisfactory and inadequate mortuary exists at Bexleyheath. This falls far short of modern requirements and is in urgent need of replacement. In 1965 an attempt was made to find a suitable site for a new building but without success. Finally in 1967 it was agreed to cooperate with the Queen Mary's Hospital Management Committee in providing a modern mortuary, with provision for H.M. Coroner's requirements, in the new hospital buildings to serve both the hospital and the Borough's needs. The plans were approved in 1969 and construction is expected to be finished in 1973. MEDICAL EXAMINATIONS STAFF The employees who entered the Council's service from other Local Authorities in 1965 were transferred without any medical investigation. All new entrants to the Council's service are required to complete a questionnaire on their health and previous medical history. All these forms are perused by a medical officer in the department and in any case in which there is any doubt, the person is required to submit to a medical examination. The department is also required to advise on sick employees who are approaching the end of their sick-pay entitlement, or on a sick employee whose complaint may affect his ability to carry out his duties. Many of these cases involve consultation with the employee's private doctor and the hospital specialist under whose care he may be receiving treatment. In a few cases it may be necessary for an independent specialist's report to be obtained in order to advise appropriately. Entrants to the teaching profession and teachers entering the Council's employment are subject to special medical scrutiny. 1965 1966 1967 1968 1969 No. of questionnaires scrutinised 786 1175 1003 1226 1163 No. of medical examinations required after scrutiny of questionnaire 554 429 471 758 1021 52 OTHER CATEGORIES Since 1968 all staff at Day Nurseries and Child Minders are subject to medical investigation to ensure safety to the health of the children with whom they are in contact. The number of medical questionnaires examined in respect of these persons is 1968 1969 210 604 53 SECTION C PREVALENCE AND CONTROL OF INFECTIOUS AND OTHER DISEASES Page Infectious Diseases 57 Vaccination and Immunisation 57 Tuberculosis, Care and After Care 58 Investigations of contacts and home 59 Smallpox and Enteric Fever Surveillance 59 Smallpox Surveillance 59 Enteric Fever Surveillance 60 Food Hygiene and Food Poisoning 61 Bacteriological 61 Chemical 62 Venereal Diseases 63 55 INFECTIOUS DISEASES The following table shows the annual incidence of infectious disease in the Borough. Measles was responsible for the majority of infectious illness. 1968 vaccination against measles has been available and it is hoped that this will prevent serious outbreaks of this troublesome complaint in the future. 1965 1966 1967 1968 1969 Scarlet Fever 89 81 109 100 125 Whooping Cough 59 41 197 88 16 Poliomyelitis (a) Paralytic - - - - - (b) Non-Paralytic - - - - - Measles 1762 2000 2431 400 584 Diphtheria - - - - - Dysentery 20 81 31 62 43 Menincoccal Infection - 1 - - 1 Acute Pneumonia 11 21 27 7 - Smallpox - - - - - Acute Encephalitis (a) Infective - - - - - (b) Post Infective - — — — - Typhoid Fever - 1 1 1 2 Paratyphoid Fever 1 - - - - Erysipelas 8 8 7 8 - Food Poisoning 5 58 55 119 44 Tuberculosis (a) Respiratory 24 44 46 23 26 (b) Meninges & CNS - 1 9 10 - (c) Other 5 11 - 3 9 Puerperal Pyrexia 34 22 23 20 - Ophthalmia Neonatorum 2 1 - 1 - Anthrax - - - 1 - Infective Jaundice - - - 15 36 Tetanus - — — — — Leptospirosis - - - - - Acute Meningitis - - - - 11 VACCINATION AND IMMUNISATION Vaccination against smallpox and immunisation against diphtheria, whooping cough, tetanus and poliomyelitis is available free-of-charge to appropriate age groups at all child welfare centres or from the person's own general medical practitioner. In 1968 and 1969 protection against influenza was made available to certain personnel in the 57 Council's employ, i.e. doctors, nurses, staff at residential old people's homes and at children's homes and to key personnel in other departments. The residents in old people's homes were also vaccinated with the agreement of the resident's own doctor. Approximately 500 persons were protected in each year. Stocks of vaccines and lymph for smallpox vaccination are held in the department and are available to general practitioners on request. Protection against tuberculosis is offered for children and young adults and also to children who are known contacts of a case of tuberculosis. Skin tests are first carried out in all such persons to ascertain whether they have already acquired protection naturally and all who are not so protected are offered B.C.G. vaccination. The following table shows the number of persons under 16 years of age protected against various diseases in the years 1965 — 1969. The table does not record the number of injections given as some of the vaccines are combined and given as a single injection, e.g. diphtheria, tetanus and whooping cough; diphtheria and whooping cough; diphtheria and tetanus. As all categories of staff in the Health Department could be required to assist in controlling an outbreak of smallpox and would thereby be exposed to risk of infection, all staff are advised to be re-vaccinated at two yearly intervals and a register is kept of the vaccination state of all members. Reminders are given when re-vaccination is due. Staff who have never been vaccinated, or for whom it is inadvisable, are thus known to the Medical Officer of Health and can be excluded from any emergency duties involving risk of infection. 1965 1966 1967 1968 1969 Primary Reinforce ment Primary Reinforce ment Primary Reinforce ment Primary Reinforce ment Primary Reinforce ment Smallpox 1855 — 2312 7 2479 23 2574 10 1610 119 Diphtheria 2653 3574 3374 4740 3396 4625 3453 5065 1342 5118 Whooping Cough 2653 2921 3345 2695 3362 2461 3386 2896 1307 2554 Tetanus 2659 3574 3382 4740 3433 4625 3453 5147 1413 5214 Poliomyelitis 3158 2008 3929 2725 3388 4180 3371 4131 1342 5044 Measles - - - - - - 5163 - 3035 - B.C.G. Contacts 253 - 232 - 276 - 208 - 187 - School Children, etc. 815 — 3352 - 1569 - 1524 - 102 - TUBERCULOSIS, CARE AND AFTER CARE The Health Department's interest in tuberculosis is primarily concerned with the prevention of spread of the disease. Treatment is a matter for the patient's private doctor and the clinic and hospital facilities of the Consultant Chest Physicians of the Regional Hospital Board. The Health Department has responsibilities for the after-care of patients under Section 28 of the National Health Service Act 1946 and these are largely delegated to the London Borough of Bexley Chest and Heart Care Committee, to which an annual grant of £220 is made by the Council. 58 The number of cases notified each year and the number of deaths from tuberculosis each year are shown in the following table : — 1965 1966 1967 1968 1969 No. of cases notified (a) Pulmonary 24 44 46 23 26 (b) Non-pulmonary 5 12 9 13 9 No. of deaths from Tuberculosis 6 3 12 2 5 INVESTIGATIONS OF CONTACTS AND HOME Visiting of cases is carried out by a Health Visitor who is employed full-time at the Chest Clinics or by the appropriate district Health Visitor, who co-operates with the Chest Physicians. SMALLPOX AND ENTERIC FEVER SURVEILLANCE Persons now go abroad for business or pleasure in greatly increased numbers, manyvisiting countries outside Europe where they are exposed to the risk of infection with diseases not normally occurring at home. All travellers abroad are advised in the official leaflet of the Ministry of Health (now the the Department of Health & Social Security) "NOTICE TO TRAVELLERS" to obtain protection against typhoid and para-typhoid fever and against smallpox if visiting countries outside Europe, Canada and the United States of America, i.e. Africa, Asia (except Turkey), the Americas (except U.S.A. and Canada) and anywhere else where smallpox is occurring or has recently occurred, as notified by the World Health Organisation. SMALLPOX SURVEILLANCE Travellers returning direct to the United Kingdom from any of these places who cannot produce a valid Certificate of Vaccination on arrival, are offered vaccination and if they refuse, or if for any reason it is not carried out at the place of arrival, are placed under surveillance for fourteen days by the Port Medical Officer of the port or airport where the person arrives. He informs the Medical Officer of Health of the area to which the traveller states he is proceeding and a Medical Officer or Health Visitor from the Health & Welfare Department makes daily contact with the person either by a visit or telephone as appropriate. In some cases in order to minimise inconvenience to the person, arrangements are made with the Medical Officer of Health of the area in which the person works to undertake surveillance. Unfortunately some returning travellers either deliberately give a wrong address or change their plans and proceed to a different destination without informing anyone of their new address. Such action is irresponsible and exposes the community to a risk which should never arise. It also adds much work to the staff of the department. 59 Fortunately the majority of travellers from abroad are most co-operative and accept the inconvenience surveillance imposes cheerfully and willingly. The number of persons from abroad kept under surveillance each year during the five year period was as follows : — From 1st April 1965 1966 1967 1968 1969 12 8 17 9 2 ENTERIC FEVER SURVEILLANCE In this country, thanks to the careful attention given in the past to the provision of safe water supplies and efficient sewage disposal measures, the enteric group of fevers had become rare in this country. In many of the European and Mediterranean countries which are now popular with holiday makers, lower standards of hygiene exist and the enteric group of fevers is still common. The danger to holiday-makers arises from the fact that a proportion of sufferers from these diseases fully recover but, although apparently well, become carriers of the causative organism which they continue to excrete for long periods, in some cases for life. These carriers can contaminate water supplies where sewage disposal and water control are inadequate or non-existent and if employed in food handling, can contaminate food if their standards of personal hygiene are less than perfect. Countries from which cases or contacts in Bexley have occurred in recent years are Tunisia, Balearic Islands, France and Spain. The number of cases and contacts under surveillance were as follows : — 1965 1966 1967 1968 1969 Cases 3 1 1 1 4 Contacts 7 5 — 15 29 In the above table the contacts in some instances related to the Bexley cases, in others the cases resided outside Bexley but the contacts were in the same holiday party and had been exposed to similar risk of infection. The 1969 cases are of interest. Two Bexley residents had been on holiday in Tunisia with a party staying at the same hotel and were among eight members who became infected. The other two cases were small immigrant children, one of whom was admitted to two hospitals before a diagnosis of typhoid fever was made, leading to a large number of hospital contacts (27 in one hospital and 58 in the other). All contacts are investigated and any who are food handlers by occupation are not permitted to handle food until laboratory examination has shown them and other family or close contacts to be free from infection. 60 FOOD HYGIENE AND FOOD POISONING The notified cases of food poisoning in the Borough are : — 1965 1966 1967 1968 1969 5 58 53 119 44 These figures do not represent the true incidence, as many persons infected do not call in their doctor and are therefore not notified. Food poisoning is of two kinds — bacteriological and chemical. The former is much the commoner being due to living organisms which are easily spread from person to person by poor food hygiene standards in shops, canteens, kitchens or the home. In some types the live organism itself is spread from person to person via food, in others the organism produces a toxin in the contaminated food and although the organism may be killed by cooking, the toxin is unaffected and can cause severe illness when the food is consumed. The food in either case can be contaminated by a human handler or indirectly by flies, rats and mice or dirty food handling appliances and equipment, e.g. knives, mincing machines, etc. Chemical food poisoning is due to accidental contamination of food by some toxic chemical material and is much rarer than bacteriological contamination. Every case notified is investigated by a Health Visitor or Public Health Inspector as soon as possible, in order to find, if possible, the source of infection and to prevent further spread. If the case or a close contact is a food-handler, appropriate laboratory investigations are made and positive cases are not alJowed to return to work until clear of infection. In the case of contacts who are food-handlers, their employers are approached to arrange alternative non-food handling duties pending clearance of the contact or they are taken off work and compensation for loss of wages is paid by the Council. The majority of cases notified are isolated instances and usually no source of infection is found. Where a number of cases occur simultaneously a common source of infection may be found and action can then be taken. Examples of both bacteriological and chemical poisoning which were fully investigated are given below BACTERIOLOGICAL FOOD POISONING OUTBREAK DUE TO CHICKEN CONTAMINATED WITH SALMONELLA ORGANISMS Salmonella Group D was isolated by the Public Health Laboratory in faecal specimens from cases of food poisoning in a neighbouring borough and also from the remains of one chicken from a meal consumed there. 61 Following information that part of a consignment of chickens involved in this outbreak of food poisoning had also been sent to a wedding reception in this Borough, a list of guests was obtained and all were visited. 87 persons were investigated, 40 in this Borough and 47 out of the Borough. 39 cases in all were found to be bacteriologically positive (23 — including 3 food handlers — in this Borough and 16 outside the Borough). Almost all on interview had stated that they had eaten chicken. Pathological Reports confirmed as the causative organisms : — Salmonella enteritidis 28 Salmonella Group C 1 Salmonella Group D 5 Salmonella unidentified 5 From observations made during the inspection of the premises concerned it would appear that surface contamination of the birds with bacteria from their guts was the likely source of infection. All infected persons recovered. CHEMICAL CADMIUM POISONING Cadmium is a metal used for plating iron and steel to prevent corrosion. Its salts if ingested are toxic and irritant, causing vomiting and gastric pain. Recovery fortunately is usually rapid. In July 1968, four members of the staff at a swimming bath and six members of the public complained of stomach pains and/or headache, vomiting and diarrhoea. Two further cases outside the Borough were also reported. Investigation showed that all had drunk a proprietary beverage served from a dispenser unit at the swimming bath cafe. Samples of the beverage were sent for both chemical and bacteriological examinations. The bacteriological results were negative, but the chemical analysis revealed the presence of cadmium 110 parts per million by weight and iron 25 parts per million by weight. The beverage is supplied in stainless steel containers which have an aperture for cleaning, normally closed by a stainless steel cover held in place by an external clamp. The particular container supplying the dispensing machine at the cafe was found to contain inside a loose clamp which should not have been there at all. The clamps were made of ordinary steel and were plated with cadmium. The acid nature of the beverage had obviously attacked the cadmium and the steel, thus accounting for the iron and cadmium found by the analyst. This type of container has been in use for many years in many countries in Europe and it is understood that this is the first time a problem of this type had arisen. Whilst the chance of a further occurrence was remote, the nationally known firm decided to be extra cautious and replace many thousands of the cadmium plated clamps with devices made from stainless steel which is unaffected by the beverage and is perfectly safe. 62 All the persons concerned made a rapid and complete recovery. This example illustrates the extent to which some manufacturers are concerned about the safety of their products and are willing to co-operate with the local authorities. VENEREAL DISEASES There are no venereal disease treatment clinics in the Borough. Patients attend for treatment at clinics in London or Kent. The following table shows the numbers of Bexley cases treated in various clinics each year : — 1965 1966 1967 1968 1969 S. G. Oth. S. G. Oth. S. G. Oth. S. G. Oth. S. G. Oth. Dreadnought Hospital Greenwich 7 35 1 4 33 1 8 56 8 39 12 60 Greenwich District Hospital 2 5 41 2 9 34 2 14 46 Whitechapel Clinic London Hospital - - - - - 3 - - 3 - - 2 - 3 5 Other Clinics - - - - — - - 3 9 - - - - 2 32 (N.B. S = Syphilis G = Gonorrhoea Oth. = Other Venereal Conditions) Contact tracing and follow up is usually undertaken by the clinics concerned, but this department assists on request from any clinic. 63 SECTION D ENVIRONMENTAL AND SANITARY CIRCUMSTANCES IN THE AREA Page Rats and Mice 67 Water Supply 67 Sewerage and Sewage Disposal 72[ Atmospheric Pollution 72 Thamesmead 74 Chimney Heights 74 Noise 75 Swimming Pools 77 Launderettes 78 Disinfection and Disinfestation 78 Fox, Pigeon and Wasp Control 79 65 RATS AND MICE The department employes four Rodent Operatives. Approximately 3,000 premises are inspected annually specifically to check for infestation of rats and mice. The inspections are made principally as a result of information received from occupiers of premises. About one third of the premises are found to be infested by rats and currently about one sixth by mice. The number of premises infested by mice has shown an increase in the last year or so and recourse has had to be made to rodenticides other than Warfarin for control measures. Major infestations are rare. In the majority of cases control treatments for rats and mice are carried out by the department's Rodent Operators. The services of a local contractor are used by a number of industrial firms in the Borough and a contractor is also employed by the British Railways to whom complaints on railway property are referred. Attention to sewers and tips is given as necessary. Treatments to private tips are usually carried out by an employee or contractor. Inspections are carried out as routine. When premises are demolished for redevelopment or otherwise, attention is given to the removal or proper filling in of abandoned drains in addition to any disconnection from the sewer. WATER SUPPLY The water supply in the Borough is provided by the Metropolitan Water Board. The Board obtains its water from a number of sources including the Rivers Thames and Lee and also more than thirty wells in and around the Greater London Area, including wells in Bexley and Crayford. Due to the complexity of the supply system, the water supplied to the London Borough of Bexley is a mixture derived from a number of sources. All necessary treatment, e.g. storage, filtration, chlorination, to render the water safe and wholesome is undertaken by the Board before the water enters the supply system and the Board makes frequent and regular laboratory examinations of the water in its mains. The Health & Welfare Department takes regular samples of the mains water supply from houses and other premises in the Borough. These are in general submitted to bacteriological examination only, although chemical examination is made if indicated. The number of water samples taken by Public Health Inspectors and submitted to the Public Health Laboratory Service for bacteriological examination is shown in the following table: — 1965 1966 1967 1968 1969 Total Number of Samples 52 46 19 38 12 167 Number found unsatisfactory None None None 3 None 3 The three unsatisfactory results were all from a well in a large industrial firm which was subject to contamination by flooding during September 1968. The well supplies both process water and drinking water, and was not given bacteriological clearance for several weeks. An alternative mains supply is available and was used during that period. 67 Close liaison exists between the Medical Officer of Health and the Medical Director of the Metropolitan Water Board and copies of all our water examination findings are sent to the Medical Director for information. I am indebted to the Medical Director of the Metropolitan Water Board, Dr. E. Windle Taylor, C.B.E., M.A., M.D., D.P.H., F.C.Path., for the following information on the water supplied by the Metropolitan Water Board in Bexley in respect of the year 1969 1. (a) The supply was satisfactory both as to (i) quality and (ii) quantity throughout 1969. (b) All new and repaired mains are disinfected with chlorine; after a predetermined period of contact the pipes are flushed out and refilled; samples of water are then collected from these treated mains; and the mains are returned to service only after results are found to be satisfactory. The quality control from these laboratories is carried out by means of daily sampling from sources of supply, from the treatment works or well stations, from the distribution system, and through to the consumer. Any sign of contamination or any other abnormality is immediately investigated. (c) (i) The Board has no record of the number of structurally separate dwellings supplied in your area, but the population supplied direct according to the Registrar-General's estimates at 30th June 1969, was 215,610. (ii) No houses were permanently supplied by standpipe. (d) No artificial fluoride was added, and where the fluoride content is indicated in the analyses it represents the naturally occurring fluoride in the water. 2. (a) The supply was derived from the following works and pumping stations : — River Thames—derived, also well water from Bexley, Crayford, Darenth, Eynsford, Horton Kirby, Wansunt and Wilmington Pumping Stations. No new sources of supply were instituted and there were no changes to the general scheme of supply in your area. The number of samples collected and the bacteriological and chemical analyses of the supply from the above sources after treatment are shown on the attached sheets. (b) On account of their hardness content and alkaline reaction the Board's river and well water supplies are not considered to be plumbo-solvent. It should however be appreciated that all types of water pick up varying amounts of metal from the material of water piping particularly when it is newly installed; this applies to copper, zinc, iron and also to lead. Surveys carried out between 1966 and 1968 on analyses of water from consumers' premises confirmed this statement. Special tests for lead were carried out during 1968 on 100 premises where a lead supply pipe is installed. The premises were chosen to given an even distribution of samples throughout the whole of the Board's area. Two samples were collected from each premises; one was the first running of 68 water standing in the lead pipe overnight and the other was a sample of water after running the tap for a few minutes. The results are set out in the following table: — Lead content of water from mains taps in consumers' premises Lead content (mg/1.Pb) Samples of water standing In lead pipe overnight Samples of water after running the tap Less than 0.01 10 37 0.01 31 57 0.02 21 4 0.03 8 1 0.04 9 0 0.05 5 0 0.06 5 0 0.07 4 1 0.08 1 0 0.09 3 0 0.10 1 0 0.12 1 0 0.16 1 0 100 premises 100 premises The above results are very satisfactory and the figures are within the limits of the World Health Organisation European Standards for Drinking Water Quality. This states that the upper limit for lead in running water in the supply should not be more than 0.1 mg/1.(Pb); but where water undertakings continue to use lead piping the concentration of lead (as Pb) should not exceed 0.3 mg/1. after 16 hours contact with the pipes. 69 70 METROPOLITAN WATER BOARD — Water Examination Department BACTERIOLOGICAL RESULTS - YEARLY AVERAGES, FOR 1969 Water supplied to the London Borough of Bexley Source of supply BEFORE TREATMENT AFTER TREATMENT Agar plate count per ml. Coliform count Escherichia coli count Agar plate count per ml. Coliform cou nt E. coli count Number of samples 20-24 hou rs at 3 days at 22°C. Per cent, samples negative in 100 ml. Cou nt per 100 ml. Per cent, samples negative in 100 ml. Count per 100 ml. Number of samples 20-24 hours at 3 days at 22°C. Per cent, samples negative in 100 ml. Per cent, samples negative in 100 ml. River Thames—Derived 8,196 66.5 — 39.79 19.0 53.97 7.0 3,698 12.9 — 99.89 100.0 Bexley 249 0.2 4 99.20 - 100.0 - 253 15.6 97 100.0 100.0 (a) Crayford No.1 146 0.1 5 99.32 - 100.0 - 253 20.9 139 100.0 100.0 (b) Crayford No.2 145 0.1 134 99.31 - 100.0 - (c) Crayford No.3 113 0.0 15 100.0 - 100.0 - Darenth 250 0.1 13 100.0 - 100.0 - 251 0.0 3 100.0 100.0 (a) Eynsford Well 169 0.2 30 99.41 - 100.0 - 252 0.0 9 99.60 99.60 (b) Eynsford Borehole 174 0.1 4 99.43 - 99.43 - (a) Horton Kirby No.1 196 0.2 73 91.84 0.4 94.90 0.3 249 0.1 8 100.0 100.0 (b) Horton Kirby No.2 199 0.1 15 94.47 0.2 96.48 0.1 (a) Wansunt No.1 216 2.3 96 99.07 - 100.0 - 252 0.1 49 100.0 100.0 (b) Wansunt No.2 234 0.6 48 100.0 - 100.0 - Wilmington 238 0.5 46 98.74 - 99.58 - 242 0.1 3 100.0 100.0 METROPOLITAN WATER BOARD — Water Examination Department Average results of the chemical examination of Water supplied to the London Borough of Bexley for 1969 Milligrammes per litre (unless otherwise stated) Description of the Sample Number of Samples Day of the month Ammoni- acal Nitrogen Albuminoid Nitrogen Nitrate Nitrogen Oxygen abs.from KMn04 4 hrs.at 27°C. B.O.D. 5 days at 20°C. Hardness (total) C3CO3 Hardness non carbonate CaC03 Magnesium as Mg Sodium as Na Potassium as K (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) River Thames — Derived 371 0.024 0.083 4.4 1.05 282 79 5 24.0 5.4 Bexley 4 0.008 0.017 5.4 0.30 335 90 (a) Crayford No.1 4 0.013 0.048 9.3 0.38 416 159 (b) Crayford No.2 4 0.004 0.022 6.9 0.08 305 79 (c) Crayford No.3 4 0.005 0.033 7.2 0.22 356 118 Darenth 4 0.006 0.016 4.6 0.12 276 54 Eynsford 8 0.008 0.018 4.7 0.08 272 51 Horton Kirby 8 0.019 0.025 4.7 0.12 277 58 Wansunt 32 0.086 0.037 6.6 0.23 256 107 Wilmington 3 0.011 0.033 7.6 0.12 295 70 Description of the Sample Chloride as CI Phosphate as P04 Silicate as Si02 Sulphate as S04 Natural Fluoride as F Surfaceactive material as Vlanoxol OT Turbidity units Colour ! Burgess units) pH value Electrical Conductivity (micromhos) (1) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) River Thames — Derived 32 2.1 9 58 0.25 0.02 0.1 11 7.9 550 Bexley 20 0.15 0.0 4 • 7.2 600 (a) Crayford No.1 33 0.25 0.1 3 7.1 750 (b) Crayford No.2 28 0.20 0.1 1 7.4 580 (c) Crayford No.3 29 0.20 0.0 2 7.3 660 Darenth 18 0.15 0.0 2 7.4 490 Eynsford 16 0.10 0.1 0 7.2 480 Horton Kirby 20 0.15 0.0 2 7.3 500 Wansunt 29 0.20 0.4 3 7.2 650 Wilmington 27 0.15 0.0 0 7.3 560 71 SEWERAGE AND SEWAGE DISPOSAL I am indebted to the Borough Engineer and Surveyor, Mr. D.T. Hurlstone, C.Eng., M.I.C.E., F.I.Mun.E., A.R.I.C.S., M.lnst.H.E., for kindly supplying the information on which the following report is based. The sewerage system of the Borough had its origin at the end of the nineteenth century when the West Kent Main Sewerage Board was established. The Board laid trunk foul sewers through the districts of Sidcup, Crayford and Bexley. In the 1930's, Erith discontinued treating its sewage at its own sewage Works and was connected to the Sewerage Board's system. The district has always been drained on the "separate sytem", i.e. storm or rain water being kept separate from the foul water drainage system. Prior to 1945 there was little provision for surface water drainage which was disposed of mainly by soakaways or drainage into streams. In the 1930's large scale housing development took place and although the foul sewer system was reasonably adequate, the surface water drainage provision was insufficient. In times of abnormal rainfall, the inadequate surface water drainage system led to flooding in many places. Also infiltration of surface water into the foul sewer system caused surcharging in some areas after abnormal rainfall. Due to the physical features of the Borough it is not possible to operate a completely gravitational drainage system and twelve foul sewage pumping stations are in operation in the Borough. Many of these pumping stations are equipped with old machinery nearing the end of its useful life and constant effort is necessary to keep the stations operational. Connections have recently been installed to rising mains to enable emergency pumps to operate should the static units breakdown. Since 1965, in order to modernise the system and expand its capacity to deal with the present and anticipated demands, a vast amount of drainage work has been put in hand in the Borough, or is in the planning stage. There are 34 major schemes in hand or planned ranging in cost from £13,000 to £900,000. In some cases where a convenient sewer has not been readily accessible to premises then it has been necessary for cesspools to remain in use or be provided. Some 56 domestic cesspools and 32 industrial cesspools are in use. The Council provides a service for emptying the contents of cesspools into the main sewerage system. With the exception of the drainage from the Thamesmead area which is conveyed to the nearby Greater London Council's Southern Outfall Works, the trunk sewers serving the Borough convey the sewage to the treatment works of the West Kent Main Sewerage Board situated in Dartford. ATMOSPHERIC POLLUTION Air is breathed by everyone from the moment of birth to death. It is the only factor in the environment which is common to everyone. Polluted air, therefore, affects the health of everyone and although the reaction to it may vary from person to person, everyone is adversely affected to some degree. Pollution arises mainly from the combustion of fossil fuels, i.e. coal or oil, for domestic heating or for industrial purposes. It consists of smoke, grit and dust and sulphur dioxide. Smoke is the 72 most important from the health point of view as it contains very damaging chemicals, e.g. organic acids and tarry materials which are in a fine state of division and therefore carried suspended in the air and breathed into the lungs with each breath. Much of the chronic bronchitis which occurs in this country undoubtedly owes its origin to atmospheric pollution and every sufferer, as also every heart case, is adversely affected by atmospheric pollution. The Clean Air Act, 1956, enables local authorities to control the pollution of the atmosphere in their area by declaring the area, or parts of it, a Smoke Control Area. Smoke Control is effected as regards householders by prohibiting the use of coal in open fires and requiring them to use a smokeless fuel, e.g. coke or some other solid smokeless fuel, gas, electricity or oil, and an approved type of appliance. Grants are available towards the approved cost of conversion of existing grates, etc. and for the installation of new ones. The need for urgent action to reduce pollution has been recognised by most local authorities and great progress has been made, especially in the Greater London Area where by 1969 approximately 75% of the premises were in Smoke Control Areas. Industry has tackled the problem by installing modern improved and more efficient heating plant or by changing to types of fuel other than coal. There are a few industries where due to technical and manufacturing problems it has so far been impossible to eliminate all sources of pollution. Many of these industries are controlled by the Alkali Inspectorate of the Ministry of Housing and Local Government, with whom close liaison is maintained. The cement works to the east of Bexley come within this category and the Council is represented by elected Members, the Medical Officer of Health and the Chief Public Health Inspector on the Thames-side Joint Committee for the Abatement of Atmospheric Pollution, which is composed of representatives of local authorities in North-east Kent and South Essex. Measurements of smoke, S02 and deposited matter are made continuously at a number of points in the Borough. Five standard deposit gauges and one directional deposit gauge are in operation and in addition, four standard volumetric gauges are installed at premises for the purpose of measuring sulphur dioxide and smoke. Measurements of both sulphur dioxide and smoke continue to show an increase during the winter months and it is considered that this is due to pollution from domestic premises. On the 1st April 1965 four Smoke Control Areas totally 1807 acres and containing 9298 premises were in operation, and one area covering 1480 acres and containing 6195 premises in the Crayford area awaited confirmation by the Minister. The following table shows the areas and properties subject to smoke control orders in operation at the various dates:— Acres Premises 31st December 1965 1807 9298 31st December 1966 1807 9298 31st December 1967 4366 12861 31st December 1968 7803 21464 31st December 1969 9589 28492 73 At 31st December 1969, one order, namely London Borough of Bexley (No.10) covering 1041 acres in the Blackfen and Lamorbey areas and containing some 6934 premises has been confirmed and is due to be brought into operation with effect from 1st December 1970. The map at the front of the report shows the smoke control areas in operation in the Borough together with the area approved but not yet in operation. Although considerable progress has been made in reducing atmospheric pollution in the Borough since 1965, it is most important to complete the programme for the whole of the Borough in accordance with the Council's policy as quickly as possible. The long-term economic costs and the adverse social effects which would follow any deferment of the programme would be a very high price to pay for any short term financial advantage. Recently there has been some shortage of solid smokeless fuels and, although the Borough has not been badly affected, consumers have in many cases had to order well in advance of requirements and/or take alternative fuels. The shortage has principally been due to the fact that the falling off of production of the gas cokes and allied fuels, owing to technological changes in the gas industry, has not been met by adequate replacement by premium and other fuels. Whilst the shortage and inconvenience is regretted, it is hoped that the balance of supply and demand will shortly be re-established. Appendix A reproduces a special report made to the Health Committee in 1965 and deals in greater detail with the problem of atmospheric pollution. THAMESMEAD A new development with an ultimate population of 50-60,000 is being built on the low ground bordering the River Thames to the north of the Borough. About one third of the accommodation will be in Bexley, the rest in Greenwich. The earlier stages of the development are in Bexley. As there is an escarpment to the south of the Bexley development, it was essential in the interest of existing residents to ensure that no avoidable atmospheric pollution problem was allowed to develop. The first action taken was to declare the area of proposed development to be a Smoke Control Area before any work had commenced on the site. The next step was to ensure that the absolute minimum of pollution was produced from the new properties. Approximately 4,000 homes envisaged in Stages I, II and III, each with its own chimneys even if burning smokeless fuels could produce a vast amount of atmospheric pollution. To avoid this possibility the Greater London Council and the Ministry of Housing and Local Government were urged to instal district heating to all the properties in the new development and it is gratifying to be able to report that this was ultimately agreed to. Under this scheme a single efficiently operating boiler house will supply hot water for domestic use and space heating to all the homes etc. thereby reducing atmospheric pollution to the absolute minimum. CHIMNEY HEIGHTS The height of certain categories of new industrial chimneys has to be approved by the Council before they are erected. This is a technical requirement concerned with the prevention of 74 pheric pollution and is dealt with by the Health Department. This approval of height is quite a separate matter from any Town Planning requirements. The majority of applications for approval are dealt with routinely in the department, but in two instances special technical problems were present which required the advice of a Consultant Engineer on the proposals submitted as it was the opinion of the department that the firms' proposals would not be satisfactory and nuisance could arise. The first of these in 1968 related to a factory with oil-fired steam-raising plant, the chimney stack from which was situated only 120' from a tall block of flats from whose tenants and those of surrounding properties complaints were being received. Due to the height and proximity of the flats a complex technical problem had arisen and it was felt in the department that the firm's proposals would not be satisfactory. Dr. Albert Parker, C.B.E., D.Sc., F.R.I.C., C.Eng., M.I.Chem.E., lately Director of the Fuel Research Stations at Maze Hill and Warren Springs, was engaged to investigate and advise the department. The other case arose in 1969 when due to the topography of adjoining terrain, a proposal for a new factory stack was considered to be unsatisfactory and Dr. Parker was again consulted. I would like to place on record the excellent co-operation received from both firms and their officers, who readily permitted our consultant access to their premises and boiler plant and supplied willingly all the data requested. The normal procedure following the non-approval of proposals is for the firms concerned to reconsider the matter and submit fresh plans, which of course could again be unacceptable to the Council. This procedure is inefficient and time-wasting. At the same time it would have been incorrect to have informed the applicant firms of the contents of the reports and the consultant's recommendations. An original solution to the problem was reached, with the consultant's approval, by offering the firms concerned a copy of the consultant's report for payment of half the consultant's fee, the department agreeing in return to approve any of the recommendations selected from the report. It is gratifying to report that both firms readily accepted this suggestion and there has been the fullest co-operation at all stages. This procedure has facilitated progress in what could otherwise have become tedious and contentious negotiations and is a good example of co-operation between local authorities and industry which could usefully be employed more widely. Throughout the negotiations and the work of modifying the chimney at the first firm's premises, the neighbouring residents were kept informed of the position by the firm and the Health Department via the local residents' association — an example of good public relations. NOISE There is a growing public awareness of and sensitivity towards noise and an increasing number of complaints is being received in the department. These complaints have involved noise originating from industrial premises, super-markets, launderettes, a children's nursery and neighbours, etc. 75 Unfortunately there is no scientific method of measuring noise, which is the subjective response to sound. Sound can be measured and a level of sound which is regarded as a noise nuisance by one person is often not complained of by other persons who are similarly exposed to it. Often complaints are from individuals who have some other basic problem to cope with, as for example, a person who buys a house near a factory without having fully investigated all the factors involved and then does not like the location and complains of noise from the factory, which has operated unchanged and without previous complaint for many years. Another source of complaint is the householder near a factory where alterations have taken place, e.g. an extension to the factory which can affect the view from a house or result in a building near to the house where none existed previously. Sometimes changes in equipment are made in factories and justifiable complaints follow. All complaints are investigated and if established, the firms concerned are usually very co-operative in carrying out voluntarily modifications to their premises or plant to reduce the noise. Recourse to court action has not been necessary in any instance. The difficult cases are those where after full investigation by the department, it has not been possible to establish that a noise nuisance exists. This never satisfies the complainant and we then have to employ consultants to undertake accurate sound measurements, usually during the night, using expensive and complex equipment. Even when independent measurements show there is no nuisance by currently aceepted sound level standards, some complainants are still not satisfied. It then remains for the complainant to take private legal action if he still feels strongly about the matter. None has so far done so. Noise complaints, being subjective reactions, take up a disproportionate amount of time of the Public Health Inspectors who have to make repeated personal observations at many different times of day and night and also frequently involve the medical staff as usually it is claimed that the noise nuisance is adversely affecting the health of the complainant and his family. Among the premises about which complaints have been received are the following Source of alleged nuisance Result of investigation Action taken Heavy Engineering Works Complaint justified Machines re-positioned and mounted on resilient pads. Sheet Metal Works Complaint justified Owners adjusted hours of work and took all precautions to reduce noise. Wholesale Commercial Depot Complaint justified Hours of night work changed, and plant and premises modified. Large industrial concern Borderline. Consultants used. Firm modified plant voluntarily. Commercial Premises Borderline. Consultants used. Firm modified plant voluntarily. Commercial distributing depot Not justified Offer by Council to rehouse complainants (not accepted by complainants). Launderettes Usually some grounds for complaint Advice given re installation and operation of plant. Children's Nursery Not justified No action. 76 With a view to reducing noise arising from road breaking equipment, the Council now includes a suitable clause in contracts where use of such equipment is likely. Contact is maintained with statutory undertakings and other bodies concerning the use of equipment and it is customary to include amongst the additional items drawn to the attention of demolition contractors, upon whom Notices under Section 29 of the Public Health Act 1961 are served, the need to ensure that equipment, concrete breakers, compressors, etc. are, where necessary, adequately muffled or screened. SWIMMING POOLS In 1965 there were three outdoor swimming pools situated in the Borough and maintained by the Council. Two were available for use by the general public and the other used exclusively by school children, youth clubs, etc. The latter pool has now been demolished. Since 1965 three indoor swimming pools have been opened, one at Bexleyheath and one at Sidcup during 1967, and one at Erith during 1968. In addition, there are three swimming pools on school premises, two are covered and the other is an open pool. There is also an indoor pool at a residential home, and an open pool at a large factory. Water samples from all these pools are frequently submitted for bacteriological examination and routine Lovibond Comparator Tests for chlorine are carried out at regular intervals. The following table gives details of bacteriological samples taken and submitted for examination to the Public Health Laboratory Service Year Samples taken Unsatisfactory 1965 85 4 1966 73 2 1967 106 11 1968 124 None 1969 158 4 Totals 546 21 Where unsatisfactory results on samples were reported visits of inspection were made to all pools and, following the giving of advice to the responsible staff, further samples were taken and these were all reported as satisfactory. It has become clear that proper instruction must be given to those responsible for the day to day operation of school swimming pools, as so often it is found that a lack of knowledge of the essentials of swimming pool water chlorination leads to an unsatisfactory and unsafe water for bathing. It cannot be emphasised enough that, when schools are embarking on the provision of a swimming pool, often through the generosity of parent associations, they should not go forward with the project without first consulting people professionally qualified to advise them. They should 77 have enough money to cover equipment for the efficient and effective chlorination and cleansing of the pool, and also for other relevant expenses such as construction and drainage of surrounds to the pool, footbaths, etc. Some of the Council's indoor pools provide additional facilities for the public, e.g. Turkish Baths, Slipper Baths and Showers. LAUNDERETTES A large number of these premises has been established over the last few years. Some include equipment for dry-cleaning clothes in addition to washing and drying facilities. The majority of the premises are coin operated, have no resident staff and are available for use during the whole of the day and night. Many are situated on the ground floor of terraces of shops and have living accommodation over, which is usually separately occupied. Complaints from established premises concern noise from equipment and extraction fans, fumes and the general activity of customers, e.g. the slamming of car doors by late night customers. In one case, where statutory action regarding nuisance from effluvia from a dry-cleaning plant was taken, the premises subsequently closed. In other cases negotiations with operators have achieved the necessary improvement. Wherever possible the selection of plant and its installation is fully discussed with operators and contractors before the premises are opened and close liaison is maintained with the Town Planning Section of the Borough Engineer and Surveyor's Department, which has in some cases been able to include conditions in the Town Planning consent to avoid possible nuisance and to restrict the hours of opening and operation. DISINFECTION AND DISINFESTATION DISINFECTION Three steam disinfecting stations were taken over in 1965 at Erith, Bexleyheath and Sidcup. All were in need of considerable expenditure to maintain and all were occupying valuable space urgently needed for other purposes. As there did not appear to be any foreseeable major need for this service, it was decided to close the existing stations and make arrangements with Greenwich London Borough Health Department to undertake any work involving steam disinfection. Fortunately very little use has required to be made of this generous concession. Disinfection of houses after cases of infectious disease is no longer practised. Outbreaks of gastro-intestinal infection occurred in Russell Stoneham Maternity Hospital, Crayford (1969) and the maternity block of Queen Mary's Hospital, Sidcup (1968 and 1969) and formaldehyde disinfection of wards etc. was undertaken at the request of and in conjunction with the Hospital Management Committees. Following disinfection the wards were re-opened and no further cases of infection occurred. 78 DISINFESTATION PERSONS As there were no facilities in the Borough for the disinfesting of persons nor for the treatment of scabies, arrangements were made with the Health Department of Greenwich London Borough for this treatment to be undertaken at their Cleansing Station in Plumstead. There has been negligible need for the treatment of cases of scabies or lousiness. One case of scabies and the family contacts were treated in 1967 and another in 1969. One case of crab-lice was treated in 1967. PREMISES Many requests for advice and/or treatment have been received and dealt with. When necessary reference is made to museums and other specialist sources for the identification of specimens. Among the cases dealt with are infestations by fleas and bed bugs, and on average 27 of the former and 20 of the latter are treated each year by the department staff using residual insecticides in liquid or powder form. In 1968 complaints of infestations by cockroaches in recently erected houses adjacent to land used for privately owned industrial controlled tipping operations were received from a number of householders. The houses are some distance from the actual tipping faces. After full investigation of these complaints, the Council undertook, in conjunction with the occupiers of some 70 houses, the treatment of garages, loft spaces, etc. with residual insecticidal dust. Advice on the most suitable forms of treatment was received from officers of the Ministry of Agriculture, Fisheries & Food who visited the site on two occasions. Occupiers were advised to continue to be on the lookout for and to report any further signs of infestation so that further treatment could be recommended or advice given if necessary. FOX, PIGEON AND WASP CONTROL FOXES It has been the practice for many years to refer all 'complaints' of foxes to the Ministry of Agriculture, Fisheries & Food, and their officers have given advice and carried out control measures by gassing, clubbing and shooting. This work previously undertaken by the Ministry until 1969 is now carried out by the Council. The Foreman Rodent Operator holds a shot-gun licence and fire-arms certificate in connection with fox control work and during 1969, 100 foxes approximately were shot in the Borough. PIGEONS Pigeons have been troublesome in some parts of the Borough, fouling buildings and footpaths and damaging garden crops. Trapping and shooting are the usual methods employed as control measures. However, where the pigeons were nesting under railway bridges a total of 50 pigeons was lifted off by hand during one night using a street lighting tower wagon for easy access to 79 nesting ledges, and a further 90 pigeons were subsequently trapped near one of the bridges. Arrangements exist properly to deal with all ringed pigeons caught during control operations. WASPS Where wasps' nests are reasonably accessible the Department offers a service to destroy nests causing a nuisance. A charge is made on the occupier of the premises for the service. The number of nests dealt with annually fluctuates according to the weather; e.g. during 1969 some 129 nests were dealt with whereas during 1968 the number was only 15. 80 SECTION E HOUSING Page Housing Acts 1957/1969 - Unfit Premises, etc. 83 Caravans and Caravan Sites 84 Common Lodging Houses 84 81 HOUSING ACTS 1957/1969 UNFIT PREMISES, ETC. Prior to amalgamation on the 1st April, 1965, each of the constituent authorities had been engaged on the final stages of their 1960/1965 Slum Clearance programmes. Shortly after that date, local authorities were required to submit to the Minister their programmes for slum clearance during the period 1965/1970 and a survey of the Borough revealed that some 355 dwellings warranted inclusion in the Slum Clearance programme. This number included 69 premises in the previous programme still to be dealt with. Alterations to the programme are made when changed circumstances warrant. A total of 31 Demolition Orders and 68 Closing Orders have been made. Undertakings from owners either to make premises fit or not to relet the premises pending demolition or reconstruction have been accepted in a further 7 cases. Four premises have been made fit as a result of Undertakings given under the Housing Act 1957, one of the Demolition Orders made was subsequently revoked following reconstruction of the premises and 8 Closing Orders determined. In one case, where premises were relet and the undertaking, which had been given to one of the previous authorities, had been broken, proceedings were taken against the owners, who was fined, and a demolition order was made on the premises. 12 areas have been declared clearance areas, involving 92 houses, 16 of which were subject to Closing Orders. In 7 areas Clearance Orders were made and in the other 5 areas, a total of 4 Compulsory Purchase Orders was made. Involved in these Compulsory Purchase Orders were 6 houses not regarded as unfit but which were included in order to achieve effective clearance of the sites. One Compulsory Purchase Order has been confirmed and the site cleared, the result of one Appeal is awaited and two other Orders are awaiting confirmation at the end of 1969. In a number of other cases, houses on the Slum Clearance Programme have been dealt with by other means, e.g. road improvement works. When the present programme is completed it is expected that the bulk of unfit houses in the Borough will have been dealt with. Nevertheless, a review of the district is being carried out in order to formulate a Slum Clearance Programme for the next four year period. In 16 cases, after receiving representations from tenants, the Council has taken action under the provisions of the Housing Act 1964 to secure 'compulsory' improvement of houses up to the full standard by the provision of bathrooms and other necessary facilities. In one case, the notice of immediate improvement was withdrawn following a request from the tenant as the alterations proposed would have caused inconvenience due to the loss of a bedroom. Houses let in multiple occupation are not a serious problem in the Borough. The Council has adopted a Code of Practice setting out the minimum standards considered necessary. No Improvement Areas were declared under the Housing Act 1964 but consideration is being given to the new powers contained in the Housing Act 1969 concerning general improvement areas. 83 Several applications have so far been received for Qualification Certificates or Certificates of provisional approval under the new provisions of the Housing Act 1969 which permit the variation of tenancies and rent for houses that are fit, in good repair and provided with bathrooms, hot water and other necessary amenities. CARAVANS AND CARAVAN SITES Five site licences, under the Caravan Sites and Control of Development Act 1960 are in force covering a total of ten caravans. In three cases the site licences are in respect of single caravans used by agricultural workers and in one case the caravan is used by a caretaker of club premises. It is usual to make the period of the site licence coincide with the approval given under Town Planning. Inspections of the sites are carried out and, where necessary, the need to comply with the site conditions is drawn to the attention of the licence holders. In a few cases individual caravans or small groups of caravans owned by itinerant travellers have been temporarily stationed on the roadside verge or on open land. Since 1966 a group of caravans has been stationed on the grass verge of the A.20 trunk road which forms the southern boundary of the Borough. The number at one time exceeded 50 but during 1969 has not exceeded 20. Some chestnut paling fencing has been erected along the grass verge to restrict the area occupied. As would be expected in the absence of any facilities that would be required on a proper site, the conditions are never good and especially during winter or inclement weather are in fact very poor. Arrangements made with a local refuse tip for the reception of refuse from the caravans have met with limited success. It has been necessary for the Council at considerable expense on several occasions to carry out extensive clearing operations of domestic and other refuse and derelict vehicles. Three refuse skips are now provided on the verge in the hope of minimising future clearing operations. It has been necessary to carry out rodent control treatment and regular surveys at the site. Until there is provision of proper sites together with the imposition of sanctions as provided for in the Caravan Sites Act of 1968, the problem on this particular roadside verge will continue as there is an awareness amongst the caravan occupiers of the Minister of Housing & Local Government's request made during 1966 to local authorities "that nothing should be done to add needlessly to the difficulties of gipsy families". It is a pity that the caravan occupiers and their spokesmen apparently fail to realise that they should make every effort from a public relations point of view to keep this site, which is in clear view of thousands of people each day, in a clean and tidy condition. COMMON LODGING HOUSES There are no premises in the Borough registered or used as common lodging houses. 84 SECTION F FOOD AND DRUGS Page Food Inspection 87 Food Sampling 87 Bacteriological Examinations of Water and Food 88 Food Complaints 89 Diseases of Animals Act 89 Slaughterhouse — Meat Inspection 89 Slaughter of Animals Act 1958 92 Liquid Egg (Pasteurisation) Regulations 1963 92 Milk Supply 92 (a) General 92 (b) The Milk (Special Designation) Regulations 1963 (as Amended) 92 (c) Sampling 93 (d) Brucella Abortus 93 Food Hygiene (General) Regulations 1960 93 85 FOOD INSPECTION It is very seldom during routine inspection of food premises or food that a Public Health Inspector finds food exposed for sale which is unsound or in an unsatisfactory condition. Much food is inspected as a result of specific requests from traders who have voluntarily withdrawn stock from sale pending inspection. Individual cases range from single tins to consignments amounting to several tons. In no case was it necessary for a Public Health Inspector to exercise his powers under the Food & Drugs Act 1955, relating to the seizure of unfit food. The table below shows the approximate weight of food surrendered for destruction during the period 1965—1969. Tons Cwts Qtrs Lbs 1965 5 17 - 4 1966 5 4 - 7 1967 21 9 - 15 1968 35 12 2 - 1969 53 7 3 15 A large number of food shops have refrigerated food cabinets in operation and the need for correct operation and use and regular maintenance is most important, because a breakdown can expose many hundred weights of food to risk of becoming unsound. Since the Imported Food Regulations of 1968 came into operation and permitted the transfer to inland places of food received at ports in locked containers, such containers have been received and inspected at two principal wholesale depots. The inspection of meat at the slaughterhouse which operated in the Borough until June 1968 is reported separately. There are no poultry processing premises operating in the Borough. FOOD SAMPLING The following table shows the number of samples of food and drugs taken under the Food & Drugs Act 1955 and submitted to the Public Analyst for analysis, together with the number found unsatisfactory:— Year No. of Samples taken Unsatisfactory 1965 517 25 1966 835 49 1967 677 29 1968 855 28 1969 822 40 Totals 3706 171 87 In none of the cases upon which the Public Analyst reported adversely was there anything endangering health. The majority of these unsatisfactory samples concerned incorrect labelling and descriptions. In these cases contact was made with the manufacturers concerned, and by meetings between their food technicians and the Senior Public Health Inspector with special responsibility for food, it has been possible to persuade manufacturers to re-draft the labels and/or descriptions for foods. A number of tea-packers have now discontinued to use the term 'tips' in relation to tea as analysis has shown this to be an improper description, similarly the description 'creamed' has been dropped by a leading manufacturer of dried, powdered potatoes. In several cases amended labels are informally submitted to the department for comment, before they are put into general use. The samples have covered a very wide range of foods, in some cases, e.g. meat pies, tinned fruit, etc., they have been taken to check on specific standards or codes of practice. Following the detection of sulphur dioxide in desiccated coconut, investigations showed that this was being absorbed during the drying process in the country of origin. Whilst only a small quantity of this coconut was in the Borough it was representative of a large consignment which was eventually withdrawn from sale and diverted to the bakery trade. As a result of this investigation several importers have tightened up their contracts for the supply of this commodity. This Authority has participated in the Scheme of Sampling carried out to enquire into the extent of contamination of foodstuffs by pesticide residues and in each of the years 1966 and 1967, 18 samples of food were submitted for examination. The Analyst did not find it necessary to comment adversely on any of the samples submitted to him. BACTERIOLOGICAL EXAMINATIONS OF WATER AND FOOD The following table shows the number of routine samples taken and submitted to the Public Health Laboratory Service. Unsatisfactory samples were all investigated and subsequent samples taken were reported as satisfactory. Reference is made elsewhere in the report to some of the samples referred to. 1965 1966 1967 1968 1969 No. taken Unsatisfactory No. taken Unsatisfactory No. taken Unsatisfactory No. taken Unsatisfactory No. taken Unsatisfactory Water (Public supply) 52 None 46 None 19 None 38 3 12 None Water (Swimming Pools) 85 4 73 2 106 11 124 None 158 4 Ice Cream 75 4 106 8 40 2 38 2 45 None Milk (Public supply) 63 1 110 4 32 None 21 None 20 None Milk (School supply) 33 None 25 None 15 None 15 2 4 None Pasteurised Egg (Dried) 1 None 2 None None None None Cream None - None - None - 3 None 1 None TOTALS 309 9 362 14 212 13 239 7 240 4 88 FOOD COMPLAINTS The following table shows the number of food complaints received by the department and also the number of special samples submitted to the Public Analyst following complaints:- Year No. of complaints investigated No. of Special Samples submitted to the Public Analyst 1965 80 19 1966 113 29 1967 93 14 1968 84 31 1969 116 26 Totals 486 119 Most of the complaints concerned mould or foreign bodies found in foodstuffs and included a needle in bread, metal in chocolate, razor blade in bread pudding, bird droppings on loaf, nail in cake, metal in baby food, cigarette butt in canned vegetables. In the first case the Public Analyst was able to show that the needle had been baked in the loaf. The number of complaints indicates that the general public is alive to the Public Health Inspector's function in this sphere. In nearly every instance reported to the department the complainant wished his complaint to be dealt with informally and did not wish to be involved in legal proceedings. However, during the period under review legal proceedings were instituted in 28 instances and in each case a conviction was obtained. Fines totalling £475 with £170 costs were awarded to the Council. In several other cases warning letters were sent to the persons concerned. Following receipt of a complaint, contact is made with retailers, wholesalers, manufacturers, etc. when appropriate as, quite apart from legal proceedings, it is necessary to investigate and correct faulty practices in an endeavour to prevent the recurrence of complaints. DISEASES OF ANIMALS ACT Functions under the above Act, which became the responsibility of this Council on the 1st April 1965, have since that date been carried out on an agency basis, in the first instance by the London Borough of Bromley and since April 1967 by the Corporation of London. Such arrangements have allowed for a full service under the Act to be carried out in the most comprehensiveand economical manner. Close liaison exists between the Department and the Veterinary Officer of the Corporation of London. SLAUGHTERHOUSE - MEAT INSPECTION A privately owned slaughterhouse situated in the Borough and which had been operating since the decontrol of meat in July 1954, ceased business in June 1968. Prior to closing a scheme involving extension of the premises and requiring a new slaughterhouse licence, had been referred to the Minister of Agriculture, Fisheries and Food in accordance with the Slaughterhouses Act 1958 and 89 Circular 52/66. However, the scheme was not proceeded with and the premises have since been demolished. With the exception of Fridays, slaughtering took place every weekend and every weekday, in some cases extending into the evenings, as no notice had been given to the occupier determining the hours that slaughtering could take place. The slaughterhouse was not licensed for the slaughter of horses. In order to carry out the inspection of carcases and offal in accordance with the Meat Inspection Regulations 1963 it was necessary for two Public Health Inspectors regularly to be in attendance, and all the Senior and District Public Health inspectors attended on a rota basis. The Meat Inspection Regulations 1963 give power to the local authority to make charges for meat inspection and charges were levied at the maximum rate permitted, i.e. 2s. 6d. per bovine animal (other than calves), 9d. per calf or pig and 6d. per sheep, lamb or goat. During the time the slaughterhouse was in operation a total of more than 600,000 animals were inspected by the Public Health Inspectors. The following table shows the weight of unfit meat found to be diseased or otherwise unfit, and duly "surrendered" by the owners, without recourse to formal seizure during the period covered by this report. Tons Cwts Qtrs Lbs. 1965 19 4 1 9 1966 22 7 2 10 1967 25 4 3 21 1968 part 9 5 2 5 The number of each class of animal slaughtered and inspected together with the details of the incidence of disease are shown in the following tables:— 90 CARCASES AND OFFAL INSPECTED AND CONDEMNED IN WHOLE OR IN PART Year Cattle excluding Cows Cows Calves Sheep and Lambs Pigs Goats Number killed 1965 2247 3324 48 7998 37525 1966 1476 3758 64 12710 38326 - 1967 963 3050 45 6594 40486 15 1968 492 1403 17 1134 16091 1 Number inspected 1965 2247 3324 48 7998 37525 — 1966 1476 3758 64 12710 38326 — 1967 963 3050 45 6594 40486 15 1968 492 1403 17 1134 16091 1 ALL DISEASES EXCEPT TUBERCULOSIS AND CYSTICERCI. Whole carcases condemned 1965 1 7 1 — 25 - 1966 — 7 1 27 58 — 1967 1 11 3 15 88 — 1968 - 3 - - 18 1 Carcases of which some part or organ was condemned 1965 362 1570 — 126 3064 - 1966 199 1818 2 730 3070 - 1967 169 1627 1 335 3956 — 1968 69 772 - 46 1263 - Percentage of the number inspected affected with disease other than tuberculosis and cysticerci 1965 16.15% 47.44% 2.08% 1.57% 8.23% _ 1966 13.48% 48.56% 4.69% 5.95% 8.16% — 1967 17.7% 53.7% 8.9% 5.3% 10% — 1968 14.02% 55.24% - 4.06% 7.96% 100% TUBERCULOSIS ONLY Whole carcases condemned 1965 — — — — — — 1966 — — — — — — 1967 - — — — - 1 — 1968 - - - - - - Carcases of which some part or organ was condemned 1965 — — _ _ 79 _ 1966 - — - - 92 - 1967 - - — — 108 — 1968 - - - - 42 - Percentage of the number inspected affected with Tuberculosis 1965 — — — _ 0.21% _ 1966 — — — — 0.24% — 1967 — — — — 0.3% — 1968 - - - - 0.26% — CYSTICERCOSIS Carcases of which some part or organ was condemned 1965 — — — — _ _ 1966 — 1 — — — _ 1967 3 4 — _ — — 1968 - - - - - - Carcases submitted to treatment by refrigeration 1965 _ 1966 — 1 — — — _ 1967 1 — — _ _ _ 1968 - - - - - - Generalised and totally condemned 1965 _ — _ 1966 — — — — — _ 1967 — — — _ _ _ 1968 - - — — — — N.B. 1968 figures are up to June only, when the slaughterhouse ceased business. 91 SLAUGHTER OF ANIMALS ACT, 1958 Licences are granted under the provisions of the above Act permitting persons to slaughter or stun animals. None of these licences permitted the slaughter of horses as the slaughterhouse situated within this Borough was not licensed for this purpose. Where applicants had not previously held a licence, the licence was issued subject to the condition that the holder would not slaughter or stun animals except under the supervision of an approved licence holder. The total number of annual licences issued was as follows :— 1965 1966 1967 1968 12 13 13 9 No licences have been issued since the slaughterhouse closed in 1968. LIQUID EGG (PASTEURISATION) REGULATIONS 1963 There are no egg pasteurisation plants situated in the district and no samples of liquid egg were submitted for the alpha-amylase test. Enquiries have shown that no imported liquid egg has been used in bakeries in this area. MILK SUPPLY (a) GENERAL In addition to dairies and dairy roundsmen, milk is supplied from a number of other retail outlets mainly grocers shops, supermarkets, etc. The trend in recent years has been to centralise dairy depots and as a result a number of local depots have closed down. There are no milk treatment and/or bottling plants in the Borough. (b) THE MILK (SPECIAL DESIGNATION) REGULATIONS 1963 (AS AMENDED). All milk sold in the Borough is required to bear a special designation, i.e. 'Pasteurised', 'Sterilised', 'Ultra Heat Treated' or 'Untreated'. Details of dealers' licences to use a special designation in relation to milk which is obtained and sold pre-packed by the dealers are as follows:— Pasteurised 114 Sterilised 106 Ultra Heat Treated 70 Untreated 40 Total 330 92 (c) SAMPLING Samples of both 'public' supplies and 'school' supplies have been submitted to the public analyst and for bacteriological examination. Reference to these is included elsewhere in the report. (d) BRUCELLA ABORTUS One sample of raw milk was submitted for examination and gave a negative result. FOOD HYGIENE (GENERAL) REGULATIONS 1960 The increasing number of food supermarkets, etc. makes it impossible to place every food premise in a specific category, however the approximate number is as follows :— Butchers 98 Bakeries 20 Fish and Chip Shops 37 Public Houses 102 Food Factories 17 Cafes/Restaurants 75 Factory Canteens 53 School Canteens 52 Grocers, etc. 190 Greengrocers 96 Registered/Licensed Clubs 69 Others 205 Without known exception all premises are fitted, where necessary, with washing facilities to comply with Regulations 16 and 19. There is a continuing need for vigilance amongst some trades and traders in order to ensure that the Food Hygiene Regulations are complied with. A great deal of advice on the application of the regulations is given to the traders by the Public Health Inspectors and also to persons proposing to operate food premises. In 375 cases it has been necessary to serve written notice upon persons operating food premises regarding matters coming within the above regulations. In one case it was necessary to institute proceedings, and in other cases warning letters were sent. 93 SECTION G GENERAL Page Public Health Acts — Statutory Nuisances 97 Pet Animals Act 1951 97 Riding Establishments Act 1964 97 Animal Boarding Establishments Act 1963 97 Offices, Shops and Railway Premises Act 1963 97 Premises and General Inspections 97 Accidents 98 Hoists and Lifts 98 Factories Act 1961 99 Factories 99 Outworkers 100 Rent Acts 1957 and 1968 — Certificates of Disrepair, etc. 100 95 PUBLIC HEALTH ACTS - STATUTORY NUISANCES During 1965—1969 it was necessary to serve the following written notices under the nuisance provisions of the Public Health Acts : — Intimation Notices 962 Abatement Notices 142 In four cases only was it necessary to institute Court proceedings against owners for the purpose of obtaining nuisance orders. PET ANIMALS ACT 1951 Persons conducting a business of selling animals as pets at premises of any nature are required to be licensed under the above Act. Conditions are attached to the licences indicating the manner in which animals are to be kept, etc. and the premises are subject to inspection. Nineteen annual licences are at present issued. A fee of £2 is payable in respect of each licence. RIDING ESTABLISHMENTS ACT 1964 A person using premises as a riding establishment, that is premises where horses are kept for the purpose of being let out for hire for riding or instruction, is required to hold an annual licence. It is a pre-requisite of licensing that a satisfactory report on the premises and horses is given by a veterinary officer authorised by the Council. The Veterinary Officer of the Corporation of London acts in this capacity and submits a report following each application. General and, where necessary, specific conditions are attached to each licence issued. In addition to the initial veterinary inspection the premises are subject to periodic inspection. Currently five annual licences are issued. A fee of £10 is payable in respect of each licence. Persons keeping premises where horses are kept only for livery purposes are not required to hold a licence under this act. ANIMAL BOARDING ESTABLISHMENTS ACT 1963 A person keeping a boarding establishment for animals is required to hold a licence under the above Act. Currently four annual licences have been issued and conditions are attached to each licence concerning, amongst other things, the manner in which the animals shall be kept on the premises. A fee of £2 is payable in respect of each annual licence, and the premises are inspected as necessary. OFFICES, SHOPS & RAILWAY PREMISES ACT 1963 PREMISES AND GENERAL INSPECTIONS A total of 1489 premises are currently registered at 31st December 1969 and it is considered that this number represents the majority of premises required to be registered. A total of 3950 97 visits were made by the Public Health Inspectors and of this number 2578 were general inspections. With much of the groundwork done it should in future be possible to achieve a higher annual rate of general inspection. There are no special difficulties due to congested, badly planned offices or office blocks in multiple occupation and the unsatisfactory conditions encountered have not required extensive remedial work, being mainly lack of hot water supplies, room thermometers and adequate space heating in cold weather, the siting and sharing of sanitary accommodation and washing facilities and the failure to display, or give to, the staff an Abstract of the Act. Some Special attention was given to lighting standards and it was found that in those cases where the lighting was unsatisfactory it was mainly in connection with premises which had been in constant unchanged use for many years. Where recommendations on lighting have been made to occupiers as to the standards they should adopt, the Illuminating Engineering Society's Code has been used as a basis. During 1965 to 1969 it has been necessary to serve some 366 Notices on persons drawing their attention to certain deficiencies and/or specifying works to be carried out to comply with the Act. ACCIDENTS During the period 1965—1969 216 accidents were notified under Section 48 of the above Act and it was considered necessary to investigate 77 of these. There were no fatalities and in only 2 instances was it necessary, because of infringement of the Act, to send a copy of the investigation report to the Deputy Superintending Inspector of Factories, and formally to warn the occupier. In all other cases advice was given where appropriate. Many of the accidents notified were of a very minor nature due to human error rather than unsuitable working conditions. HOISTS AND LIFTS The Offices, Shops and Railway Premises (Hoists and Lifts) Regulations 1968 which came into operation in May 1960 apply safety standards to those hoists or lifts situated in premises to which the main Act applies. The attention of six firms has been drawn to infringements and work to remedy them has been completed or is in hand. 98 FACTORIES ACT 1961 A. FACTORIES 1. INSPECTIONS for purposes of provisions as to health made during the period : — Premises Number on Register Inspections Number of Written notices Occupiers prosecuted (1) (2) (3) (4) (5) (1) Factories in which Sections 1,2,3,4 and 6 are to be enforced by Local Authorities 6 83 2 Nil (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 497 1021 26 Nil (iii) Other Premises in which Section 7 is enforced by the Local Authority — (excluding out-workers' premises) 50 390 Nil Nil TOTAL 553 1494 28 Nil 2. Cases in which DEFECTS were found : — Number of cases in which defects were found Particulars Found Remedied Referred No. of cases in which prosecutions were instituted To H.M. Inspector By H.M. Inspector (1) (2) (3) (4) (5) (6) Want of cleanliness (S.1) — — 1 — — Overcrowding (S.2) — — — — — Unreasonable temperature (S.3) — — — — — Inadequate ventilation (S.4) — — — — — Ineffective drainage of floors (S.6) — — — — — Sanitary Conveniences (S.7) — — — — — (a) Insufficient 7 6 — 3 — (b) Unsuitable or defective 43 39 — 25 — (c) Not separate for sexes 2 2 — 1 — Other offences against the Act (not including offences relating to Outwork) 3 3 2 — — TOTAL 55 50 3 29 Nil 99 RENT ACTS 1957 AND 1968 CERTIFICATES OF DISREPAIR, ETC. The number of applications for Certificates of Disrepair have been comparatively few in recent years but the table overleaf sets out details of the applications received. 100 The following table shows the numbers employed in various categories, as notified in the periodic lists submitted to the respective local authorities by employers, together with other relevant detail. Nos. employed Defaults in submitting lists Prosecutions No. of unwholesome premises Notices served Prosecutions Wearing apparel making, etc. 70 Nil Nil Nil Nil Nil Box making 1 Nil Nil Nil Nil Nil Lampshade making 25 Nil Nil Nil Nil Nil B. OUTWORKERS The number of persons employed in 'Outwork' has declined in recent years.(174 in 1965 to 96 in 1969.) 3. GENERAL The system whereby plans deposited with the Council for Town Planning and/or Building Regulation purposes are passed to the Public Health Inspectors for comment has resulted in alterations and corrections being made thereby preventing what would otherwise have been offences under the Act and the Sanitary Accommodation Regulations of 1938. 101 1965 1966 1967 1968 1969 PART 1. Application for Certificates of Repair 1. No. of applications for certificates 2 16 11 8 3 2. No. of decisions not to issue certificates certificates – 2 (1 withdrawn) 1 (1 withdrawn) 1 1 (1 withdrawn) 3. No. of decisions to issue certificates (a) in respect of some but not all defects 2 10 4 1 (b) in respect of all defects – 4 5 6 2 4. No. of undertakings given by landlord – 8 7 3 2 5. No. of undertakings refused by the local authority Nil Nil Nil Nil Nil 6. No. of certificates issued Nil 6 1 3 Nil PART II. Application for Cancellation of Certificate 7. Application by landlord to local authority 1 9 1 Nil Nil 8. Objection by tenant to cancellation of certificate Nil 4 Nil Nil Nil 9. Decisions by local authority to cancel in spite of tenant's objection Nil Nil Nil Nil Nil lO.Certificates cancelled by the local authority 1 5 1 Nil Nil REPORT of the PRINCIPAL SCHOOL MEDICAL OFFICER 103 The following children were on the school registers at the end of each year Primary Schools 1965 1966 1967 1968 1969 17,868 18,414 19,501 20,116 20,999 Secondary Schools 12,459 12,557 12,623 12,559 12,964 TOTALS 30,327 30,971 32,124 32,675 33,963 90 full-time equivalent nursery places are also provided. In addition, the following were attending special schools outside this Borough : — 1965 1966 1967 1968 1969 Residential School 128 142 121 134 131 Day School 162 145 148 133 138 CHILDREN EXAMINED ROUTINE MEDICAL INSPECTIONS Routine medical inspections are carried out according to the regulations prescribed by the Minister of Education and the Department of Education and Science and the following groups are examined (i) every pupil who is admitted to school for the first time; (ii) first year pupils in Secondary Schools; and (iii) school leaver age group. The following table shows the number in the three groups : — 1965 1966 1967 1968 1969 Entrants 2,539 2,812 2,447 3,986 3,694 Intermediate 2,823 2,708 2,381 1,793 3,320 Leavers 2,363 3,508 2,876 3,024 2,837 TOTALS 7,725 9,028 7,704 8,803 9,851 Any child found to have a defect, or about whom the examining doctor is concerned for any reason, is noted for a re-examination and is re-examined at the next inspection at school or by earlier special appointment. The following re-examinations were carried out : — 1965 1966 1967 1968 1969 2,631 2,053 3,618 3,573 3,551 The physical condition of children examined was very good and less than 1% of children seen were found to be in an unsatisfactory state. 105 SPECIAL EXAMINATIONS The following special examinations were carried out, either at school or at a clinic. These figures include assessments, employment examinations, clearance certificates before returning to residential schools, etc. 1965 1966 1967 1968 1969 1,769 1,283 912 1,162 1,045 EXAMINATIONS UNDER SECTION 57 OF THE EDUCATION ACT The number of children examined under Section 57 of the Education Act and found to be unsuitable for education in school was as follows : — 1965 1966 1967 1968 1969 15 12 16 13 11 CLEANLINESS The incidence of head infestation has continued to decline and the following table gives the number of inspections carried out and the number of infestations found 1965 1966 1967 1968 1969 Inspections 20,050 20,007 20,153 13,194 14,880 Infestations 108 76 77 45 54 SKIN DISEASES The number of cases of skin disorders requiring treatment found at routine medical inspections was as follows 1965 1966 1967 1968 1969 Entrants 16 14 34 56 62 Intermediates 66 64 62 56 227 Leavers 73 82 84 63 104 TOTAL 155 160 180 175 393 In addition to the above, during 1965 one case of ringworm of the body and 16 cases of other skin diseases were treated at the school clinics. In 1966 one case of skin disease was treated at a clinic before this form of treatment was discontinued at the clinics, patients being referred to General Practitioners or local hospitals. 106 In addition a 'Keystone' vision test is carried out. The 'Keystone' is a portable vision screening apparatus of American design and manufacture, and it has several advantages over the more usual method of vision testing. A wider range of tests can be carried out, it only takes a few minutes to test each child, limited space is required to operate it and it gives standard illumination for the tests. It is easy to use and the children enjoy the experience of being tested by it. The apparatus was introduced in 1966 and during the first two years of use all children from 6 to 13 years were tested. Now the 6 to 7, 8 to 9 and 10 to 11 age groups are tested each year so that children aged 6 to 11 years are tested every other year during this period of their school life. Children failing any tests are first referred to a School Medical Officer for further examination, who then decides whether reference to the Ophthalmic Clinic or Hospital is required. During 1969 Head Teachers reported the following cases Scabies 5 Impetigo 31 Other skin diseases 3 EYE DISEASE At the routine medical inspections the following eye conditions were found to require treatment : — 1965 1966 1967 1968 1969 Vision defects Entrants 112 168 134 193 212 Intermediates 373 286 198 106 250 Leavers 343 323 223 218 183 Squint Entrants 52 61 47 59 75 Intermediates 50 27 23 17 23 Leavers 10 16 11 14 11 Other Conditions Entrants 3 3 3 4 10 Intermediates 43 44 17 14 40 Leavers 13 28 4 28 8 A summary of the results obtained are set out overleaf : — 107 1966 1967 1968 1969 No. of children tested 8730 9295 9092 10363 No. of children passed 7399 8343 7766 8762 No. of children failed 1331 946 1333 1515 Failed distant vision 767 828 906 1111 Failed near vision 530 467 435 542 Failed muscle balance 440 723 637 632 Failed depth 116 352 487 423 Failed colour vision 37 141 123 74 No. for retesting Not recorded 1203 2574 2585 No. of children referred to S.M.O. „ 91 213 140 Spectacles were prescribed at the school ophthalmic clinics as follows : — 1965 1966 1967 1968 1969 788 983 1111 884 910 DEFECTS OF THE EAR, NOSE AND THROAT The following conditions of the ear, nose and throat requiring treatment were found at the routine medical inspections : — 1965 1966 1967 1968 1969 Defective hearing Entrants 13 22 27 45 44 Intermediates 46 21 17 23 33 Leavers 7 13 14 9 2 Otitis Media Entrants 8 13 14 14 22 Intermediates 8 5 3 2 5 Leavers 2 4 2 3 2 Other Conditions Entrants 2 6 4 5 6 Intermediates 13 10 6 3 12 Leavers 5 15 2 8 5 108 The following numbers of children receiving operative treatment for conditions of the ear, nose and throat were : — 1965 1966 1967 1968 1969 Diseases of the ear – 7 10 13 14 Adenoids and chronic tonsilitis 267 181 169 176 174 Other nose and throat conditions 20 3 2 1 – AUDIOMETRY Routine audiometry of all children aged 6 — 7 years by means of group test with a pure tone audiometer is carried out each year. Any child who fails to pass the group test is given an individual test at a special clinic held for the purpose. 1965 1966 1967 1968 1969 Passed group test 1066 1308 2747 2825 3694 Failed group test 106 202 519 309 284 1172 1510 3266 3134 3978 B.C.G. VACCINATION B.C.G. vaccination is offered to all 13 years old children and the following vaccinations have been carried out. 1965 1966 1967 1968 1969 No. of children tested 815 3847 2121 1807 156 No. found positive 74 420 437 137 44 No. found negative 741 3352 1569 1524 102 No. vaccinated 741 3352 1569 1524 102 The low figures for 1969 are due to changes in the programme of B.C.G. vaccination which now takes place later in the school year. MEASLES During 1968 vaccine became available for protection against measles for children who had not had the disease. As this vaccine was in short supply it was necessary to restrict this protection to various sections of the child population. Vaccination was first offered to all children between 4 years and 7 years and to children attending day nurseries, play groups and nursery schools. Letters were sent by post to the parents of all children born between 1st April 1963 and 31st July 1964 via the schools to parents of children at infants' schools. 109 included in the scheme and the following table shows the number of vaccinations carried out in the two years : — 1968 1969 Year of birth No. vaccinated Year of birth No. vaccinated 1968 15 1969 — 1967 781 1968 636 1966 760 1967 875 1965 728 1966 588 1961-1964 2535 1962-1965 709 Others under 16 344 Others under 16 227 TOTALS 5163 3035 CHILD GUIDANCE CLINIC The following number of children attended the Child Guidance Clinic 1965 1966 1967 1968 1969 London Borough of Bexley Children 77 90 126 111 174 Kent County Council Children 31 7 — 1 — No. of children whose treatment continued from previous year : — London Borough of Bexley 163 207 341 272 337 Kent County Council 61 86 98 36 30 110 Later in 1968 it was possible to extend the scheme to all children under school age who had reached their first birthday and all junior school children. In 1969 senior schoolchildren were REPORT on the DENTAL SERVICES (1969) by the CHIEF DENTAL OFFICER J.H. FORRESTER, L.D.S., R.C.S.(Eng.). 111 DENTAL SERVICES The model scheme for school dental service has been set out in Appendix 'C' of "Health of the School Child" of 1962/63 which states that "The aim of the service is to ensure that, as far as possible, through dental health education and a high standard of dental care, children shall leave school free from dental disease and irregularity, with an understanding of the importance of good natural teeth, zealous in looking after them". This aspect of Dental Public Health can be divided into five divisions: Prevention, Inspection, Staffing, Treatment, Dental Health Education. (a) PREVENTION In a survey carried out on new entrants to schools, (5 year olds) it was found that an average child had 5.2 decayed, missing and filled teeth. This means that amongst our annual intake of this age group there were approximately 14,500 teeth in need of treatment. This is an appalling state of affairs, which is in parallel with the situations found in other areas, other than where fluoridation of water supplies has been undertaken, where the incidence of dental decay has been reduced by at least 50% (Department of Health & Social Security Publication No. 122 "The Fluoridation Studies in U.K. and the results achieved after eleven years"). It is, therefore, all the more depressing that such a certain and well tried measure of prevention as fluoridation has not been undertaken in the Greater London Area. In spite of Council's agreement for the fluoridation of water supplies it is regrettable that no action can be taken in this Borough, because although 21 Boroughs are in favour and 9 agree in principle, 2 are opposed to this measure. (b) INSPECTION Routine inspection of pupils in schools is an essential part of any Dental Public Health Measure, in order that the prevalence and incidence of dental disease may be established. The number of pupils inspected at schools were : — 1965 10,666 1966 11,073 1967 25,542 1968 27,253 1969 29,702 Approximately 89% of school population was inspected in 1968. All schools were dentally inspected in 1969. It is appropriate to record that this could not have been undertaken without the willing co-operation of Head Teachers and their staffs. 113 In the latter part of 1969 the establishment has increased by 1.4. full-time officers to the highest it has been since 1965. The continuance of this recruitment trend depends on the image the service creates. The attraction of personnel of the right calibre depends on an adequate pay structure and the creation of a modern concept of dental practice. This particularly relates to the Dental Surgery Assistants whose national scale of remuneration prohibits the recruitment of young personnel. (d) TREATMENT In 1968, 3415 school children received treatment and 4199 courses of treatment were completed, an increase of approximately 44% over 1965. 10,011 fillings were inserted, giving an average of 6.7 per session compared with 4.1 in 1965. The fact that the treatment provided is of a continuing conservative nature is indicated by the ratio teeth filled to extracted which was 19.0:1 in permanent dentition and 3.2:1 in deciduous dentition. In the specialised field of orthodontics, 53 appliances were fitted and five fixed appliances. The services of Kent County Council's orthodontist are used for two sessions a month, largely in a consultative capacity, the dental officers carrying out the treatment prescribed. (e) DENTAL HEALTH EDUCATION In 1965, 1966 and 1967, dental health education was limited mainly to chairside instruction. However, this has been readily extended through 1968 and 1969 to include instruction in Infant and Junior Schools, Maternity & Child Welfare clinics. Mothers Clubs, etc. being undertaken entirely by the Dental Auxiliary, who is specially trained in this field. This was initiated by a visit to 35 Infant and Junior Schools of "Pierre the Clown", arranged through the General Dental Council, who performed to 10,500 children. 114 (c) STAFFING Establishment No. of posts Number in post at 31st December (Whole time equivalent) Designation 1965 1966 1967 1968 1969 Principal School Dental Officer and Chief Dental Officer 1 1 1 1 1 1 Senior Dental Officer 1 — — — — 1 Dental Officers. 5 5.15 3.10 3.90 3.4 4.0 Dental Surgery Assistants 6 5.4 5.4 5.4 5.4 6.0 Dental Auxiliaries 3 — 1.0 1.0 1.0 1.0 Oral Hygienists 3 — — — — — TOTALS 19 11.55 10.50 11.3 10.8 13.0 (i) Instruction for Dental Health 1968 1969 No. of Infants and Junior Schools 14 27 No. of pupils instructed 4500 7300 Maternity & Child Welfare clinics 21 35 Persons instructed 210 345 Mothers Clubs, etc. 3 3 Persons instructed 50 45 It is intended to extend this field of activity through ante-natal and post-natal clinics, etc. in conjunction with the health programme of health visitor staff in order to bring to the notice of parents the measures available to reduce the incidence of dental caries amongst the pre school children. (ii) Clinics and Equipment There are seven clinics with eight surgeries. In 1965 x-rays were installed in five surgeries. In 1968 obsolete anaesthetic machines were replaced. In view of the Department of Education and Science report on service and their request for restraint on expenditure and the possibility of new Health Centres being established, re-equipment of surgeries has not been undertaken. However, there is a pressing need for this to be done in order to keep pace with modern trends in dental practice. (iii) Maternity and Child Welfare Approximately 10% of dental service is devoted to this priority group. As only 3% of 5-year old new entrants had received treatment before reaching school, obviously a greater effort must be made through Dental Health Education to reach the parents of these children. In practice treatment is available at all our clinics and is combined with treatment of school children, in order to encourage "family" participation. No particular sessions are therefore devoted to maternity and child welfare treatment. Statistics relating to school health service and maternity and child welfare service are as follows:— 115 116 DENTAL SERVICES FOR EXPECTANT AND NURSING MOTHERS AND PRE SCHOOL CHILDREN A. ATTENDANCES AND TREATMENT 1965 1966 1967 1968 1969 No. of visits for treatment during year First visit EM.&N.M. 21 22 17 24 23 Children 208 225 210 287 421 Subsequent visits EM.&N.M. 54 52 66 64 50 Children 228 181 315 182 355 Total visits EM.&N.M. 75 74 83 88 73 Children 436 406 525 469 776 No. of additional courses of treatment other than 1st course EM.&N.M. 6 2 2 5 10 Children 43 36 95 97 145 Treatment provided during the year EM.&N.M. 35 71 89 78 113 No. of fillings Children 182 279 371 223 570 Teeth filled EM.&N.M. 31 62 62 45 69 Children 146 268 311 175 436 Teeth extracted EM.&N.M. 13 6 4 5 3 Children 41 52 55 42 46 General Anaesthetics given EM.&N.M. 4 2 — — — Children 19 33 27 26 24 Emergency visits by patients EM.&N.M. — — — — 1 Children — 14 9 5 6 Patients X-rayed EM.&N.M. 4 2 4 1 1 Children — 1 1 — — Patients treated by scaling &/or removal of stains from teeth EM.&N.M. 6 14 12 27 16 Children 27 138 207 186 215 Teeth otherwise conserved Children 37 60 84 54 88 Teeth Root Filled EM.&N.M. — 2 — — — Inlays EM.&N.M. — — — — — Crowns EM.&N.M. — — — — — No. of courses of treatment EM.&N.M. 11 14 14 23 19 Children 114 258 285 280 403 B. PROSTHETICS 1965 1966 1967 1968 1969 Patients supplied with F.U. or F.L. (First time) 3 1 1 1 — Patients supplied with Other Dentures 1 — 2 1 — No. of Dentures supplied 4 1 3 2 — C. ANAESTHETICS General Anaesthetics administered by Dental Officers 1965 1966 1967 1968 1969 — — — — — D. INSPECTIONS 1965 1966 1967 1968 1969 No. of patients given first inspections EM.&N.M. 21 22 17 21 19 Children 208 565 432 322 431 No. of patients in A and D who required treatment EM.&N.M. 17 22 15 18 16 Children 115 270 210 190 298 No. of patients in B and E who were offered treatment EM.&N.M. 17 21 15 18 16 Children 103 233 185 173 289 E. SESSIONS 1965 1966 1967 1968 1969 No. of Dental Officer Sessions (i.e. equivalent complete half days) devoted to Maternity & Child Welfare Patients: For treatment 43 68 116.0 63 100.8 For Health Education 7 19 47.0 30 37.0 SCHOOL DENTAL SERVICE ATTENDANCES AND TREATMENT 1965 1966 1967 1968 1969 First Visit Ages 5 — 9 1273 1247 1497 1651 2233 I O 840 961 1085 1402 1638 " 15 & over 182 270 262 362 478 TOTAL 2295 2478 2844 3415 4349 Subsequent visits Ages 5 — 9 2106 2217 3029 2671 3936 " 10-14 2549 2988 2755 3186 3512 " 15 & over 625 892 627 987 1051 TOTAL 5280 6097 6411 6844 8499 Total visits Ages 5 — 9 3379 3464 4526 4322 6169 " 10-14 3389 3949 3840 4588 5150 " 15 & over 807 1162 889 1349 1529 TOTAL 7575 8575 9255 10259 12848 Additional courses of treatment commenced Ages 5 — 9 384 291 779 1055 1519 " 10-14 257 297 447 907 1105 " 15 & over 58 82 69 24 206 TOTAL 699 670 1295 1986 2884 Fillings in permanent teeth Ages 5 — 9 904 1298 1756 1666 2766 I o 2002 2247 2648 3978 4915 " 15 & over 527 1064 774 1178 1748 TOTAL 3433 4609 5178 6822 9429 Fillings in deciduous teeth Ages 5 — 9 1386 1939 3519 2816 4568 I o 124 359 649 373 463 " 15 & over — — — — — TOTAL 1510 2298 4168 3189 5031 Permanent teeth filled Ages 5 — 9 797 1173 1415 1447 2224 " 10-14 1815 2123 2148 3262 3828 " 15 & over 475 926 569 1035 1174 TOTAL 3087 4222 4132 5744 7226 117 1965 1966 1967 1968 1969 Deciduous teeth filled Ages 5 — 9 1242 1729 2583 2117 3195 " 10-14 114 325 484 296 331 " 15 & over — — — — — TOTAL 1356 2054 3067 2413 3526 Permanent teeth extracted Ages 5 — 9 47 56 45 66 53 " 10-14 241 249 161 214 218 " 15 & over 47 45 33 78 95 TOTAL 335 350 239 358 366 Deciduous teeth extracted Ages 5 — 9 926 596 402 602 786 " 10-14 311 178 160 260 244 " 15 & over — — — — — TOTAL 1237 774 562 862 1030 General anaesthetics Ages 5 — 9 294 219 195 315 360 " 10-14 178 164 97 154 179 " 15 & over 18 29 8 27 17 TOTAL 490 412 300 496 556 Emergencies Ages 5 — 9 110 97 65 52 77 " 10-14 63 73 24 28 32 " 15 & over 16 21 10 8 10 TOTAL 189 191 99 88 119 No. of Pupils X-rayed 144 169 184 272 325 Prophylaxis 919 994 1639 1792 2448 Teeth otherwise conserved 1304 762 416 547 704 No. of teeth root filled 13 11 9 9 27 Inlays 1 1 — — — Crowns 7 3 3 4 15 Courses of treatment completed 2454 2688 3149 4199 5169 ORTHODONTICS 1965 1966 1967 1968 1969 Cases remaining from previous year 73 68 113 64 47 New cases commenced during year 18 28 12 18 74 Cases completed during year 10 33 18 30 28 Cases discontinued during year 13 6 4 5 5 No. of removable appliances fitted 56 78 82 53 68 No. of fixed appliances fitted 10 11 5 3 1 Pupils referred to Hospital Consultant 1 19 5 7 12 PROSTHETICS 1965 1966 1967 1968 1969 Pupils supplied with F.U. or F.L. (first time) Ages 5 — 9 — — — — — " 10-14 — — — — — " 15 & over — — — — — TOTAL — — — — — Pupils supplied with other dentures (first time) Ages 5 — 9 2 — — — — " 10-14 2 3 4 5 2 " 15 & over 6 2 1 3 1 TOTAL 10 5 5 8 3 No. of dentures supplied Ages 5 — 9 2 — — — — " 10-14 2 4 4 5 3 " 15 & over 7 2 1 3 2 TOTAL 11 6 5 8 5 118 APPENDIX 'A' REPORT ON ATMOSPHERIC POLLUTION Page 1. General 112 2. Origin and Nature of Atmospheric Pollution 112 3. Sources of Pollution 112 4. Effects of Atmospheric Pollution 113 (a) On Health 113 (b) On Vegetation 114 (c) On Metalwork 115 (d) On Stonework 115 (e) Other Materials 115 (f) On Paintwork 115 (g) On Aircraft 115 (h) Wastage of Fuel 115 5. Prevention 116 6. Powers of a Local Authority 116 7. Present Position 117 8. Conclusion 118 8th July, 1965 119 LONDON BOROUGH OF BEXLEY SMOKE CONTROL AREAS POSITION AT 31st Dec. 1969 Areas in Operation Area being brought into Operation 120 ATMOSPHERIC POLLUTION An early decision is necessary regarding the future policy of the Health Committee and the Council in respect of the elimination of atmospheric pollution. The following information is given to assist Members of the Committee in considering this most important matter. 1. GENERAL Atmospheric pollution is the most important Public Health problem facing the inhabitants of this country today, because it affects almost all parts of the country and no one can escape its ill effects, as we all have to breathe air in order to survive. It is also important because it is one of the few major health problems for which there is a solution that is simple to apply. If the nation is so minded, the problem could be eliminated or reduced to negligible proportions in a relatively short time, with immense health and economic benefits to everyone. 2. ORIGIN AND NATURE OF ATMOSPHERIC POLLUTION The majority of materials polluting the atmosphere are derived from the combustion of fuels of various kinds, e.g. coal, oil, wood, and their derivatives. A small proportion arises from chemical works and dusty industrial processes. The main pollutants derived from fuels are 1. Smoke 2. Sulphur di-oxide 3. Ash Smoke is the visible product of combustion and consists mainly of unburned carbon and volatile tarry matter. Its presence always indicates imperfect combustion of fuel and thus waste of fuel. Sulphure di-oxide (SO2) is the end product of the combustion of sulphur which is present in most fuels (in coal and coke sulphure averages about 1.5% by weight, in fuel oils from 0.4%). Ash is the con-combustible material present in solid fuels and its proportion varies from 2-10% depending on the quality of the fuel. Most of it remains in the domestic grate but about 0.3% of the finest dust is carried up the flue with smoke to pollute the atmosphere. Coal is the principle source of pollution in this country, and it gives rise to all three forms of pollution, viz: smoke, SO2 and ash. Coke is a smokeless fuel but still gives rise to SO2 and ash. Oil can produce smoke and SO2 but is virtually free from ash. 3. SOURCES OF POLLUTION The burning of coal domestically and industrially accounts for most of the pollution in the atmosphere. 121 The relative proportions of smoke from domestic and industrial chimneys in any area depend mainly on whether the area is residential or industrial. Over the whole country roughly equal amounts of smoke — about one million tons per annum — are produced from each type of chimney, i.e. a total of approximately two million tons of smoke each year. There are important chemical differences between domestic and industrial smoke. The domestic smoke is produced at low temperatures and contains much tarry matter. Industrial smoke contains much less tarry material. Industrial chimneys account for about twice as much SO2 and ash as domestic chimneys. Railway locomotives, ships and internal combustion engines are further sources of atmospheric pollution. Locomotives and ships produce localised problems. The internal combustion engine is relatively unimportant but will become a factor when the present more important sources, e.g. coal, have been dealt with. 4. EFFECTS OF ATMOSPHERIC POLLUTION (a) On Health If we compare the mortality from respiratory complaints in this country with the rest of world, we are struck by the much higher rates found in this country than anywhere else in world:— Percentage of deaths due to respiratory complaints England and Wales 6.97 Scotland 3.9 Northern Ireland 3.7 Average for European Countries 1.89 Sweden (lowest in Europe) 0.47 Morocco 2.73 South Africa 2.09 Japan 1.88 U.S.A. 0.2 The death rate for respiratory complaints in England and Wales is about 15 times as high as in Sweden and 35 times as high as in the U.S.A. The highest respiratory death rates in England and Wales are in the most densely populated areas where the atmospheric pollution is also highest. Bronchitis is the commonest respiratory disease in this country accounting for 30,000 or more deaths each year. In addition to the deaths it also causes enormous economic loss through and serious disablement and misery to individual sufferers who experience many years of inevitable increasing distress and disability. Men are more commonly affected than women. The mortality rate from bronchitis in the Greater London Area is comparable to those of the industrial North, the Midlands and South Wales. 122 The death rate from bronchitis in England and Wales is about 50 times as great as in Denmark and 20 times as great as in Norway and Sweden. These countries have climates not unlike our own and winters which are generally much more severe. All three are non-industrial and use very little coal as fuel and have clean atmospheres. It is now generally accepted that atmospheric pollution is the important factor responsible for the uniquely high incidence in this country of chest complaints and especially bronchitis. Of the two polluting factors involved, smoke and SO2, smoke is much the more damaging to health, hence the urgent need for the rapid introduction of smoke control areas throughout the country. There are available reliable figures which show that as the amount of smoke increases, as in fogs and smogs, the number of cases of respiratory illness and deaths from chest complaints increases also. Fortunately, it is a much simpler technical problem to remove smoke from the atmosphere than SO2. Smoke is also a possible factor in the causation of lung cancer as smoke contains tarry matter and tar contains materials capable of causing cancer. Animals are not immune from the adverse effects of air pollution and many members will remember the deaths in the December 1952 smog of valuable pedigree animals at the Smithfield Show in London, which it will be recalled killed over 4,000 London residents as a result of the 4 or 5 days of intense smoke pollution. Sheep and cattle are also particularly sensitive to fluorine which can be a form of atmospheric pollution near certain industries. Other adverse effects on health of smoke in the atmosphere are due to a serious reduction in the amount of sunshine and ultra-violet light which we receive, thereby predisposing to general ill-health and especially tuberculosis and rickets. Most British towns lose from 25% to 55% of the possible daylight from the presence of smoke alone. On gloomy days up to 90% of the natural light may be lost which causes eye strain in indoor workers and leads to the frequent use of artificial light. The effects of breathing heavy concentrations of dust in industrial processes may be serious and even fatal, but the amount of dust in the general atmosphere is too small to be of direct danger to health. It does, however, add materially to the housewife's labours calling for additional physical effort and reducing her time for relaxation and recreation. In persons of appropriate temperament this could lead to psychological strain. Complaints about grit and dust often arise from residents near factory chimneys, coal fired power stations being common offenders causing heavy deposits of grit to fall on surrounding areas. (b) On Vegetation An enormous amount of damage is done each year to vegetation by atmospheric pollution. This affects plants in two ways:— (i) by direct poisoning effects of the SO2 to which plants are particularly sensitive, and (ii) by the clogging of the breathing pores in the leaves of the plant by smoke particles. 123 Sulphur di-oxide also pollutes rain which kills the bacteria in the soil and thus prevents the plant obtaining its normal food supplies. A concentration of less than three parts in 10,000,000 would injure vegetation. Smoke in the atmosphere also reduces the ultra violet light and daylight to the detriment of vegetation. Damage to vegetation by atmospheric pollution directly affects the food supplies of the whole nation. (c) On Metalwork The rate of corrosion of metals is three times as rapid in densely populated areas as in country districts. This applies to both ferrous and non-ferrous metals and is due to the very highly corrosive action of SO2 in the presence of moisture and particles from the atmosphere. If atmospheric particles are removed the corrosive effect of the SO2 and moisture together is negligible. (d) On Stonework Most building materials are attacked by atmospheric pollution and all are rendered dingy by smoke. Some forms of stone and brick are very susceptible to the action of smoke and its acid components and rapidly disintegrate. The repairs to Westminster Abbey of damage largely the result of atmospheric pollution recently cost £¾ million. (e) Other Materials Wool, cotton and leather goods are rapidly rotted in a polluted atmospher. Damage to textiles, e.g. curtains, clothes, etc. affects every household in a polluted atmosphere. In addition the washing of household linen is rendered more difficult in industrial towns than in the rural areas, requiring more expenditure on soap, a longer time for the task and subjecting the garments etc. to more wear and tear in the process of cleansing. The effects on leather can seriously damage leather bound books in libraries in smoky areas. (f) On Paintwork In smoky towns external paintwork on buildings requires renewal more frequently, often on alternate years. Expenditure on painting and cleaning buildings in smoky towns may be 40% more than in clean towns. (g) On Aircraft The presence of smoke in the atmosphere seriously reduces visibility for aircraft flying in the vicinity of towns and adds to the difficulties of aircraft using airports in the vicinity of industrial areas through the marked reduction of visibility caused by smoke in the atmosphere. (h) Wastage of Fuel It has been estimated that the combustible material, both visible and invisible, which accompanies smoke is worth £26,000,000 per annum. 124 The estimated Total Cost of damage plus waste was £250,000,000 in 1954. THIS DOES NOT INCLUDE DAMAGE TO HEALTH!!! 5. PREVENTION Many uninformed people think that remedial measures are not worth while but in considering the problem it is essential to weigh the relatively small cost of remedial measures against the enormous damage to health and economic wastage which pollution causes each year. In this connection one need only draw a parallel with diphtheria immunisation. The same attitude of mind existed towards this procedure only a few years ago, yet in the last 20 years through persistent efforts of Health Departments and other enlightened members of the community, this once dread disease, which had a very high mortality rate and a similarly high crippling rate and cost the nation vast sums in hospital charges each year, has now been virtually eliminated. It only requires the same attitude towards atmospheric pollution to eliminate it completely, or at least to reduce markedly the damage to health and property which at present arises therefrom. It has been estimated that in Great Britain each ton of smoke produced does £20—£30 worth of damage at least, (one modest factory produces one ton of smoke per week and ten domestic fires produce this quantity in one year). As mentioned above, the elimination of smoke from the air is a relatively simple matter. It merely requires the householder to discontinue burning raw coal and to change over to using an approved smokeless fuel (see below) and for industrial users to instal modern efficient boilers and other fuel burning appliances and to ensure his plant is properly operated and maintained. 6. POWERS OF A LOCAL AUTHORITY Since the introduction of the Clean Air Act in 1956, Local Authorities have had available the power to eradicate the major causes of atmospheric pollution in their areas, both domestic and industrial. Unfortunately these powers have not been exercised vigorously by the majority of local authorities although a few enlightened Councils have pressed ahead and have rendered their areas smoke free. The procedure under the Clean Air Act is for an Authority to designate a part (or parts) of its area to be a "Smoke Control Area" in which, after a given date, it will be an offence for smoke to be produced from any domestic or other chimney, and an offence for 'black' smoke to be produced from any industrial chimney. Special provision is made to permit limited unavoidable smoke emissions from industrial plants and for the lighting of domestic fires where no alternative to the use of sticks and paper exists. As regards domestic premises, these can be heated smokelessly in many ways and it has always been the accepted policy to follow freedom of choice to the householder as to which method or methods he uses. Gas and electricity are inherently smoke free and are becoming increasingly popular as methods of smokeless domestic heating. Persons wishing to use solid fuels have available a wide choice of officially approved solid smokeless fuels including gas coke, hard coke, reactive cokes (Cleanglow, Phimax, etc.), special low temperature carbonisation fuels (such as Coalite, Rexco), Anthracite, low volatile steam coals, carbonised briquetted fuels, etc. In addition oil-fired central heating systems can be used. 125 Unfortunately, one cannot burn certain of the solid smokeless fuels in old-type domestic fireplaces and others, whilst they will burn, cannot be burned economically, It is, therefore, necessary, when introducing smoke control areas, for the local authority to require the provision of modern approved types of grate to be fitted where these are not already installed. Where such grate replacement is necessary the Council has to contribute towards the cost of the new grate and its installation. The grant from the Council is 7/10 of the cost, the owner or householder paying 3/10. The Council ultimately recovers 4/10 of the cost from the Treasury leaving only 3/10 to fall on the ratepayers. The Clean Air Act also gives a local authority power to pay 100% of the cost in certain special cases, e.g. old age pensioners, persons on National Assistance, charities, etc. The Treasury's 4/10 is payable in these '100%' cases also. As regards industry, the local authority exercises its control by observing the chimneys of existing plants to see that smoke emissions, if any, comply with those permitted under the Act and by approving all proposed installations of new boiler plant (over 55,000 B.T.U's per hour) and other types of furnace, before they are actually installed. This enables the Council to satisfy itself beforehand that any new industrial plant can be operated virtually smokelessly or if not so satisfied, to refuse to approve its installation. Local Authorities also have power to control the height of industrial chimneys to avoid nuisance to neighbouring premises and to ensure adequate dispersal and dilution of flue gases. Apart from the benefits to health and the avoidance of preventable damage and consequent economic loss to the country, the installation of modern domestic heating appliances gives other important benefits. An open fire burning coal heats solely by radiation and is about 5% efficient, i.e. for every ton of coal bought only between 1/6 and 1/7 of the available heat paid for is actually used, the rest is wasted as smoke and heat up the chimney. A modern open fire burning smokeless fuel instead of coal is about 22% efficient merely by eliminating the production of smoke. Convector open fires are 30—35% efficient and free standing openable stoves, if used as closed stoves, from 50—60% efficient. One can, therefore, gain considerable additional benefit by changing to modern appliances burning solid smokeless fuels — either one spends less money on fuel for the same amount of heat, or spends the same money on fuel and obtains many times the heat, which adds greatly to comfort and health. 7. PRESENT POSITION The present position in the London Borough of Bexley is that 4 Smoke Control Areas exist, all having been introduced by constituent authorities as follows:— 126 Smoke Control Area Area in Acres Number of Properties Bexley No. 1 109 1,367 Crayford No. 1 756 986 Crayford No. 2 463 3,661 Erith No. 1 390 3,281 Totals 1,718 9,295 Two further Smoke Control Orders have been made but have not yet been confirmed by the Minister of Housing and Local Government. They are as follows: — Smoke Control Area Area in Acres Number of Properties Provisional Operative date Bexley No. 2 457 2,786 1st October, 1966 Crayford No. 3 1,480 5,704 July, 1968 Totals 1,937 8,490 The total number of houses and shops with dwelling accommodation in the new Borough is about 70,000. Since 1956 only approximately 1/9 of the area of the Borough and 1/8 of the houses have so far been brought within operational Smoke Control Areas. At this rate of progress it will take another sixty years at least to obtain a "smoke controlled" Borough! In my opinion the aim should be to have the whole of the Borough "smoke controlled" within ten years or even less. This is practicable if the Council so wishes. I feel it would be wrong for the public to have to wait any longer for such a universally beneficial and long overdue measure. It is so easily overlooked that the damage from atmospheric pollution is continuous and cumulative. The new-born babe is being adversely affected from its very first breath. It is ridiculous to spend vast sums of money on new hospitals to treat people for illness much of which could have been prevented for all time by far less expenditure now on the elimination or reduction of atmospheric pollution. 8. CONCLUSION The above brief summary outlines the problem and the preventive measures open to the Council. It is my sincere wish that the Health Committee will recognise the enormous importance to the inhabitants of Bexley of ensuring that as far as is within the Council's power, they have a smoke free atmosphere in which to live and work. I hope that the Council will support this view and provide a good example and give every encouragement to the ratepayers to achieve a "smoke controlled" Borough of Bexley as quickly as possible. 127 An early decision on policy by the Council is necessary so that detailed schemes and programmes can be prepared for the Committee's consideration and in order to enable financial provision to be made in the Estimates. H.L. SETTLE Medical Officer of Health and Chief Welfare Officer 128 APPENDIX 'B' OBSERVATIONS ON THE GREEN PAPER ON THE NATIONAL HEALTH SERVICE by H.L. SETTLE The Green Paper follows a decision by the Minister of Health that the present structure of health service administration is no longer suited to present day requirements and needs to be radically changed. His proposals envisage the scrapping of the present tripartite administrative structure — Hospitals, General Practitioner Services and Local Authority Services — and its replacement by single all purpose area boards responsible for all aspects of the Health Service and each serving a population of 1 — 2 million. Forty to fifty such boards would be required to England and Wales. Under these proposals the London Borough of Bexley would lose its personal and environmental Health Services and the Health Department would disappear. The Personal Services which would be transferred include: Health Visiting Home Nursing Domiciliary Midwifery Maternity and Child Welfare Mental Health Care and After Care (Nursing aids, Convalescence, etc.) Vaccination and Immunisation Health Education Family Planning Etc., The Environmental Services to be transferred could include: Housing Food and Drugs, and Food Hygiene Clean Air Nuisances Infectious Diseases Etc., (N.B. Paragraph 46 is less positive than paragraphs 24-32 which deal with the personal services.) I have no doubt that the personal health services I have mentioned could be administered by an Area Board along with the Hospital and General Practitioner Services. Whether the services would be as satisfactory for the patient (and let us not forget that he or she is the sole reason for the existence of the services) as under present arrangements is a matter of opinion. 129 In this conception of area control I am reminded of the Brontosaurus which became extinct because it grew so large that its brain was too far from its limbs. Perhaps there is a lesson to be learned here! When we come to the environmental services the Green Paper is vague and proposes that medical advice would be available to local authorities from Medical Officers on the staff of the Area Boards. The Green Paper envisages that the functions and powers of the Medical Officer of Health in respect of personal and environmental services would be transferred to the Area Board, but it does not say how they are then to be carried out. If a post equivalent to that of Medical Officer of Health is to be established under the Area Board he is in danger of becoming merely an "adviser" and spending most of his time on Committees where his special knowledge and experience will be wasted. The Medical Officer of Health is, or should be, a specialist field worker whose major interest is the prevention and control of disease and not its treatment. One of the great weaknesses of the National Health Service is its emphasis on illness and its neglect of prevention and the price we have had to pay for this is astronomical and will continue to increase. My view is that already the London Boroughs are too large as far as the Health Departments are concerned — although I concede that for other services they may be ideal. If a Medical Officer of Health is to carry out his preventive duties properly he needs to be relieved of those personal health services which deal with the individual and to concentrate his efforts on the Community and the prevention of illness. The Area Board proposal would not appear to encourage or permit this. I have for years advocated the separation of Local Authority Health Services into two divisions each under a medical officer of equal status. The Medical Officer of Health would continue in charge of Environmental and Preventive Services, the other Medical Officer in charge of the Personal Services. They would collaborate closely but each would have time to do his job properly, and most important of all, the preventive aspects would receive proper attention which they are not doing at present, to the country's cost. Communication within a large Local Government organisation seems to deteriorate geometrically with the size of the organisation and whatever the theorists may imagine, the larger the set-up the greater the problem of technical and professional control at the perimeter and of obtaining prompt and accurate information. From my 30 years experience in Local Government I have no hesitation in stating I made my most useful contribution to the public welfare and derived the greatest satisfaction from my work, when I was Medical Officer of Health and Principal School Medical Officer of a Borough of 35,000 and did everything single-handed. In my view the proposed services under Area Boards could function, but whether the new arrangement would bring any benefit to the public I very much doubt. The cost would be greater than at present and the preventive aspects of disease would get pushed further and further into the background, as the curative sections of medicine would undoubtedly dominate the activities, interests and finances of the Boards. I have deliberately kept away from the effects on the Hospital and General Practitioner Services as these are not spheres of which I have first-hand knowledge, nor have I concerned 130 myself with the problems of membership of Boards and how they are to be appointed. That does not mean to say these matters are insignificant, but they are not matters on which I am able to express any views. One general matter with which I would like to deal briefly is that since 1948 there has been an ever diminishing number of Medical Officer of Health posts in the country due to reorganization and combinations of authorities for health purposes. This trend has seriously affected the prospects open to a newly qualified medical practitioner who might otherwise have been attracted to Public Health work and the proposal to reduce the top posts to only forty or fifty will, in my opinion, stop recruitment completely. Even the issuing of the Seebohm Report and the Green Paper must adversely affect the future recruitment of medical and probably other categories of Local Government service. At present there are 175 Local Health Authorities each with a Medical Officer of Health and 956 Local Sanitary Authorities with 396 Medical Officers of Health. It will be recalled that the recent reorganisation in London reduced more than 100 posts of Medical Officer of Health to 32 eliminating about 70 in the process. The Green Paper envisages setting up forty or fifty Boards for England and Wales and thus the number of top posts in Public Health will again be very drastically reduced. H.L. SETTLE Medical Officer of Health and Director of Welfare Services November, 1968 131 APPENDIX V OBSERVATIONS ON THE REPORT OF THE COMMITTEE ON LOCAL AUTHORITY AND ALLIED PERSONAL SOCIAL SERVICES by H.L. SETTLE It is important to get the problem in perspective. The Seebohm report is a powerful document on a very emotional subject. I always wonder when considering reports on subjects which are largely matters of opinion whether, given the same evidence, a committee of a different composition might not have come to very different conclusions. One member of the Seebohm Committee has stated that the Committee was established as a result of "pressures to set up a Family Service", and that the social services "were believed" to have been in a state of crisis for 10 years or more, and that "dissatisfaction with the social services was widespread". He also said that either the crisis is phoney or else it requires a radical solution. I would suggest that many will share his doubts as to whether a crisis does exist. In Bexley, I am not aware of a crisis although much requires to be done to extend and develop our welfare provisions. I would have expected the Seebohm Committee first to have satisfied itself as to the true position but nowhere can I find any scientific statistical evidence to support the radical changes proposed. In fact, paragraph 42 states that one of the main lines of enquiry was "to discover the opinions of all those concerned with the services" whilst in paragraph 42 we learn "We were, regrettably, unable to sound consumer reaction to the services in any systematic fashion". In view of these contradictory statements, the value one can place on the findings of the Committee is conjectural. The main faults attributed by the Committee to the present arrangements are:— 1. a failure to provide sufficient services, 2. a failure to provide the necessary types of service, 3. inadequacies in the quality of service provided, 4. poor co-ordination, etc. All the above short-comings, and no-one would disagree that they do exist in varying degree, could be eliminated from the existing services by the provision of adequate funds. I suggest that even under the Seebohm proposals some of these short-comings will still exist even if vast sums of money are made available. Seebohm would seek to isolate the social services from medical direction and control, and I feel this is wrong. All handicaps have a medical basis and most, if not all, handicapped persons are under medical supervision, some constantly, some intermittently, but all receive medical care at more than the average rate for non-handicapped persons. 133 I am not suggesting the Medical Officer of Health should be the person in charge of the new Service. I have long advocated that the Medical Officer of Health should be responsible for environmental and preventive services and another medical officer of equal status should control all the personal services, i.e. the Medical Officer of Health would be concerned with matters affecting the community and with preventing illness and disease, whilst the other Medical Officer would control the services supporting the individual sick or handicapped person. This type of arrangement existed in London prior to 1965 when the Metropolitan Borough Medical Officer of Health concerned himself with environmental and preventive matters and the London County Council Divisional Medical Officer controlled the personal services, and in my experience was very successful. The Seebohm Committee fully recognises the important part the medical services have to play in their proposals and I should have thought it would be logical to place a service in which ill health and handicap loom so large, under a person qualified to assess the needs of patients and their progress in a first-hand professional manner. It has been said that the Seebohm proposals will produce a chasm between the Social and Medical Services into which the patient will fall! The report has been called a "Charter for the Social Worker" — not for the patient! Social workers can become very involved emotionally with the problems of the persons for whom they are responsible and if unable to make progress in alleviating the patient's lot could sublimate their frustration by blaming imagined short-comings of the service instead of their own inadequacies, or their failure to realise that they were dealing with an insoluble problem. As regards the widespread dissatisfaction with the existing services referred to by one member of the Seebohm Committee, I would suggest many patients are encouraged by the press, radio and television to expect too much from both medical science and the social services on which they have come to depend so much. When their condition does not improve as they may have hoped, they will then blame imagined inadequacies of the service, instead of themselves or their condition. The increased emphasis which is proposed to be given under Seebohm to the socially handicapped will only aggravate this problem further and will not alleviate it. It is well known that the elderly, and others too, will invent complaints in order to get attention. Social workers tend to over prescribe for their charges, thereby often encouraging the patient to become more and more dependent on the social services. There is a school of thought which considers too much welfare is bad for patients and they they should be encouraged to live with their handicap and as far as possible to ignore it. This could be done in many cases with benefit to the individual and to the economy. Too much support from social workers tends to discourage this attitude in the patient and must engender in all but the strongest characters a feeling of evergrowing dependence on others. Far too much publicity is given today to disease and illness and the public are encouraged to try and find something wrong with themselves, either medically or socially. If there is as much real illness, physical or mental, in the community as the National Health Service figures suggest, then something must be radically wrong with us as a race and we are basically poor stock, or else there something very seriously wrong with our way of life which should be ascertained and rectified immediately. 134 If the sickness figures for the population of this country and the picture painted by Seebohm of the social problems are correct, then I am appalled Parliament is content merely to treat and pander to symptoms, as Seebohm proposes, instead of making an immediate and determined effort to find the causes of our troubles and to eliminate them as quickly as possible. It is a great reflection on our national intelligence that even when we know how to prevent disease we do not take prompt and adequate steps to deal with it. May I quote one example which refers to this Borough and which will have a long term effect on your future welfare provision possibly for the next 60 or 70 years. The Ministry of Technology is conducting a National Survey of Smoke and Sulphur dioxide in the atmosphere. In a report recently distributed throughout the country on a pilot study of Southeast London and South-east England, London Borough of Bexley has the unenviable distinction of being singled out as "an area that needs the most urgent action", and the report urges that the Borough be brought under smoke control as soon as possible. Some members will recall that one of my first tasks after taking up duty as your Medical Officer of Health was to issue a report on 8th July 1965 pointing out the dangers of atmospheric pollution, the negligible action that had so far been taken — indeed, I pointed out that at the rate of progress made up to July 1965 by the previous Authorities it would take another 60 years at least to get a smoke controlled borough — and I urged action to speed the completion of this programme in not more than 10 years. (See Appendix A, pages 111—119.) You will be wondering why I mention smoke control measures in conneciton with Seebohm and social services. The reason is simple. Atmospheric pollution causes chronic bronchitis and aggravates other chest complaints. Chronic bronchitis can occur at any age but its main effects are felt after 30 years of age, and continue during a man's working life which can be shortened or seriously interfered with by long absences due to illness, both of which mean impaired earning capacity and social problems. Many sufferers have to give up work long before they are 60 and become cases for the social services. Others are unable to look after themselves adequately and enter Old People's Homes earlier than the average. The cost to the community of this type of handicap over a man's life is enormous and yet even though we know the answer to the problem little or nothing has been done about it. It is impossible to calculate what the lack of interest and effort by the previous authorities in respect of atmospheric pollution will ultimately cost you in the provision of welfare services in the future, but it will be a colossal sum and you can do nothing now to avoid that cost. Many people walking the streets of Bexley today will have already been affected and if the Borough became smoke-free tomorrow they will at a later date, still become victims from the damage already done and they will become chronically handicapped and need social support, and possibly admission to hospital or an Old Person's Home. Today, new-born babies and children arecontinuously exposed to the dangers of atmospheric pollution and of these some are certain to succumb in later life to the effects of atmospheric pollution which they have to breathe today. 135 Instead of wasting time and resources on super elaborate welfare services I suggest we should be concentrating our limited cash and resources on prevention and the matter of clean air is only one which can be tackled immediately if the Council so wishes. In my opinion Seebohm is the wrong type of approach to our current ills. Emphasis must in the national interest and that of the patient be given to finding the reasons why so many of the population nowadays become dependent on social support and to iliminating, if possible, the causes. To erect an elaborate edifice of a social services department as envisaged by Seebohm and to abolish the health department with its 100 years or more of real progress in preventing disease, as envisaged in the Green Paper, would be hazardous and short-sighted in the extreme. H.L. SETTLE Medical Officer of Health and Director of Welfare Services November, 1968 136 Printed by the Reprographic Section, Town Clerk's Department, London Borough of Bexley, Town Hall, Erith, Kent.