LONDON BOROUGH OF BEXLEY ANNUAL REPORT OF THE MEDICAL OFFICER OF HEALTH AND PRINCIPAL SCHOOL MEDICAL OFFICER FOR THE YEAR 1970 BEX 31 LONDON BOROUGH OF BEXLEY ANNUAL REPORT of the MEDICAL OFFICER OF HEALTH and PRINCIPAL SCHOOL MEDICAL OFFICER for the year 1970 H. James, L.R.C.P., L.R.C.S.(E), L.R.F.P.S.(G), D.P.H. Medical Officer of Health CONTENTS Page Members of Committees 3 Health & Welfare Department Staff 4 Introduction 10 SECTION A. Statistics and Social Conditions 13 SECTION B. Health Services in the Area 37 SECTION C. Prevalence and Control of Infectious and Other Diseases 99 SECTION D. Environmental and Sanitary Circumstances in the Area 113 SECTION E. Housing 125 SECTION F. Food and Drugs 131 SECTION G. Offices, Shops & Railway Premises Act 1963 137 SECTION H. General 143 Report of the Principal School Medical Officer 147 Report on the Dental Services (1970) by the Chief Dental Officer, J.H. Forrester, L.D.S., R.C.S.(Eng.). 157 APPENDIX A. Nursing Attachments to General Practice 167 APPENDIX B. Midwifery Training 169 An index is given at the beginning of each Section. 1 MEMBERS OF THE SOCIAL SERVICES (AND CHILDREN'S) COMMITTEE (as at December 1970) Ex-Officio The Worshipful the Mayor (Councillor R. Pope) 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 „ J.M.V. Collie „ D.I. Evans, T.D., J.P. „ 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 R.J. Sisk Co-opted Members: Mr. J.N. Powrie Executive Council for South East London and Kent Dr. M.J. Barnard, M.B.B.S. Kent Local Medical Committee Mrs. C.A. Driver W.R.V.S. Mr. J.C. McLean, C.B.E., J.P. South East Metropolitan Regional Hospital Board Mr. A.J. Saunders, A.I.B., A.C.I.S. Kent Association for the Blind Mr. G.B. Hodgson, M.B.E. 3 PRINCIPAL STAFF OF THE HEALTH AND WELFARE DEPARTMENT (at 31st December, 1970) Acting Medical Officer of Health, Ian Browne Millar, Acting Principal School Medical Officer M.D., B.Ch., B.A.O., D.P.H. and Acting Director of Welfare Services (1.1.70 to 31.9.70) Medical Officer of Health, Herbert James, Principal School Medical Officer L.R.C.P., L.R.C.S.(E)., L.R.F.P.S.(G), D.P.H and Director of Welfare Services (from 1.10.70) Principal Medical Officer Fanny Stang, M.D., L.R.C.P., L.R.C.S., D.P.H. Chief Dental Officer J.H. Forrester, L.D.S., R.C.S.(Eng.) Chief Public Health Inspector P.R. Hickson, M.R.S.H., M.A.P.H.I. Deputy Chief Public Health Inspector A.W. Kent, M.R.S.H., M.A.P.H.I. Chief Administrative Assistant F.E. Young Senior Administrative Assistant G.A. Pearson Director of Social Services N.G. Hustler, M.I.S.W. Deputy Chief Welfare Officer R.J.B. King Principal Mental Welfare Officer H.E. Causey, C.S.W., M.R.S.H., M.S.M.W.O. Deputy Principal Mental Welfare Officer J.R. Allam, C.S.W. Senior Area Nursing Officer and Miss M.C. Gooderham, S.R.N., S.C.M., Non-Medical Supervisor of Midwives Queens Certificate, H.V. Certificate Deputy Superintendent of District Nurses Mrs. F. Pearce, S.R.N., S.C.M., and Non-Medical Supervisor of Midwives District Nurse Certificate Area Nursing Officer Mrs. N.G.V. Cooper, S.R.N., S.C.M., H.V. Certificate, Nursery Nurses Certificate Deputy Superintendent Health Visitor Miss J.M. Patchett, S.R.N., C.M.B.(Part 1), H.V. Certificate Home Help Organiser Miss J.M. Smith, Inst. H.H.O. Chief Chiropodist B.R. Marsh, M.C.H.S., S.R.C.H. Senior Speech Therapist Mrs. C. Leech, Lie. of College of Speech Therapists Public Analyst H. Amphlett Williams, Ph.D., A.C.G.F.C., F.R.I.C., F.R.S.H. 4 Health and Welfare Department, 9 Brampton Road, Bexleyheath, Kent. To: The Worshipful The Mayor, Aldermen and Councillors of the London Borough of Bexley. Mr. Mayor, Ladies and Gentlemen, I have the honour of presenting my first Annual Report, for the year 1970, produced in accordance with the Department of Health and Social Security Circular 1/71. I would have liked to have produced this report at an earlier date, but due to the constant pressure of work brought by relative staff shortages gnd by constantly changing emphasis on the services of the Department this has not proved possible. Tribute must be paid at the outset to the Acting Medical Officer of Health, Dr. Millar, and his loyal and hard working colleagues, who have produced the majority of the material for this report. Special mention should be made of Dr. Millar, whose great loyalty and sound knowledge of the situation helped to smooth the path on so many occasions. The report is written in the light of the many changes brought about by the introduction of the Social Services Act 1970, and the likelihood of further legislation in 1974 covering the unification of the Health Services, and I would welcome my new colleague, Mr. No6l Hustler, the Director of Social Services, appointed at the same time as I was, to wish him and his Department well in the future, and to assure him of the fullest support of the Health Department staff. In October, when first appointed, it became clear to me that the prime objective in the remaining months of the year was to make sure of the continued effectiveness of those parts of the Health and Welfare Department which would remain with the re-organised Health Department, as well as making sure that those parts to be administered in future by the Social Services Department, i.e. Welfare, Mental Health and Home Help Services, would be considered to be fully functional until full integration of the various social services was achieved. The Management Services Department advised the Council that certain services might more efficiently and economically be administered on a shared basis between Health and Social Services. The Social Services Department was allocated the buildings on the east side of Brampton Road, except for a small number of rooms in the house previously occupied by the Public Health Inspectors and the Health Department the existing buildings on the west side. The post and reprographic, as well as messenger, services to be provided by the Health Department, while the Typing Pool and Transport would in future oe jointly operated by the Social Services Department. A major innovation attempted, perhaps with slightly mixed feelings, was the creation of a Finance Section shared with Social Services, directly under the control of a Senior Officer of the Borough Treasurer. To my knowledge this is the first time this has been attempted by a Health Department, and I am sure that the functioning of this section will require careful observation to see it fulfils its hoped for purpose. 5 This report, the last of the Bexley Health and Welfare Department, is written with a certain amount of nostalgia, for it is a matter of considerable regret that in the past a number of people in their enthusiasm for bringing about the new Social Services Act, have felt it necessary to denigrate the work which had been carried out in this department, often in the face of considerable difficulty and staff shortages. The impression that concern for the underprivileged started only with the formation of the new department is erroneous. It is palpably unfair to the highly dedicated staff of the Health Department, working hard and making the best use of the skills and resources available. It must never be forgotten that deficiencies in any services can be well known to the members of the Department, but that the progress made depends very much on national and local resources. Another major move during the year was that of the Public Health Inspectorate to the premises of the former Children's Department at Gravel Hill. It enabled the whole of the Social Services Department to be concentrated at Brampton Road, bringing with it shorter distances of communication, and the chance of joint services. Unfortunately the site was not big enough to include also the Public Health Inspectorate. The move was undertaken with some reluctance and trepidation because traditionally, and in practice, the work of the Inspectorate is closely interwoven with the rest of the Health Department. Nevertheless first indications are that the move has in no way undermined the close working relationships which in general are so dependent on personalities. My grateful thanks are due to the Chairman and Members of the Social Services (and Children's) Committee, and to all Members of the Council, for their active help and encouragement in this difficult year. Grateful acknowledgement and thanks are also made to all my colleagues in other health fields for their co-operation and collaboration in Community Medicine in the service of the residents of Bexley. I am particularly indebted to all General Practitioners, and to Hospital and Voluntary Association staffs. My thanks are also due to colleagues in other Departments of the Council for their co-operation and help, and, perhaps most of all, to the members of the staff of the Health Department who have at all times given me their full co-operation and willingness in trying to achieve the objectives of the Department in a difficult and harrassing period of time when change was so imminent. Without their hard and diligent work I could not have performed this task. I am. Yours respectfully, HERBERT JAMES Medical Officer of Health & Principal School Medical Officer December, 1970 6 REPORT OF I.B. MILLAR, M.D., B.Ch., B.A.O., D.P.H. ACTING MEDICAL OFFICER OF HEALTH ACTING PRINCIPAL SCHOOL MEDICAL OFFICER and ACTING DIRECTOR OF WELFARE SERVICES for the period JANUARY 1 to SEPTEMBER 30, 1970 7 -» Health and welfare Department, 9 Brampton road Bexleyheath, kent To: The Council of the London Borough of Bexley. Mr. Mayor, Ladies and Gentlemen, This report deals with the greater part of the year and, as can be seen by each sectional index, it is intended to be representative of the work of the Department. It does not purport to be a detailed account of all that happened because this period was too active and time too limited to permit adequate current reporting. The preceeding Annual Report referred to the difficult circumstances affecting the new department during the previous years. One of these circumstances was the shortage of senior medical staff which persisted right up to the end of 1969. It is perhaps not surprising that this report has something to say along these lines, seeing that these problems became so much more acute in 1970. Despite these difficulties however the services of the Department to the public were well maintained and the general community health remained satisfactory. Fortunately no serious outbreak of infectious disease occurred, but if it had occurred, the necessary adjustments, however unwelcome, could have been made. Single or family cases were fully investigated including several cases where the possibility of smallpox had to be ruled out. There are many within the Local Government at Bexley to whom thanks are due for helpful support and assistance during this period. Amongst them are the Chairman and Members of the Social Services (and Children's) Committee and the Chief Officers and Heads of Departments and their staffs. The staff of the Health and Welfare Department, themselves under the scrutiny of an organisation and methods enquiry, gave loyal and unstinting support, the manner of which, by its obvious sincerity, augured well for the future efficiency of the Department. Thanks are due to them and it is with much appreciation that they are recorded here. Your Obedient Servant, I.B. MILLAR Acting Medical Officer of Health, Acting Principal School Medical Officer and Acting Director of Welfare Services September 1970 9 INTRODUCTION The first nine months of 1970 were eventful and the Department was working under pressure. There can be no doubt however that the event of the year was reorganisation. It is not possible to calculate the time and thought that was spent on this exercise or to express it statistically because it pervaded or influenced.activities and meetings other than those directly concerned with the subject. During these nine months the number of meetings attended by the Acting Medical Officer of Health was about one per day, approximately half of them being meetings of officer groups and/or Council Members. Delegation was practised as far as it was feasible to do so but one was constantly up against two intransigent difficulties, the shortage of senior staff and the unusual volume of work including reorganisation requiring the Chief Officer's attention. The Principal Medical Officer had to undertake more duties and eventually was recognised as Acting Deputy Medical Officer of Health. Attempts of different kinds were also made to recruit suitable staff within the existing terms of employment, but these were completely unsuccessful and only a long term solution to the problem seemed possible. Such a solution would have to be dependent upon prolonged negotiations involving the already protracted exercise of Organisation and Methods, prolonged discussions on the new departmental structures, the social services legislation, and the discussions of the Mallaby Working Party on the organisation of the whole Council service. Although shortage of staff was not new it had now become much more acute and it was under this serious handicap that the dynamic situation of these months had to be faced. Management, just then in the vigour of its ascendancy and with a controlling interest in most staffing matters, had no ready answers. During this time there were no less than thirteen special staffing problems demanding attention, only about half of which were capable of resolution within the Department. In general it seemed that the staffing of the Department was less cumbersome in 1965 when there was a more direct control. An important policy decision was reached by the Council in May. The Organisation and Methods survey of the Department, which had started in the summer of 1969, was said to be within weeks of completion, but a report was not presented. Instead however, attention was focused upon the top tier structures of the Health and Welfare Department and the Children's Department in what became at very short notice a reorganisation exercise. An intensive appraisal of various management concepts followed and the Council accepted the two-department concept now in operation, a concept not surprisingly favoured in the main by the officers of those departments. An alternative concept having obvious appeal in management circles would have meant the creation of a new post of Director of Community Services over both departments, a post open to candidates from all professions and lay administrators. The rejection of this idea will probably prove to have been a wise decision. It was a salutary experience nevertheless to be forced back to fundamental principles and to have to state their continuing relevance in response to unexpected and challenging proposals from outsiders to these services. It was proposed for example to transfer the environmental health section of the Department to the Town Clerk's Department, although on Green Paper theory there was to be no separation of the local authority health services until 1974. Another suggestion was to transfer all the accident prevention work of the health visiting section of the Department to the Road Safety Section of the Town Clerk's Department, presumably in the interests of tidier management. 10 Management is not as new as its recent prominence might suggest and the health and social services have not been bereft until now of good administrations or of administrators sensitive to improvements in management. The Medical Officer of Health for Greenwich London Borough writing critically on this subject in his Annual Report for 1969, "the year when management consultants arrived in the Borough", sounded a note of caution about the danger that in some forms of management, the way local government must work in a democracy has not been clearly understood and the means are often more deeply considered than the ends. This concern was also being expressed at the time of the dialogue of management in Bexley. Those probing the management of the Department must have learned much from their studies of these particular services, much by volume of information and, one suspects, much of value to their own work. Their critics within these services certainly wanted to know what were management's own achievements. Successful or no, management must expect to submit to the criteria it uses in judging others. All too often local authority personal services have to operate under a general financial control which is insensitive to the true economy of these services. Already non-profit making, their effectiveness is very much at the mercy of available national and local financial resources. If these are reduced below a certain level, services must be cut. To measure such circumstances according to human needs rather than as a business transaction is a task rightly belonging to the heads of these service departments. Likewise because of its nature, the evaluation of a health or social service should be a built-in feature of that service and not part of the general statistical enquiry arrangements for the Borough, although association with a statistical unit would have undoubted value. The obvious setting for such work would be within the planning and development section of the Department. Apart from the legislation which led to the creation of two new departments, the main administrative change was a trisection of the Borough into three geographical areas for three area teams of social workers. This was in line with the philosophy of the Seebohm Report to bring services and offices closer to the people. The basis for this decision was the size and location of the case loads in each of the social work disciplines as deduced from the 0. and M. enquiries. Although the need for area health teams was not so pressing because of probable further health centre development, it was agreed nevertheless that such an approach to the health service administration would be acceptable. In the first place it would help to preserve the long association between health and social work, secondly it might attract staff more readily being novel to the tradition of this type of employment in the London area, and thirdly it could be thought of as experimental because the administrative base for the health teams would still remain at the central office. The social work teams under an area social services officer would include a senior social welfare officer, a senior mental welfare officer, a senior child care and family care off icer, and an area home help organiser. The health teams under a principal medical officer would include a senior dental officer, an area nursing officer and representatives of the professions ancillary to medicine. The Social Services Department would also have a central administrative division and a division for residential care services and certain central services such as adoption and social work training. The Health Department would also have a central administrative division, and an environmental health division (later accommodated at Gravel Hill). School Health, including the Child Guidance Clinic services would continue to be administered 11 centrally and through the areas. Inevitably there was considerable discussion on the administrative services that could serve both departments, the final decision being to have a common finance division suitably conditioned to safeguard the independence of action of the chiefs of the two new departments. 12 SECTION A STATISTICS AND SOCIAL CONDITIONS Page General Conditions of the Borough 15 General Statistics 15 Vital Statistics 16 Live births 16 Still births 16 Infant Deaths under 1 year of age 16 Infant Mortality Rate 16 Neo-Natal Mortality 16 Maternal Mortality 16 Premature Births 16 Number of Births and Birth Rate comparison (London Borough of Bexley and England and Wales) 18 Number Mortality Rate comparison (London Borough of Bexley and England and Wales) 18 Tables of Causes of Infant Deaths under 1 year of age 1970 19 Tables of Causes of Death, in sex and age groups 21 13 GENERAL CONDITIONS OF THE BOROUGH One change in the physical features of the Borough was becoming noticeable in 1970 and that was the development of a skyline at Thamesmead which stood out in sharp contrast to the historic ruins of Lessness Abbey. There is a relatively small number of immigrants in the Borough, the Erith area being the most popular place of residence. The London Borough of Bexley is among those with the lowest population of immigrants, the most recent figure available being 6,330 (2.96% 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 1969 1970 Population (Registrar General's estimates) 215,610 215,140 Rateable Value £11,175,821 £11,383,931 Product of a penny rate £45,000 £46,127 Number of dwellings 72,255 74,669 Number of Council dwellings 11,442 12,004 15 VITAL STATISTICS (Comparison figures with SD.52—1969. These are amended figures) Bexley London Borough England 1969 1970 1970 Live Births 1802 (M) 1742 (M) 1674(F) 1655(F) TOTAL 3476 3397 741,995 Birth Rate per 1000 population 16.1 15.8 16.0 Illegitimate births 86 (M) 86 (M) 79(F) 77(F) TOTAL 165 163 61,879 Percentage of total live births 4.8 4.8 8.3 Stillbirths 21 (M) 15 (M) 16(F) 19(F) TOTAL 37 34 9,704 Total Live and Stillbirths 1823 (M) 1757 (M) 1690 (F) 1674(F) TOTAL 3513 3431 Stillbirth Rate per 1000 live and stillbirths 11.0 9.9 12.9 Note.' Stillbirth rates 1965—1968 were: 14.3 12.6 14.2 14.0 Infant Mortality Rate per 1000 live births 16.0 15.9 18.15 Legitimate 15.77 17 Illegitimate 30.0 18.4 26 Early Neonatal Mortality Rate (first 7 days) per 1000 live births 10.0 9.4 10.5 Note: Early neonatal rates 1965—1968 were: 8.7 3.7 11.2 8.6 Perinatal Mortality Rate 20.0 19.2 23.4 Note: Perinatal mortality rates 1965—1968 were: 22.9 18.8 25.2 23.0 Maternal Mortality Number of deaths – – 109 Maternal Mortality Rate per 1000 live and stillbirth – 0.29 0.15 16 17 VITAL STATISTICS 1970 BEXLEY LONDON BOROUGH Local Authority Area England & Wales (Total) Local Authority Area England & Wales Males Females Estimated mid-year home population. 215,140 48,987,700 Live births Total 1,742 1,655 3,397 784,482 Live birth rates, etc. Live births per 1,000 home population (crude rate) 15.8 16.0 Legitimate 1,656 1,578 3,234 719,738 Illegitimate 86 77 163 64,744 Area comparability factor 1.00 1.00 Local adjusted rate 15.8 16.0 Ratio of local adjusted rate to national rate .99 1.00 Illegitimate live births as percentage of all live births 5 8 Stillbirths Total 15 19 34 10,341 Stillbirth rate Stillbirths per 1,000 total live and still births 10 13 Legitimate 13 17 30 9,297 Illegitimate 2 2 4 1,044 Total live and still births Total 1,757 1,674 3,431 794,823 Legitimate 1,669 1,595 3,264 729,035 Illegitimate 88 79 167 65,788 Deaths of Infants under 1 year of age Total 33 21 54 14,269 Infant mortality rates Deaths under 1 year per 1,000 live births 16 18 Legitimate 31 20 51 12,592 Deaths of legitimate infants under 1 year per 1,000 legitimate live births 16 17 Illegitimate 2 1 3 1,677 Deaths of illegitimate infants under 1 year per 1,000 illegitimate live births 18 26 under 4 weeks of age Total 26 13 39 9,663 Neonatal mortality rate Deaths under 4 weeks per 1,000 live births 11 12 Legitimate 24 13 37 8,548 Illegitimate 2 — 2 1,115 under 1 week of age Total 18 13 31 8,328 Early neonatal mortality rate Deaths under 1 week per 1,000 total live births 9 11 Legitimate 17 13 30 7,343 Illegitimate 1 1 985 Perinatal mortality rate Stillbirths and deaths under 1 week combined per 1,000 total live and still births 19 23 Deaths - all ages 1,185 999 2,184 575,208 Deaths rates, etc. — all ages Deaths per 1,000 home population (crude rate] 10.2 11.7 Area comparability factor 1.12 1.00 Local adjusted rate 11.4 11.7 Ratio of local adjusted rate to national rate .98 1.00 BIRTHS (The Birth Rate is the number of live births per thousand population. The Stillbirth Rate is the number of stillbirths per thousand total births) Birth Rate Stillbirth Rate Bexley England & Wales Bexley England & Wales 1969 16.1 16.3 11.0 13.0 1970 15.8 16.0 10.0 13.0 BIRTHS The birth rate continued the decline apparent in the annual rates since 1965 in parallel with a similar decline in England & Wales. STILLBIRTHS The number of stillbirths per thousand total births has also declined in recent years in parallel with the national stillbirth rates, though at a lower level. INFANT DEATHS The number of infants dying under one year of age was the same as in 1969, but with fewer births the rate went up from 15.0 to 16.0 per thousand live births compared with 18.0 for England & Wales: Bexley England & Wales 1969 15.00 18.00 1970 16.00 18.00 Details of these infant deaths are shown in the following table: 18 INFANT MORTALITY 1970 Deaths from stated causes at various ages under 1 year of age Causes of death as certified DAYS MONTHS 0 1 2 3 4 5 6 7 14 21 28 2 3 4 5 6 7 8 9 10 11 12 Respiratory distress syndrome 3 1 1 1 Cardiac respiratory arrest 2 1 Abruptio placentae 1 Prematurity 5 1 3 1 Neonatal asphyxia 1 Haemorrhagic disease of newborn 1 Subdural haemorrhage 1 Congenital heart disease 1 1 1 1 Cardiac arrest— congenital heart defect 1 Chronic renal failure 1 Hypogycalmia 1 Pneumococcal meningitis 1 Abortion 2 Multiple congenital heart abnormalities 1 a.c. haemorrhagic pneumonia 1 a.c. epiglottitis 1 Bronchopneumonia 1 1 Septicaemia and interstial necrosis 1 Interstial pneumonia 1 Congenital nephrotic syndrome 1 Ruptured superior cerebral veins 1 a.c. tracheobronchitis 4 1 Interstial bronchopneumonia 1 Cardiac failure— congenital heart disease 1 14 4 7 3 1 1 — 3 2 2 — 6 — 1 1 — 2 — — 2 — — 19 INFANT MORTALITY 1970 (contd.) Causes of death as certified DAYS MONTHS 0 1 2 3 4 5 6 7 14 21 28 2 3 4 5 6 7 8 9 10 11 12 Intra ventricular cerebral haemorrhage 1 Asphyxia neonatorum 1 a.c. fulminating bronchitis 1 Hydrocephalus — spina bifida 1 Menings encephalitis— otitis media 1 2 — — — — — — — — — — 1 1 — — — -— -— 1 — — — 20 S.D.25 BEXLEY 1970 S.D.25 NUMBERS OF DEATHS BY CAUSE, IN SEX AND AGE GROUPS CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B5 Tuberculosis of Respiratory System M 2 — — — — — — — — 1 1 — F — — — — — — — — — — — — B6(1) Late effects of Respiratory T;B. M 1 — — — — — — — 1 — — — F — — — — — — — — — — — — B18 Other infective and parasitic diseases M 2 — — — — 1 — — — — 1 — F — — — — — — — — — — — — B19(1) Malignant Neoplasm, Buccal Cavity etc. M 4 — — — — — — — — 1 1 2 F 1 — — — — — — — — — — 1 B19(2) Malignant Neoplasm, Oesophagus M 9 — — — — — — — 2 2 2 3 F 3 — — — — — — — — — 1 2 B19(3) Malignant Neoplasm, Stomach M 31 — — — — — — 1 5 9 10 6 F 19 — — — — — — 2 — 3 5 9 B19(4) Malignant Neoplasm, Intestine M 23 — — — — — 2 2 — 4 7 8 F 30 — — — — — — — 3 5 9 13 B19(5) Malignant Neoplasm, Larynx M 3 — — — — — — — — 3 — — F — — — — — — — — — — — — B19(6) Malignant Neoplasm, Lung, Bronchus M 120 — — — — — 1 2 10 36 52 19 F 19 — — — — — — — 5 5 5 4 B19(7) Malignant Neoplasm, Breast M — — — — — — — — — — — — F 51 — — — — — 2 7 13 11 11 7 B19(8) Malignant Neoplasm, Uterus F 21 — — — — — — — 5 5 8 3 B19(9) Malignant Neoplasm, Prostate M 17 — — — — — — — — — 5 12 B19(10) Leukaemia M 10 — — — — — — 1 — 7 — 2 F 6 — — — — 2 — — 1 — 1 2 B19(11) Other Malignant Neoplasms M 63 — — 1 1 3 — 3 11 13 16 15 F 73 — — 1 — 1 1 2 5 18 19 26 B20 Benign and Unspecified Neoplasms M 1 — — — — — — — — 1 — — F 2 — — — — — — — — — — 2 B21 Diabetes Mellitus M 6 — — — — — — — 1 1 1 2 F 8 — — — — — — — — — 4 4 21 BEXLEY 1970 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B46(1) Other Endocrine etc. diseases M 2 — — — — — — — 1 — — 1 F 5 — — -— 1 — — — — 1 — 3 B23 Anaemias M 3 — — — 1 — — — — — 2 — F 3 — — — — — — — — — 1 2 B46(3) Mental Disorders M 2 — — — — — — — — — 1 1 F 2 — — — — — — — — — — 2 B24 Meningitis M 2 2 — — — — — — — — — — F 1 — — — — — — — — 1 — — B46(4) Multiple Sclerosis M 1 — — — — — — — 1 — — — F 3 — — — — -— -— 1 2 — — — B46(5) Other Diseases of Nervous System M 4 — — — — — — — — 2 2 — F 8 — — 1 1 — — 1 — 1 3 1 B26 Chronic Rheumatic Heart Disease M 12 — — — — — — — 2 1 7 2 F 24 — — — — — — 1 3 5 5 10 B27 Hypertensive Disease M 25 — — — — — — 1 1 3 13 7 F 15 — — — — — — 1 — 2 5 7 B28 Ischaemic Heart Disease M 353 — — — — — 3 4 42 103 109 92 F 227 — — — — — — — 3 26 51 147 B29 Other forms of Heart Disease M 26 — — — — — — 2 — 2 6 16 F 29 — — — — — — — — — 4 25 B30 Cerebrovascular Disease M 91 — — — — — 1 1 3 13 27 46 F 143 — — — 1 — 1 2 4 15 33 87 B46(6) Other Diseases of Circulatory System M 52 — — — — — — 1 2 10 18 21 F 53 — — — — — — 1 — 7 11 34 B31 Influenza M 9 — — — — — — 1 — 2 3 3 F 9 — — — — — — — — 2 5 2 B32 Pneumonia M 87 — 1 — 1 — 1 1 1 4 31 47 F 110 1 2 2 1 — — — 1 2 20 81 B33(1) Bronchitis and Emphysema M 96 — — — — — — 1 2 12 33 48 F 37 — — — — — — — 1 4 14 18 B46(7) Other Diseases of Respiratory System M 10 1 3 2 — — — — — — 2 2 F 15 — 3 — — — — — 2 1 5 4 B34 Peptic Ulcer M 17 — — — — — — — — 1 7 9 F 6 — — — — — — — 1 — 1 4 B36 Intestinal Obstruction and Hernia M 4 — — — — — — — — — — 4 F 6 — — — — — — — 2 1 3 — 22 BEXLEY 1970 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B37 Cirrhosis of Liver M 2 — — — — — — — — 2 — — F 1 — — — — — — — — — 1 — B46(8) Other Diseases of Digestive System M 8 1 — — — — — 1 1 2 2 1 F 13 — — — — 1 1 — — 3 4 4 B38 Nephritis and Nephrosis M 9 — 1 — — — 1 — — 3 2 2 F 3 — — — — — — — — — 2 1 B39 Hyperplasia of Prostate M 7 — — — — — — — — — 3 4 B46(9) Other Diseases, Genito-Urinary System M 9 — — — — — 2 — 1 1 2 3 F 9 — — — — — — — 1 2 2 4 B46(10) Diseases of Skin, Subcutaneous Tissue M — — — — — — — — — — — — F 1 — — — — — — — — 1 — — B46(11) Diseases of Musculo-Skeletal System M 3 — — — — — — — — — 1 2 F 2 — — — — — 1 — — — — 1 B42 Congenital Anomalies M 8 4 2 1 — — — — — 1 — — F 6 1 3 — — 1 — — — 1 — — B43 Birth Injury, Difficult Labour, etc. M 9 9 — — — — — — — — — — F 4 4 — — — — — — — — — — B44 Other causes of Perinatal Mortality M 8 8 — — — — — — — — — — F 7 7 — — — — — — — — — — B45 Symptoms and III Defined Conditions M 2 — — — — — — — — — — 2 F 2 — — — — — — — — — — 2 BE47 Motor Vehicle Accidents M 9 — — — 1 3 4 — — 1 — — F 5 — — — — — — 1 1 — — 3 BE48 All Other Accidents M 16 1 — — 1 1 3 5 2 1 — 2 F 12 — — — — — — 1 2 — 4 5 Be49 Suicide and Self-inflicted Injuries M 6 — — — — — 1 2 — 1 1 1 F 4 — — — — — — 1 1 2 — — BE50 All Other External Causes M 1 — — — — — — — — — 1 — F 1 — — — — — — 1 — — — — TOTAL ALL CAUSES M 1,185 26 7 4 6 8 19 29 89 243 369 385 F 999 13 8 4 4 5 7 21 56 124 237 520 23 S.D.25 BEXLEY 1969 S.D.25 NUMBERS OF DEATHS BY CAUSE, IN SEX AND AGE GROUPS CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B4 Enteritis and other Diarrhoeal Diseases M 1 — — — — — — — — — 1 — F 1 — — 1 — — — — — — — — B5 Tuberculosis of Respiratory System M — — — — — — — — — — — — F 1 — — — — — — — — — 1 — B6 Other Tuberculosis, incl. Late Effects M 3 — — — — — — — — — 2 1 F 1 — — — — — — — — — — 1 B11 Meningococcal Infection M — — — — — — — — — — — — F 1 — — — — 1 — — — — — — B18 Other Infective and Parasitic Diseases M 1 — — — — — — — — — 1 — F 2 — 1 — — — — — — — — 1 B19(1) Malignant Neoplasm, Buccal Cavity etc. M 5 — — — — — — — — 2 2 1 F 2 — — — — — — — 1 — — 1 B19(2) Malignant Neoplasm, Oesophagus M 7 — — — — — — 1 1 3 1 1 F 6 — — — — — — — 1 — 4 1 B19(3) Malignant Neoplasm, Stomach M 22 — — — — — — 1 1 6 7 7 F 17 — — — — — — — 2 2 5 8 B19(4) Malignant Neoplasm, Intestine M 27 — — — — — — — 4 7 7 9 F 30 — — — — — — — 1 4 12 13 B19(6) Malignant Neoplasm, Lung, Bronchus M 118 — — — — — — 2 14 26 52 24 F 22 — — — — — — — 2 10 5 5 B19(7) Malignant Neoplasm, Breast M — — — — — — — — — — — — F 53 — — — — — — 3 6 20 19 5 B19(8) Malignant Neoplasm, Uterus F 13 — — — — — — — 1 3 4 5 B19(9) Malignant Neoplasm, Prostate M 17 — — — — — — — — — 5 12 B19( 10) Leukaemia M 7 — — 1 — — — 1 — 3 1 1 F 11 — — 2 — — 1 1 1 2 1 3 B19( 11) Other Malignant Neoplasms M 71 — — — 1 1 — 5 10 17 24 13 F 70 — — 1 — 2 1 2 6 15 23 20 B20 Benign and Unspecified Neoplasms M 1 — — — — — — — — — 1 — F 7 — — — — — — 1 — 3 — 3 B21 Diabetes Mellitus M 10 — — — — — — 1 — 2 4 3 F 7 — — — — — — — — — 2 5 B46(1) Other Endocrine etc. Diseases M — — — — — — — — — — — — F 4 — — — — — — — — 1 1 2 B23 Anaemias M — — — — — — — — — — — — F 2 — — — — — — — — — — 2 24 BEXLEY 1969 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B46(2) Other Diseases of Blood, etc. M — — — — — — — — — — — — F 1 — — — — — — — 1 — — — B46(3) Mental Disorders M 4 — — — — 1 — — — 1 — 2 F 4 — — — — — — — — 1 1 2 B24 Meningitis M 3 1 — 1 — — — — 1 — — — F — — — — — — — — — — — — B46(4) Other Diseases of Nervous System, etc. M 14 — — — — — — — 1 5 4 4 F 5 — — — — 1 — — — 1 2 1 B26 Chronic Rheumatic Heart Disease M 11 — — — — — — — 1 5 4 1 F 25 — — — — — — 1 5 6 5 8 B27 Hypertensive Disease M 18 — — — — — — — — 4 8 6 F 24 — — — — — — — — — 6 18 B28 Ischaemic Heart Disease M 360 — — — — — 1 7 38 80 116 118 F 253 — — — — — 1 — 5 22 71 154 B29 Other Forms of Heart Disease M 43 — — — — — — 1 1 8 12 21 F 65 — — — — — — — 1 4 16 44 B30 Cerebrovascular Disease M 114 — — — 1 — — 4 5 18 25 61 F 155 — — — — — 1 — 4 14 25 111 B46(5) Other Diseases of Circulatory System M 46 — — — — — — — 3 12 8 23 F 52 — — — — — — — 3 3 10 36 B31 Influenza M 8 — — — — — — — 1 2 3 2 F 4 — — — — — — — 2 — 1 1 B32 Pneumonia M 75 2 2 — 1 — — 1 1 6 18 44 F 103 — 1 1 — 1 — 1 — 7 19 73 B33(1) Bronchitis and Emphysema M 106 — — — — — — — 7 17 48 34 F 34 — — — — — — — — 5 11 18 B33(2) Asthma M 6 — — — 1 1 — 1 1 2 — — F 3 — — — — — — — — 1 1 1 B46(6) Other Diseases of Respiratory System M 14 1 4 2 — — — — 1 2 1 3 F 13 — 3 — — — — — 1 2 1 6 25 BEXLEY 1969 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B34 Peptic Ulcer M 7 — — — — — — — — 2 4 1 F 10 — — — — — — — 1 — 3 6 B35 Appendicitis M 1 — — 1 — — — — — — — — F — — — — — — — — — — — — B36 Intestinal Obstruction and Hernia M 3 — — — — — — — — — 1 2 F 7 — — — — — — — — 1 3 3 C37 Cirrhosis of Liver M — — — — — — — — — — — — F 4 — — — — — — — 1 3 — — B46(7) Other Diseases of Digestive System M 8 — — — — — 1 — — 4 2 1 F 13 — — — — — — 1 — 1 7 4 B38 Nephritis and Nephrosis M 10 — — — — — — — — 3 3 4 F 2 — — — — — — — — 2 — — B39 Hyperplasia of Prostate M 5 — — — — — — — — — 1 4 B46(8) Other Diseases, Genito-Urinary System M 7 — — — — — — — — 1 2 4 F 15 — 2 1 — — — — 2 2 1 7 B46(9) Diseases of Skin, Subcutaneous Tissue M 1 — — — — — — — — — — 1 F 1 — — — — — — — — — 1 — B46(10) Diseases of Musculo-Skeletal System M 1 — — — — — — — — — 1 — F 9 — — — — — — — 1 4 1 3 B42 Congenital Anomalies M 5 4 — — 1 — — — — — — — F 9 5 1 — 1 — — — — 1 1 — B43 Birth Injury, Difficult Labour, etc. M 12 12 — — — — — — — — — — F 4 4 — — — — — — — — — — B44 Other Causes of Perinatal Mortality M 7 7 — — — — — — — — — — F 3 3 — — — — — — — — — — B45 Symptoms and III Defined Conditions M 3 — — — — — — — 1 — — 2 F — — — — — — — — — — — — BE47 Motor Vehicle Accidents M 16 — — — — 4 4 — 3 1 1 3 F 6 — — — 2 1 — — — 1 2 — BE48 All Other Accidents M 8 — — — — 3 1 2 1 — — 1 F 8 — — — — 1 — — 1 — 1 5 BE49 Suicide and Self-inflicted Injuries M 7 — — — — 1 — 1 — 3 2 — F 4 — — — — — — — 2 — 1 1 BE50 All Other External Causes M — — — — — — — — — — — — F 3 — 1 — — — — — — 1 1 — TOTAL ALL CAUSES M 1,213 27 6 5 5 11 7 28 96 242 372 414 F 1,089 12 9 6 3 7 4 10 51 142 268 577 26 S.D.25 BEXLEY 1968 S.D.25 NUMBERS OF DEATHS BY CAUSE, IN SEX AND AGE GROUPS CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B4 Enteritis and Other Diarrhoeal Diseases M 1 — 1 — — — — — — — — — F 1 — — — — — — — — — — 1 B5 Tuberculosis of Respiratory System M 2 — — — — — — 1 — 1 — — F — — — — — — — — — — — — B18 Other Infective and Parasitic Diseases M 4 — — — 1 1 — — — 2 — — F 2 — — — — — — — — — — 2 B19(1) Malignant Neoplasm — Stomach M 22 — — — — — — — 1 5 5 11 F 11 — — — — — — — 1 1 5 4 B19(2) Malignant Neoplasm — Lung, Bronchus M 108 — — — — — — 1 10 33 44 20 F 30 — — — — — 1 1 4 9 11 4 B19(3) Malignant Neoplasm — Breast M — — — — — — — — — — — — F 40 — — — — — — 4 9 9 12 6 B19(4) Malignant Neoplasm — Uterus F 15 — — 1 — — — -— 2 6 5 1 B19(5) Leukaemia M 11 — — 1 — 2 1 — 1 2 2 2 F 6 — — — 1 — — — — 1 2 2 B19(6) Other Malignant Neoplasms, etc. M 126 — — — 2 — 2 2 16 30 37 37 F 110 — — — 1 — 3 2 9 28 30 37 B20 Benign and Unspecified Neoplasms M 4 — — — — — — — 2 1 — 1 F 6 — — — — — — — 2 2 — 2 B21 Diabetes Mellitus M 4 — — — — — — 1 — — 2 1 F 9 — — — — — — — — 1 4 4 B46(1) Other Endocrine etc. Diseases M — — — — — — — — — — — — F 3 — — — — — — — 1 — — 2 B23 Anaemias M 1 — — — — — — — — — — 1 F 1 — — — — — — — — — — 1 B46(3) Mental Disorders M 1 — — — — — — — — — — 1 F 2 — — — — 1 1 — — — — — B46(4) Other Diseases of Nervous System, etc. M 7 — — — — — — 1 2 1 — 3 F 14 — 1 — — — 2 — 1 2 3 5 B26 Chronic Rheumatic Heart Disease M 6 — — — — — — 1 — 1 1 3 F 17 — — — — — — 1 2 5 7 2 B27 Hypertensive Disease M 26 — — — — — — — 1 7 9 9 F 30 — — — — — — — — 3 10 17 B28 Ischaemic Heart Disease M 365 — — — — — — 11 37 91 119 107 F 220 — — — — — — 1 1 16 63 139 B29 Other Forms of Heart Disease M 55 — — — — — — — 3 9 14 29 F 52 — — — — — — — 3 2 12 35 27 BEXLEY 1968 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B30 Cerebrovascular Disease M 106 — — — — — — 2 4 19 31 50 F 160 — — — — 1 2 4 3 18 27 105 B46(5) Other Diseases of Circulatory System M 54 — — — — — — — 2 8 16 28 F 60 — — — — — — — 3 4 7 46 B31 Influenza M 5 — — — — — — — — — 2 3 F 18 — — — — — 1 — — 3 5 9 B32 Pneumonia M 78 — — — — — — — 5 6 20 47 F 95 — 4 1 — — — — 1 3 13 73 B33(1) Bronchitis and Emphysema M 103 — — — — — — 1 5 23 32 20 F 31 — — — — — — — — 4 7 20 B33(2) Asthma M 6 — — — 1 — — 1 — — 4 — F 3 — — — — — 1 — — 2 — — B46(6) Other Diseases of Respiratory System M 15 — 3 — — — — — 2 — 4 6 F 8 — 1 — — — — — — — 2 5 B34 Peptic Ulcer M 9 — — — — — — — 2 1 3 3 F 6 — — — — — — — — — — 6 B35 Appendicitis M 1 — — — — — — — — — — 1 F 1 — — — 1 — — — — — — — B36 Intestinal Obstruction and Hernia M 7 — — — 1 1 — — — 1 1 3 F 4 — — — — — — — — — 1 3 B37 Cirrhosis of Liver M 2 — — — — — — — 1 — — 1 F — — — — — — — — — — — — B46(7) Other Diseases of Digestive System M 13 — — — — — 1 1 1 1 7 2 8 — — — — — — — — — 2 6 B38 Nephritis and Nephrosis M 9 — — — — — — — 1 2 5 1 F 6 — — — — 1 — — — — 3 2 B39 Hyperplasia of Prostate M 4 — — — — — — — — — — 4 B46(8) Other Diseases, Genito-Urinary System M 7 — — — — — — — — 1 2 4 F 16 — — — — 1 — — 1 3 2 9 B41 Other Complications of Pregnancy, etc. F 3 — — — — 1 1 1 — — — — B46(9) Diseases of Skin, Subcutaneous Tissue M 1 — — — — — — — — — — 1 F — — — — — — — — — — — — B46(10) Diseases of Musculo-Skeletal System M 5 — — — — — — — — — 2 3 F 7 — — — — — 1 — — 1 2 3 B42 Congenital Anomalies M 12 4 5 — 1 1 — — — — — 1 F 9 6 2 — — — — — 1 — — — 28 BEXLEY 1968 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over B43 Birth Injury, Difficult Labour, etc. M 11 11 — — — — — — — — — — F 5 5 — — — — — — — — — — B44 Other Causes of Perinatal Mortality M 6 6 — — — — — — — — — — F 3 3 — — — — — — — — — — B45 Symptoms and Ill-Defined Conditions M 1 — — — — — — — — — — 1 F 6 — — — — — — — — — — 6 BE47 Motor Vehicle Accidents M 12 — — 1 2 5 — — 1 — 3 — F 4 — — — 1 — — — 1 — 1 1 BE48 All Other Accidents M 8 — — — 1 2 2 — 1 2 — — F 5 — — 1 1 — — — 1 — — 2 BE49 Suicide and Self-inflicted Injuries M 6 — — — — — — 3 — 2 1 — F 9 — — — — — — 2 — 3 2 2 BE50 All Other External Causes M 1 — — — — 1 — — — — — — F 1 — — 1 — — — — — — — — TOTAL ALL CAUSES M 1,225 21 9 2 9 13 6 26 98 249 366 426 F 1,037 14 8 4 5 5 13 16 46 126 238 562 29 S.D.25 BEXLEY 1967 S.D.25 NUMBERS OF DEATHS BY CAUSE, IN SEX AND AGE GROUPS CAUSE OF DEATH Sex All ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over Tuberculosis, Respiratory M 7 — — — — — — 1 — 1 3 2 F 4 — — — — — — — 1 — 1 2 Tubercusolos, Other M 1 — — — — — — — — — 1 — F — — — — — — — — — — — — Syphilitic Disease M 3 — — — — — — — — — 2 1 F — — — — — — — — — — — — Other Infective and Parasitic Diseases M 2 — — — — — — — — — 1 1 F — — — — — — — — — — — — Malignant Neoplasm, Stomach M 28 — — — — — — — 1 8 10 9 F 19 — — — — — — 1 2 4 7 5 Malignant Neoplasm, Lung, Bronchus M 104 — — — — — — — 6 42 41 15 F 23 — — — — — — 1 3 4 12 3 Malignant Neoplasm, Breast M — — — — — — — — — — — — F 46 — — — — — 1 8 4 14 10 9 Malignant Neoplasm, Uterus F 8 — — — — — — — 1 6 — 1 Other Malignant and Lymphatic Neoplasms M 111 — — — — 1 1 3 11 29 30 36 F 97 — — — — 1 — 4 13 26 27 26 Leukaemia, Aleukaemia M 10 — 1 — 1 — 2 — 1 3 2 — F 6 — — — — — — 2 — — 2 2 Diabetes M — — — — — — — — — — — — F 7 — — — 1 — — — — 1 3 2 Vascular Lesions of Nervous System M 103 — — — — — — 2 5 17 31 43 F 161 — — — — — 1 1 4 17 31 107 Coronory Disease, Angina M 304 — — — — — — 8 30 79 94 93 F 184 — — — — — — 1 3 18 50 112 Hypertension with Heart Disease M 19 — — — — — — 1 — 1 11 6 F 26 — — — — — — — — 3 5 18 Other Heart Disease M 65 — — — — — — 3 — 9 17 36 F 96 — — — — — 1 1 3 9 17 65 Other Circulatory Disease M 48 — — — — 1 — — 1 9 16 21 F 48 — — — — — — 3 — 2 11 32 Influenza M — — — — — — — — — — — — F 2 — — — — — — — — — — 2 Pneumonia M 73 — 2 — — — — 1 2 8 20 40 F 74 — 2 2 — — — — — 3 10 57 Bronchitis M 73 — 2 1 1 — — — 3 17 22 27 F 27 — 2 — — — — — 1 2 3 19 30 BEXLEY 1967 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over Other Diseases of Respiratory System M 7 — — — — — 1 — — — 2 4 F 5 — 1 — — — — — — 1 1 2 Ulcer of Stomach and Duodenum M 7 — — — — — — — — 1 2 4 F 4 — — — — — — — 2 — 1 1 Gastritis, Enteritis and Diarrhoea M 5 — 1 — — — — — — 1 1 2 F 4 — 1 1 — — — — — 2 — -— Nephritis and Nephrosis M 5 — — — — — — — 1 — 1 3 F 4 — — — — — — — 1 1 1 1 Hyperplasia of Prostate M 9 — — — — — — — — 2 2 5 Pregnancy, Childbirth, Abortion F 2 — — — — 1 1 — — — — — Congenital Malformations M 10 8 1 — — — 1 — — — — — F 10 5 — 4 — — — — 1 — — — Other Defined and Ill-Defined Diseases M 70 22 — 1 2 — — 4 6 6 15 14 F 70 10 — 2 1 1 2 2 5 8 13 26 Motor Vehicles Accidents M 29 — — — 2 9 5 4 2 2 2 3 F 9 — — — — 1 — — — 2 2 4 All Other Accidents M 15 — — 2 — 3 2 1 3 2 — 2 F 5 — — — — — 1 — — — 2 2 Suicide M 7 — — — — — — 1 2 2 2 — F 4 — — — — — — — 1 2 1 — TOTAL ALL CAUSES M 1,115 30 7 4 6 14 12 29 74 239 3?8 372 F 945 15 6 9 2 4 1 24 45 125 210 498 31 S.D.25 BEXLEY 1966 S.D.25 NUMBERS OF DEATHS BY CAUSE, IN SEX AND AGE GROUPS CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over Tuberculosis, Respiratory M 1 — — — — — — — — — 1 — F 1 — — — — — — — — — — 1 Tuberculosis, Other M 2 — — — — — — — 2 — — — F — — — — — — — — — — — — Syphilitic Disease M 2 — — — — — — — — — 2 — F 1 — — — — — — — — 1 — — Other Infective and Parasitic Diseases M 2 — — — 1 — — 1 — — — — F 2 — — — — — — — — — 1 1 Malignant Neoplasm, Stomach M 31 — — — — — — — 5 10 7 9 F 18 — — — — — — 1 1 2 10 4 Malignant Neoplasm, Lung, Bronchus M 105 — — — — — — — 10 49 36 10 F 27 — — — — — 1 — 6 7 9 4 Malignant Neoplasm, Breast M — — — — — — — — — — — — F 39 — — — — — — 2 10 6 12 9 Malignant Neoplasm, Uterus F 13 — — — — — — 1 1 3 5 3 Other Malignant and Lymphatic Neoplasms M 110 — — 2 — 1 1 6 8 31 39 22 F 120 — — 2 — — — 7 11 28 30 42 Leukaemia, Aleukaemia M 10 — — — — — 1 2 2 — 2 3 F 7 — — 1 — — — 1 — 2 1 2 Diabetes M 2 — — — — — — — — 1 — 1 F 9 — — — — — — — — 1 4 4 Vascular Lesions of Nervous System M 94 — — — — 1 — — 4 11 33 45 F 132 — — — — — — 1 4 9 28 90 Coronory Disease, Angina M 291 — — — — — — 11 39 84 78 79 F 153 — — — — — — — 2 16 41 94 Hypertension with Heart Disease M 15 — — — — — — — 1 1 5 8 F 14 — — — — — — — 1 — 1 12 Other Heart Disease M 74 — — — — — 1 — 2 5 25 41 F 100 — — — — — 1 2 3 10 18 66 Other Circulatory Disease M 47 1 — 1 — — — 1 4 9 17 14 F 44 — — — — — 1 1 2 1 13 26 Influenza M 5 — — — — — — — — 1 1 3 F 6 — — — — — — — 1 — 1 4 Pneumonia M 78 — 2 1 — — — — — 7 22 46 F 86 1 1 — 1 — — — — 4 12 67 32 BEXLEY 1966 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over Bronchitis M 77 — 1 2 — — — — 3 18 23 30 F 27 — 2 — — — — — 1 4 2 18 Other Diseases of Respiratory System M 20 — 1 — — — — — 2 6 4 6 F 4 — — — — — — — — — — 4 Ulcer of Stomach and Duodenum M 16 — — — — — — — 3 1 8 4 F 7 — — — — — — — — — 4 3 Gastritis, Enteritis and Diarrhoea M 5 — — — — — — — 1 3 1 — F 6 — — — — — — — — — 2 4 Nephritis and Nephrosis M 7 — 2 — — — — — 1 2 2 — F 5 — — — — — — — 1 1 2 1 Hyperplasia of Prostate M 6 — — — — — — — — — 1 5 Congenital Malformations M 12 4 5 — — — — — — 2 1 — F 8 2 1 1 1 — 1 — 1 — — 1 Other Defined and Ill-Defined Diseases M 39 5 — 1 1 2 — 1 6 4 6 13 F 93 17 1 1 — 1 2 2 6 16 16 31 Motor Vehicle Accidents M 17 — — — 2 5 3 2 1 2 1 1 F 5 — — 1 — — 1 1 1 — — 1 All other Accidents M 16 — — — 1 2 3 4 — 3 2 1 F 6 — — — — — — — 1 2 2 1 Suicide M 8 — — — — 1 1 2 2 2 — — F 15 — — — — — 3 — 6 5 1 — Homicide and Operations of War M — — — — — — — — — — — — F 1 — — — — — — 1 — — — — TOTAL ALL CAUSES M 1,092 11 11 7 5 12 10 30 96 252 317 341 F 949 20 5 6 2 1 10 20 59 118 215 493 33 S.D.25 BEXLEY 1965 S.D.25 NUMBERS OF DEATHS BY CAUSE, IN SEX AND AGE GROUPS CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over Tuberculosis, Respiratory M 4 — — — — — — — 1 3 — — F 2 — — — — — — — — — — 2 Syphilitic Disease M 5 — — — — — — — — — 2 3 F 3 — — — — — — — — 1 — 2 Other Infective and Parasitic Diseases M 1 — — — — 1 — — — — — — F — — — — — — — — — — — — Malignant, Neoplasm, Stomach M 15 — — — — — — — 2 3 7 3 F 22 — — — — — — — 1 7 4 10 Malignant Neoplasm, Lung, Bronchus M 90 — — — — — — 2 5 36 29 18 F 25 — — — — — — 1 4 9 10 1 Malignant Neoplasm, Breast M — — — — — — — — — — — — F 41 — — — — — — 3 7 16 10 5 Malignant Neoplasm, Uterus F 21 — — — — — — — 3 3 4 11 Other Malignant and Lymphatic Neoplasms M 100 — — 1 2 2 2 3 11 29 28 22 F 104 — — — — — 2 4 11 29 26 32 Leukaemia, Aleukaemia M 8 — — — — — — — 1 4 2 1 F 6 — — — 1 1 — — — 1 2 1 Diabetes M 7 — — — — 1 — — 1 1 4 — F 8 — 1 — — — — — 1 — 1 5 Vascular Lesions of Nervous System M 99 — — — — — — 2 11 13 27 46 F 182 — — — — — — 1 8 13 46 114 Coronory Disease, Angina M 286 — — — — — 1 7 30 77 90 81 F 177 — — — — — — — 2 26 65 93 Hypertension with Heart Disease M 10 — — — — — — — — 5 2 3 F 24 — — — — — — — 1 3 8 12 Other Heart Disease M 77 1 — — — — — 6 2 9 18 41 F 78 — — — — — — — 5 5 13 55 Other Circulatory Disease M 35 — — — — — — — 3 8 8 16 F 46 — — — — — — 2 2 3 7 32 Influenza M — — — — — — — — — — — — F 2 — — — — — — — — 1 — 1 Pneumonia M 82 — 2 2 — — 1 — 2 7 15 53 F 72 — 1 2 — — — — — 6 10 53 Bronchitis M 89 — 4 1 — — — — 3 21 34 26 F 25 — — 1 — — — — 3 1 6 14 34 BEXLEY 1965 (continued) CAUSE OF DEATH Sex All Ages Under 4 weeks 4 weeks and under 1 year Age in years 1-4 5-14 15-24 25-34 35-44 45-54 55-64 65-74 75 and over Other Diseases of Respiratory System M 9 — — — — — — — 1 1 4 3 F 1 — — — — — — — — — 3 4 Ulcer of Stomach and Duodenum M 10 — — — — — — — 1 2 1 6 F 8 — — — — — — — 1 1 3 3 Gastritis, Enteritis and Diarrhoea M 2 — — — — — — — 1 1 — — F 9 — — — — — — — — — 1 8 Nephritis and Nephrosis M 7 — — — — 1 — 1 — 3 2 — F 9 — — — — — — — 1 1 2 5 Hyperplasia of Prostate M 10 — — — — — — — — — 2 8 Congenital Malformations M 16 4 3 3 — 1 — 1 2 1 1 — F 12 5 4 — 3 — — — — — — — Other Defined and Ill-Defined Diseases M 67 14 — 3 3 3 2 5 5 8 14 10 F 86 15 1 — 2 3 1 3 4 8 13 36 Motor Vehicle Accidents M 21 — — — 3 6 2 1 2 1 4 2 F 5 — — — 1 — — — — 4 — — All Other Accidents M 10 — — — — 1 1 1 1 3 1 2 F 14 — 1 — — — — — — — 3 10 Suicide M 8 — — — — — — — 2 4 2 — F 10 — — — — — — 3 2 3 2 — Homicide and Operations of War M — — — — — — — — — — — — F 1 — — — — — — — — 1 — — TOTAL ALL CAUSES M 1,068 19 9 10 8 16 9 29 87 240 297 344 F 999 20 8 3 7 4 3 17 56 142 230 509 35 SECTION B HEALTH SERVICES IN THE AREA Page Hospital and Specialist Services 39 Co-ordination and Co-operation with Hospitals and Family Doctors 39 Nursing Homes 42 Local Authority Services 43 Clinic and Welfare Centres 43 Child Health Clinics 45 Distribution of Welfare Foods 46 Day Nurseries, Child Minders and Play Groups 46 Nursery Nursing Courses 48 Low Birth Weight Babies 49 Illegitimate Births 51 At Risk Register 51 Congenital Malformations at Birth 52 Battered Babies 53 Assessment Groups for Handicapped Children 55 Health Visiting 57 Deafness in Early Childhood 59 General Midwifery Provision 60 Midwifery Training 61 Home Nursing 61 Nursing Aids 62 Home Help Service 62 Recuperative Care 63 Mental Health Service 63 Re-Instate Ltd . 64 Mentally Handicapped Persons 64 Junior Training Centres 66 Hostel for Mentally Sub-Normal Children 67 Social and Recreation Club for Mentally Sub-Normal Adults 76 In-service training for Training Centre Staff 76 37 HEALTH SERVICES IN THE AREA (contd.) Page Family Planning 77 Chiropody 77 Health Education 78 Renal Dialysis 79 Health Centres 82 Cancer 85 Deaths from Neoplasm 87 Housing 87 Meals Service for the Elderly 88 Appendix — Report of Working Party 91 Mortuary 97 Medical Examinations 97 38 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 21 beds for maternity cases Queen Mary's Hospital, Sidcup A general hospital with 365 beds mainly for acute cases. The maternity block with 56 beds and 8 cots for special care cases has greatly improved facilities in the area. Most of the residents in the Borough would attend the following Hospitals: — Bexley Hospital, Dartford Heath, Bexley Brook General Hospital, Shooters Hill Road, S.E.18. Darenth Park Hospital, Dartford, Kent. Joyce Green Hospital, Dartford, Kent. Memorial Hospital, Shooters Hill, S.E.18. Oakwood Hospital, Maidstone, Kent. St. Nicholas Hospital, Tewson Road, Plumstead, S.E.18. West Hill Hospital, West Hill, Dartford. CO-ORDINATION AND CO-OPERATION WITH HOSPITALS AND FAMILY DOCTORS The second Green Paper was published in February and in its foreword the Secretary of State for Social Services indicated several Governmental decisions, one of which pointed clearly to an integration of the personal health services. In the previous Annual Report for Bexley reference was made to the full co-operation which had been maintained in the Borough between the Health & Welfare Department and the various hospitals and local medical practitioners. Professional, traditional or statutory links existed and in recent years others were fostered. Subject to Council approval, the Medical Officer of Health was able to make any of the services of the Department available to the other branches of the National Health Service, or to seek the co-operation of these other branches in the 39 furtherance of a Council service or scheme. In general the services of the Department most sought after by hospitals and medical practitioners were those concerned with nursing (including health visiting), domestic help, the provision of nursing aids or recuperative care, housing on medical grounds, aids for the handicapped, mental and social welfare and residential care. In its turn the Department made most use of hospital services for the young and the old. One of the earliest forms of co-operation was the arrangement permitting the better use of two scarce commodities, geriatric hospital beds and places in homes for old people. By exchanging suitable cases the two establishments functioned more efficiently even if the total number of beds remained the same. The Department also employed general medical practitioners on a sessional basis for various purposes. It was comparatively easy to co-operate with the other health services in the interests of the patient or the potential patient, one example being the direct contacts by medical officers and the Director of the Child Guidance Clinic with the hospitals and general practitioners in dealing with clinical problems. The developmental assessment of children and the mental health aspects of paediatrics involved the Principal Medical Officer in continuous liaison with two local hospitals and it is of interest that this liaison also contributed to the part she played in dealing with the vexed subject of battered babies (see elsewhere under Child Health). Health visitors with special experience attended the hospital chest disease clinics to ensure proper after-care of patients. Plans were being made early in 1970 to extend this type of co-operation to other specialities. Exchange visits for district nurses with Queen Mary's hospital nursing staff were arranged which meant that each district nurse would spend a week becoming reacquainted with hospital nursing practice and the hospital nursing staff would spend a week seeing district nursing at first hand. Mental welfare officers had their statutory duties connected with general medical practitioners and hospitals. Secondment of a speech therapist to a hospital clinic assisted the hospital in a shortage of their own speech therapists and it helped the Department in dealing with certain adult cases requiring this type of treatment. Administrative staff of the Department and the appropriate hospital staff together contributed to the smooth running of schemes like those of cervical cytology for women and the early detection of congenital abnormalities amongst the newborn. Co-operation with the Erith College of Technology on the training of medical secretaries and receptionists was extended in the early part of 1970 by providing the College with a miniature course for these students lasting one week. The Acting Medical Officer of Health and Principal Officers from the Department gave talks throughout this week and arrangements were made for the students to see some interesting aspects of the work of the Health & Welfare Department. The 40 Superintendent Health Visitor gave talks at Queen Mary's Hospital School of Nursing to the student nurses, who in turn spent a day with a health visitor as part of their training. On some matters more formal arrangements prevailed. The Deputy Medical Officer of Health was a member of the Kent Local Medical Committee and Reinstate Ltd. The Medical Officer of Health and later the Acting Medical Officer of Health were members of the Thamesmead Joint Health Services Advisory Committee and the Committee on Applied Epidemiology of the Public Health Laboratory Service. Later in 1970, in accordance with the policy of the South East Metropolitan Regional Hospital Board, the Acting Medical Officer of Health was amongst those who received invitations to serve as Honorary Consultants on the Control of Infection Committees for local hospitals, thus recognising the co-operation already apparent in this field. Since 1965 the Deputy Medical Officer of Health and the Supervisor of Midwives have served on three maternity liaison committees themselves representative of the three main branches of the National Health Service. Through this liaison, three schemes, similar in nature but with interesting variations, for the early discharge of women from hospitals after their confinements were put into operation, thus to some extent anticipating the Peel Report (1970). Against this background of co-operation, and prompted also by definite requests for nursing attachments from three medical practices, the Acting Medical Officer of Health proposed, and the Council accepted, two schemes designed to promote a measure of integration of the nursing services likely to be in line with subsequent legislation. These two schemes were: — 1. Nursing Attachments to General Practice (see Appendix A) 2. Midwifery Training (see Appendix B) A further attempt was made to introduce physiotherapy as a community service because in the first place there were domiciliary cases who could benefit from it, and secondly the Department had the physiotherapists. Unfortunately it was not possible to obtain a dispensation from the Department of Health and Social Security for this purpose because nationally the resources of such staff were too scanty to permit their employment outside the hospital services. The administrator's insight into the merits of liaison, co-operation and eventually integration must be compatible with the basic freedoms of good medical practice. Community medicine should serve the health interests of the community as distinct from medical practice, which is essentially for the individual. This is no new recommendation, rather it is a repetition of what has always been a tenet of the Health Department at Bexley, but it must go further and become better defined. It is to be hoped that out of the transpositional changes made by the Social Services Act and the Green Paper there will emerge a useful new pattern. It is inherent in both of these documents that the patient or the client should be spared a duplicati'on of either services or personnel. 41 NURSING HOMES The number of nursing homes registered with the Council at the end of the year was 4, and they provided 67 places for chronic sick and aged persons. One unregistered home with 6 beds was under observation pending registration but before this stage was reached it closed down following the death of the applicant. The homes are under the supervision of the Principal Medical Officer and Senior Nursing Staff. Visits of inspection were carried out to ensure that the homes were adequately staffed and that their management and provision for patients were adequate. Special attention was paid to heating during the colder weather. Several homes reported great difficulties in obtaining trained staff. In November The Dudley Nursing Home of 21 beds closed as it was being sold for redevelopment. The Elmhurst Nursing Home, 14 beds 11 Victoria Road, Sidcup The Winston Nursing Home, 22 beds 31 Crook Log, Bexleyheath Hatherley Nursing Home, 13 beds 12 Hatherley Road, Sidcup The Eaves Nursing Home, 18 beds 68 Picardy Road, Belvedere 42 LOCAL AUTHORITY SERVICES CHILD HEALTH CLINICS At the end of the year the following sessions were being held 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 (Dental by appointment) Mons: 2—4 p.m. Tues: 9.30—11.30 a.m. Weds: 2—4 p.m. Fridays: 2—4 p.m. Fridays: 10—12 noon (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. (by appointment) Station Approach Tues: 2—4 p.m. Weds: 10—12 noon Thurs: 2—4 p.m. – Fri: 10—12 noon (by appointment) (Orthopaedic 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, Station Road Mons: 2—4 p.m. Weds: 2—4 p.m. — – 43 Clinics Child Welfare Ante-Natal Relaxation 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 Toddlers — Fridays: 2—4 p.m. (by appointment) – Weds: 10—11.30 a.m. 69, Sidcup Hill Tues: 10—12 noon Thurs: 1.30—3.30 p.m. (1st in month) Thurs: 9.30-12.30 (by appointment) (Dental and Speech Therapy by appointment) Erith: Hainau It, Lesney Park Road Tues: 10—12 noon Thurs: 2—4 p.m. — Tues: 2—4 p.m. (by appointment) (Dental and Ophthalmic by appointment) Belvedere: Congregational Hall, Picardy Road Tues: 2—4 p.m. Thurs: 2—4 p.m. — — St. Augustine's School, Abbey 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—4 p.m. Weds: 2—3 p.m. Weds: 10—12 noon (by appointment) Crayford: Town Hall Weds: 2—4 p.m. Fri: 9.30- 11.30 a.m. - Thurs: 1.30—3.30 p.m. (by appointment) (Ophthalmic and Orthopaedic by pppointment) 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, Bridge Road Fridays: 10—12 noon 2—4 p.m. – – Barnehurst: Methodist Hall, Risedale Road Thurs: 2—4 p.m. 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. – – Cytology appointments arranged through Health Department. School Clinic appointments arranged through Health Department. Child Guidance Clinic: 18, Crook Log, Bexleyheath — open all week. 44 CHILD HEALTH CLINICS The total number of sessions held during the year was 2,016 and 12,272 children made 69,496 attendances. The details are as follows (a) Born in 1970 2,954 (b) Born in 1969 3,088 (c) Born in 1965-68 6,230 Total 12,272 Total for 1969 13,842 CHILD WELFARE SESSIONS: 1969 1970 Held by Assistant Medical Officers 1,056 813 Held by Sessional Doctors 833 1,085 Held by Health Visitors 129 118 Total number of children under 5 attending 13,842 12,272 No. of Doctor Consultations 24,090 25,996 Total number of attendances 72,617 69,496 Owing to the shortage of available full time medical officers, the number of sessions by general practitioners has increased. I am grateful to these general practitioners who have assisted me in continuing a service which might have otherwise had to be curtailed. The number of premises in use at the end of the year for these services is shown as follows: Health Centres 1 Maternity and Child Health Centres:— (a) Purpose built 6 (b) Adapted 7 (c) Other buildings (sessional) 6 Total 20 The number of pre-school children referred to the special clinics was: — 1969 1970 Audiology 58 89 Child Guidance 19 30 Dental 421 324 Ophthalmic 24 59 Physiotherapy 15 7 Speech Therapy 52 60 45 DISTRIBUTION OF WELFARE FOODS During the year the following foods or dietary supplements were distributed from welfare food centres or clinics. (1969 figures are given for comparison). 1969 1970 National Dried Milk (Packets) 3,687 2,256 National Orange Juice (Bottles) 78,600 82,488 National Cod Liver Oil (Bottles) 2,320 2,089 A. & D. Tablets (Packets) 3,243 3,364 Proprietary Dried Milk (Packets) 50,580 41,174 Proprietary Vitamin Preparations (Items) 34,091 33,358 Other (Packets) 10,272 8,810 There was an obvious preference being shown for proprietary dried milk as against national dried milk; there appears to be a decline in the overall sales of these commodities and it will be interesting to note if this will continue in future years. The use of clinics as alternatives to chemists shops is not encouraged, in fact advice to mothers to be able to give their infants properly balanced diets is one of the most important functions of the child health service. DAY NURSERIES, CHILD MINDERS AND PLAY GROUPS NURSERY AND CHILD MINDERS' ACT This Act came into force in 1968, which made it the local authority's responsibility to register all premises in which children under the age of 5 were looked after for over 2 hours a day and to register all those persons who undertake the daily minding of any child under school age. The numbers of registered premises and child minders, and places available in each year, in each category, are shown in the following table: 1968 1969 1970 No. No. of places No. No. of places No. No. of places Day Nurseries 3 148 4 178 4 178 Child Minders 12 101 223 495 272 526 Play Groups 30 908 42 1,286 47 1,447 46 The following criteria were applied in day nurseries and play groups: (i) a minimal floor area of 25 sq.ft. per child (ii) one W.C. for each 10 children (iii) one wash basin for 5 children (iv) a minimum of staff of 2 in the smallest group, and (v) one member of staff to 10 children in the larger groups. Staffing also depended on rooms available, i.e. small rooms catering for a group of less than 10 established the need for an additional member of staff. Child minders were on the whole limited to undertake the daily care of no more than 3 children under the age of 5 when working single handed. This number included any children of their own in this age group. Every applicant for day nursery or play group was interviewed and the premises inspected by a senior member of the nursing staff. Child minders were interviewed by the health visitor in the area. Their recommendations were scrutinised and discussed with the Principal Medical Officer. Applicants for day nurseries and play groups were advised to apply to Town and Country Planning, and the Fire Prevention Officer for clearance. In the case of child minders living in Council accommodation the Housing Manager was advised of pending registration and his comments were invited. All applicants completed an application form after interview as this enabled members of staff to dissuade obviously unsuitable applicants from proceeding beyond this stage. This considerably reduced the number of those who had to be rejected and also appeals to committee. In fact only one applicant appealed but withdrew this at the last moment. The following were dissuaded from persevering with their application: 1968 1969 1970 Child Minders - 13 6 Play Groups - 1 2 Day Nurseries - — — Health Visitors in this authority have been trained to look upon the supervision of children in day care by either child minders or in play groups or day nurseries as part of their responsibility for the health care of the "under fives". They have kept records of their monthly routine visits and inform each other of problems which come to their notice during these visits in children from other health visitors' areas. They have also had a chance to discuss child minders who also act as foster parents with child care officers and consult with social workers on special problems. In many day nurseries and play groups they have been looked upon for advice and guidance, very much as in schools where the school nurses are called on. In some cases these 47 visits proved particularly useful in the follow-up of "at risk" children who had stopped attendance at child health clinics and whose health visitor had paid fruitless visits to their homes. Any difficulties could be discussed with the Principal Medical Officer and the appropriate action taken. During the year the number of first effective visits by health visitors to daily minders or nurseries was 553 and the number of subsequent visits was 2,238. It must be borne in m'md that in any future transfer of this service to the Social Services Department the health of these children needs to be particularly safeguarded as mothers using the day nurseries, child minders and play groups very often do not attend their general practitioners or the child health clinic unless the child is seriously ill. This makes supervision by the health visitor of paramount importance. PLACEMENT OF CHILDREN IN PLAY GROUPS OR NURSERIES ON MEDICAL GROUNDS. From time to time cases arise where placement of children in play groups or nurseries should be made on medical grounds whether or not a charge is recovered from the parents. A mother for one reason or another is sometimes unable to cope with her family or again a child's care suffers because of the mother's inadequacy to cope with the situation. In these cases there may be real hardship through families living on income from Social Security or other very low income, although sometimes parents on sufficient income are also inadequate and accumulate debts owing to poor budgeting. In cases of this type it is often not possible for the expenditure to be met under the Children's Acts and other ways of meeting the cost must be found, including payment for day care under Section 22(2) of the National Health Service Act, 1946. During the year 7 cases were placed in part time nursery groups under this section of the Act. NURSERY NURSING COURSES During the early part of the year courses for the training of nursery nurses were arranged by the Principal of Erith Technical College in conjunction with representatives from the departments able to assist in the training, i.e., the Health and Welfare Department, the Children's Department and the Education Department. It is hoped to open the first class for 15 students in September 1971. The students would spend fifty per cent of the time at the college and the other fifty per cent in placements, either at day or residential nurseries or at nursery schools or classes. Further detailed arrangements are to be made. 48 CHILD HEALTH LOW BIRTH WEIGHT BABIES Low birth weight may be the consequence of a short gestation or slower foetal growth. Prematurity, defined only in terms of weight is now considered to be less accurate. Birth weight becomes more useful when related to gestational age. In 1970 there were 212 premature livebirths and 20 premature still-births. These figures represent 6.24 per cent of all livebirths and 58.82 per cent of all still-births. For the country as a whole these percentages were 6.8 per cent and 60 per cent respectively. The following tables give further details:— Number Weight Category Deaths within 28 days Livebirths Born at home 11 2001—2500 grammes Born at home transferred to hospital 3 (a) 2001 —2500 grammes (2 babies) (b) 1001—2000 grammes (1 baby) 1 Born in hospital 198 (a) 2001—2500 grammes (138 babies) 5 (b) 1001—2000 grammes (50 babies) 9 (c) 1000 grammes or less (10 babies) 10 TOTAL 212 TOTAL 25 Stillbirths Born at home 1 1501—2000 grammes Born in hospital 19 (a) 2001—2500 grammes (2 babies) (b) 1001—2000 grammes (16 babies) (c) 1000 grammes or less (1 baby) 49 QUARTERLY LOW BIRTH WEIGHT STATISTICS 1969-70 (including neonatal deaths under 28 days) 1969 1000 grammes or less 10011500 grammes 1501- 2000 grammes 2001- 2250 grammes 2251- 2500 grammes Neonatal Deaths over 2500 grammes Total Neonatal Death Rate per 1000 livebirths January — March Livebirths 2 4 10 10 29 55 8.1 Stillbirths 2 2 1 1 6 Neonatal deaths 1 2 1 3 7 April — June Livebirths 1 4 14 7 18 44 13.3 Stillbirths 1 2 2 1 1 7 Neonatal deaths 1 2 3 1 5 12 July — September Livebirths 7 6 15 28 7.4 Stillbirths 2 3 5 Neonatal deaths 1 5 6 October — December Livebirths 1 7 15 15 30 68 17.4 Stillbirths 2 2 3 7 Neonatal deaths 1 5 4 1 3 14 1970 January — March Livebirths 8 10 27 45 9.45 Stillbirths 1 2 3 Neonatal deaths 1 1 1 6 9 April — June Livebirths 1 6 8 9 29 53 7.94 Stillbirths 1 3 4 Neonatal deaths 1 1 1 4 7 July — September Livebirths 3 5 9 18 18 53 10.56 Stillbirths 4 1 5 Neonatal deaths 3 1 1 4 9 October — December Livebirths 6 7 8 7 33 61 23.8 Stillbirths 2 4 1 1 8 Neonatal 6 4 1 2 1 5 19 50 The high neonatal death rates for the fourth quarter of each year are undoubtedly associated with the greater number of very low weight births in that quarter. Between April 5 and 11 the Department contributed to the survey being carried out during that week on approximately 17,000 births in England and Wales, Scotland and Northern Ireland under the auspices of the National Birthday Trust Fund and the Royal College of Obstetricians and Gynaecologists. One of the objects of the survey was to learn more about those babies who were small in relation to the period of gestation. Congenital malnutrition is a well documented condition as far as animal studies are concerned, and it is likely to be one of the factors to be considered. 5.4 per cent of the births occurring during that week were of low birth weight. ILLEGITIMATE BIRTHS The number of illegitimate births was 163 as compared with 165 in the previous year. This represents 5.0 per cent of total births compared with 8.0 per cent in England. AT RISK REGISTER The idea of keeping a register of babies who might be liable to disease or disorder was put forward in the early sixties and has been practised widely in recent years, especially since the Report on Child Welfare Centres (Central Health Services Council) 1967 showed the need for it. In Bexley London Borough a scheme of this type was initiated in 1966. The laudable principle on which it is based is that awareness of possible departures from normal can be recorded as part of a general plan of child health with a better chance of prevention or amelioration of handicaps and disabilities as the reward. It has both selective and screening features. Certain conditions before and during birth are selected for their known hazards and they will dictate the need or otherwise for registration. Other conditions may require for their detection a complete screening of the population in question, in this case babies in their first year. Registration takes account of the results of screening tests, for example sight and hearing tests and other observations on development. Names are removed from the register as soon as it is clear that hazards are unrealised and screening tests are normal, or on the other hand that a definite diagnosis has been made. The number of handicaps brought to light during the year as a result of the scheme was 57. This is an average figure including some from previous years and not accounting for those on the register at the end of the year who might add to the recorded handicaps in subsequent years. The whole subject of keeping these registers is now under review by a small Working Group set up in the Department of Health and Social Security in July. A limited survey during the previous year had revealed that several local health authorities had abandoned the risk register because of poor results and a leading article in the Lancet concluded that there was no advantage in continuing the present form of register. As too many children may be included who subsequently develop normally and the number of handicapped children who have been identified in this way was lower than expected. 51 Whatever the outcome of these further deliberations there can be no doubt that the exercise has proved valuable in alerting all concerned to the importance of developmental tests and early detection of abnormality. The considerable experience of this scheme gained in Bexley does not point to its discontinuation. CONGENITAL MALFORMATIONS AT BIRTH The number of congenital malformations and the number of cases and deaths due to them in 1970 with those also for 1969 shown for comparison were as follows:— 1969 1970 Total number of malformations 91 92 Number of cases with malformations 71 83 Number of deaths due to malformations 12 8 (Total deaths of infants under one year of age from all causes) 54 54 Appreciable increases in notification were noticed in a number of areas of the country for certain types of malformation but they were probably due to chance and when they occurred in more than four areas they were not related geographically or in time (Chief Medical Officer's Annual Report, 1970, Department of Health and Social Security). Only about half of such small marginal increases as there were in Bexley corresponded with the types of malformation showing increases in England and Wales. Further details of these malformations in Bexley are as follows: — 1969 1970 Central Nervous System Anencephalus 7 4 Hydrocephalus 5 2 Spina Bifida 8 2 Other 2 3 22 11 Eye and Ear Eye 2 1 Ear 5 4 Other — — 7 5 Alimentary System Cleft lip 1 5 Cleft palate 4 7 Other 4 6 9 18 52  1969 1970 Heart and Circulatory System 5 5 Urino-Genital System Hypospadias or Epispadias 5 6 Hydrocele 1 4 Other 3 4 9 14 Limbs Polydactyly 5 2 Syndactyly 6 4 Talipes 17 17 Hip dislocation 1 3 Other 2 2 31 28 Musculoskeletal System 3 2 Other Systems 2 2 Other Malformations Mongalism — 4 Other 3 4 3 8 TOTAL 91 93 The registration of congenital malformations is required by the Offices of Population Censuses and Surveys at regular monthly intervals. Returns are made on the first day of the second month following the month of birth, which would appear to be too soon in some cases, e.g., during the year there were 7 deaths connected with congenital heart disease and only 5 notifications. As two of the deaths occurred over the age of 4 months, it is possible that they were notified as cases during the previous year, nevertheless, although malformations occurring in Bexley are thought to be well reported, this is one of the few malformations known to be under-reported in some other parts of the country. The total number of malformations of the central nervous system for the year was much less than usual and the number of cases of congenital dislocation of the hip was average. There were no cases of anophthalmos. The number of deaths due to congenital defect was as expected. BATTERED BABIES In February, a letter, CMO 2/70 from the Department of Health and Social Security was received drawing attention to this problem and urging Medical Officers of Health to consult 53 Children's Officers and bring into their discussion other agencies such as the N.S.P.C.C. and to prepare by the 1st October, 1970, a report on the progress of such arrangements. By that time, this authority had already started a register of children suspected of having been abused and interdisciplinary case conferences were being held whenever such a diagnosis was made. The approach favoured by local authorities closely reflected the advice given by the Central Health Services Council in their Memorandum on the Battered Baby (mid-1970). The Principal Medical Officer acted as co-ordinating officer for the Health and Welfare Department and a preliminary meeting took place at the Postgraduate Centre, Brook Hospital, on 20th October 1970, with representatives from the Health and Children's Departments, Brook Hospital Paediatricians, Local Medical Committee, N.S.P.C.C. and the Police. The discussion centred around the following three points:— (i) awareness of this syndrome (ii) early notification of suspected cases (iii) education of medical, legal and social workers to develop a more understanding approach to the problem. It was decided that the only way to ensure appropriate action was to designate one person to be responsible for collating all reports of suspected cases and organising follow-up. In the view of the Committee this person should be medically qualified. The Principal Medical Officer was nominated as the designated Medical Officer for this purpose and all General Practitioners were informed. The Group Medical Advisory Committee of the Hospitals was approached and representatives of the Casualty Departments of the Hospitals were invited to subsequent meetings. A short synopsis of the cases notified between meetings is discussed by the Committee. Discussions with the Orthopaedic Surgeons responsible for Casualty Departments in Hospital took place. All injured children under the age of three years, treated in the Out-Patients Departments serving this area are notified. The previous histories and home conditions known to the Health Department are compared and the results assessed by this Committee. During 1969 four cases had come to the knowledge of the Health Department, three have been placed through the Children's Department with Foster Parents and one by the Health Department with a Child Minder. During 1970, 17 cases (14 boys, 3 girls) were suspected of having suffered wilfully inflicted injuries. Subsequently 4 were cleared and the remaining 13 were dealt with in the following ways:— 3 came before the Court (one was referred for psychiatric treatment, one was returned to the parents, although neglect had been proved, and one was placed in the care of a foster mother — this was an illegitimate child). 54 In 1 case the mother was put under psychiatric treatment. In 2 cases the parents subsequently parted. 4 remained in the care of their parents under supervision of the Consultant Paediatrician and Health Department Staff. 3 parents were persuaded to accept daily minding. During the last two years, one death occurred from Subarachnoid haemorrhage where the presumptive diagnosis led one to believe that it had been an inflicted injury by a foster parent. The children reported have remained under constant observation and nothing further has been detected attributable to wilful injiry. ASSESSMENT GROUPS FOR HANDICAPPED CHILDREN The absence of day nurseries and nursery schools and shortage of nursery class places has been particularly felt by the group of handicapped children who are in need — either due to their own short-coming or an impoverished home background or both — of this kind of provision. The more emphasis was placed on ascertainment by consultation with other professions and observation of developmental progress over a period rather than one examination — the more it appeared necessary to provide some form of group activity in existing premises rather than wait for the fruition of schemes in brick and mortar. In November 1967 the first assessment group was started in the Child Health Clinic, Ellenborough Road on the North Cray estate. The building is purpose-built a.nd offers ample room for activities and good storage space for equipment. The group met on two mornings every week and during the first month seven children were admitted: One with severe cardiac defect, one spastic child, and 5 mentally retarded children of varying degree and aetiology. The group was supervised by a children's nurse and two voluntary assistants, one is a nursery nurse. This clinic is surrounded by a council estate and advantage was taken by the Mothers' Club to start a play group for normal children on the three other mornings when the handicapped children did not meet. This has proved a very fertile ground to foster a community spirit in this neighbourhood. Equipment such as climbing frames, chutes, large boxes and toys were supplied through the mothers' club and other voluntary bodies, and volunteers, encouraged by the clinic staff, have cleaned, painted and mended many of the toys. In February 1969 six children without obvious handicap were introduced from the ordinary play group, which was found to stimulate this group. These children were moved on in the 55 new term and replaced by others. It was interesting to observe that both the handicapped and normal child appeared to gain by this experience. In April 1970 the group was given a small electric organ by the Sidcup Ladies Circle, who expressed interest in the group. This was very much appreciated by the staff and children, and new singing games and movement to music were introduced. The handicapped children are observed and assessed by a Medical Officer with special experience in this field and recommended for placement in consultation with teachers, speech therapist, physiotherapist and others concerned, as for instance in the case of a child with defective hearing the peripatetic teacher of the deaf be consulted. The parents were given a chance to learn about their child's handicap and to accept the child's ability to function in the placement considered best for him. By the end of the year thirty-five children had passed through the group. Table A shows the reason for admission, and Table B the ultimate placement:— TABLE A Reasons for Admission Physically handicapped 9 Mentally handicapped 8 Physically and mentally handicapped 3 Sight Defect 1 Speech Defect 4 Handicapped Parent 3 Social Reasons 7 TABLE B Placements on Discharge Physically Handicapped School 2 Recommended E.S.N. School 3 Training Centre 8 Nursery Class in School 2 Hospital for S.S.N. 1 Ordinary school 6 Moved from area 4 Transferred to ordinary group 3 Still in Special Group 5 Died 1 56 Difficulties have been experienced as transport is not provided, and only a few mothers can assist in bringing not only their own child but also somebody else's to the group. This service has been very much appreciated by mothers of handicapped children and their demand for a further group induced the opening on the 1st September of one in Murchison Avenue Child Health Clinic, which is run on similar lines, and supervised by the same Medical Officer and a trained nursery nurse who also works in the other group. In addition voluntary helpers again assist. This is a small group and children with the following handicaps have been admitted:— a retarded hyperactive epileptic boy; another boy who was said to be out of control at home, who is no problem in the group and acts as a "stimulus" for some of the slower children; three children with spina bifida and a Spitz-Holter valve; and a mentally retarded child with slow speech development. This clinic has the advantage that a speech therapist is in the building on one morning when the group meets and a physiotherapist on the other. This makes for easy inter disciplinary consultation and decision making. HEALTH VISITING The section has an establishment of 43 health visitors and is headed by a Superintendent Health Visitor, together with a Deputy and three Group Advisors. The full establishment of trained health visitors has not yet been attained, but the service was kept going fairly well by the use of clinic nurses who undertook much of the health visitors' routine work. These nurses possess the basic nursing qualifications. The recruitment of trained health visitors was generally sufficient to balance retirement but a positive gain towards a hundred per cent trained staff was not achieved, nor is it likely to be achieved easily in the face of the national shortage of such staff. Approximately one third of the established post for health visitors were filled by clinic nurses. At the Careers Evening held by the Youth Employment Officer the health visiting stand was thought to be a potential source of recruitment even if the London Borough of Bexley did not always benefit from it. The Council sponsors up to five student health visitors each year for training and in the year four of these places were filled, one of them by a student being trained on the new integrated nurse-health visiting course at Southampton. Eventually however, the Department gained only two new health visitors because, although the other two students also qualified, family committments prevented them from taking up post. There is a need for male health visitors but as yet health visitor training is not available to male nurses. 57 Health Visitors continued to give courses of lectures at three senior girls' schools as part of the school curriculum covering such subjects as parentcraft, dangers of smoking, personal hygiene, etc. This is one way in which a male health visitor would be of great help in dealing with the equally necessary education of senior boys in health matters. Child development talks were also given to mothers with children attending St. Andrews Play Group, Sidcup. The following table shows that about a quarter of the expectant mothers in the Borough attended ante natal sessions run by health visitors. The average number of attendances for each expectant mother at these sessions was four and a half. Some ante natal work is done in maternity hospitals and units but mostly it is carried out by general medical practitioners. The attachment of health visitors to general practices is likely to bring about an improvement in these figures. ANTE NATAL, MOTHERCRAFT AND RELAXATION CLASSES Number of women who attended during the year: (a) Hospital booked 703 (b) Domiciliary booked 145 848 Total number of attendances during the year 3,812 The following table shows the other main activities of the health visitor during the year. Visiting by tradition and definition is an essential part of the work of the health visitor, yet during the year it only accounted for about one third of her time, the remainder being used for clinic sessions of various kinds and some clerical work. Concentration of effort at clinics and health centres is desirable but health visiting itself still remains vital and if anything should be sacrificed, it should be some of the clerical work which in the year was reported by the health visitors to amount to nine per cent of her time. Health Visitors and Clinic Nurses attended the following sessions: 1969 1970 Periodical School Medical Inspections 1,021 1,010 School Hygiene Inspections 140 466* B.C.G. sessions 53 34 M. & C.W. Clinic sessions 5071 5347 Cases visited by Health Visitors Total number of children under 5 visited 13,903 14,265 Persons aged 65 or over 182 213 Mentally disordered persons 25 13 Persons, excluding maternity cases, discharged from hospital (Other than mental hospitals) 12 11 58  1969 1970 Number of tuberculous households visited 26 156 Number of households visited on account of other infectious diseases 1072 8251† Number of tuberculous households visited by tuberculosis health visitors 703 544† *During the year the School Hygiene Inspections increased because an effort was made to examine all school childrens feet for verrucae (referred to on page 105). †Visits on account of tuberculosis and other infectious diseases have decreased by approx. 20%. It is to be hoped that the necessity for visiting in future years will show a decline. DEAFNESS IN EARLY CHILDHOOD The Memorandum on Deafness in Early Childhood by the Standing Medical Advisory Committee (Central Health Services Council, 1971) was being prepared in 1970. It is pleasant to be able to record that many of the main measures urged in this Memorandum were in operation in Bexley London Borough from 1967 onwards and perhaps a brief note on the history of this service might not be out of place. It was in 1967 that the idea of a comprehensive service for the deaf was the theme of a conference in London, taking into account almost every viewpoint on the subject. The importance of the very early detection of impaired hearing in babies had been realised for many years, but the facilities for putting this principle into action were lacking. In developing a comprehensive service the first aim was to encourage the fullest growth of the deaf child's personality, and the first fundamental step in that direction was therefore to ensure early ascertainment of such children so that special training could be commenced for them before the age of two years. If these childhood services should be increasingly successful, the welfare services for the adult deaf within the age-span 16-64 years might be expected to decrease. In mid-1968 there were 90 children up to the age of 15 years known to the Department to have some degree of hearing loss and 101 persons within the 16-64 age-group on the handicapped register had varying degrees of hearing loss. In 1966-67 there were three important developments: — (1) An audiology unit staffed by an otologist, a medical officer, a peripatetic teacher for the deaf and a nurse-audiometrician was set up at 315, Broadway. (2) Early ascertainment of babies with impaired hearing was commenced by medical officers and a few health visitors. These members of staff had attended appropriate courses of training. (3) Early auditory training of babies, including parental guidance, was begun in the home by the peripatetic teacher of the deaf. Later it was intended to develop this aspect of the work by forming small auditory training groups at the Unit. 59 In 1968 a special two-day in-service training course was held for all medical officers and health visitors. Thereafter the aim was realised of testing every baby's hearing between six and ten months of age as part of the At Risk screening programme. The audiology unit comprises the basic staff needed for this purpose, but when further expert opinion is required, this can easily be arranged. Sometimes neurological, visual or psychiatric opinion may have to be sought especially where deafness may only be a part of a more complicated disorder of communication. By mutual arrangement between the Bexley and Bromley Education Authorities, special shared accommodation for partially hearing children was made. Places were allocated to Bexley children at the new school for the partially hearing children of nursery and primary school age in Bromley, Darnick Wood School. Reciprocally, it was hoped to make available places for Bromley children at the new unit for children of secondary school age attached to Crayford Secondary School. These changes were made in 1969. On the Welfare side all persons aged 16-64 years on the register in mid-1968 were in employment, not just in the traditional leather and shoe trade but in a remarkable array of no less then 31 different occupations. The Department provided a direct service for the deaf, for example, assistance with speech and lip-reading, and interpreting in many different types of situation. Both sections of the Department had useful co-operation with the two well-known voluntary societies in this field, the Royal National Institute for the Deaf and the National Deaf Children's Society. A service of this kind could not be considered as comprehensive if it did not include the seeds of its own dissolution. Preventive measures fall into two main groups, medical and environmental, and in the year there were two radical developments, one in each of these spheres. Rubella vaccination for young females commenced throughout the country (see elsewhere under Infectious Diseases). The Noise Advisory Council was inaugurated to advise the Government on the problems of noise from traffic, aircraft or the neighbourhood. Similar industrial bodies were beginning to look more closely at the problems of noise in industry. These developments may be expected to yield an appreciable quota to the total preventive effort. GENERAL MIDWIFERY PROVISION The domiciliary midwifery service was staffed in 1970 by the Non-Medical Supervisor of Midwives, Deputy Non-Medical Supervisor and 14 midwives. The 3 general practitioner maternity units, the obstetric unit at Queen Mary's Hospital and the early discharge schemes continued. The trend towards more hospital confinements, also noted in the last Report became more positive as the following percentage indicate:— 60  1969 1970 Hospital Confinements (percentage of all confinements) 83.2 85.9 Hospital Deliveries by Domiciliary Midwives (percentage of all confinements) 3.0 3.6 During 1970 home confinements accounted for 481 out of a total of 3,409 births. There were 292 early discharges from hospital attended by the domiciliary midwives and 122 of these were actually delivered by the domiciliary midwives in hospital. This trend towards more deliveries of appropriate cases by domiciliary midwives in hospitals coupled with the scheme of attachment of nurses to general practices described earlier in this report represents a potent phase in the integration of the health services and at the same time it is in line with the 1970 Peel Report on Domiciliary Midwifery and Maternity Bed Needs. The number of ante natal and post natal clinic sessions held by midwives was 339 out of a total of 480 during the year. Antenatal care and its expression in statistics are likely to be affected favourably by present trends of co-operation and integration of services. MIDWIFERY TRAINING The number of midwives recognised as teachers for the district training of pupil midwives was 10 in the year (unchanged from 1969) and the number of pupils dealt with by them increased from 40 in 1969 to 42 in 1970. In Appendix B, page 169 of this report reference is made to the integrated training scheme with Queen Mary's Hospital and to the need for the teacher midwives to have brief refresher courses. This became necessary because of the earlier introduction of pupil midwives to domiciliary work. This may become more pressing if or when the scheme with the Woolwich Group of Hospitals is realised. HOME NURSING Involvement of the home nursing in the scheme of attachment to general medical practices is mentioned in Appendix A, page 167. The number on the establishment during the year was 33. (a) Cases visited for the first time during the year 1969 1970 (i) aged under 5 12 20 (ii) aged 5 and under 65 706 681 (iii) aged 65 and over 1,493 1,725 Total cases 2,211 2,426 (b) Total visits during the year 117,258 118,364 6,277 visits were made by the nursing auxiliaries during the year. 61 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. We are indebted to the British Red Cross for their assistance in this matter and 4 depots at Albany Park, Sidcup, Barnehurst and Bexleyheath have been established in the Borough to issue such aids as wheelchairs, commodes, bed pans, back rests, cradles, and rubber sheets. The Council makes a grant of £50 towards their expenses. The department 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. HOME HELP SERVICE The home help service continued to meet approximately the same level of demand for it as there was in 1969 although it will be seen from the following figures that cases aqed 65 years and over formed an increasing proportion of the total over formed an increasing proportion of the total. They accounted for 82 per cent of the total compared with 80.6 per cent in 1969 and 73 per cent in 1966. Cases 1969 1970 Aged 65 years or over on first visit 1,768 1.837 Under 65 years (a) Chronic sick and T.B. 163 166 (b) Mentally disorded 7 9 (c) Maternity 78 47 (d) Others 177 181 TOTAL 2,193 2,240 The general and special functions of this service continued throughout the year. The general duties of the home help include keeping the home clean and tidy, cooking and preparing meals for the patient and dependants, caring for the children doing the normal family washing and shopping and collecting pensions if necessary. The special functions are (a) Family care service— for a maximum of three months in families temporarily deprived of the care of the mother or female guardian. Help commences when the father leaves for work and ceases when he returns at night. (b) Family welfare service — for problem families on the recommendation of the health visitor or social welfare officer. (c) Night service for elderly — requires certain services day and night for three weeks in the first instance and then subject to review. Help commences at 10 p.m. and ends at 6 a.m. 62 (d) Emergency services — evening and week-end calls for a small number of patients whose circumstances require it. Home helps provide meals for many housebound old persons during the week-ends as on other days. RECUPERATIVE CARE This service has continued during the year. It is intended to assist those who need this service to return to as normal a life as they are capable of and who are unable to provide this care for themselves or through any other agencies. They are usually recommended by general practitioners and visited and assessed by health visitors before being passed. The number of cases dealt with during the year was 17 (21 in 1969). MENTAL HEALTH SERVICE MENTALLY ILL PERSONS Care of the mentally ill was given by the staff of Mental Welfare Officers who, by 1970, were organised into two well-balanced teams serving northern and southern halves of the Borough. This arrangement fitted in with the hospital catchment areas, the training centres and social and recreation clubs for mentally subnormal adults. The following table A shows the sources from which the 279 new mentally ill patients were referred during the year and table B shows that most of the total number of mentally ill patients (527) were receiving home visits. Table A Source of Referral of Mentally III Patients Under 16 years 16 years and over Male Female Male Female General Practitioners 1 22 64 Hospitals on discharge from in-patient treatment 32 48 Hospitals after or during out-patients or day treatment 10 8 Police or Courts 3 1 Other sources 42 48 TOTAL 1 109 169 63 Table B Type of Care:- Mentally III 16 years and over Elderly Mentally Infirm TOTAL Male Female Male Female Receiving home visits 160 275 20 55 510 Attending day hospital 1 2 3 Attending workshops, day centre or training centre (including special units) 3 7 10 Resident in other homes/hostels 1 3 4 TOTAL 165 287 20 55 527 There were four places for the mentally ill made available to the Authority by other organisations. RE-INSTATE LIMITED Re-Instate Limited which is the controlling body of the rehabilitation unit at St. John's Hall, Erith and on which the Department was represented by the Deputy and then Acting Medical Officer of Health, had just recovered from its financial difficulties of the previous year. A lack of working capital had been the main problem and, with further financial assistance from the Council, the Unit began to make small gains. Its main achievement however was the number of mentally ill patients who were returned to their homes and jobs again. During 1970 the Company was giving serious consideration to an extension of its activities so as to include the provision of hostel accommodation within a reasonable distance of the Unit. The possibility of a joint enterprise of this kind with two other voluntary bodies was being pursued. The number of patients in attendance and patients discharged were:- Bexley residents who were Bexley Hospital patients. 13 Patients from the Community. 18 Patients discharged successfully to home and employment (Bexley London Borough) 4 Total number of persons successfully discharged to home and employment since 1968. 13 MENTALLY HANDICAPPED PERSONS The highlights of the year were the completion of two of the Department's capital projects, a junior training centre and a hostel for mentally handicapped children. 64 The following table (A) shows the sources from which the 27 new mentally and severely mentally handicapped persons were referred during 1970, table (B) shows the type of care being provided for the 342 persons in these categories, table (C) shows the number awaiting entry to hospital and table (D) shows the number admitted for temporary residential care during the year. (A) Sources of Referral Mentally Handicapped Severely Mentally Handicapped TOTAL Under 16 years 16 years and over Under 16 years 16 years and over Male Female Male Female Male Female Male Female General Practitioners 1 1 Hospitals on discharge from in-patient treatment 2 3 2 7 Local Education Authorities 1 1 3 5 Other Sources 4 3 2 1 2 1 1 14 TOTALS 8 4 8 3 2 1 1 27 (B) Type of Care Mentally Handicapped Severely Mentally Handicapped TOTAL Under 16 years 16 years and over Under 16 years 16 years and over Male Female Male Female Male Female Male Female Receiving home visits 8 5 64 34 2 11 16 140 Attending workshops, day centres or training centres 13 8 17 18 39 31 32 22 180 Receiving home tuition 2 2 2 1 7 Resident in local authority hostel/ home 4 1 2 7 Resident in other home/hostel 3 2 2 7 Boarded out in private household 1 1 TOTALS 23 13 86 55 47 33 45 40 342 (C) Awaiting admission to hospital Mentally Handicapped Severely Mentally Handicapped TOTAL Under 16 years 16 years and over Under 16 years 16 years and over Male Female Male Female Male Female Male Female Number of persons in local health authority area on waiting list for admission to hospital (not in urgent need of hospital care) 1 1 TOTALS 1 1 65 (D) Admitted for temporary residential care Mentally Handicapped Severely Mentally Handicapped TOTAL Under 16 years 16 years and over Under 16 years 16 years and over Male Female Male Female Male Female Male Female Number of admissions for temporary residential care to relieve the family (a) to N.H.S. Hospital 1 2 1 6 8 3 4 25 (b) To Local Authority Residential Accommodation 2 3 1 6 (c) Elsewhere 1 1 1 1 4 TOTAL UNDER (D) 3 1 2 2 9 10 3 5 35 MARLBOROUGH JUNIOR TRAINING CENTRE Marlborough Junior Training Centre in Marlborough Park Avenue, Sidcup which opened in April, was the long awaited new purpose-built centre for 60 mentally handicapped children including a special care unit for 10 children (see plan). The outline plan and brief for this centre were prepared in 1967 by the Deputy Medical Officer of Health. This meant the closure of the 40-place centre at Lamorbey Hall and a net gain of 10 places and 10 new special care places. It was not expected that expansion to the new limit of 60 places could be achieved before September because of the need for a settling-in period and the difficulty in obtaining suitable staff. In fact by the end of the year 40 children and 5 special care cases were attending the Centre. The decision of the Government to transfer junior training centres to education departments was an additional complicating factor in regard to staff because of the differing origins, concepts, status, terms and conditions of employment of the teaching profession in schools and supervisors in training centres. Originally the mentally handicapped were kept occupied partly to relieve the home situation, hence the term occupation centre. They were then given training and sheltered forms of employment, hence the term training centre. Now the borderline between training and education was being crossed and, not surprisingly, created some complications. In one respect however there was comparatively little difficulty and that was in accepting the change itself because all concerned in the Department had for long been orientated towards the modern methods of dealing with these children. The individual courses and the regular in-service training courses for training centre staff organised in collaboration with neighbouring authorities and hospitals (see below) contributed greatly to the creation of an enlightened opinion on such matters amongst the staff and consequently their own approach was forward-looking. Against a background of staff shortage, the fact that some authorities paid salaries in excess of the National Joint Council scale was not helpful to those seeking experienced and well recommended staff to fill the new posts. Eventually the teaching aspect of the work of the centres was 66 fully reflected in the salary structure which was then agreed and accepted by the Council. There were also certain site difficulties during the early months involving landscaping and fencing and considerable damage was caused to the building during one week-end by hooligans. The Dartford, Bexleyheath and District Society for Mentally Handicapped Children proposed that an adventure playground sponsored by them should be constructed on the site and to this end they were prepared to subscribe £2,000. This proposal and the generous offer were accepted by the Council. The playground will be used by children attending the training centre and children known to the Society who are in the main those also attending the training centre. They would be able to play there at weekends and during holiday times under voluntary supervision arranged by the Society and they would also have the use of part of the centre itself at such times. The official opening of the centre by the Mayor, Councillor R. Pope, was on December 16th 1970, which was also the occasion of the Christmas Party. FALCONWOOD HOSTEL Falconwood Hostel for 13 mentally and severely mentally handicapped children under 16 years was a new purpose-built hostel situated at The Green, Welling (see plan) and opened in June by the Mayor, Councillor R. Pope. It was beset at first with problems relating to staff. A matron and deputy matron had been appointed some months earlier but it was not easy to obtain supporting staff and when the deputy matron became ill within a week of taking up duty it was clear that the hostel would not be fully operative in September as at first had been anticipated. A settling-in period was also to be expected, even more so than in the case of the Marlborough Training Centre. The hostel was planned to serve the needs of these children in relation to difficult family situations as well as their own needs and as much flexibility as possible was introduced so as to meet the main variations of these needs. Temporary and permanent care, five or seven-day and week-end care were to be provided. Four of the thirteen beds were on the ground floor for those who were also physically handicapped and whose needs had been taken into account in the design of that floor. The Matron's flat is situated on the ground floor and the Deputy Matron's onebedroomed flat on the first floor. In addition to the Matron and Deputy Matron, one full-time housemother and part-time domestic workers and assistants were appointed. By the end of the year 6 children were in residence. It was intended that most of the children would attend the Marlborough Training Centre including its special care unit. SHENSTONE JUNIOR TRAINING CENTRE A decision was required about the future of the Junior Training Centre at Shenstone because, although its replacement was in the Capital Building Programme for 1971-72, an alternative proposal referred to in the previous Annual Report was still under consideration. That proposal was for a Day Unit and Training Centre to be built at Goldie Leigh Hospital to serve jointly the 67 needs of the two London Boroughs of Bexley and Greenwich and the hospital itself. Such a proposal had obvious mutual benefits for all concerned as was plain from the representative meeting of all interested parties at which the project was first considered. The Senior Administrative Medical Officer for the South East Metropolitan Regional Hospital Board was not prepared to go ahead with the scheme for the time being and perhaps not at all in view of the re-organisation of hospital services in the region. In these circumstances the proposal to commence the re-building of Shenstone Training Centre in 1971-72 was confirmed. ADULT TRAINING CENTRE The activities at the Shenstone Adult Training Centre, referred to in the previous Annual Report, continued successfully during the year. The planning of the new centre at Carlton Road, Sidcup advanced steadily in the early part of the year with a view of a start being made on the actual building work later in the year. Here again there was a welcome contribution towards the new centre by a voluntary association. The Shenstone Adult Training Centre Parent/Teacher Association proposed to erect a heated greenhouse in the grounds and the Association's early forethought in this matter was intended to ensure co-operation with the Council's plans for heating, siting etc. HOLIDAY FOR ADULT TRAINEES A party of approximatley 70 adult trainees from Bexley Borough, Bromley Borough and Kent County Council area enjoyed a week's holiday at Gibson's Holiday Camp, Bracklesham Bay, Sussex, early in September. The Supervisor of Shenstone Adult Training Centre led the party assisted by staff from the Department's mental welfare services and volunteers provided by Bexley Unit for Service by Youth (B.U.S.B.V.) and the Bexleyheath and Dartford Society for Mentally Handicapped Children who also donated £100 towards the cost of the holiday. The number of places available in training centres during the year was Bexley London Borough Training Centres Under 16 years 16 years and over TOTAL 120 (Inclusive of 10 places in the special care unit and 18 places made available to other local authorities) 45 165 Places made available by other local authorities (a) in training centres for the mentally handicapped 46 46 (b) in workshops or dav centres for the mentally ill 10 10 120 101 221 (of which 203 are available to Bexley L.B.) 68 69 70 71 72 73 74 75 The number of places available in hostels, homes and social centres during the year was as follows: — Hostels 13 for children aged under 16 years Places in homes/hostels made available by (a) other Authorities 2 for mentally handicapped and severely mentally handicapped adults (b) other organisations 8 for mentally handicapped and severely mentally handicapped adults. 4 for the mentally ill. Total number of places: 27 SOCIAL AND RECREATION CLUB FOR MENTALLY SUB-NORMAL ADULTS The local branches of the National Society for Mentally Handicapped Children continued to assist in running a social and recreation centre for severely handicapped subnormal adults and the Council also continued to permit 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 between the ages of 16 and 36 years. IN-SERVICE TRAINING FOR TRAINING CENTRE STAFF This year, the 2 study days established during previous years were held on 22nd May and 23rd November for the staff of Bromley and Bexley, and Darenth Park and Goldie Leigh Hospitals for the severely mentally subnormal. The staff from junior and adult centres in the Local Authorities and hospitals attended and were joined for part of the day by members of the Mental Health Section. One of the participating authorities acts as host thus cutting expenditure to a minimum while offering one platform for study and discussion of problems common to all. The study day in May was chaired by Dr. W. Wollen, Psychiatrist, Darenth Park, and was held in that hospital. The film "A Place like Home" was shown and discussed. Papers on "Aims and Methods in Adult Training Centres" and 'The Future Services for the Mentally Handicapped Child" were read and discussed. The second meeting in November took place in the newly opened purpose built Marlborough Training Centre in Bexley and a paper on the topical subject of 'Transition" was followed by short papers prepared by members of staff on special activities in their individual centres. In the afternoon the Headmaster of Meldreth Training School presented a paper on 'The training and education of the mentally and physically handicapped" followed by a short paper on "Mime and Speech". 76 The day was much enjoyed by all members of staff and the hope was expressed that these study days might continue in the coming year to provide a much needed link in what would then become a service provided by the S.E. Metropolitan Regional Hospital Board, the Social Services Department, as well as the Education Department and the School Health Section of the Health Department of the Local Authority. FAMILY PLANNING During the year the Council made a grant of £2,500 to the Family Planning Association and permitted that Association to use several clinic premises and the Thamesmead Temporary Health Centre free of charge. The Association therefore acted as the Council's agent and within the grant it received it was able to provide a free service including advice and supplies for medical cases referred under Sections 22 and 28 of the National Health Service Act and similarly for necessitous cases referred by general medical practitioners. The Association was able to make charges forthe service in other cases where appropriate. In this way other non-medical persons and the unmarried, were accepted, but the service did not extend to domiciliary visiting. The relevant statistics were as follows Number of clinic sessions 904 Number of Doctors sessions 1,126 (at several clinics there are more than one doctor present) Total number of patients seen 5228 (of which 197 were medical or social cases) Health Visitors and Midwives, most of whom have attended courses on family planning, contributed appropriately to the efficiency of this service. Language difficulties with immigrants were overcome by the use of the interpreter supplied by the Bexley Council of Social Service. The clinic at Thamesmead Temporary Health Centre was the thousandth clinic in the country to be opened by the Family Planning Association and in the early summer the Association marked the occasion by arranging a reception at the Centre attended by the Mayors of Bexley and Greenwich and 40 guests. This particular clinic is staffed by a general practitioner who has attended one of the special training courses which are organised by the Family Planning Association. On family planning matters he deals with his own patients at the Centre by arrangement with the Association. 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. 77 The number of local authority clinics has been increased each year since 1966. There are now five 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 Wren Road, Sidcup 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. DIRECT SERVICE No. of Sessions No. of Treatments No. of Patients Clinics (5) 634 3341 828 Domiciliary 305 1,323 342 Old People's Homes (4) 113 872 226 CONTRACTUAL SERVICE No. of Treatments No. of Patients Surgery Domiciliary 7247 4,157 2138 HEALTH EDUCATION Considerable progress was made with health education during the year despite the lack of accommodation and staff. Large scale campaigns were out of the question but many small worthwhile projects were carried out or commenced. Talks were given by medical officers and one medical officer in particular used her experience as a pharmacist to good effect in giving talks on the thorny problem of drugs. In the main however, it was through the health visiting section of the Department that so much was achieved, especially through one Health Visitor with special interest in this subject who was made responsible for the health education programme for health visitors and the co-ordination of their work in this field throughout the Borough. Under her guidance and after careful preparation the health visitors used health education material of various kinds, some home made, some bought, to put over ideas more forcefully on specific health subjects at clinics or schools. The existing stock of visual aids was in her care and substantial additions were made to it during the year. These included a new 16 mm. cine projector and a drawings cabinet, film strips, transparencies, more casettes on specific subjects, a daylight screen and further basic equipment. 78 A brief mention must be made of other interesting work started by the health visitors during the first half of the year. (1) As a result of an approach made by a general practitioner to the Acting Medical Officer of Health, a small discussion group of mothers with new babies chosen by the doctor and the health visitor commenced at the practitioner's surgery. (2) Education evenings were held for mothers at clinics. (3) Health visiting staff participated in the "Welcome to Citizenship" evening at Erith School. (4) Observation visits to clinics by school girls followed talks in schools by heath visitors. (5) A health visitor was selected to attend a group discussion course arranged by the London Boroughs Training Committee. The need for health education on correct diets prompted one of the midwives to set up a slimmers' club in May 1970 in her own home. She wanted to provide a club atmosphere for women who do not fit readily into other social activities or clubs. The response was so good that she sought clinic accommodation and in July the Council gave its approval for a trial period to the use of Station Approach Clinic at Welling one evening per week for this purpose. By October the number of women attending had grown to 48 and special speakers were being invited occasionally to address the group. There were two practical results of these activities. The average weight loss was observed to be about 2½ lbs. per week and many had also made friends amongst whom there grew up a sense of mutual support against urges to eat forbidden items of diet. The second benefit stemmed from the charge of 3/6d. to members which by the end of the year made it possible to hand over a sum of £40 to the Marie Curie Foundation. RENAL DIALYSIS Following receipt of Circular 2/68 from the Ministry of Health referring to adaptation to homes for the purpose of installing artificial kidney machines, there have been five cases in the Borough, each presenting individual and sometimes fairly complex problems. The Council's existing scheme offered assistance to each applicant by giving practical help in the preparation of plans and specifications in conjunction with the hospital authorities and the Metropolitan Water Board, the cost to the applicant being determined by the Council's assessment regulations. At that time the Council had contributed approximately £1,600 towards the total cost of £2300 for the first four cases excluding the cost to the Borough Architect's Department for preparing and supervising schemes. By the end of 1969 four adaptations had been completed and the possibility of promoting some form of joint action by the Social Services and Housing Committees to adapt one or more Council-owned houses for this purpose was being explored. 79 Most London Boroughs were experiencing some difficulty in providing this service and generally it was being found that conversions were taking from four to five months, although it was realised that with the maximum co-operation of all concerned an adaptation could be effected within two months from contract to completion of work. Attainment of the shorter period was highly desirable because most patients were becoming fully trained within three months of admission to hospital. The commonest problems were of a legal and financial nature although spiralling building costs and contracting difficulties were contributory factors. Often the comment was made that geographical locality rather than the patient's need determined the outcome. In varying degrees Bexley was affected by these problems. The Housing Working Party dealing with this proposition considered alternative schemes and recommended that Council property should be let permanently to the Social Services (and Children's) Committee and thereafter adapted on a multiple-user basis. Interpretation of home dialysis as a type of community care pointed to some form of concentration of effort. It was agreed at the Social Services (and Children's) Committee however that further enquiries on the medical and legal aspects of the scheme should be made. The Acting Medical Officer of Health conducted the enquiries which are summarised below. (a) GENERAL As applied to the population at large, dialysis is a new phenomenon not yet old enough to yield accurate statistics. There are many variables such as the age groups treated and the availability of organs for transplantation. In one recent report the shortage of organs was given as the most serious impediment to the efficient use of the unit. Eventually a balanced integration of hospital and home dialysis and renal transplantation must be reached. It has been estimated that the initial capital cost is £3000 per patient plus £1,000 per year thereafter. In a group of patients dependent on artificial organs at the Royal Free Hospital, two thirds were able to return to their usual full-time employment with a few minor adjustments. (b) SIZE OF PROBLEM On present estimates the London Borough of Bexley might expect to have anything from six to thirteen new cases per year, of which approximately three quarters might be suitable for kidney transplantation. Some of these cases might fail and again require home dialysis pending one or more further attempts at organ transplantation. If one takes an average of ten new cases per year, then one might expect a residual 15% to 20% to remain on home dialysis. Being cumulative there might be an increase of one or two cases per year until an "undefined ceiling" had been reached at some time in the future. (c) THE MULTIPLE-USER UNIT A meeting of the consultants concerned was convened by the Acting Medical Officer of Health and a representative of the Department of Health and Social Security was also present. The 80 Bexley scheme was fully discussed but was not favoured because in the opinions of the consultants, the proposed premises would be virtually hospital units. The stringent regulations applicable to such units would probably make them uneconomic from the local authority point of view. The idea of a purely local unit as a satellite of a main unit had been discussed, planned and tried experimentally. Experience showed however, that whenever two or three machines were to be used by a number of different patients, a separate unit became necessary with its own establishment of technical, nursing and medical staff. Other contrary features were (i) It would be necessary to employ night and day nursing staff. One house would probably require at least three nurses for a six-day week, fifty-two weeks per year. Even if patients did all the cleaning and preparatory work connected with the machines, this would mean all night work for the nurses on a permanent basis, which few might be willing to accept. In a unit of the type suggested some latitude of choice in the times at which the patient dialyses himself would be lost. (ii) There would be some loss of social and family freedom and also loss of the trained members of the patient's family. (iii) Nationally there is difficulty in recruiting staff of the right technical ability and reliability to take on this type of work, which is essentially dull, but might spring an emergency at any moment, and the known risk of infection associated with these units might also add to this difficulty. (iv) In the light of the considerable advances being made in the design of dialysis equipment which would be associated with a marked reduction in cost, it might not be wise in terms of either capital or revenue, to proceed with the scheme. (d) MOBILE UNITS The firm of Portakabin is now producing such units, but they require the usual foundations, plumbing and drainage work which can be expensive items of the total cost. They would appear to be of doubtful value in a London Borough. (e) OTHER LONDON BOROUGHS Arrangements vary considerably throughout the London area and even within a single Borough, but generally as at February 1970, they were as follows:— Number of Boroughs assessing and charging for instaltation according to patient's income and capital 20 Number of Boroughs making no charge for installation 12 81 Number of Boroughs making special arrangements where major adaptations to private properties have been necessary (or would be required) (a) By "second mortgage" or similar method (b) By rehousing in Council property 3 1 Number of Boroughs retaining adapted Council properties for future use, granting life tenancies without charge for the service or having this in mind 2 Number of Boroughs making charges for reinstatement of adapted properties maintenance charges and incidental expenses 3 In one local authority area installation costs were met in full either by the Council or the employers or from charitable sources or else a Council house was adapted. In another authority, no charge was made to tenants (Council or private) and owners also were not charged unless the cost exceeded £100 in which case a second interest-free mortgage repayable when the patient was no longer in residence was made. In another authority, the usual assessment applied but the authority bore the first £50 and half of the remaining balance. The London Boroughs Association was taking a somewhat different view at this time. The Social Services Committee of that body enquired of the Secretary of State if the use of home dialysis was not a continuation of hospital treatment, and as such, outside local authority jurisdiction. The reply to this query made it clear that although these patients need the backing of hospital departments, they live and work in the community and their care to the extent outlined in Circular 2/68 should be a proper function of the local health authority. The Town Clerk was informed by the Department of Health and Social Security that the legal interpretation of such a unit would place it within the definition of specialist services normally provided under Part II of the National Health Service Act 1946. The existing scheme was therefore retained and improved. One improvement under consideration was the setting-up of a panel of contractors either with experience of this type of work or willing to gain such experience. The costing analysis of Wood and Lee (1970) supported our view that there need be no alarming price quotations. The two health centre projects at Thamesmead and Erith continued to make progress in 1970 but nothing came of a further attempt to elicit interest in the site at 315/317 Broadway. In consequence a two-stage project was considered and put forward to the Department of Health and Social Security for approval. There was further correspondence but approval had still not been obtained by the end of the year. Completion of Stage I (Local Health Authority Education services only) of the project would give this populous area of the Borough a much needed centre from HEALTH CENTRES 82 which the local health authority services could operate. The services at the existing premises have grown more complex and numerous because of their central position. They include for example the only audiology unit and orthoptic clinic in the Borough and the pressure for accommodation has been such that on occasion a service has not been able to expand, or a new service has had to be refused. The only child guidance clinic in the Borough is situated little more than a hundred yards from this site and it is intended that it also should form part of the new centre. There would appear to be ample reason to go ahead with a Stage I project. THAMESMEAD HEALTH CENTRE The temporary health centre, after comparatively little use in the latter half of 1969, due to building delays in the area, became increasingly active and functionally diversified thoughout 1970 in response to the needs of the incoming population. In all large new developments of this type involving a rapid growth of population which has been somewhat arbitrarily and sociologically chosen, it is beneficial to all concerned if the centre staff has some prior knowledge of the new arrivals. Early in 1970 the Greater London Council Housing Department agreed to let the Acting Medical Officer of Health have information which would ensure that new families could not arrive unknown to the health visitor. The centre itself required various adjustments affecting its structure, equipment and personnel throughout these months and such changes and its future planning were facilitated by the formation of a committee initially composed of the general practitioner, the dental practitioner, the Secretary of the Joint Health Services Advisory Committee, a representative of the Clerk of the South East London and Kent Executive Council, the Chief Dental Officer and the Acting Medical Officer of Health as its first chairman. Reports from this committee were submitted to the Joint Health Services Advisory Committee. The second medical practitioner to the Centre, Dr. R.M. Turner, M.B., B.S. was appointed in May and the second dental practitioner, Mr. P.J. Mainwaring, B.D.S. was appointed in June. As with the first practitioners, these also were given appointments on the staff of Guy's Hospital, and employed on a sessional basis by the Local Authority, thus continuing the full integration of all three branches of the health services. In addition to the provision of basic health services, such as diagnosis, treatment and antenatal care, other innovations were planned or initiated, such as group discussions on specific subjects led by a member of the Centre team, and clinics dealing with special conditions or with specific age groups. The team was reinforced by others from the Health & Welfare Department and elsewhere. Speech therapy was commenced, a dietician from the Brook Hospital gave guidance to the weight-watchers group, and a family planning clinic, the thousandth clinic of the Family Planning Association, was opened. In these early months a social worker from the nearby Thamesmead Christian Community Office also co-operated in the work of the Centre. During the summer three medical students from Guy's Hospital worked at the Centre. Later in the year it was becoming apparent that these activities were rapidly filling the weekly programme. The general practitioners who at first had been able to devote some of their local authority time to other clinics in the Borough were now less able to do so and the two dental practitioners had to share the one and only surgery. By September the general practice list had grown to 1,600 and about 500 dental patients had attended the Centre. It was clear however that the needs of the population were being met and that prevention in its various forms was being practised both in word and deed. 83 Progress on the permanent Thamesmead health centre was delayed owing to labour difficulties, but as these applied to the whole area, no imbalance was created affecting only the health services. Piling of the site was completed in Autumn 1968 and the building commenced in March 1970. The situation was kept under review by the Joint Health Services Advisory Committee on the five occasions it met during the first nine months of the year. In July the meeting took the form of an Open Day during which a large number of invited guests, including members of Bexley London Borough Council, heard about the project generally and paid a visit to the temporary health centre and the site of the permanent centre. Two agreed modifications of the original plan (shown in the previous Annual Report) were that the most northerly of the consulting rooms — marked Dental Hygienist in the plan previously — would be equipped for audiological work and the dental surgery nearest to this room would be loaned and converted temporarily to use for ophthalmic services. ERITH HEALTH CENTRE In January 1970 there was a reactivation of interest in the development of a health centre at Erith Town Centre. In 1967 planning had reached a fairly advanced stage but had come virtually to a halt due to the difficulties and delays affecting the redevelopment as a whole. Lengthy discussions between the Council and the Development Company resulted in a considerable contraction of the original commercial part of the development scheme without obviating the need to provide a health centre. There were now two pressing reasons for moving ahead with some haste. In the first place it was essential to have a medical centre ready before demolition of the existing practice premises. It will be recalled that the earliest steps to form this centre, taken before 1965, were prompted by the need to provide alternative premises for the practices involved in the redevelopment, hence the term "medical centre". After 1965 the idea of a health centre was introduced and it is to the credit of the practitioners concerned that they accepted it, even if at first, owing to its origins, it was more like a bilateral project with the Council than a fully integrated scheme. They are the first of the Borough's general practitioners to do so and even though it has been the Council's policy to encourage the development of health centres, no other practitioners so far have shown an active interest in them. Limitations at the site at first appeared to be dictating a two-stage development of the centre, the practitioner services being in the first stage. Fortunately with the passage of time another site emerged from the changing pattern which permitted a comprehensive approach and early in 1970 this was agreed with the Executive Council and the general practitioners. Secondly, the need for a health centre was becoming ever more urgent because the existing local health services were continuing to operate year after year in the same inadequate premises situated well away from the new development. In addition medical opinion was coming rapidly to approve of health centre practice. It was to be expected also, in view of the growing experience of health centre design, that some modification of the original plans would be necessary. Comments on the revised plans together with a draft Design Guide for Health Centres were received from the Department of Health and Social Security in March 1970, following which the second and final revisions of the plan were submitted to the Department of Health and Social Security during the 84 subsequent months. Some of the factors being considered during this period prior to the final approval of the plans were the restrictions of the site, the separate nature of the participating practices, and the changing pattern of the health and social services' administration, including the possibility that there might be separate area offices for social workers. The proximity of the Erith and District Hospital made it unnecessary to include hospital services, but in respect of the main community health services the plans were comprehensive. CANCER The environmental causes of cancer deserve more attention. The Pfizer International Symposium Monograph No.2 on Racial and Geographical Factors in Tumour Incidence, and the International Agency for Cancer Research Reports are recent expressions of this viewpoint. Globally it is easier to see such causes than in a comparatively small area like a London Borough. Statistical methods were used initially in directing attention to the hazards of cigarette smoking and it is possible that such methods used in conjunction with local epidemiological intelligence on this subject might be productive of useful information in the future. In the meantime the national anti-smoking campaign pursued its long slow progress which included the local use of publicity material and the giving of talks to groups in schools or other places in Bexley. The adverse effects of smoking by expectant mothers on their unborn children were emphasised in the appropriate settings. CERVICAL CYTOLOGY The cervical cytology scheme in Bexley continued as described in the previous Annual Report. When the demand for tests went up or down the number of clinics was adjusted accordingly, but at no time was the service under the serious pressure which applied to it in 1966-67 nor was the waiting period for it above the unavoidable minimum. All three branches of the National Health Service and the Family Planning Association undertake cervical cytology tests. The local health authority scheme for Bexley can be described in the following three respects BEXLEY LONDON BOROUGH CYTOLOGY SCHEME (1) General publicity and provision of cervical cytology clinics for all women aged 25 years and upwards. (2) Specific publicity and specially arranged clinics for groups of women in co-operation with industrial firms employing women and with voluntary organisations of primary interest to women. (3) Deliberate extension of the scheme to selected women thought to be at greater than average risk, for example those approaching middle age. This part of the scheme operated with the full participation of general practitioners who selected from amongst their patients those women of any age for whom the examination might be desirable on clinical grounds, also some women between 25 and 65 years on socio-economic grounds and all their female 85 patients between 45 and 55 years. These women who were somewhat conspicuous by their absence from the lists of those being tested in the first year of the scheme were then given the invitation to attend a Borough cytology clinic. Most general practitioners took part in the scheme and it was these doctors who gave out the invitations. The frequency of testing as far as the local health authority scheme in Bexley was concerned was improved from once every three years to once every two years. It must be emphasised that this increased frequency was possible without prejudice to those requiring first tests. The numbers examined in 1969 and 1970 at the three cytology clinics were Local Authority Clinics 1969 1970 Colyers Lane 1,076 1,271 The Oval, Sidcup 958 1,165 Sidcup Hill, Sidcup 784 778 TOTALS 2,318 3,214 Other (non-local authority Clinics, G.P.'s, industry) 3,085 3,512 GRAND TOTAL 5,903 6726 Distribution of tests according to age groups Under 25 25-29 30-34 35-39 40-44 45-49 50-54 d over Colyers Lane, Erith 47 148 223 210 197 217 130 99 The Oval, Sidcup 35 112 195 191 211 173 128 120 Sidcup Hill, Sidcup 12 61 111 122 128 146 99 99 TOTALS 94 321 529 523 536 536 357 318 GRAND TOTAL 3214 The following results were obtained:— 1969 1970 Total smears examined 2798 3,161 Positive for cancer 6 9 Revealing other conditions 725 885 Normal 2067 2267 No smear taken 20 53 86 There are two pleasing aspects of the 1970 statistics. The total number of women tested was the highest since the scheme started and, for the first time, there was a numerical preponderance of tests, even if slight, in the 40-50 age group. Having said this however, it is probably true to say that the majority of women eligible for the test have still not availed themselves of it. In 1966 it was estimated that there were 57,630 women between the ages of 25 and 65 in the Borough. Since then 12,268 tests, many of them re-tests, have been carried out at the Borough's local authority cytology clinics. It is estimated that nearly 12,000 tests have been carried out since 1966 at nonlocal authority clinics or surgeries on Bexley women. Even if all these tests were first-timers (approximately 24,000) it can be seen that more than half have not been tested. Looked at in another way, only about 12½% of eligible women in the Borough were tested in 1970. At that rate only about 37Vi% would be completed by the time a re-test was due if the interval between tests were still to remain at 3 years. There is obviously room for increased health education. DEATHS FROM NEOPLASMS The following table of deaths from cancer shows the commoner sites of the disease:— Site 1969 1970 Malignant Neoplasm Stomach 38 49 Intestine 57 53 Lung and Bronchus 140 139 Breast 53 51 Uterus 13 21 Buccal Cavity 7 5 Oesophagus 13 12 Prostate 17 17 Other Malignant and Lymphatic Neoplasms 141 138 Benign and Unspecified Neoplasms 8 3 Leukaemia 18 16 HOUSING A very good relationship exists between the Housing Department and this Department and a scheme for priority re-housing on medical grounds has been worked out which seems to work well. Every housing applicant when completing an application form states if he considers that he is eligible for re-housing on medical grounds. If this is confirmed this department is informed. The applicant is then approached by this department to consent to information being obtained from his general practitioner and/or consultant. Special forms have been designed stating the type of condition for which priority can be obtained and most doctors amplify by personal comments. The final decision is reached after a visit by a Senior Medical Officer in all those cases recommended. 87 This procedure involves the department in an average of about five to ten visits a week and a monthly case conference with the staff of the Housing Department. Really urgent cases can be dealt with by telephone, and it is hoped that a fair distribution is achieved. Table below shows statistical data:— Applications received 502 Applications supported 164 MEALS SERVICE FOR THE ELDERLY A Working Party was set up following a report on this subject by the Medical Officer of Health to the Social Services (and Children's) Committee in September 1969. In that report the importance of an adequate diet for the elderly was pointed out. Many aged persons, especially if living alone, are known to avoid the expense and trouble of cooking and soon come to live on a simple diet which involves no cooking nor extensive shopping. They avoid fresh meat and fish, fresh vegetables and fruit and live to a large extent on bread, jam and tinned or ready cooked items. In many cases this type of diet provides sufficient calories for the persons'requirements but it can be deficient in essential factors such as vitamins, salts, roughage, etc. as past surveys of diets have shown. Preventable illness, with early breakdown and need for admission to old people's homes or hospital, is often the result. The meals-on-wheels service and luncheon clubs were introduced to overcome this unsatisfactory state of affairs, the meals-on-wheels service providing a properly balanced hot meal, delivered to the home of housebound elderly, whilst luncheon clubs provide a similar meal together with social opportunities, for the ambulant elderly. The danger of contamination of bulk food supplies was also pointed out in the report, especially in relation to the elderly. The highest standards of food hygiene would therefore be necessary at all stages of preparation, handling and distribution of meals for the elderly. Kitchens would have to be properly designed and constructed and adequately equipped and kitchen and other staff would have to be trained in the essentials of hygienic food handling. Four meetings of the Working Party were held and a report was submitted to and accepted by the Social Services (and Children's) Committee in January 1970, (see Appendix), and in due course by the Council. The Working Party looked into the possibility of producing and delivering meals at the weekends when it was known that some old people were completely alone, but no definite recommendation could be made. The work of the Home Helps in this respect was noted and the project by Bexley Unit of Service by Youth would be watched with interest. The Working Party in recommending a trebling of the service in the first year advised that this should be done selectively in view of the unequal supply position of the existing service. The following distribution was suggested:— 88 District Existing Number of Persons Extra Number of Persons Total Number of Persons Weekly Number of Meals Sidcup 105 Nil 105 420 Bexley 92 48 140 560 Erith 65 35 100 400 Crayford 58 22 80 320 Totals 320 105 425 1,700 This arrangement took into account the poor service in the Welling area and the known number of old persons requiring meals in that vicinity. On the use of frozen meals the Working Party agreed with the earlier report that they had much to offer in the future, but enquiries also revealed that frozen meals, like orthodox meals, would have to be plated individually before delivery because single pre-packed deep frozen meals were no longer available. The existing Borough meals' potential seemed to be sufficient for the first two or three years of the expansion and at this stage there did not appear to be any cost benefits in favour of frozen meals. 89 APPENDIX REPORT OF WORKING PARTY (1) LUNCHEON CLUBS (a) Existing Service: As reported in September this is limited to: Centre No. of Meals per week Selling Price Remarks Hadlow Road Day Centre 110 1/6d. Council subsidised Old Bexley Lunch Club 30 1/6d. Council subsidised St. Paulinus Church 30 2/6d. Mainly Church assisted (b) Possible Expansion: Expansion should relate to non-housebound elderly persons. There are about 50 Old Persons' Clubs in the Borough with an average attendance of 100 but from the voluntary workers' side it appeared that expansion would have to be limited to 10—15 clubs over a three-year period. The importance of a social atmosphere in such clubs was stressed. In addition to the supplies from schools to the meals-onwheels service referred to later, school kitchens could also supply 400 meals in bulk daily to clubs, if necessary. The premises at North Heath Playing Fields Cafeteria were inspected to see if they might be suitable for a lunch club or even as a Day Centre for the elderly. As far as the year 1970—71 is concerned it was felt that the development of Day Care Centres was more important and that financial assistance for meals should be allocated to such centres. Additional provision has been made in the draft rate estimates for 1970—71 in this respect. 91 (2) MEALS-ON-WHEELS (a) Existing Service: District Average No. of persons Average No. of meals per week Source Bexley 85 170 WRVS Kitchen, Gravel Hill * Crayford 55 115 WRVS Kitchen, Town Hall, Crayford Erith 60 130 Corinthian Restaurant Sidcup 100 215 Hadlow Road Day Centre * The kitchen at Gravel Hill has been the subject of special inspection because it falls short of standard modern requirements. (b) Possible Expansion: Of an estimated 2000 housebound old persons only 1,000 to 1,500 might be willing to accept meals and it was agreed that a target might be set of 1,000 persons requiring 4000 meals per week. The immediate target should ensure 4 meals per week to those already receiving only 2 meals. In view of the significant social advantages of helping old people to remain in their own homes it was thought that the Committee would wish to expand the service as quickly as possible to its optimum level. In this context a three-year programme of expansion is suggested, i.e.: Meals per week Persons Existing service 630 300 1970-71 1.700 425 1971-72 2,800 700 1972-73 4,000 1,000 Special Considerations of The Working Party: (i) In the first year no economic advantages would be expected from the use of frozen foods but later on this method would merit closer study. In the meantime their introduction by the WRVS at the Gravel Hill Kitchen would be followed with interest. (ii) The services and experience of the WRVS should be incorporated in the scheme. (iii) The existing resources of the Council should be utilised as fully as possible. 92 (iv) Attention should be concentrated on the year 1970—71 in order to make provision in the draft estimates. The remainder of this report therefore relates to 1970—71. Target for 1970—71 District No. of Persons No. of Meals per week Bexley 140 560 Crayford 80 320 Erith 100 400 Sidcup 105 420 425 1700* * i.e. 4 meals per person per week, the total number being delivered over 5 days. (c) Sources of Production: The following table shows the sources of supply and their capacity at present levels of staffing and equipment, and their existing use for this service based on a service spread over five days per week. Kitchen Capacity per week Existing production per week (average) WRVS Bexley 240 170 WRVS Crayford 120 110 Corinthian Restaurant 750 120 Hadlow Road Day Centre 270 200 Schools: North Heath 500 Barnes Cray 500 Crook Log 500 Sidcup Girls 500 3,380 600 NOTE: During school holidays extra staff for school kitchens will be needed. (d) Distribution — Transport and Personnel: The varying strength of the WRVS throughout the Borough is the primary reason for the present disparity of the service as between one district and another. 93 The following factors formed the basis of the Working Party's consideration of the problem: (i) The WRVS fleet of 9 vehicles would be available within a Council scheme and at present one of the vehicles appeares to need replacement. They are restricted to some extent to certain areas but the Society would have no objection to the employment of male drivers where necessary. (ii) On WRVS experience in Bexley, 28—29 meal deliveries per 2 hour lunch period was the reasonable maximum. Over a five-day week they could carry about 1,270 meals. (iii) Three existing Health and Welfare Department vehicles could be made available over the mid-day period and they could deal with the remaining 430 meals per week. (iv) Drivers and mates would have to be employed for varying times according to how far the WRVS scheme falls short of a five-day delivery service. It was suggested that retired ambulance drivers or bus drivers, or shift workers would be very suitable as potential employees. (v) A stand-by vehicle and relief driver would be required. (vi) The project begun by Bexley Unit of Service by Youth (B.U.S.B.Y.) to provide meals at weekends from Hadlow Road Day Centre suggested an extension of the service to six days per week, thus spreading the total load, but there was not enough time to reach a conclusion on this possibility. At present Home Helps provide meals for many housebound old persons during the weekends, as on other days. (vii) The WRVS service would need to be supplemented by part-time employees for which provision would have to be made in the establishment. Based on a three-hour day at rates of 11/- per hour for drivers and 8/- per hour for mates the estimated cost in 1970—71 would be £4,500. (viii) Provision has now been made in the draft estimates for a mini-van to replace the oldest WRVS vehicle and a mini-bus to serve various departmental purposes and to act as a stand-by for the meals service. (e) Administration The administrative implications of an expanding service would also increase due to the preparation of rotas, routes, transport etc. It was agreed that the Health and Welfare Department would be the best suited to assume responsibility for the 94 general administration and co-ordination of the scheme. During the first year, however, the WRVS would be able to cope with the increase in its own clerical work but the Department would need an increase of establishment to the extent of one Clerk. (f) Cost The cost of the expansion is expressed below in two sets of figures. The more important of these is the additional cost to the Council which is based on the cost of producing an additional meal from existing resources. This is virtually the cost of ingredients only, plus the cost of distribution. The other figures represent the additional cost provided in the estimates against the meals service, part of which is offset by additions to income shown under other service heads. These are based on average costs per meal plus costs of distribution. Additional Meals produced Additional Cost to Council Additional Cost Per meals estimates Production per week Per Meal Total £ Per Meal Total £ WRVS Kitchens 100 1/2 303 1/2 net 303 School kitchens 650 1/2 1,972 3/- 5,070 (plus for school holidays) 737 Corinthian Restaurant 280 2/- 1,456 2/9 net 2,002 Hadlow Road Day Centre 70 1/9 319 2/9 470 1,100 – 4,790 – 7,845 Distribution Wages – 4,500 – 4,500 Vehicle running costs – 1,140 – 1,140 Equipment – 400 – 400 Administration Clerk – 1,000 – 1,000 – 11,830 – 14,885 Less Income 1/6 4,120 1/6 3,580 Net additional Running Cost 7,710 11,305 Capital Cost Mini-bus (part cost) – 500 – 500 Total additional cost – 8,210 – 11,805 95 (g) Future Expansion The additional cost of expansion in 1970—71 is reduced by reason of the availability and under-use of WRVS vehicles. In later years extra vehicles would be required although it might be possible to reduce this requirement by spreading the service over six or seven days per week. The Corinthian Restaurant kitchen could produce up to 1000 meals per day without additional capital expenditure. Inevitably, however, there would be proportionately greater capital costs and increases in production and distribution costs. Further detailed consideration would be required. RECOMMENDATIONS 1. A three-year programme aimed to deliver at least 4 meals per week to 1000 housebound old persons be introduced from 1970—71. 2. During 1970—71 the existing service be trebled, i.e. 4 meals per week to 425 people. 3. The service should operate mainly over a five-day week leaving voluntary agencies to pioneer weekend meals. 4. Administratively the service be the responsibility of the Health and Welfare Department and provision be made in the establishment for — (a) Drivers and mates — see paragraph (d) (vii) (b) Clerical Assistant — see paragraph (e) 96 MORTUARY As mentioned in the previous Annual Report, the new mortuary to be built at Queen Mary's Hospital, Sidcup, is proceeding according to plan and it is hoped that it will be finished in 1973. MEDICAL EXAMINATIONS STAFF 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. 1969 1970 No. of questionnaires scrutinised 1,163 1,537 No. of medical examinations required after scrutiny of questionnaire 1,021 957 OTHER CATEGORIES All Child Minders and staff at Day Nurseries are required to send in health statements and submit x-ray results. The number of medical questionnaires examined in respect of these persons is 1969 1970 604* 319 *The increase during 1969 was a consequence of the Nurseries and Child-Minders Regulation Act 1968, which came into force during 1969. ADDITIONAL EXAMINATIONS Entrants to the teaching profession and teachers entering the Council's employment are subject to special medical scrutiny. Teacher Training College admissions 233 Medical Certificates completed for Department of Education and Science 70 Medicals Arranged for other Authorities 8 311 97 SECTION C PREVALENCE AND CONTROL OF INFECTIOUS AND OTHER DISEASES Page Infectious Diseases 101 Vaccination and Immunisation 102 Tuberculosis, Care and After Care 104 Smallpox and Enteric Fever Surveillance 105 Smallpox Surveillance 105 Enteric Fever Surveillance 105 Venereal Diseases 107 Elderly in Residential Care 108 99 INFECTIOUS DISEASES The notifications of infectious disease for 1970 are set out below together with the 1969 figures for comparison. In all, there were 685 notifications during the year compared with 897 during the previous year, the reduction being proportional throughout the list of causes except for whooping cough. The comments that follow will also include observations on two outbreaks of infection in schools. 1969 1970 Scarlet Fever 125 83 Whooping Cough 16 61 Poliomyelitis (a) Paralytic — — (b) Non-Paralytic — — Measles 584 459 Diphtheria — — Dysentery 43 14 Acute Pneumonia — — Smallpox — — Acute Encephalitis (a) Infective — 1 (b) Post Infective — — Typhoid Fever 2 1 Paratyphoid Fever — 1 Erysipelas — — Food Poisoning 44 20 T uberculosis (a) Respiratory 26 12 (b) Meninges & CNS — — (c) Other 9 4 Puerperal Pyrexia — — Ophthalmia Neonatorum — — Anthrax — — Infective Jaundice 36 24 Tetanus — — Leptospirosis — — Acute Meningitis 12 4 Malaria — 1 TOTALS 897 685 101 The number of cases of measles continued to remain appreciable though greatly reduced from former years since the commencement of vaccination against it. The total for the year was less than in 1969 which contrasts with England as a whole where the 1970 incidence was over double that for 1969. In both Bexley and England the peak was in the third quarter. The restrictions on the vaccination campaign during 1969, which stemmed from a national shortage of vaccine, were lifted in 1970 when a sufficient supply became available. The Department of Health and Social Security urged a vigorous resumption of the campaign for protection of all susceptible children up to the age of 15 years because by early 1970 the number of such children in England was probably at least as great as it had been at the outset of the campaign in 1968. In all probability the lower number of measles cases in Bexley can be attributed to an extra supply of vaccine which fortunately the Health and Welfare Department was able to obtain in 1969. The number of vaccinations against measles in 1970 was almost as high (2944) as in 1969 (3035). VACCINATION AND IMMUNISATION Bexley London Borough continued to occupy its usual high place in the league table for vaccinations and immunisations as the following comparative figures show : — Percentage of children born in 1968 and vaccinated by December 31st 1970 against: Diphtheria Whooping Cough Poliomyelitis Smallpox (children under 2 years) Bexley London Borough 90 89 87 46 England 81 79 79 35 The percentage figure for tetanus is not given for England, but the following numbers of immunisations and vaccinations of persons under the age of 16 years in Bexley London Borough in 1970 speak for themselves. The actual number of injections is not given as some of the vaccines, in particular diphtheria, whooping cough and tetanus are combined. Immunisation against German Measles (Rubella) commenced towards the end of 1970 and is shown in the table for the first time. The arrangement for the vaccination of staff against Smallpox as described in the previous Annual Report continued throughout 1970. 102  Primary Immunisations Re-inforcing Immunisations 1969 1970 1969 1970 Smallpox 1610 2014 119 412 Diphtheria 1342 2720 5118 4388 Whooping Cough 1307 2631 2554 1757 Tetanus 1413 3034 5214 4611 Poliomyelitis 1342 2783 5044 4767 Measles 3035 2944 Rubella - 398 Tuberculosis (a) Contacts 187 182 (b) School children etc. 102 1574 * *This increase is because of a change in procedure whereby children are now immunised during the Autumn Term instead of the Spring Term. From the above it will be seen that vaccination and immunisation work in 1970 was approximately 21% greater than in 1969. RUBELLA Rubella or German Measles, although well known as a mild disease, is capable of damaging the foetus in various ways especially during the early months of pregnancy, the risk being highest in the first month. Recent evidence suggests that even in later months there may be some risk. The resulting congenital malformations can be very severe, especially those involving the heart, eye and auditory apparatus. Protection of women against Rubella during the child-bearing period was at first attempted by the use of serum but it proved to be ineffective. During recent years work has been going on in an endeavour to develop a vaccine against Rubella and early in 1970 the Chief Medical Officer informed doctors that a vaccine from the Cendehill strain was available. It was important to be sure that a woman was not pregnant at the time of vaccination or for two months after it. As far as local health authorities were concerned the vaccination scheme would apply to all girls between their 11th and 14th birthdays, but in order to facilitate the programme in its early stages, vaccine was made available without cost to local authorities (until 31st March, 1971) for the immunisation of girls in their 14th year. Routine vaccination began throughout the country in September and during the remainder of the year almost 400 Bexley school girls were given the vaccine. The aim is not to eradicate rubella from the community but rather to protect girls before they reach child-bearing years against the disease when it occurs and it is of course during epidemic years that most cases will occur. 103 TUBERCULOSIS The number of cases notified during the year was 16 compared with 26 in 1969. There were three deaths due to tuberculosis during the year, all males aged 45 years and over and none of them amongst the notified cases. This compares with five deaths in 1969. PROTECTION OF CHILDREN AGAINST TUBERCULOSIS In addition to B.C.G. Vaccination against Tuberculosis another protective measure was taken early in 1970. It was arranged with the Director of the Mass Miniature Radiography Service and the Chief Education Officer to station the MMR Unit at certain convenient points in the Borough for the benefit of teachers who were then able to avail themselves of the service. It was estimated that coverage of the teacher population would be complete within 1% to 2 years. Up to September only one case had not been pronounced clear and this case was not due to Tuberculosis. All cases not cleared at the first screening are further investigated and the Principal School Medical Officer is informed. CHEST CARE AND AFTER CARE In recent years the welcome fall in tuberculosis rates of notification and mortality unfortunately has been matched by a rise in other conditions, notorious amongst them being bronchitis, lung cancer and coronary heart disease, all having very strong links with cigarette smoking. Nationally this trend has been shown during the sixties in relation to sickness benefit (D.H.S.S. Annual Report of Chief Medical Officer 1970). In these terms bronchitis continues to account for by far the highest number of lost days due to certified incapacity for both males and females and it must be expected to go on doing so until the campaign against cigarette smoking is more successful. During the last decade male and female lung cancer death rates nationally have gone up remorselessly year after year, particularly so for females who did not become involved in the cigarette smoking epidemic until much later in this century than was the case for males. Much has been written about the concurrent rise in mortality from heart disease which prompted the choice of the new title for the National Association for the Prevention of Tuberculosis, now the Chest and Heart Association. During the year in Bexley London Borough there were two features of after-care which reflected these trends. In the early months of the year the Bexley Chest and Heart Care Committee confirmed its position in relation to these changing needs and in doing so invited medical and nursing representation from the Health and Welfare Department, thereby ensuring a mutually satisfactory framework for the after-care of such patients. In the second place, the health visitors at chest clinics had been dealing with more and more non-tubercular conditions. This change also was confirmed and the after-care arrangements were extended to include other respiratory diseases and the patients of any other chest consultant who might request this service. 104 SMALLPOX SURVEILLANCE The arrangements continued as described in the previous Annual Report. The number of persons kept under surveillance during the year was 3 compared with 2 in 1969. ENTERIC FEVER SURVEILLANCE The arrangements remained as described previously and eight persons were under surveillance during the year. TWO OUTBREAKS OF INFECTION IN SCHOOLS VERRUCAE Early in 1970 information was received that cases of verrucae of the feet were evident amongst those attending two of the Borough's swimming baths. This was not a new way to learn about a possible outbreak of this type of skin infection, nor was it a new suggestion that there might have been a causative association between the cases occurring in school children and swimming in the public baths. This suggestion was reinforced by the fact that surface water from the floor in the dressing area at one of the baths was not draining properly and so might be spreading the infection. Reports of investigations elsewhere in the country, which were quoted by the Chief Medical Officer of the Department of Education and Science, failed to substantiate any association with swimming or physical education over and above any other type of communal contact at school. Nevertheless a full scale enquiry was mounted and school children in all schools in the Borough were inspected for two specific reasons, first of all to assess the size of the outbreak and see if the existing arrangements were adequate to deal with it and secondly to test the significance or otherwise of public bath swimming as a cause. The answer to the second of these questions came first because the first schools to be dealt with were those using the baths with the faulty floor. In these ten schools 2644 children were examined and 105 were found to be affected and approximately half of these children did not attend the baths. Thus 36,364 inspections were carried out (some schools were re-inspected after a period of about 6—9 months at the request of Head Teachers), and 1313 children were found to have planter warts at the time of the inspection. This amounted to 3.6% of the school population. A further study was carried out to ascertain if there was any difference in the infection of children attending the swimming baths and those known not to attend, with the following results: — 105 21,359 children were known to attend swimming baths 829 were found to have planter warts (3.9%) 12,714 children known not to attend swimming baths 421 of these had planter warts (3.3%) These figures show that although children attending the swimming baths were affected in greater numbers, there was a very substantial number of affected children among those not attending the baths. Long before the final figures were known it was realised that the number affected was proving to be higher than expected and sufficient to merit special consideration. Although the usual procedure was to refer such cases to their own doctors for treatment, the numbers were so great that some were finding their way to private chiropodists outside the National Health Service and others were receiving no treatment whatever. It was decided therefore to set up a central clinic at 315, Broadway under the guidance of the Chief Chiropodist. Children not cured by two treatments administered by a qualified clinic nurse were thereafter referred to this central clinic for further treatment by the Chiropodist. Shortly afterwards a second clinic was introduced at Sidcup. The response of the general practitioners to this scheme was favourable and from April onwards it was fully operational. The following figures cover the period from 15th April 1970 to 31st December, 1970 Bexleyheath Sidcup Total Sessions 86 60 146 New Cases 290 152 442 Treatments 710 450 1160 It is interesting that during the year these inspections also revealed some 500 cases of ringworm of the feet, commonly known as athlete's foot. EPIDEMIC OF UNKNOWN ORIGIN In the Welling area and in particular at Eastcote County Primary School in Welling there was a sudden sharp outbreak of illness of a type thought to be due to a virus. The main symptoms were upper respiratory with fever and headache, sore throat, rash, abdominal pain and pain and weakness in lower limbs. At this school the majority of pupils were affected during the course of about a week. The number of absentees built up to a peak of almost 100 in the middle of this period. Some of the children were quite ill, but in general they recovered in two or three days. Despite exhaustive laboratory tests, the actual cause of the outbreak was not discovered. 106 VENEREAL DISEASES The following table shows the number of Bexley cases treated in various clinics during 1970. The total of 221 sexually transmitted diseases was 45 more than in 1969, itself the worst year since the Borough was formed. The increase was due mainly to gonorrhoea and to other venereal conditions and some of these other conditions are capable of causing serious complications and disability. V.D. RETURNS Hospital Totals — All Venereal Conditions Syphilis Gonorrhoea Other Venereal Conditions 1969 1970 1969 1970 1969 1970 1969 1970 Seamen's Hospital S.E.10 72 97 — — 12 21 60 76 Greenwich District Hospital 62 51 2 2 14 12 46 37 Whitechapel Clinic London Hospital, E.1. 8 12 — — 3 — 5 12 St. Bartholomew's Hospital 34 28 — 1 2 2 32 25 St. Thomas' Hospital 14 — 1 13 Westminster Hospital, S.W.1. 8 — 3 3 Middlesex Hospital 11 — 2 9 TOTALS 176 221 Although the figures for Bexley are well below the national average for 1970, there is no room for complacency, because the Bexley rates are following the national upward trend. The reasons for the increase are not hard to find. The powerful inducements to sexual incontinence do not require description. It is not surprising that there is no evidence of any decrease in promiscuity. The change in practice from barrier contraceptives to the use of the "pill" by women must also have been a factor in increasing the chance of acquiring one or more of these diseases. Contact tracing remains an important weapon of case finding and disease control; hitherto it has been undertaken mainly from the hospital clinics concerned in this work but the Health and Welfare Department is well equipped to assist when so requested. Health education obviously is important but there is room for much improvement in both its content and presentation. In his 1970 Annual Report the Chief Medical Officer points to the steady increase in sexually transmitted disease amongst girls and boys in spite of the fact that school authorities continue to promote teaching in classes on the biology of sex to the younger children and on the importance of personal relationships to the older ones, albeit with varying degrees of efficiency and enthusiasm. 107 ELDERLY IN RESIDENTIAL CARE In the early months of the year a national survey on the subject of the residential care of old persons was carried out and this report deals with some of the information collected in Bexley London Borough and sent to the Department of Health and Social Security. The enquiry related to premises and residents, but no comment is made here on the buildings, which, fortunately, are mostly modern and attractively sited. There is of course a well-recognised need for more homes but there is also a progressing capital development programme to meet that need. The first home in the programme (Dovedale Close) was nearing completion at the end of 1970. The number of persons involved in this survey in the London Borough of Bexley was 328 including one male short-stay resident in the 65-74 age group. Their distribution is shown in the following table from which it will be seen that almost 50 per cent of the local authority residents were 85 years or over as against 13 per cent in the voluntary homes. AGE GROUP MALE FEMALE Local Authority Homes Voluntary Homes Local Authority Homes Voluntary Homes 30-49 1 — — — 50-64 — 4 2 — 65-74 9 43 9 1 75-84 28 52 60 — 85 and over 27 13 76 2 TOTAL 65 112 147 3 MALE : 177 FEMALE : 150 As might be expected from this age distribution there is a more rapid turnover of accommodation in local authority homes than in voluntary homes. Of the 212 local authority residents 76 (36 per cent) had been admitted during the previous twelve months, whereas of the 115 residents in voluntary homes 20 (17 per cent) had been admitted during the previous twelve months. The following table shows the sources from which these new residents came. Most of them had been living in ordinary housing accommodation, alone or with others, and many had come from hospital. Certainly this was true of the 34 aged 85 and over, 31 of whom came from these sources and 30 of whom went into local authority homes. 108 PLACE FROM WHICH ADMITTED DURING THE PREVIOUS TWELVE MONTHS AGE GROUP AND SOURCE MALE FEMALE TOTALS Local Authority Homes Voluntary Homes Local Authority Homes Voluntary Homes SHELTERED HOMES 30-49 1 5 50-64 1 65-74 2 1 1 3 1 HOSPITALS 50-64 1 18 65-74 1 1 75-84 4 3 85 or over 2 6 7 2 9 PRIVATE & CORPORATION DWELLINGS. HOUSING LIVING ALONE 50-64 1 23 65-74 1 2 75-84 4 1 6 85 or over 1 7 5 2 16 PRIVATE & CORPORATION DWELLINGS. HOUSING - LIVING WITH OTHERS 65-74 1 3 3 32 75-84 3 7 85 or over 4 1 10 5 7 20 HOTEL, BOARDING HOUSES OR LODGINGS 65-74 3 10 75-84 2 1 1 85 or over 2 1 4 4 2 109 AGE GROUP AND SOURCE MALE FEMALE TOTALS Local Authority Homes Voluntary Homes Local Authortity Homes Voluntary Homes RESIDENTIAL HOMES 65-74 1 2 75-84 1 2 NONE OF THESE PLACES 65-74 1 6 75-84 2 3 2 1 3 TOTALS 26 19 50 1 96 About 20 per cent of local authority residents and 10 per cent of voluntary home residents had some difficulty regarding continence, females being affected more than males. The details are as follows CONTINENCE DIFFICULTIES AGE GROUP MALE FEMALE TOTALS Local Authority Homes Voluntary Homes Local Authority Homes Voluntary Homes 50-64 2 1 3 65-74 1 3 1 5 75-84 6 1 22 29 85 or over 4 3 13 1 21 TOTALS 11 9 36 2 58 The state of mobility was also assessed and 63 per cent were found to be ambulant without assistance or only required assistance on stairways. 75 per cent of male residents had this degree of mobility compared with 50 per cent of female residents and this difference extended into the oldest age group. A lesser degree of mobility might be expected amongst local authority residents because of the presence in local authority homes of more women aged 85 years or over and also because practically all of the residents in voluntary homes in all age groups were men; in fact 56 per cent of local authority residents had this degree of mobility compared with 75 per cent amongst voluntary home residents. The fact that this percentage difference persists when the oldest age group is excluded appears to confirm a general sex difference in this respect. Details of mobility are shown as follows 110 MOBILITY AGE GROUP MALE FEMALE TOTALS Local Authority Homes Voluntary Homes Local Authority Homes Voluntary Homes AMBULANT WITHOUT ASSISTANCE 50-64 1 1 2 65-74 4 31 4 39 75-84 17 45 16 78 85 or over 10 8 17 1 36 31 85 38 1 155 AMBULANT BUT NEEDS ASSISTANCE FOR STAIRS 65-74 3 1 4 75-84 3 17 20 85 or over 9 17 26 15 35 50 AMBULANT ONLY WITH ARTIFICIAL AID 30-49 1 1 50-64 2 1 3 65-74 2 5 3 10 75-84 3 4 10 17 85 or over 7 2 29 1 39 13 13 43 1 70 AMBULANT ONLY WITH HELP OF OTHERS 50-64 1 1 65-74 1 3 1 5 75-84 4 2 8 14 85 or over 1 2 9 12 6 8 18 32 MOBILE WITH SELF-PROPELLED WHEELCHAIR 65-74 3 3 75-84 1 1 85 or over 1 1 2 4 2 6 MOBILE ONLY IN POWER OR PUSH-CHAIR 65-74 1 1 75-84 1 8 9 85 or over 3 3 1 1 11 13 BEDFAST OR MAINLY SO 65-74 1 1 75-84 1 1 1 1 2 111 An attempt was also made to assess the mental condition of the residents in terms of either alertness or confusion with the following results. It would appear that 20 per cent of the men and 54 per cent of the women showed some degree of confusion. At ages 85 years or over these percentages were 35 per cent and 51 per cent respectively. MENTAL CONDITION AGE GROUP MALE FEMALE TOTALS Local Authority Homes Voluntary Homes Local Authority Homes Voluntary Homes MENTALLY ALERT 30-49 1 1 50-64 4 1 5 65-74 7 38 5 1 51 75-84 17 48 24 89 85 or over 17 9 37 1 64 42 99 67 2 210 MILDLY CONFUSED 50-64 1 1 65-74 2 5 3 10 75-84 10 4 22 36 85 or over 9 3 30 1 43 21 12 56 1 90 SEVERELY CONFUSED 65-74 1 1 2 75-84 1 14 15 85 or over 1 1 9 11 3 1 24 28 The homes vary to some extent in all these respects. Russell House, for example, had many residents who could be described as borderline cases for admission to hospital. Sydney House on the other hand had a higher than average number of residents aged 85 years or over. A greater number than average at this home had some degree of mental confusion, but mobility was average and contrary to expectation, fewer than average had difficulties of continence. 112 SECTION D ENVIRONMENTAL AND SANITARY CIRCUMSTANCES IN THE AREA Page Water Supply 115 Swimming Pools 119 Sewerage and Sewage Disposal 119 Noise 119 Launderettes 120 Atmospheric Pollution 121 Thamesmead 121 Chimney Heights 122 Rats and Mice 122 Disinfection and Disinfestation 122 Fox, Pigeon and Wasp Control 123 113 WATER SUPPLY The mains water supplies to this Borough were described in the previous Annual Report. It will be seen from the results of chemical examination of these supplies in 1970 that the highest level of natural fluoride was 0.20 parts per million. This compares unfavourably with the optimum level of 1 part per million which is the desirable amount of the fluoride element in water to give the best effect on tooth development. During the year the number of water samples taken by Public Health Inspectors and submitted to the Public Health Laboratory Service for bacteriological examination was ten of which none was found to be unsatisfactory. There was close liaison between the Acting Medical Officer of Health and the Medical Director of the Metropolitan Water Board on water problems and questions regarding the health of Bexley residents employed by the Board and other employees of the Board working in Bexley. Dr. E. Windle Taylor, C.B.E., M.A., M.D., D.P.H., F.C.Path., the Medical Director of the Metropolitan Water Board kindly prepared and sent the following information to the Medical Officer of Health regarding water supplied by the Metropolitan Water Board in Bexley in respect of the whole year 1. (a) The supply was satisfactory both as to (i) quality, and (ii) quantity throughout 1970. (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 the analytical 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 the area, but the population supplied direct according to the Registrar-General's estimates at 30th June, 1970, was 215,140. (ii) No houses were permanently supplied by standpipe. (d) No artificial fluoride is being 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 water from Hampton, Kempton Park and Surbiton pumping stations. Well water from Wilmington, Darenth, Wansunt, Crayford, Eynsford, Horton Kirby and Bexley pumping stations. 115 No new sources of supply were instituted and there were no changes to the general scheme of supply in the 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 shown to be not 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. 116 METROPOLITAN WATER BOARD — Water Examination Department BACTERIOLOGICAL RESULTS - YEARLY AVERAGES, 1970 OF THE WATER SUPPLIED TO THE LONDON BOROUGH OF BEXLEY Source of supply BEFORE TREATMENT AFTER TREATMENT Number of samples Agar plate count per ml. Coliform count Escherichia coli count Number of samples Agar plate count per ml. Coliform count E. coli count 20-24 hours at 37°C. 3 days at 22°C. Per cent. samples negative in 100 ml. Count per 100 ml. Per cent. samples negative in 100 ml. Count per 100 ml. 20-24 hours at 37°C. 3 days at 22°C. Per cent. samples negative in 100 ml. Per cent. samples negative in 100 ml. River Thames-derived 8,259 31.9 37.91 17.3 53.58 4.7 3,710 8.0 99.92 99.97 Bexley 269 0.0 12 99.26 - 100.0 - 253 0.1 46 99.60 100.0 Crayford No.1 151 0.1 52 92.72 0.3 96.69 0.1 254 0.5 10 100.0 100.0 Crayford No.2 148 0.1 131 83.78 4.9 88.51 - Crayford No.3 102 0.0 5 97.06 0.1 98.04 - 250 0.0 1 100.0 100.0 Darenth 244 0.1 15 100.0 - 100.0 - Eynsford Well 175 0.0 7 99.43 - 100.0 - 252 0.1 8 100.0 100.0 Eynsford Borehole 195 0.0 1 100.0 - 100.0 - Horton Kirby No.1 138 0.1 68 97.83 - 100.0 - 253 0.0 5 100.0 100.0 Horton Kirby No.2 193 0.0 15 99.48 - 99.48 - Wansunt Borehole 223 0.3 31 99.10 - 100.0 - 237 0.1 89 100.0 100.0 Wansunt Well 203 1.0 50 99.56 - 100.0 - Wilmington 248 0.7 43 98.79 - 100.0 - 253 0.1 20 99.60 100.0 117 METROPOLITAN WATER BOARD — Water Examination Department Average results of the chemical examination of Water supplied to the London Borough of Bexley during 1970 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) CaC03 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 363 0.026 0.083 4.8 1.02 274 79 5 27.7 5.6 Bexley 4 0.010 0.014 5.7 0.19 327 85 (a) Crayford No.1 4 0.008 0.032 8.4 0.24 391 132 (b) Crayford No.2 4 0.007 0.019 6.2 0.10 302 76 (c) Crayford No.3 4 0.009 0.039 7.4 0.19 341 104 Darenth 4 0.004 0.028 4.8 0.11 270 44 Eynsford 8 0.008 0.015 3.7 0.09 266 39 Horton Kirby 9 0.005 0.016 4.8 0.08 275 57 Wansunt 52 0.160 0.038 6.3 0.21 248 94 Wilmington 4 0.005 0.022 7.5 0.13 295 65 Description of the Sample Chloride as CI Phosphate as P04 Silicate as Si02 Sulphate as S04 Natural Fluoride as F Surfaceactive material as Manoxol OT Turbidity units Colour (Burgess units) pH value Electrical ConductI ivity (micromhos) (1) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) River Thames — Derived 40 2.7 9 70 0.20 0.03 0.1 11 7.9 570 Bexley 23 0.10 0.0 3 7.3 580 (a) Crayford No.1 34 0.15 0.0 1 7.1 640 (b) Crayford No.2 28 0.15 0.1 2[ 7.2 550 (c) Crayford No.3 29 0.15 0.0 4 7.2 600 Darenth 18 0.10 0.0 2 7.2 480 Eynsford 18 0.10 0.0 2 7.3 480 Horton Kirby 23 0.10 0.1 2 7.2 480 Wansunt 31 0.10 0.1 3 7.1 640 Wilmington 29 0.15 0.1 1 7.2 540 118 SWIMMING POOLS The Council operates covered swimming pools at Lamorbey, Riverside Erith, and Crook Log Bexleyheath and open-air pools in Danson Park and Martens Grove. In addition, there are situated at a small number of schools, pools provided principally by parent/teacher associations. A large factory in the area has its own open-air pool, and an indoor pool exists at a large residential home. Apart from the control of water purity by the staff concerned, a number of samples are taken by Public Health Inspectors for routine Lovibond comparator tests and for bacteriological examination. During the year none of the 103 samples submitted to the Public Health Laboratory Service for bacteriological examination was reported as unsatisfactory and the operators of the swimming pools in the area are to be congratulated on the efficient manner in which they have carried out chlorination of the pools. SEWERAGE AND SEWAGE DISPOSAL The previous Annual Report contained a general statement concerning the arrangements for sewerage and sewage disposal. With the exception of the Thamesmead development the Borough's sewage is conveyed by trunk sewers to the outfall works of the West Kent Main Sewerage Board at Dartford. There are a small number of cesspools serving domestic and industrial premises. I am advised by the Borough Engineer & Surveyor that during the year improvements have continued to be made to the existing system including the various pumping stations and that all new premises erected have been connected to the main system. Work on the large main sewer scheme in the Northern part of Erith and Belvedere and amounting to some £850,000 in total, has continued and is expected to be completed some time during the first part of 1972. NOISE Nationally the Noise Advisory Council came into being in 1970 and it is worth recording its aims which were "to keep under review the progress made generally in preventing and abating the generation of noise, to make recommendations to Ministries with responsibility in this field and to advise on such matters as they may refer to the Council". The Noise Advisory Council, unlike other noise committee, is not entirely limited in its responsibilities to one government department. The Council has a special value in being able to range over matters for which various government departments are responsible. Advice can be offered to planners just as much as to designers of aircraft and other equipment. During 1970 this happened on the local level when advice was sought by the Borough's Planning Officer on the licensing of the Crayford Stadium for stock car racing. The racing of these "bangers" had been the cause of a number of complaints. The results of readings taken by a member of the Greater 119 London Council Scientific Branch at various points outside the stadium showed that the noise from stock cars was only marginally above the background level and at all points was well within the prescribed limits for sound and distance. As a matter of interest this sound limit was also the sound limit later agreed by the Noise Advisory Council's Working Party on Traffic Noise as suitable for planning purposes. Inside the stadium the levels were up to 9 decibels higher than speech from the public address system. It was considered however that at these levels no danger of permanent loss of hearing was likely to occur. The situation would continue to be kept under observation. During the year a noise nuisance under close investigation in 1969 continued to be the subject of complaint. It was one of those difficult cases mentioned in the previous Annual Report where, after full investigation by the Department, it was not possible to establish that it constituted a nuisance. The firm of consultants who made the original measurements in 1969 was asked to report on the efficiency of various schemes of improvement proposed and subsequently some costly works were carried out. The problem is typical of the difficulties associated with fairly extensive refrigeration plant which is nowadays a feature of supermarkets and similar premises. Pollution of the atmosphere by noise continues to cause widespread concern and this is not restricted to the industrial parts of the Borough. Whilst background noise and some intrustive noise is accepted during the day, residents are more aware of and ready to complain about occasions when noise intrudes above the background level during the night. This may be due to night working at factories or the operation of plant e.g. refrigeration plant at commercial premises near to residential premises. Where possible steps are taken to reduce the noise levels to as near as possible to the background level and to guard against a 'creeping' background level. The expense of employing consultants and carrying out alterations sometimes to newly installed plant would in many cases have been more wisely spent in better original planning and equipment. The means of reducing the annoyance and inconvenience of noisy roadworks involving the use of compressors and concrete breakers continues to get a lot of attention from the industry in order to meet contract requirements and silenced compressors and muffled road breakers are now much more in evidence. Where such precautions can be incorporated into the design of the equipment the extent of human failure is reduced. LAUNDERETTES In view of the problems that arise from noise, vibration and fumes from the above premises attention continues to be given not only to existing premises but also those brought to our attention by the Borough Engineer & Surveyor's Department as a result of plans submitted to that Department with whom we continue to work in close liaison. Apart from the physical problems of adapting existing or new buildings, there remains the need to exercise the utmost care in the design and layout of equipment and service to ensure that nuisances do not arise. If the fullest consideration to these aspects is given at an early stage and their importance constantly borne in mind by individuals, contractors and companies concerned, sometimes difficult and expensive modifications can be prevented. 120 ATMOSPHERIC POLLUTION SMOKE CONTROL AREAS The bringing into operation of Smoke Control areas continues to be an important contribution to the reduction of atmospheric pollution and it was interesting to note that a report issued during the year indicates that the reduction of smoke concentration in Central London appears to have increased the duration of sunshine since 1958 by about 50% during the months of November to January. Subject to certain procedures, a householder who needs to carry out works of adapting or replacing heating appliances in order to comply with the Smoke Control Order may obtain a grant towards the costs involved. At the commencement of the year 9 Smoke Control Orders were in operation and a further Order in the Blackfen and Lamorbey areas was awaiting confirmation by the Minister. This Order was duly confirmed and action was taken throughout the year to bring it into effect. In the second half of the year local authorities were advised by the Minister of Housing & Local Government that in certain areas there would be a shortage of solid smokeless fuel during the winter of 1970 and 1971. With a view to recommending a course of action in the London area this matter was considered by the London Boroughs Association and as a result of their advice and discussions held with other interested parties, the Council asked the Minister to suspend during five winter months 4 Smoke Control Orders covering approximately 40% of the premises contained in Smoke Control areas. Steps were taken to defer until the 1st April 1971 the operative date for the Smoke Control Order due to come into operation on the 1st December 1970. At December 31st 1970, 9,589 acres covering some 28,500 premises were subject to Smoke Control Orders. These figures include the four Orders temporarily suspended but do not include the Order deferred. The total number of premises shown is an aggregate of the number of premises contained in the Smoke Control areas at the times when the Orders were submitted for confirmation by the Minister and should, therefore, not be directly compared with the total premises in the Borough. DISTRICT HEATING - THAMESMEAD Reference was made in the previous Annual Reports to the fact that a district heating system with its resulting benefits in terms of atmospheric pollution control was in operation in the Thamesmead area. Heating is provided from a central boilerhouse temporarily situated near the Northern end of Harrow Manorway. The boilerhouse will be re-sited North of the main sewer bank as the development of Thamesmead continues. 121 CHIMNEY HEIGHTS Quite apart from any other requirements the heights of chimneys serving certain categories of furnace e.g. one burning gaseous or liquid fuel at the rate of 1% million or more British Thermal Units per hour require to be approved by the local authority as means of controlling atmospheric pollution. Where applications are made there is a need for extension technical assessment involving the installation engineers and others but on no occasion during the year has it been necessary to call in outside consultants although arrangements exist whereby this can be done. RATS AND MICE The problem of infestations by rats and mice continues to occupy a large proportion of time of the Foreman and three Operators employed in the department. Major infestations by either species are rare and many of the requests for control treatment have been for small infestations, especially of living accommodation by domestic mice. Although Warfarin is the main rodenticide used, recourse has to be made to other materials in persistent or difficult cases. The elimination of infestations require the close co-operation of the occupier as otherwise some resistence to normal control measures may occur and pockets of infestation become established. Approximately 825 complaints of rats and 700 complaints of mice have been dealt with during the year; in some cases incidents are reported by more than one person, for example in cases where rats are seen in house gardens, but this indicates the public awareness to the fact that control measures are necessary. Where necessary local treatments of the drainage system are carried out particularly where it is thought that surface infestations may be associated with the system but the indications are that the degree cf infestation of the drainage system is low. DISINFECTION The widespread disinfection of houses by gaseous methods after the occurrence of infectious diseases is not now carried out although advice and service is provided where necessary. Where articles cannot be effectively disinfected on site then arrangements exist for them to be transported to an adjoining local authority for attention in their disinfecting chamber. PERSONS Arrangements exist with an adjoining local authority for transfer to their Cleansing Station of persons and suitable articles requiring disinfestation. The calls for this service are now fortunately rare. 122 PREMISES A small number of requests are still received for treatment to destroy bugs and fleas and services for these are available in the department together with the general advice invariably necessary in such cases. Although it is possible that some isolated infestations of bugs will occur from time to time, the fact that a concerted effort including vigilance for a period can effectively deal with infestations makes these unpleasant vermin less of a.menace than formerly. Advice has also been sought on a variety of other insects and 'animals' including garden insects, moles, squirrels and snakes. Where information is not available attempts are made to obtain it elsewhere or persons are referred to other sources for advice. FOX, PIGEON AND WASP CONTROL It is not the function of this department to rigorously control any of these species but a number of complaints are received and undoubtedly nuisance is caused by each on some occasions. FOXES About 152 foxes were accounted for by various control measures during the year. The department is fortunate to have amongst its rodent control staff the necessary skill and contacts. PIGEONS Where feral pigeons roost the fouling and damaging of buildings, and the fouling of footpaths invariably occurs. Action has been taken to deal with pigeons that have become established in various derelict houses. By shooting and trapping, 638 pigeons have been dealt with in various locations during the year. Local arrangements exist for returning to the owners through the approved channels any ringed pigeons caught. WASPS The year was again a busy year for complaints and some 184 nests were dealt with. Only nests easily accessible are tackled by this department and a charge is made for the service. Where nests are inaccessible or require the removal of the roof tiles, etc., advice is given and individuals referred to other persons who may be able to assist them. 123 SECTION E HOUSING Page Housing Acts 1957/1969 — Unfit Premises, etc. 127 Caravans and Caravan Sites 128 Common Lodging Houses 129 Rent Act 1968 — Certificates of Disrepair, etc. 129 125 HOUSING ACTS 1957/1969 UNFIT PREMISES Early in the year the Slum Clearance Programme 1970/73 was submitted to the Ministry of Housing & Local Government. It revealed that there were approximately 211 houses in small groups within the Borough, which were in such a condition that they should be dealt with by clearance. In addition to these there will continue to be cases where isolated properties, which are brought to the attention of the department by complaint or survey and found to be unfit, will require Demolition or Closing Orders. During the year one clearance area was declared involving premises in Upton Buildings, Chapel Hill, Crayford. The Minister confirmed Compulsory Purchase Orders for two other areas previously declared relating to premises in Gladeswood Road, Belvedere and Nuxely Road, Belvedere. An area involving some 19 houses in Sidcup was surveyed and all the preliminary work was completed but before an Official Representation was made the houses were offered by the owner to the Council and the Council commenced negotiations for their purchase without recourse to statutory action. A total of 3 Demolition Orders and 15 Closing Orders were made and in two other cases undertakings were given not to relet the properties. IMPROVEMENT Applications for improvement grants are passed to this department by the Town Clerk's Department and any necessary information is given to the Borough Engineer & Surveyor's Department. In 5 cases tenants made representations to the Council with a view to securing the compulsory improvement of their dwellings as their requests made to their landlords had not brought about the improvements which they desired. In all 5 cases Immediate Improvement Notices were served requiring the houses to be brought up to the full standard by way of providing bathrooms and other necessary facilities. In 2 cases where Improvement Notices had been served prior to 1970 the dwellings were brought up to the required full standard during the course of the year. HOUSES IN MULTIPLE OCCUPATION The number of premises falling within this category does not constitute a serious problem in this Borough but on several occasions negotiations have been carried out with owners to secure the conversion of the houses into self-contained flats. The premises in which multiple occupation had occurred in the post-war period are to a large extent detached premises the sites of which are suitable for redevelopment. 127 QUALIFICATION CERTIFICATES Provision is made in the Housing Act 1969 for an owner to apply to the Council for a Qualification Certificate where a dwelling was provided with all the standard amenities, was in good repair and in all other respects fit for human habitation. It further provides for a Provisional Certificate to be issued where proposals are made and submitted to the Council for bringing a property up to the required standard. Where a certificate is issued to the owner he can present this to the Rent Officer who fixes a fair rent. All applications are made to the Town Clerk's Department and all inspections and technical work are carried out by the Public Health Inspectorate. Qualification Certificates issued 182 Applications cancelled or Qualification Certificates refused or not entertained 241 Qualification Certificates held in abeyance following letters and negotiations to the owners requiring repair works, etc. 161 TOTAL APPLICATIONS RECEIVED 584 Applications for Certificates of Provisional Approval granted 72 Applications refused or cancelled 13 TOTAL APPLICATIONS RECEIVED 85 Work in this aspect of housing occupied a large amount of the Public Health Inspectors' time; some 2,000 visits and inspections were made. Likewise a considerable amount of office work was involved. Although this meant that certain aspects of housing, e.g. general improvement areas, were not pursued, it was felt that the time given to Qualification Certificates was well'spent as, overall, a considerable amount of repair work was carried out in many cases on properties which had not received maintenance over the course of many years. The procedure by which applications were held in abeyance in order to allow owners to carry out required repairs was usefully adopted and Qualification Certificates were subsequently issued on many of the premises involved. CARAVANS AND CARAVAN SITES In most cases caravans used as dwellings require, in addition to Town Planning approval, a licence issued by the local authority under the Carravan Sites and Control of Development Act 1960. Only five site licences are in operation involving a total of ten caravans. In four cases a single caravan only is involved. Generally these sites are maintained in a satisfactory condition. A number of caravans remain stationed near Crittals Corner on the grass verge of the A.20 trunk road which forms the Southern boundary of the Borough. The caravans have been there 128 since early 1966 and the number fluctuates but usually remains between 15 and 20. Some protective chestnut paling fencing has been erected to restrict the number of caravans gaining access to this grass verge. Action is taken from time to time to deal with refuse accumulations and rat infestations but the general conditions remain poor as can be expected where there is an absence of basic necessities including hard-standings. Each London Borough is required to make provision for those caravans stationed in or resorting to their Borough up to a maximum of 15 unless they can show that no suitable land is available for a permanent caravan site. Such a site provided and controlled by the local authority should provide the means not only of dealing with the public health problems on unauthorised or temporary sites but should also provide the stabilised situation that many caravan dwellers now apparently seek. No permanent caravan site has yet been provided but efforts continued to be made to obtain and provide a site. GENERAL IMPROVEMENT AREAS The provisions contained in the Housing Act 1969 whereby a Council can declare certain areas to be General Improvement Areas were given some preliminary consideration by the Officers but due, to the pressure of other work under the Housing Act 1969, no full assessment of the local need for generally improved areas was made during the year. COMMON LODGING HOUSES No premises in this Borough are known to be used as a common lodging house. RENT ACT 1968 CERTIFICATES OF DISREPAIR, ETC. The tenant of controlled' property may in certain circumstances apply to the local authority for a Certificate of Disrepair. Failure by a landlord to give or carry out an undertaking involving repairs considered necessary results in the issuing of a Certificate of Disrepair and a reduction in rent whilst the premises remain in disrepair. The number of applications for Certificates of Disrepair continued to decline. The following table shows the action taken on the applications received during the year. 129 PART 1. Application for Certificates of Repair 1. No. of applications for certificates 4 2. No. of decisions not to issue certificates - 3. No. of decisions to issue certificates (a) in respect of some but not all defects - (b) in respect of all defects 1 4. No. of undertakings given by landlord 3 5. No. of undertakings refused by the local authority Nil 6. No. of certificates issued 1 PART II. Application for Cancellation of Certificate 7. Application by landlord to local authority Nil 8. Objection by tenant to cancellation of certificate Nil 9. Decisions by local authority to cancel in spite of tenant's objection Nil 10. Certificates cancelled by the local authority Nil SECTION F FOOD AND DRUGS Page Food Inspection 133 Imported Food 133 Food Sampling 133 Food Complaints 133 Milk Supply 134 Bacteriological Examinations of Water and Food 134 131 FOOB INSPECTION Frequent requests are received in the department for the inspection of food at shops, etc., believed to be unfit or unsuitable for human consumption and where this is confirmed by a Public Health Inspector the food is 'surrendered' for destruction. Approximately 42 tons of food have been dealt with in this way during the year and a fair proportion of this would have arisen from breakdowns in large refrigerated food cabinets. In no case has it been necessary to 'seize' food under the provisions of the Food and Drugs Act 1955 for it to be dealt with by a Court. There are no slaughterhouses or poultry processing premises situated in the Borough. IMPORTED FOOD An increase in the number of sealed containers forwarded to premises within this Borough in accordance with the Imported Food Regulations 1968 has occurred during the year and similarly the number of depots receiving such containers has increased. Two large warehouses continue to receive the bulk of imports by this means. Where necessary, following examination of the containers, samples are procured for examination by the Public Analyst and 53 samples were dealt with in this way. FOOD SAMPLING The following table shows the number of samples of food taken under the Food and Drugs Act 1955 and submitted to the Public Analyst for analysis, together with the number found unsatisfactory. No. of samples taken Unsatisfactory 743 33 Unsatisfactory labelling of food was the main reason for many of the unsatisfactory, none of a serious nature. Excessive amounts of tin were found in a few imported canned fruit samples. Unfortunately, there is no legal standard for tin content and the Public Analyst has to rely on a food standard recommendation that the tin content in a sample should not exceed 250 parts per million. A deficiency in the meat content in some canned meat products was found. The attention of producers was drawn to the deficiencies and follow-up samples gave satisfactory results. A few samples reported as unsatisfactory were the result of retailers selling old stock and shows the necessity for strict supervision of stock rotation. 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. 133 No of complaints investigated No. of Special Samples submitted to the Public Analyst 107 17 Of the complaints received and investigated the most popular foods were meat products, bread and milk, in that order. Mould was the main reason for complaint as far as the meat products. The complaints regarding bread were usually found to refer to vegetable oil which has coagulated with a little flour and given to the inside of the loaf an unpleasant appearance. Foreign material in bottles of milk was the main reason for complaints being received, due to misuse before washing and bottling, and the foreign material not being detected by the 'spotters' at the Milk Depot. Prosecutions were successfully instigated in six cases and fines and costs totalling £135 imposed by the Courts. One case was adjourned sine die by the Court. The defendant who was charged with serving a meal containing a cigarette end was leaving the country. MILK SUPPLY All milk sold in the Borough is required to be sold with a Special Designation i.e. Pasteurised, Sterilised, Ultra Heat Treated or Untreated. There are five main retail distributors in the Borough. Three of these have large distributing depots but there are no treatment or bottling plants. In addition to milk delivered to houses there are some 140 retail outlets mainly grocers and supermarkets. BACTERIOLOGICAL EXAMINATIONS OF WATER AND FOOD The following table shows the number of routine samples taken and submitted to the Public Health Laboratory Service. No. Taken Unsatisfactory Water 10 None Water (Swimming Pool) 103 None Ice Cream 32 None Milk (Public supply) 10 None Milk (School supply) 4 None Cream 3 None It was very gratifying to report satisfactorily on the above samples. 134 Following the report of a number of dead fish in Danson Park lake, bacteriological samples of the water were obtained for examination as part of the investigation. No unusual results were obtained but the use of the lake for recreation was suspended for a few days. It was ascertained that the fish had in fact died as a result of a parasitic infection. A concurrent inspection of the local surface water drainage system revealed two defects which were rectified. 135 SECTION G OFFICES, SHOPS AND RAILWAY PREMISES ACT 1963 Page Premises and General Inspections 139 Accidents 139 Hoists and Lifts 139 Factories Act 1961 139 Factories 139 Outworkers 141 137 OFFICES, SHOPS & RAILWAY PREMISES ACT 1963 (a) PREMISES AND GENERAL INSPECTIONS The number of premises registered, 1572, represents a slight increase during the year and, although there is a constant need to add to and subtract from the register, it is believed to represent the majority of premises which need to be registered under the Act. Approximately two thirds of the registered premises are retail shops. 801 visits of all kinds were made to premises and one third of the registered premises received general inspections. In addition to verbal notices given to occupiers to rectify defaults in compliance with the Act, some 24 written notices were served during the year. (b) ACCIDENTS 40 notifications were received of accidents which had taken place in offices or shops and which had resulted in the persons being away from work for three or more days. No fatal or severe accidents were notified; in fact many that were notified were of a fairly trivial nature. 5 accidents were investigated in detail and where necessary recommendations were made but it was not necessary on any occasion to forward details of accident investigations to H.M. Factory Inspectorate. It is believed that many accidents resulting in persons being away from work are not notified under the procedure and occupiers of premises are reminded of this and that failure to notify is in itself a contravention of the Act. (c) HOISTS AND LIFTS The Offices, Shops and Railway Premises (Hoists and Lifts) Regulations 1968 which came into operation in May 1969 apply safety standards to those hoists or lifts situated in premises to which the main Act applies. The attention of four firms has been drawn to infringements and work to remedy them has been completed or is in hand. FACTORIES ACT 1961 A. FACTORIES 1. INSPECTIONS for the purpose of provisions of the above Act enforced by this Council were carried out as follows during the year. Where necessary the attention of the occupiers were drawn to certain matters either by informal or written notice. In 139 In no case was it necessary to institute proceedings for contravention of the Act. Premises (1) Number on Register (2) Inspections (3) Number of Written notices (4) (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 30 33 (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 486 314 8 (iii) Other Premises in which Section 7 is enforced by the Local Authority — (excluding out-workers' premises) 42 165 TOTAL 558 512 8 2. Cases in which DEFECTS were found Particulars (1) Number of cases in which defects were found Found (2) Remedied (3) Referred To H.M. Inspector (4) By H.M. Inspector (5) Want of cleanliness (S.1) 2 2 — — Overcrowding (S.2) — — — — Unreasonable temperature (S.3) — — — — Inadequate ventilation (S.4) 2 2 — — Ineffective drainage of floors (S.6) — — — — Sanitary Conveniences (S.7) (a) Insufficient — — — — (b) Unsuitable or defective 4 4 — 4 (c) Not separate for sexes — — — — Other offences against the Act (not including offences relating to Outwork) 2 2 — — TOTAL 10 10 — 4 140 3. GENERAL Several would-be contraventions of the Act and the Sanitary Accommodation Regulations have been prevented by discussion with developers following the sight of plans deposited with this Council for planning permission and/or approval under the Building Regulations. As far as sanitary accommodation goes this area of factory premises still seems to be one where lack of attention to satisfactory facilities and compliance with the law is given at the initial planning stage. B. OUTWORKERS Employers of persons carrying out 'outwork' at their homes, periodically are required to submit brief details to the Local Authority. Some people seem to continue this kind of activity over a long time but for many others their period of employment is relatively short. During the year some 125 persons were carrying out 'outwork', all employed in various forms of making or finishing wearing apparel. In no case was it necessary to serve notice or take action in respect of unsatisfactory premises. 141 SECTION H GENERAL Page Public Health Acts — Statutory Nuisances 145 Slaughter of Animals Act 145 Diseases of Animals Act 145 Riding Establishments Act 1964 145 Animal Boarding Establishments Act 1963 146 Pet Animals Act 1951 146 143 PUBLIC HEALTH ACTS - STATUTORY NUISANCES Principally as a result of investigations by Public Health Inspectors, following receipt of complaints from tenancts of private houses, it has been necessary during the year to serve:— 142 written Intimation Notices 20 Abatement Notices on owners of houses or other persons responsible to carry out work to remedy nuisances. The service of Abatement Notices has been simplified with the delegation of powers adopted by the Council following consideration of the 'Maud' report. In no case has it been necessary to obtain a Nuisance Order from the Court for the noncompliance of an Abatement Notice. SLAUGHTER OF ANIMALS ACT 1958 Persons employed in slaughterhouses to stun or slaughter animals are required to hold a licence under the above Act. It is customary for the licences to be granted by the local authority in whose area the person is employed as a slaughterman. In the absence of any slaughterhouses in this Borough no licences are currently issued by this Council. DISEASES OF ANIMALS ACT 1950 In company with many of the other London Boroughs, this Borough's functions under the Diseases of Animals Act 1950 and the many Orders made thereunder concerning farm animals, poultry and pets are carried out on an agency basis by the Corporation of London. On no occasion during the year was it necessary for the Veterinary Officer of the Corporation of London to place restriction orders on any premises within this Borough concerning Foot and Mouth Disease or Swine Fever although the movements were restricted for a period of dogs which had been at kennels outside the Borough where a case of rabies had occurred. RIDING ESTABLISHMENTS ACTS 1964-1970 Persons who carry on a business of keeping horses for the purpose of their being let out on hire for riding or for the purpose of their being used in providing, in return of payment, instruction in riding are required to hold a licence under the above Acts. Five licences were in force during the year. Following an application for a licence a Veterinary Officer's report on all the animals is made and regard is had to this and the other circumstances of the riding establishment before a licence is issued. Establishments where no instruction is given and where livery only is provided for privately owned horses do not require to be licensed. 145 ANIMAL BOARDING ESTABLISHMENTS ACT 1963 Four annual licences were issued permitting persons to keep establishments for the boarding of other persons animals. Each of the licences sets out the maximum number of animals to be boarded and applies other conditions, relating to animal welfare, to the licence. Consideration is being given by the British Veterinary Association to revising the recommended conditions that should be applied. PET ANIMALS ACT 1951 Licences are issued annually to persons who keep pet animal shops. A fee of £2.00 is paid for each licence which requires the person to carry on a business in a proper manner according to the animals sold and to comply with certain conditions affecting the animals welfare. Inspections of the premises are carried out as necessary, veterinary advice is available, if required, and liaison with the Royal Society for the Prevention of Cruelty to Animals occurs from time to time. Twenty licences were in force during the year. 146 REPORT of the PRINCIPAL SCHOOL MEDICAL OFFICER 147 SCHOOL HEALTH SERVICE The health of the school child should be measured not so much in terms of the statistics of the school health service or by the absence of disease and disorder in the school child as by signs of "complete physical, mental and social wellbeing" (World Health definition). It is easier to invent parameters of health however, than it is to define what is being measured. A study was made some years ago of the incidence and causation of health amongst 10—11 year old school children in the Borough of Bexley. Two significant results which emerged from the physical, mental and personality assessments were that good ante-natal care and birth weight were common features of the early histories of the most healthy children. A more recent study, in which the Department has been involved, concerned seven-year old children. This study was of children born during one week in March 1958, when all births in England, Scotland and Wales were the subjects of a survey sponsored by the National Birthday Trust Fund and the Royal College of Obstetricians and Gynaecologists. In the First Report of the National Child Development Study on these seven-year old children two conclusions were reached, firstly, that the need for specific teaching of reading skill is not by any means confined to infant schools and classes and, secondly, the extent of educational backwardness and other difficulties in school at the infant stage is greater than has been realised hitherto. Educationally, socially and medically, boys were found to be more vulnerable than girls. Boys were more likely than girls to have learning and speech difficulties, accidents, medical conditions and develop mental problems. There were, however, no sex differences related to vision and hearing and the proportions with defective vision being found in the survey children and in the Bexley children of approximately the same ages in 1970 were similar. One fundamental aspect of a child's health and education is his eyesight and the Department has always placed much emphasis and given much priority to this part of the service. It was of particular interest, therefore, that in June 1970 a meeting was convened by the Senior Administrative Medical Officer of the South East Metropolitan Regional Hospital Board to discuss the future arrangement of the school eye clinics in the Region. The Ophthalmic Sub-Committee of the Regional Board thought it advisable that all new referrals should be supervised by a consultant. Attempts had been made by this Department since 1965 to secure consultant ophthalmologists for the expansion of this work but none was available. It was obvious from this meeting and from previous knowledge that when and where they were available for this work, it was possible to integrate all the desirable features of the local authority and hospital services into one scheme. It was hoped in future to include work in the school eye clinic in the contracts of newly appointed consultants in ophthalmology. The Department's school ophthalmic arrangements, although not integrated with the hospital, continued nevertheless to function throughout the year in a comprehensive and satisfactory manner. Despite the changes and shortages of departmental medical officers, it was always possible to staff the school health service with the medical members of the Department rather than temporary or sessional doctors. 149 SCHOOL POPULATION 1969 1970 Number of children on school register (including 175 nursery places) 34,083 35,328 In addition 131 attended special residential schools outside the Borough and 135 attended special day schools outside the Borough. ROUTINE MEDICAL INSPECTIONS The same age groups of children were examined as in previous years. 1969 1970 Number given full medical examination 9,839 9,348 Number of those examined requiring treatment These 1,224 children had 1,340 defects including 599 caused by defective vision. In addition to these 1,340 defects requiring treatment there were also 5,185 requiring observation. 1,705 1,224 Number of special medical inspections (at the request of a parent, doctor, nurse, teacher, etc.) 1,045 772 Number of re-inspections 3,366 3,551 Children found unsuitable for education at school:— (i) No. of children who were the subject of new decisions recorded under Section 57 of the Education Act 1944 5 (ii) No. of reviews carried out under the provisions of Section 57A of the Education Act 1944 3 (iii) No. of decisions cancelled under Section 57A(2) of the Education Act 1944 3 CLEANLINESS INSPECTIONS 1969 / Number of individual examinations of pupils in schools by school nurses or other authorised persons 14,880 19,716 150  1969 1970 Number found to have head infestation (Comment: There is a definite increase again after two lower years. This has also been found in other areas and shows the necessity for continued vigilance.) 54 74 The details of the 1340 defects requiring treatment are as follows :— SKIN DISORDERS Number of skin disorders requiring treatment found at routine medical inspections 1969 1970 Entrants 62 62 Leavers 104 80 Others 227 105 The number of children inspected for plantar warts is referred to elsewhere in this Report (see under Infectious Diseases). During the year the following cases were reported : — 1969 1970 Ringworm 1 1 Impetigo 31 27 Other conditions 7 2 39 30 EYE DEFECTS At the routine medical inspections the following defects were found to require treatment: Vision Squint Other Conditions Totals 1969 1970 1969 1970 1969 1970 1969 1970 Entrants 212 110 75 43 10 5 297 158 Leavers 183 201 11 2 8 5 202 208 Others 250 200 23 20 40 13 313 233 Grand Totals 645 511 109 65 58 23 812 599 The special "Keystone" vision screening test continued to be used extensively throughout the Borough in 1970. The majority of those failing this test were added to the 599 shown above giving the following totals : — 151  1969 1970 Number of cases of external and other eye conditions excluding errors of refraction and squint known to have been dealt with 115 350 Number of cases of errors of refraction including squint known to have been dealt with 2,000 2,903 Total 2,115 3,253 The number of pupils for whom spectacles were prescribed was 1,081 (910 in 1969). The detailed results of tests carried out using the "Keystone" apparatus are as follows: — 1969 1970 No. of children tested 10,363 8,842 No. of children passed 8,762 7,471 No. of children failed 1,515 1,371 Failed distant vision 1,111 889 Failed near vision 542 484 Failed muscle balance 632 493 Failed depth 423 507 Failed colour vision 74 111 No. for retesting 2,585 1,977 No. of children referred to School Medical Officer 140 65 NOTE: Cuts in the electricity supply during the Autumn of 1970 were responsible for the reductions in the number of tests. Vision screening tests were carried out on entry to school and between 6 and 7 years, 8 and 9 years and between 10 and 11 years. Colour-vision tests were given to boys and girls at the age of 10 years. All these routine tests were performed by a clinic nurse who specialises in this work. She refers children who fail the test to the school medical officers for further examination. Further referral to one of the four ophthalmic clinics or to hospital may then be made. DEFECTS OF EAR, NOSE AND THROAT The following 91 ear, nose and throat conditions requiring treatment were found : — Defective Hearing Otitis Media Other Conditions 1969 1970 1969 1970 1969 1970 Entrants 44 25 22 24 6 15 Leavers 2 8 2 2 5 1 Others 33 14 5 1 12 1 Nose & Throat 56 36 22 12 31 12 152 It should be rioted that 246 (281 — 1969) children (including 168 (212—1969) entrants) were found at routine medical inspections to require observation regarding their hearing. AUDIOMETRY During the year routine audiometry continued to be carried out in the schools in the Borough on children aged seven years. These screening tests are performed by a clinic nurse specialising in this work. She is also the nurse-audiometrician at the audiology unit (see under Deafness in Early Childhood).The detailed results of her tests are as follows CLINIC SESSION No. of children tested 536 No. of children passed 294 No. of children failed 242 No. of children re-tested 197 No. of children passed 72 No. of children failed 125 SCHOOL SWEEPS No. of sweeps 40 No. of children tested 2344 No. of children passed 2083 No. of children failed 261 GRAPHS No. of graphs carried out 409 No. of children passed 139 No. of children failed 270 No. of children referred to School Medical Officer 169 Absentees (Sweep) 113 No. of children tested 176 No. of children passed 164 No. of children failed 12 The following numbers of children received operative treatment for ear, nose and throat conditions 1969 1970 Disease of the ear 14 7 Adenoids and chronic tonsillitis 174 125 Other nose and throat conditions 1 5 189 137 153 REFERRALS FROM E.N.T. Specialist 100 General Practitioners 7 Head Teachers 20 Speech Therapists 14 The audiology unit is centrally situated in the Borough and babies first diagnosed there as having impaired hearing can be followed up in school or special school. New cases occurring during the school years can be referred to the Unit either as a result of the screening tests at the age of seven years or from the school medical examinations, routine or special. HEARING AIDS The total number of pupils still on the register of schools at 31st December 1970 known to have been provided with hearing aids during 1970 was 13. SPEECH DEFECTS The following numbers of new children required treatment for speech defects : — 1969 1970 Entrants 43 15 Leavers — 2 Others 9 10 There were also 209 (229—1969) children requiring observation. These children were referred to the Department's speech therapists who had a total of 166 children under treatment during the year. Children are always seen by the school medical officers in the first instance before referral. Many of these children were under treatment from previous years. A temporary shortage of speech therapists caused some accumulation of cases and it was necessary to ask medical officers to be selective in referring cases for several months leaving the remainder to be referred later. It is obvious that there are many other children who ought to have some speech therapy treatment, but were not reported because it was known that only the most urgent cases could be seen. ORTHOPAEDIC AND POSTURAL DEFECTS The following 65 cases were discovered at routine medical inspections to require treatment:— Posture Feet Other Conditions 1969 1970 1969 1970 1969 1970 Entrants 5 1 16 7 27 10 Leavers 1 4 1 10 16 11 Others 11 1 10 13 13 8 154 The actual number treated at clinics or out-patient departments was 79, some having been under treatment before 1970. There were also 102 postural defects, 264 foot defects and 252 other orthopaedic defects requiring observation. PSYCHOLOGICAL CONDITIONS AFFECTING DEVELOPMENT AND STABILITY There were seven (21—1969) cases requiring treatment, but 109 (97—1969) and 435 (542— 1969) required observation regarding their development and stability respectively. THE CHILD GUIDANCE CLINIC 504 families visited the Child Guidance Clinic during the year, of these 234 attended for the first time. Most of these families were seen several times and given an opportunity of discussing matters in greater detail, some attended as often as weekly. We have been able to keep abreast of the demand and the waiting list is, on average, not more than four weeks despite the fact that the Psychiatric Social Worker has been single handed for part of the year. It is hoped to appoint further staff in the near future and when the clinics is back to its full complement of three Social Workers, it is expected to be able to give an even speedier service. There can be no doubt that the child guidance unit is still understaffed, and, in view of this. Medical Officers in the department had to be selective in referring cases. 155 REPORT on the DENTAL SERVICES (1970) by the CHIEF DENTAL OFFICER J.H. FORRESTER, L.D.S., R.C.S.(Eng.) 157 DENTAL SERVICES STAFFING The major problem of recruitment of staff was apparent again this year, Dental Officers being compelled on many occasions to work unaided, through shortage of Dental Surgery Assistants, thus creating difficulties for all staff. This is the result of the poor salary scale at present offered by Whitley Councils. The school and other priority dental services share staff and premises so all aspects of this report relate to both school health and care of pre-school children and expectant and nursing mothers. Statistics are, however, recorded for each service. Establishment 1970 No. in post 31st December (whole time equiv.) Designation No. of Posts 1969 1970 Principal School Dental Officer 1 1 1 Senior Dental Officers 2 1 1 Dental Officers 4.25 4.0 4.4 Dental Auxiliaries 4 1 0.8 Supervisor Dental Surgery Assistant 1 - 1 Dental Surgery Assistants 6.25 6.0 5.8 19.5 13.0 14.0 Although there is an apparent improvement in the staffing by dental officers, it is regrettable that we are unable to attract younger applicants, as the average age of dental officers is 55 years, which includes a dentist of 72 and one of 26. It is hoped that with improved working conditions and installation of modern equipment this situation will be remedied DENTAL SURGERY ASSISTANTS As result of internal training, voluntarily organised in the evenings by the Supervisor Dental Surgery Assistant, 4 Surgery Assistants obtained the National Certificate of the British Dental Surgery Assistants Association. All are to be congratulated. CLINICS The replacement of obsolete dental equipment, over a period of 3 years, was commenced. Modern equipment being installed at Danson and Sidcup Hill Clinics. It is essential to maintain this policy if we are to attract dental surgeons of the righ-t calibre. 159 DENTAL SERVICES FOR EXPECTANT AND NURSING MOTHERS AND PRE SCHOOL CHILDREN A. ATTENDANCES AND TREATMENT 1969 1970 No. of visits for treatment during year First visit EM.&N.M. 23 21 Children 421 324 Subsequent visits EM.&N.M. 50 46 Children 355 280 Total visits EM.&N.M. 73 67 Children 776 604 No. of additional courses of treatment other than 1st course Treatment provided during the year EM.&N.M. 10 10 Children 145 165 No. of fillings EM.&N.M. 113 85 Children 570 540 Teeth filled EM.&N.M. 69 48 Children 436 379 Teeth extracted EM.&N.M. 3 10 Children 46 48 General Anaesthetics given EM.&N.M. — 2 Children 24 18 Emergency visits by patients EM.&N.M. 1 3 Children 6 9 Patients X-rayed EM.&N.M. 1 7 Children — 1 Patients treated by scaling &/or removal of stains from teeth EM.&N.M. 16 15 Children 215 186 Teeth otherwise conserved Children 88 51 Teeth Root Filled EM.&N.M. — — Inlays EM.&N.M. — — Crowns EM.&N.M. — — No. of courses of treatment EM.&N.M. 19 18 Children 403 388 B. PROSTHETICS 1969 1970 Patients supplied with F.U. or F.L. (First time) — 1 Patients supplied with Other Dentures — — No. of Dentures supplied — 2 160 C. ANAESTHETICS 1969 1970 General Anaesthetics administered by Dental Officers — 1 D. INSPECTIONS 1969 1970 No. of patients given first inspections EM.&N.M. 19 21 Children 431 327 No. of patients in A and D who required treatment EM.&N.M. 16 19 Children 298 228 No. of patients in B and E who were offered treatment EM.&N.M. 16 19 Children 289 228 E. SESSIONS 1969 1970 No. of Dental Officer Sessions (i.e. equivalent complete half days) devoted to Maternity & Child Welfare Patients: For treatment 100.8 107 For Health Education 37.10 — SCHOOL DENTAL SERVICE INSPECTIONS 1969 1970 First inspection at school. No. of pupils 29,702 28,976 First inspection at clinic. No. of pupils 4366 4536 Number found to require treatment. 14,437 13,469 Number offered treatment 13,152 11,918 Pupils re-inspected at school or clinic. 2387 2799 Number re-inspected and found to require treatment. 2,501 2,267 ATTENDANCES AND TREATMENT 1969 1970 First Visit Ages 5—9 2,233 2,254 " 10—14 1,638 1,701 " 15 & over 478 477 TOTAL 4349 4,432 161  1969 1970 General anaesthetics Ages 5—9 360 260 " 10—14 179 159 " 15 & over 17 11 TOTAL 556 430 Emergencies Ages 5—9 77 125 " 10—14 32 65 " 15 & over 10 8 TOTAL 119 198 No. of Pupils X-rayed 325 327 Prophylaxis 2,448 2476 Teeth otherwise conserved 704 763 No. of teeth root filled 27 27 Inlays — — Crowns 15 24 ORTHODONTICS 1969 1970 Cases remaining from previous year 47 34 New cases commenced during year 74 21 Cases completed during year 28 27 Cases discontinued during year 5 9 No. of removable appliances fitted 68 56 No. of fixed appliances fitted 1 1 Pupils referred to Hospital Consultant 12 6 PROSTHETICS 1969 1970 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 — — " 10—14 2 1 " 15 & over 1 1 TOTAL 3 2 No. of dentures supplied Ages 5—9 — — " 10—14 3 1 " 15 & over 2 1 TOTAL 5 2 162  1969 1970 Subsequent visits Ages 5—9 3,936 3,679 " 10—14 3,512 2,983 " 15 & over 1,051 968 TOTAL 8,499 7,630 Total visits Ages 5—9 6,169 5,933 " 10—14 5,150 4,684 " 15 & over 1,529 1,445 TOTAL 12,848 12062 Additional courses of treatment commenced Ages 5—9 1,519 1,624 " 10—14 1,105 1209 " 15 & over 206 280 TOTAL 2,884 3,113 Total courses commenced Ages 5—9 3752 3878 " 10—14 2743 2910 " 15 & over 738 757 TOTAL 7233 7545 Courses completed Fillings in permanent teeth 5,169 6232 Ages 5—9 2,766 3,029 " 10—14 4,915 4,580 " 15 & over 1,748 1,595 TOTAL 9,429 9,504 Fillings in deciduous teeth Ages 5—9 4,568 5,388 " 10—14 463 663 " 15 & over — — TOTAL 5,031 6,051 Permanent teeth filled Ages 5—9 2,224 2,121 " 10—14 3,828 3,236 " 15 & over 1,174 1,297 TOTAL 7,226 6,654 Deciduous teeth filled Ages 5—9 3,195 3,397 " 10—14 331 408 " 15 & over — — TOTAL 3,526 3,505 Permanent teeth extracted Ages 5—9 53 35 " 10—14 218 229 " 15 & over 95 42 TOTAL 366 306 Deciduous teeth extracted Ages 5—9 786 731 " 10—14 244 320 " 15 & over — — TOTAL 1,030 1,051 163 ANAESTHETICS 1969 1970 Number of general anaesthetics administered by Dental Officers — 1 * SESSIONS 1969 1970 Sessions devoted to treatment 2,188 2,298 Sessions devoted to inspection 289 295 Sessions devoted to Dental Health Education 161 56 * An emergency extraction by the Chief Dental Officer. PREVENTION The London Boroughs Association in November 1969 drew the Council's attention to their decision that fluoridation is such an important national issue that it should be taken out of the area of local government, and since there seems little prospect of achieving total unanimity, they are informing the Minister that he should himself decide whether or not it should be nationally implemented. It is gratifying to report that this recommendation was strongly supported by this Council, and it is hoped that such a well proven preventative measure to add fluoride to the water supply, raising the level to an optimum of one part per million will soon be implemented. TREATMENT During the year 4,432 (4349—1969) school children received treatment, an increase of 2% over 1969. 6,232 courses of treatment were completed which was 80% of those commenced (7545). The continuing conservative nature of treatment is indicated by ratio of teeth filled to extracted, which was 20.5: 1 in permanent dentition, which does not include extractions for orthodontic treatment, and 3.6: 1 in deciduous dentition. It was only found necessary to fit 2 dentures. In the specialised field of orthodontics 56 removable appliances were fitted and 1 fixed appliance. The Thamesmead Temporary Health Centre developed rapidly and was used for 4 sessions a week to meet present demand on Local Authority services. INSPECTIONS The number of pupils inspected at school was 28,976, of whom 42% were found to be in need of treatment. 164 From inspections it was ascertained that approximately 36% of school children did not receive regular dental care from general dental service or local authority services. An indication of the failure to use available dental resources in areas of Borough is shown below: Area Not seeking regular care Sidcup 24.4% Bexley 25.7% Welling 31.8% Crayford 34.4% Erith 65.2% However, it is encouraging to note from the 1961 Annual Report of the Medical Officer of Health for the Boroughof Bexley, the dental need in schools at Welling was 69% whereas at the moment it is 35%. For various reasons including building extensions, inadequate accommodation etc. 3 schools were not inspected. Once again we must thank the Head Teachers and their staffs for their co-operation, sometimes under great difficulty due to individual environment in schools. DENTAL HEALTH EDUCATION In July the Council approved a dental health project involving the issue of simple dental kits to 2,000 children of pre-school and school entrant age in order to encourage them in the care of their teeth. The kits, obtainable from Messrs. Gibbs at greatly reduced cost consisted of a plastic beaker, a tube of toothpaste, a tooth brush and a standard letter to parents giving the relevant points relating to dental health. In the absence of a fluoridated water supply, this scheme was considered to be of more than usual value. No. of talks and Nos. involved 1969 1970 Infants & Junior Schools 27 30 Pupils instructed 7,300 6,249 M. & C.W. Clinics 35 70 Public instructed 345 1,011 Mothers' Clubs etc. 3 8 Public instructed 45 149 MATERNITY & CHILD WELFARE This was continued as an integral part of an overall activity to follow the policy of "family" care. Approximately 7% of the dental service was devoted to this priority group. The treatment pattern here is indicated by the ratio of teeth filled to extraction 7.9 : 1 in pre-school children. With increased use of topical fluorides and increased time spent on Dental Health Education in priority groups, it is hoped, in the long term to reduce the incidence of dental disease. 165 APPENDIX 'A' NURSING ATTACHMENTS TO GENERAL PRACTICE The Acting Medical Officer of Health reported as follows to the Social Services (& Children's) Committee on 29th June, 1970 Attachment of local health authority nursing staff to general practice is a concept now applied on a wide scale. The three main types of nurse — health visitor, midwife and district nurseare involved. Hitherto in Bexley only the co-operative type of attachment has been practised although in one practice a Type III attachment (see below) has been tried. The geographical allocation of nursing duties does not usually favour the introduction of schemes of attachment and indeed this has been one of the difficulties in the Bexley area. The Council's policy of the development of health centres is not prejudiced in any way; if anything the scheme of attachment might be expected to aid that development or at least be complementary to it. TYPES OF ATTACHMENT I. Full attachment to specified practices with provision of local health authority services exclusively to those practices. A qualified full attachment would apply when a health visitor retains a geographical district for some particular purpose such as school health work. II. Partial Attachment (a) Schemes of full attachment to specified practices but also involving traditional arrangements with other practices. (b) As in (a) except that when patients live outside the nurse's area, she is responsible for liaison between the general practitioner and the appropriate nurse. III. Association. Geographical areas are maintained but regular contact is made with specific general practices, e.g. by staffing general practitioner clinics. IV. Co-operation. Informal meetings or contacts are made when there is a need to exchange information. Possible effects on:— (1) Manpower In a recent survey (D.H.S.S. 1969) some increase in staff was involved in a proportion of the schemes due to increased travelling, surgery time, more follow-up work, earlier referral of more seriously ill patients, and an increased amount of borderline chronic work. On the other hand recruitment of staff was said to have been improved by virtue of these schemes. 167 (2) Cost Extra staff and travelling may increase the costs but some balance may be effected by the use of auxiliaries on a more static basis. The trend towards more hospital confinements will eventually have a reducing effect upon the local health authority costs as also will be tendency of some general practitioners to restrict their practices to smaller areas. (3) Organisation (a) Complete re-arrangement of areas will be involved in full attachment schemes. (b) The work load of the nursing staff will be greater and at the same time more selective. By wider use of the skills of qualified local authority nursing staff, doctors will be relieved of tasks inappropriate to their role. (4) Patients A recent survey showed that patients' reactions were generally favourable. (5) General Practitioners There is evidence that growth in partnerships may be paralleled by growth in attachments. Conversely it is possible that the provision of attachments might promote group practice or even the demand for health centres. SCHEME PREPARATION After initiat discussion with the Local Medical Committee, the Acting Medical Officer of Health would communicate with the general practitioners of the area to explain the scheme and to ascertain the likely degree of response. At first it might be advisable to extend the liaison schemes as a preliminary to full attachment. Surgery office facilities and receptionist arrangements would require investigation and detailed discussion on the working of the schemes would have to take place. Attachment would never be so complete as to preclude central control of the staff by the local health authority through the Medical Officer of Health who would retain the right for example, to select staff, make boundaries, prescribe certain duties connected with child health, health education and student training and determine the feasibility of proposed attachment schemes. Initial caution is advisable, however, and the possibility of some degree of reorganisation with a modest increase of staff and costs should be realised. Approval was given in principle to the attachment of local health authority nursing staff to general practices in the Borough in those cases where the Acting Medical Officer of Health considered it appropriate, wherever possible the existing form of liaison to be extended. The Acting Medical Officer of Health, in conjunction with the Local Medical Committee and the general practitioners, to ascertain the demand for attachment of nurses to practices in the Borough and prepare a scheme for consideration by the Committee. 168 APPENDIX 'B' MIDWIFERY TRAINING The Acting Medical Officer of Health reported as follows to the Social Services (& Children's) Committee on 29th June, 1970 Attention is drawn to the Report of the Working Party on the Future Development of Midwifery Training which suggests a radical alteration of the existing course of training. At present a two-part course covers a training time of one year and the domiciliary component of the course takes place during the last three months of the Part II training period. Statutory lectures have been given to student midwives during the last few years by the Deputy Medical Officer of Health and the Principal Medical Officer. Partly owing to the trend towards more hospital deliveries, which leaves fewer domiciliary cases for training purposes, and partly due to the evidence from two pilot schemes at Southampton and Newcastle that the new single integrated courses produce better midwives, the Central Midwives Board advocates the extension of this new single 52-week course to other areas. A suggestion is now made that the Queen Mary's Hospital Midwives Training School and the London Borough of Bexley Local Health Authority should combine to provide such a course which might be known as the Queen Mary's Hospital and London Borough of Bexley Midwifery Training Scheme. The course would fall into three periods covering a total of 12 calendar months and the participation of the local authority would consist of several lectures towards the end of the first period and responsibility for the whole of the second period. With new entrant pupils every three months these arrangements would apply four times each year. The first introductory period of the training would be spent in hospital. The second period would last 12 weeks during which the student midwife would receive clinical instruction and practical experience of domiciliary midwifery under the direct supervision of a midwife teacher. She would also become acquainted with the community health and social services that are available to the mother and thus become more aware of the complex issues associated with modern midwifery practice. The final period in hospital would be largely clinical in character. The community period would fall into two roughly equal parts, one clinical and the other theoretical. In-service training would include lectures given by the Authority's medical and nursing staff, a visiting medical specialist in venereal diseases, a home help organiser, a probation officer, a senior mental welfare officer, a children's officer a family caseworker and a public health inspector. Practical demonstrations and visits to see the appropriate services in operation would be arranged especially to see those concerned with day minding, day nurseries, fostering, adoption, care of deprived children, children in need of care, and family planning. The detailed programme would be submitted for the approval of the Central Midwives Board with the intention of putting it into operation on or after April 1971. 169 A proposal to set up a similar scheme has now been received from the Group Secretary of the Woolwich Group of Hospitals. These integrated courses are in accordance with the developments suggested in the Green Paper and much of the arrangements would also serve to provide similar integrated training for district nurses which is a likely development at a later date. Owing to the earlier introduction of pupil midwives to domiciliary work it is intended that the teacher midwives should have brief refresher courses. The cost to the Local Authority will be reflected mainly in officers' time spent on in-service training. Much of this time, however, will be replacement time for domiciliary training being given at present to pupil midwives. The contribution of other members of staff hitherto uninvolved in this type of work might amount to about 30% of the training time. Some small expenditure may be necessary for lecturers' fees and the possible rental of a room large enough for 20 pupils. If this scheme were to commence on time, some preparation will be necessary, especially in relation to the refresher courses. The Council approved in principle the scheme set out above, and instructed the Acting Medical Officer of Health to negotiate joint arrangements with the appropriate hospital authorities and that such joint arrangements be submitted to the Central Midwives Board for approval. 170